VAGINAL VERSUS ABDOMINAL SECTION IN DISEASES OF THE FEMALE

PELVIC ORGANS.

BY WILLIAM M. POLK, M.D, LL.D.,

OF NEW YORK;

PROFESSOR OF OBSTETRICS AND GYNECOLOGY, MEDICAL Department, UNIVERSITY OF THE CITY OF NEW YORK.

THE rapid evolution of the surgery of the female pelvic organs is one of the great things of this part of our century. Question succeeded question in quick succession until many felt that the end had been reached, and all that remained was the task of perfecting what had been developed. Hardly had we settled down in complacent contemplation of our results with the Trendelenburg posture when we were rudely shaken by this cry of the "vaginal method." Turn from it as often as we may, it yet sings in our ears, and will not be silenced. Intrench ourselves behind a resolution to see in it nothing of good for our patients; view it as a new hobby upon which those of shallow judgment are riding to notoriety, not to honest repute ; decry it in all and every way, and it will not down. This is proven by the experience of the past year in this country alone, not to mention what has occurred abroad.

We are to be congratulated that such has been the result of the agitation, for it shows the virility of the subject, and proves that there is a great deal in it for our consideration. As a matter of fact, it is probably the last great question in the surgery of the female pelvis, and deserves to be treated as such by our best men.

Vaginal section has already been injured by exaggerated claims in its behalf. It is folly to talk of driving abdominal section from the field with it, for the reason that conditions will always occur which can be so much better met by the former that no good surgeon would decline to employ it. I think also that the vaginal section will always serve as subordinate to the abdominal, even though it diminish the frequency of the latter one half or two-thirds. This belief is based upon the acknowledgment that abdominal section must sometimes be used to complete the work begun through the vagina. In other words, there are cases supposedly entirely amenable to vaginal section, but which demand, as the operation proceeds, a better operative field, which can only be had by combined section. This single admission shows the interdependence of the methods, and suggests that wherever the boundary between them be drawn it must be made movable; nothing hard and fast can be tolerated.

It is interesting to recall that vaginal section not so long ago held the vantage-ground in this territory, and was driven out except in the case of carcinoma because of its poor results. This was due to its faulty technique in part, and in part to a lack of

familiarity with the actual condition which could be present with a diseased uterus and appendages. Through abdominal section it has now informed itself and perfected its technique, and again comes forward for recognition.

Our attitude in this contention can be best expressed by assuming one hundred as the total of all cases of disease in question now recognized as suitable for section. One year ago I thought this could be divided equally between the vaginal and the abdominal. I now think seventy-five can be assigned to vaginal section, leaving twenty-five to be treated by the abdominal.

As the indications for or against depend largely upon the dimension of the diseased area or growth, one must admit that the earlier the operation is done, the greater the chance for vaginal section. So, assuming that one could observe all cases of uterine and adnexal disease from the outset, it is probable that the ratio would be still further increased in favor of the vaginal route.

Beginning this work at Bellevue Hospital in Feb. ruary, 1892, we have now performed seventy-two vaginal sections, with three deaths, covering every species of disorder for which it has been advocated. This ignores vaginal hysterectomies for carcinoma done in the years prior to 1892, for we wish to eliminate from this discussion as much old timber as possible. What we have to say is based upon our own work; work in no way original, however, although it has not been checked by the observations of others, for we tried to approach the subject with an unbiased mind and aimed at independent work, so that when informed from personal experience we could compare conclusions with cotemporaries and with those who had preceded us. It is evident from this statement that we are prepared to modify our conclusions when it can be shown that they are not properly based.

With this understood, we now submit a statement of conditions favorable, on the one hand, to vaginal section, and, on the other, to abdominal section.

