[Reprinted from the Transactions of the Southern Surgical and Gynecological 
Association, November, 1892.] 
EXPERIENCES IN PELVIC SURGERY. 
By A. V. L. Brokaw, M.D., 
St. Louis, Mo. 
Of all the surgical problems difficult to solve it may be 
truthfully said that those met with in the pelvis are the 
most trying. I know of no surgical work which can 
compare with the experiences found in the pelvis: such 
a diversity of conditions, complications, and unexpected 
happenings are ever presenting. 
In a series of many operations but few will be alike in 
every particular. Uncertainty of making an absolutely 
correct diagnosis before operations enters largely into the 
experience of all operators in this field. When I had 
little experience in this work, I could always make a diag- 
nosis, and quite frequently verify it after operating. With 
an increasing experience I find myself well satisfied with 
an approximate diagnosis. 
The diagnosis of pus cases is usually clear, and one 
makes a correct diagnosis in the majority of cases. It is 
in the other pelvic conditions where we make our errors 
of diagnosis. We might very properly state that only 
those without operative experience, or the theorist, always 
make correct analyses of their cases. Individually, I 
frankly admit my inability to correctly diagnose the 
character of abdominal and pelvic troubles as my expe- 
rience becomes larger. I have diagnosed pus tubes, and 
found extra-uterine pregnancy; diagnosed extra-uterine 
pregnancy, and found pus; diagnosed ovarian lesions, 
and found the trouble located in the tubes, and vice versa. 2 
EXPERIENCES IN PELVIC SURGERY. 
This experience tallies with that of all the most promi- 
nent workers in this domain of surgery with whom I 
have conversed. 
The bad results in pelvic work are frequently found to 
be the result of neglect, often ignorance, and very fre- 
quently a want of resolution in the attendant. An early 
use of the knife in many cases which eventually pass 
into our hands, would have given far more brilliant re- 
sults and improved generally the present statistics in 
pelvic surgery. The number of cases we see in the early 
stages of disease are relatively infrequent; by far the 
greater number are in a late stage of disease; not a few 
on the verge of dissolution. 
The criticism passed upon pelvic surgeons, that they 
often operate when operative proceedings are unnecessary, 
is usually unjust, and simply the gratuitous statement, 
actuated by bad motives, of those without personal 
experience. No conscientious, earnest surgeon has a 
thought but for the best interest of those placed under 
his charge. 
When well-defined pelvic lesions exist, nothing short of 
radical measures succeed. Abortive attempts at dealing 
with pus or other threatening conditions only bring dis- 
astrous results. I am a believer in the conservatism so 
well defined by McMurtry in a recent paper, and I 
heartily recommend the perusal of that erudite article 
to the critics who never operate. 
That needless, reckless surgical exercises are perpe- 
trated in the pelvic work of a few we will not attempt 
to deny; however, the same is true in other directions, 
particularly so in the cerebro-spinal surgery which re- 
cently threatened to become epidemic. 
The routine gynecologists are largely responsible for 
much of our work. By a routine gynecologist I refer to 
the gynecologist who treats all his cases alike: introduces 
a speculum, paints the cervix with iodine, makes local 
applications to the cervical canal or within the uterus A. V. L. BRO KA W. 
3 
itself, insufflates some boric acid, introduces a glycerin 
tampon or pessary, and requests the patient to come again 
in two days. This soft impeachment cannot be denied. 
The specialist should recognize conditions demanding 
imperatively operative interference, and not nurse cases 
along in the described manner until they become 
" wrecks," wretched examples of what electricity, the 
sound, dilator, and cautery can do for women. 
What I have said in these paragraphs does not apply to 
all specialists in women's diseases, but, unfortunately for 
the other sex, it does apply to the majority. Much of my 
work comes to me after all the methods of minor " gyne- 
cological tinkerings " have been exhausted. The most 
difficult "pus" operations I have performed have fol- 
lowed prolonged treatment at the hands of gynecologists, 
or, better, the pseudo-gynecologists. An example of the 
character of the cases one meets with after meddlesome 
manipulation with the sound will be apropos: 
Mrs. C., suffering with dysinenorrhoea of some severity, was 
recommended to a local specialist, who told her " that the mouth 
of her womb was closed up," and it would be necessary to dilate 
it at once, which operation he immediately set about to perform. 
A uterine sound was introduced. This caused no little pain, but 
she was assured that was to be expected. At midnight her 
attendant was summoned in haste, to see his patient suffering 
excruciatingly. A high temperature and great abdominal ten- 
derness were present, and then for six weeks a severe form of peri- 
tonitis was combated. As a result of the opium treatment of the 
peritonitis, the patient became addicted to morphine, was treated 
by various local neurologists ; wound up in Philadelphia, tem- 
porarily cured of the habit by Dr. Mitchell. While in the East 
was examined by our distinguished friend, Dr. Barton Cooke 
Hirst, who advised operation for the well-marked tubular disease 
and abscess of the ovaries. The case was referred to me for 
operation after her return, St. Louis being her home. Operation 
revealed universal adhesions, multiple pelvic abscesses, ovaries 
and tubes containing several ounces of pus. The adhesions were 4 
EXPERIENCES IN PELVIC SURGERY. 
dense, and the most difficult to deal with that I have ever met. 
The serous coat of the neighboring intestines was stripped off in 
many places in the process of enucleation. After a free flushing, 
a tube was introduced and my troubles began. The morphine 
mania returned, and the patient became uncontrollable and 
insisted on having morphine whenever she desired, in spite of 
earnest entreaty. From then on she took full charge of her case, 
and the nurses were unable to manage her. The tube began to 
discharge fecal matter on the third night after the operation and 
continued to do so for seventeen days, when it suddenly ceased, 
the stercoraceous fistula closing rapidly. 
I might detail other cases which have come under my 
observation demanding operative interference, where the 
inflammatory conditions were the result of the introduc- 
tion of the sound, caustics, etc. 
But a few weeks since it was necessary to operate in an 
emergency on a leaky pus tube which had its origin in a 
similar manner. The original tubal disease had been 
treated with an intra-uterine grooved stem pessary, the 
idea of the attendant being that drainage per viam 
naturalis would follow. Vaginal incision is a favorite 
method of treatment of pelvic pathological collections 
with some. In my experience, but few, if any, of these 
cases can be considered properly or perfectly cured by 
such means. 
We find multiple abscesses in the largest proportion of 
cases which cannot be drained by efforts so blindly and 
indirectly made. The abscesses may or may not be com- 
municate with one another, and usually only one such 
abscess would be drained by a single vaginal incision. 
An intelligent practitioner recently requested me to see his 
wife, who had been having recurrent attacks of peritonitis. She 
had undergone a vaginal incision eighteen months before her 
present attack of peritonitis. Was relieved for a few months, but 
latterly had been losing ground on account of numerous attacks 
of peritonitis. I found the pelvis choked up with inflammatory 
masses, a fixed uterus, and at the site of the old incision a soft A. V. L. BROKAW. 
5 
bulging point in the otherwise board-like vaginal vault. Her 
husband wished me to open the threatening abscess, which I 
refused to do as a matter of principle. The abdomen was dis- 
tended, with signs of an aggressive peritonitis present. A tem- 
perature of 103° and over had existed for two weeks prior to my 
visit. I suggested a section, which was not agreed to. A few 
days later I was summoned in haste. All the symptoms had 
become aggravated and her condition, indeed, alarming. Con- 
sent was given to an operation. The peritoneum was thickened ; 
omentum agglutinated in every direction ; matted intestines; a 
pint of pus in the pelvis; multiple abscesses surrounding the 
uterus on all sides. An abscess the size of an egg, isolated from 
the other pus collections, proved to be the one pointing into the 
vagina. The abdomen was flushed, tubes inserted, and my late 
evening visit found a normal temperature, and recovery from 
then on was uneventful. 
Had I been persuaded to make the vaginal incision, the 
register would have rung up another surgical failure. 
An experience in extra-uterine pregnancy forces upon 
me the conviction of the wisdom of Tait's law of explora- 
tory incisions in obscure disease of the pelvis and abdomen. 