Exploratory incisions. There are certain obscure conditions of the appendages of the uterus and sigmoid flexure in which exploratory abdominal section has become a recognized operation. Accurate vaginal and rectal bimanual palpation under ether is insufficient to discover enough gross lesions to account for symptoms. Direct palpation or inspection is needed for diagnosis. For instance:

CASE I. A young married woman, the victim of constant pelvic pain and dysmenorrhoea, came to the writer for operation, having been told by competent authority that nothing short of removal of the ovaries would effect a cure. The pain was referred to the region of the left appendages. Examination without ether revealed what appeared to

Or take another instance (Case II.). Following curettage and trachelorrhaphy an inflammatory mass developed in the outer upper region of the right broad ligament. Supposing it to be salpingitis plus ovaritis, the cul-de-sac was opened with a view to removal or evacuation. To our surprise tube, ovary, and surrounding peritoneal area were normal. But as the swelling was all the more evident it was carefully palpated with a view to operation. The uterus was drawn down by volsella and two fingers were swept over the entire pelvis. First over the posterior surface of uterus, then the anterior, then along the upper border of the broad ligaments, then down into the paravesical fossæ, thence over the bladder, the anterior pelvic, and lastly the posterior pelvic walls. The following abnormality was in this way mapped out. The outer upper region of the right broad ligament, including its line of connection with the pelvic wall, contained a hard mass; between it and the uterus was a distinct sulcus, in which the tissue, though thickened, appeared in fair condition. To the front, the right paravesical fossa was wellnigh obliterated, the outline of the linea | terminalis from the attachment of the broad ligament forward to near the symphysis was obscured all by soft swollen tissue, which evidently was nothing more than a collection of pus connected with and springing from the mass in the broad ligament. We were now at liberty to select an exit for the pus. This could be had in two ways. A direct incision above Poupart's ligament, turning up the peritoneum, reaching the pus about the pectineal eminence. Another route, and the one selected, was directly from the vagina. The cul-de-sac was closed; then, in order to reach the pus and at the same time avoid the ureter, an opening was made as in anterior colpotomy; this was extended beneath the peritoneum, upward and outward to the region of induration, whence the pus thus freely escaped.

Displacements fixed by adhesions. From several cases we select one (Case III.) in which the uterus was retroverted, ovaries prolapsed, and both, with

Ovarian tumors. All such tumors small enough to be contained, wholly or in large part, in the pelvic cavity should be removed by vaginal section. Tumors large enough to reach beyond the umbilicus, especially if they are pedunculated and are wholly outside the true pelvis, can be best treated by abdominal section. This observation applies with greatest force to multilocular colloid growths, but even then it is susceptible of modification in favor of vaginal section if it can be shown that both ovaries are hopelessly diseased. Then hysterectomy being permissible, sufficient opening is secured to evacuate properly and withdraw even such colloid growths. If this be true of these latter tumors, it applies with greater force to unilocular cysts with more fluid contents. From this it must appear that while tumors wholly outside the pelvis can be best treated by abdominal section, many of these can be reached by the vagina, provided it be proper to remove the uterus. In these cases it is wise to operate with the hips somewhat raised, else the intestines and omentum will occupy the field, and are apt to cut off the escape of fluid, which then tends to ascend and accumulate just under the abdominal walls.

CASE IV. An intraligamentous ovarian cyst of the left side, with dimensions about equal to the foetal head at seven months, was removed per vagina through the cul-de-sac. Some difficulty was experienced in enucleating the sac. This was overcome, however, by opening the anterior fornix, through which the sac was easily removed. Our experience in this case impressed us with the advantages of the anterior over the posterior line of approach in the intraligamentous growths. By this route most of them can be removed without entering the peritoneal cavity. After reaching the under surface of the peritoneum in the utero-vesical fold, it is only necessary to push aside the tissue with the finger, when the wall of the sac contiguous to the lateral uterine wall is easily reached and punctured. Subsequent enucleation can then be readily made. By hugging the uterus well up to the region of the body before attempting puncture of the sac, one easily avoids ureter and bladder. Hemorrhage is readily controlled by forceps.