The force of his arguments cannot but grow in favor and 
importance in the estimation of anyone with surgical 
instincts who desires to do what is best for his patient. 
The one condition above all others where exploratory 
incision should be adopted is in cases of suspected extra- 
uterine pregnancy. It is correct and good surgery to 
open the abdomen, and not wait for all the classical signs 
to appear. They may come, it is true, and your patient may 
be lost by procrastination. It may not meet with the kind 
accord of this body of distinguished specialists, but it is my 
belief that we should, in all cases of suspected extra-uterine 
pregnancy, do an exploratory operation-a short, clean 
incision. If nothing is found, you have at least relieved 
your mind of anxiety born of the fearful experience such 
cases only can give. What surgeon hesitates to operate 
in accessible aneurisms? Yet in extra-uterine pregnancy 6 
EXPERIENCES IN PELVIC SURGERY. 
do we not have a condition equally as bad ? The text- 
books advise that electricity and other measures be tried 
first, and operative procedures later. The results of such 
teaching we read in the mortuary columns of the daily 
press. 
The symptoms of extra-uterine pregnancy are so fre- 
quently obscure and unreliable that I am firmly convinced 
that the radical position taken is correct. 
An example of an unusual history in a case of extra- 
uterine pregnancy is now under my care, operated upon 
three weeks ago: 
Mrs. T., at twenty-eight, the mother of four children, desirous 
of no further increase in her family, having missed one period, 
on advice of a neighbor took repeatedly large doses of oil of 
tansy; was seized with flooding, and supposed she had aborted. 
Hemorrhage became quite profuse. After several days called in 
a physician. " Had some fever and slight chills." The dis- 
charge was offensive, and the womb was curetted with a blunt 
curette and a few clots removed. Fever did not abate, but 
rapidly rose; great tenderness ; symptoms of peritonitis rapidly 
developed. Seen by me the night of the eleventh day. Tempera- 
ture 105°; surroundings were bad, and patient was sent to the 
hospital at once. Operation early the following morning. Ap- 
pearance of patient peculiarly bad, pulse weak. Section; 
abdomen filled with blood ; extra-uterine pregnancy; right side. 
Patient's condition on table alarming-almost pulseless when 
abdomen was opened. Tubes rapidly enucleated ; tied off; free 
saline irrigation; drainage-tube placed in position; usual treatment 
of impending collapse instituted. Reaction very gradual, but 
followed by complete recovery, temperature never reaching 
above 101° ; normal after the first week. 
My faith in the dorsal position, short incisions, the 
drainage-tube in nearly every case, and free use of hot 
water remains, and I do not see the advantage, if any, of 
a departure from such technique. DISCUSSION. 
7 
DISCUSSION. 
Dr. William Warren Potter, of Buffalo.-Mr. President, 
though you have taken me somewhat by surprise in inviting me 
so kindly to open the discussion on this paper, and as a conse- 
quence I have not formulated any special line of argument, yet I 
recognize the fact that it is a paper deserving of a prominent 
place in the proceedings of this Association, and ought to have 
that further recognition which is accorded to valuable papers, by 
thorough discussion. 
Dr. Brokaw has given groundwork for a discussion upon 
several important subjects, but I will now only allude to two. 
He has made some statements with reference to the uterine sound 
with which I find myself in accord. It was my privilege, as well 
as pleasure-and I then felt it a duty-to bring an indictment 
some six or eight years ago against the uterine sound. That 
indictment, singularly enough, was brought to the city of St. 
Louis, the home of the author of the paper under discussion, and 
I am glad to hear him repeat in this presence to-day an approval 
of many of the principles that I then sought to enforce. At the 
time they were uttered they were accorded either condemnation 
or but faint praise. They were by some regarded as false teach- 
ing, by others as somewhat in advance of the time in which they 
were uttered. From the tone of this paper, as well as other 
reports that are occasionally heard, I infer that the time has crept 
up close to the position that I then took, and I especially com- 
mend what Dr. Brokaw says on the subject. 
The paper, indeed, as a whole, demands very little antago- 
nism or adverse criticism from anyone who has had personal 
experiences in the practice of pelvic surgery. I particularly 
commend that portion of it which relates to an early exploratory 
incision in suspected cases of extra-uterine pregnancy, or where 
there is made a presumptive diagnosis of that condition. This is 
one of the most important questions connected with abdominal 
surgery at the present time, because it is of frequent occurrence, 
is so often overlooked, and so seldom proceeds to other than fatal 
termination unless a prompt operation is made. It is one of the 
easiest operations, ordinarily speaking, in the whole range of 8 
EXPERIENCES IN PELVIC SURGERY. 
abdominal surgery: incision, turning out clots, tying off, irri- 
gation, drainage, and closure, being the several steps of the opera- 
tion that are to be promptly and understandingly taken by a sur- 
geon of experience. The principles involved are quite the same 
as enter into a case of crushing, or other injury, of the extremi- 
ties from railway or gunshot accidents. Here, there is frequently 
hemorrhage and shock to contend with ; and so, likewise, is there 
in cases of ectopic pregnancy. How there can be a question as 
to the propriety of prompt surgical interference, it is not easy for 
me to understand. But I have already exceeded the limits I had 
laid out for myself, when I arose simply to speak of these points 
made by the essayist, and to com mend his paper for its intel- 
ligent presentation of them. 
Pr. Joseph Taber Johnson, of Washington, D. C.-Dr. 
Brokaw has given us a very suggestive and interesting paper. I 
agree with Dr. Potter that it is a pity to allow the excellent 
points he has brought out to go by without discussion. The 
points made in his paper were so numerous that it is impossible 
to take them up seriatim in the five minutes allotted to each 
speaker. I want to say a word about the question of diagnosis. 
I have known a number of cases in abdominal surgery to have 
been spoiled for the abdominal surgeon on account of the delay 
for the purpose of making an accurate diagnosis. It seems to 
me on this question, that the ground which we need to take is, 
that when we have diagnosed something in the abdominal cavity 
which ought not to be there, anatomically or physiologically, and 
is histologically wrong, threatening life, it should come out. If 
we could reach that conclusion scientifically, it would be a good 
thing. I think an exploratory operation is justifiable, and we 
should base our further procedures on what we find after making 
the exploration. 
So far as the author's statements are concerned in regard to 
neglected cases, I agree with him in his experience. The operator 
is often hampered and his operation jeopardized in many cases, 
and patients are absolutely lost by the neglect and delay of those 
who previously had charge of the case, or the surgeon's own lack 
of courage in carrying out his convictions. 
I agree with the essayist, also, that the critics of pelvic and 
abdominal operations are in a great many cases men who have DISCUSSION. 
9 
never operated, and who, being without experience, have no right 
to criticise. So far as tinkering is concerned, I do not quite agree 
with the Doctor that it is as bad as he would have us believe, and 
that the routine gynecologist is given over entirely to the use of 
the speculum, nitrate of silver, tincture of iodine, etc. The class 
of men who practise gynecology in my vicinity have a wider 
range of appreciation of these troubles than the paper would seem 
to indicate, hence I feel that he has rather overstated the matter 
in that respect. I do not go quite so far as Drs. Price, Potter, or 
Brokaw, and say that the uterine sound should never be used. I 
think it is a good instrument in some cases. I think that while 
whiskey and opium have done considerable harm, still there is 
some good in them when properly used ; I think the same may 
be said of the sound. While I may have done harm with the 
sound, I am positive I have done much good with it. In the 
operation for lacerated cervix, curetting the diseased glands of 
the cervical canal, and curetting after dilatation of the cervix for 
the purpose of curing endometritis, I think a great advance has 
been made on the old method of treating the latter condition 
especially, and this kind of tinkering, if it is properly termed so, 
has resulted in much good in the treatment of this disease, which 
has heretofore taken months, if not years, to cure. 