CASE VI. Extra-uterine pregnancy.—This was an example of an extra-uterine fœtation, in which incision, evacuation, and drainage brought a speedy cure. Bleeding points were many, but they were secured by forceps, which were left in place fortyeight hours. This is a condition which, prior to rupture, one can always elect to reach by the vagina. The tumor from first to last is well down in the posterior regions of the pelvis, and is easily reached through the posterior vaginal wall. It may be necessary to remove the uterus, however, for without this addition we may have excessive hemorrhage. Still, if one can get hold of the connection of the mass by clamping upon its two sides, outer and inner, bleeding can be stopped. After the placenta is fully formed, the child being alive, the suprapubic route would no doubt be preferable. Touching those cases, whether early or late, in which from antecedent rupture or otherwise the fœtus is dead, the infrapubic route will meet every requirement, as we have then little more than to evacuate and drain.

Inflammation and suppurative disease of the appendages, including tubercular disease. This field is particularly rich in opportunities for vaginal section. In fact, there appears to be no stage which positively contraindicates it. It offers the best means of checking the ravages of acute inflammation, thus tending to the highest kind of conservatism; it affords opportunity for the partial plastic operations upon the adnexa and uterus, and it gives us the best operation for suppurative disease of these same adnexæ, when their removal is demanded, as in tubercular disease and in the destructive inflammation of both appendages.

It is interesting to note that this class of cases has furnished the battle-ground of this question. But the increasing belief that the uterus must go with the appendages, that hysterectomy in destructive double adnexal disease is required, and, further, that plastic so-called conservative operation upon the uterus and appendages can be done through the vagina bids fair soon to settle the question in favor of vaginal section.

CASE VII. Acute processes.-This is an instance of acute salpingitis and pelvic peritonitis following abortion at two and one-half months. The uterus was cleansed and packed with sterilized gauze; the cul-de-sac by a free opening evacuated of turbid serum. The inflamed appendages were not dis

water. Finally, the vagina was loosely packed with gauze. This was removed at the end of forty-eight hours, the final result being all that could be asked. This case illustrates what will probably be a common application of one step of the infrapubic operation, namely, the incision into the cul-de-sac with a view to drainage. This step appears to promise much in mitigating the damage which befalls the appendages in the face of the inflammations which come to them through those very common causes-abortions and gonorrhoea. The cleansing of the uterus, together with free drainage from the pelvic peritoneal area, seems to be the rational way of treating such cases, but it is a selfevident proposition that to be of service it must be done early.

CASE VIII. Acute puerperal metritis, etc. In connection with the preceding case the present one illustrates the ease with which one may go to extremes when necessary in puerperal septic cases. A woman was septic five days, the form being sapræmia rather than mere sepsis. In ten minutes the uterus was removed and the operation completed. The relaxed and dilated state of the whole genital

easy.

tract makes the operation exceptionally From this we infer that all such cases are peculiarly fitted for the infrapubic operation. Chronic processes. For illustration, a synopsis of three cases is now given.

CASE I. By means of anterior colpotomy the uterus was anteverted, the fundus and the appendages were brought through into the vagina. The right appendage was normal, the left diseased. The left was removed. The remaining organs were then returned to the peritoneal cavity. The opening in the peritoneum was closed, that in the vaginal wall left open. The uterus was curetted and packed; patient out of bed in a week.

CASE II. By means of posterior colpotomy an adherent and purulent ovary and tube were discovered on the left side. They were removed, a clamp being used. Upon the right side the appendages, being normal, were not removed. The uterus was treated as in Case I. and the patient did quite as well.

CASE III. represented a double ovarian abscess and double pyosalpinx. The pelvis was practically filled with the mass and the associated adhesions. The uterus was first cut out, and then the left and, lastly, the right appendages were removed. The process was tedious, and, owing to the intimate and firm attachment of the rectum, this intestine was torn. No attempt at closure was made, as the opening was small. The recovery was quick, but a fecal fistula remained for two months, when it finally closed spontaneously.