If you have an ovarian or tubal abscess divided into compart- 
ments, as so frequently occurs, you cannot puncture through the 
vagina and poke your instrument in various directions to find 
pus. It seems to me that the woman's condition is better in the 
long run, and safer in a large number of cases, if we do an 
abdominal operation rather than vaginal puncture. When you 
have emptied one cavity you may have a pyogenic membrane 
left, one cavity is filling up while the other is emptied by opera- 
tion. The Doctor has alluded to operations with high tempera- 
■ture. Some surgeons are frightened by the bad condition of the 
patient and the alarm of her friends. I have seen patients res- 
cued from death by a proper operation with a temperature of 
105° and a pulse of 140. 
I quite agree with the writer of the paper that we should make 
exploratory operations more frequently, but we should stop when 
we find the case incurable before having done more harm than 
simply to explore. Half-finished operations are more fatal than 10 
EXPERIENCES IN PELVIC SURGERY. 
when completed. I have seen much unexpected good result from 
a mere exploration when it was considered too dangerous to pro- 
ceed, but only disaster from abandoned incomplete operations. 
Ruptured or unruptured tubal pregnancies should always be 
operated on as soon as diagnosed. There is no safety in delay, 
and electricity is too uncertain to rely upon. Even when it kills 
the foetus the woman is not cured and is exposed to many 
dangers. 
Dr. W. E. B. Davis, of Birmingham, Ala.-It would be diffi- 
cult to discuss Dr. Brokaw's paper intelligently without covering 
the whole field of pelvic surgery. I believe that a great many of 
the so-called " tinkerers " who succeed in relieving their patients, 
do not accomplish it so much by the local treatment they use as 
by having the women under their care, keeping the bowels open, 
and seeing them regularly. It is not the glycerin tampon and 
boric acid that do all the good, but the patients are benefited 
by coming to the physician regularly, and being instructed as to 
diet, exercise, etc. Thus the mild cases of pelvic trouble are 
frequently relieved. There is no question as to what should be 
done in severe tubal or ovarian inflammations. The profession 
is agreed that in these cases nothing will succeed but a section, 
and the removal of the diseased organs. 
In regard to diagnosis, I fully agree with Dr. Brokaw, that it 
is generally the men who do not open the abdomen who can con- 
fidently diagnose these cases. Those surgeons who are opening 
the abdomen constantly are so frequently mistaken, that they are 
rarely willing to give a positive diagnosis. I have seen a small 
cyst in the abdomen where there had been an attack of peritonitis, 
and not having seen the case before, when called, I thought it 
was an abscess. I have made the mistake twice within the last 
year. It is exceedingly difficult sometimes to diagnose pelvic 
growths, and especially ectopic cases. 
I believe that the teachings we get from Dr. Price are good, 
still I think he goes too far in saying that an endometritis is a 
small matter. His views are extreme in this regard. I think 
where we have an endometritis, that by relieving it we prevent 
tubal trouble, and thus avoid an operation in the future. Many 
of our tubal diseases are due to neglected cases of endometritis, 
and there can be no doubt as to the value of the treatment DISCUSSION. 
11 
that has been practised so largely recently, of curetting the 
uterus and packing it with gauze. The trouble is, a great many 
cases fall into the hands of incompetent practitioners who abuse 
the operation. 
Dr. Brokaw.-I wish to emphasize the point in regard to 
uncertainty of diagnosis. Recently a writer in New York, with 
an experience of one case of extra-uterine pregnancy, felt called 
upon to write an article on the subject, and tells us we should 
diagnose our cases of extra-uterine pregnancy early, wait until 
rupture before operating, and even then, wait till reaction takes 
place. We find gentlemen from the East writing upon this 
subject, giving the means by which they diagnose extra-uterine 
pregnancy before rupture. If there is a man in the East who 
diagnoses these cases always, I am pretty sure that he has some 
method of diagnosis unknown to us. I have seen these cases 
before and after rupture when unsuspected. I have made this 
mistake in two supposed pus cases, and I found tubal pregnancy. 
We do not often make a diagnosis before rupture. Whenever 
we have a suspicion of extra-uterine pregnancy, I believe it is 
good surgery to open the abdomen at once. I have never 
regretted the cases I have explored and found nothing. My 
mind was relieved. I have never lost an exploratory case. 
The operation is not done often enough. I believe in every case 
of suspected extra-uterine pregnancy wre ought to make an 
exploratory incision and operate before rupture.