Indications for Total Castration by the Vagina. BY Charles Jacobs, M. D., BRUSSELS. REPRINTED FROM THE American Gynecological and Obstetrical Journal for June, 1895. [Reprinted from the American Gynaecological and Obstetrical Journal for June, 1895.] INDICATIONS FOR TOTAL CASTRATION BY THE VAGINA* Charles Jacobs, M. D., Brussels. Before everything else, kindly allow me to express to you the senti- ments of gratitude which I feel for the kind invitation you have sent me to assist at your meeting, as well as for the sympathetic and hearty manner in which you have welcomed me among you. The circumstances which have brought me here, the honor of speaking among you, your kind greeting, everything in fact contrib- utes to my never forgetting the date of this meeting. I wish to put before you the principles I have so often supported in Europe, viz. : the indications for hysterectomy by the vagina. I do not intend to retrace to you the history of the above operation, to point out the numerous processes, to recall to your memory the opinions for or against, nor the struggles fought out. That would be going over facts, which will remain graven in the history of modern surgery. My programme is more modest. I wish to submit to your judgment, so as to try and gain your convictions, the results of my own personal practice : what I have done, how and why I have done so, the good and bad results I have obtained. I wish to do that without passion or personal attack. And if I bring a few among you to be convinced, I shall consider myself happy, for I shall have accomplished a useful and benefi- cent task. From 1889 up to the 1st of April, 1895, I have practiced 403 operations of this kind. I have obtained 391 operative cures with 12 deaths, which carries the death-rate to 2.9 per cent. * Read before the American Gynaecological Society, May 29, 1895 Copyright, 1895, by J. D. Emmet and A. H. Buckmaster. 2 Charles Jacobs, M. D. Details of the Aforementioned Operations. Indications. Cases. Cured. Deaths. A. Uterine cancer. Epithelioma colli * 35 34 I Epithelioma corporis 3 3 Sarcoma Adenoma malignum 5 5 B. Uterine fibroid. Simple vaginal hysterectomy 23 23 Hysterectomy by morcellation i5 13 2 C. Extra-uterine pregnancy . 3 3 D. Total genital prolapse i9 18 I E. Bilateral diseases ofi appendages. Purulent-Pyosalpinx 142 J39 3 Abscess of the ovaries Haematosalpinx 33 15 33 Chronic parenchymatous salpingo-obpho- ritis, without adjacent or uterine com- plications 82 79 3 F. Chronic and incurable diseases of uterus or appendages. Tuberculosis 6 Pelvic neuralgias 6 5 5 I G. Secondary hysterectomy after abdominal opera- tion 14 14 403 391 12 As a general rule, it may now be said that vaginal hysterectomy finds its indications in- 1. Uterine cancer. 2. Fibroids of the uterus. 3. Extra-uterine pregnancy. 4. Total genital prolapse. 5. The inflammatory diseases of the appendages. 6. The chronic and incurable diseases of the appendages and of the uterus. 7. The diseases of the uterus after abdominal operation. The great extent of the subject prevents me from entering into full particulars. I also wish to avoid in the discussion all arguments of which the non-value is at present known : the abdominal cicatrix Indications for Total Castration by the Vagina. 3 of the coeliotomy, the dangers subsequent to abdominal operations, resulting from the leaving in the pelvis a diseased uterus, etc. I shall also pass over in silence the medical treatments and other opera- tions, directed against the same diseases : such as vaginal functions, vaginal incisions, vaginal laparotomy, etc. Let us go quickly through the operative indications in the differ- ent cases. A. Uterine Cancer.-Vaginal hysterectomy has very clear indica- tions. To practice the operation with success, we must find- 1. Integrity of the vaginal cul-de-sac. 2. Complete mobility of the uterus. 3. A satisfactory general state of health. But the invasion of the vagina, the intense pain which indicates the encroaching upon the broad ligaments, peri-uterine adhesions absolutely contra-indicate it. Can we conscientiously advise uterine extirpation in cancer ? Is not that a useless operation ? In the present state of science, I consider that the extirpation should always be attempted under the above-mentioned conditions. If it is true that recidivation is almost unavoidable, at least we may procure for our patients the chance of survival for a time, greater or less, which other operations do not afford. Out of 45 cases, upon which I have operated, I have had 1 death ; being 2.3 per cent. I have lost sight of 9 patients and have kept sight of 33. Before 1 year 4 After 1 " 3 ... . After 2 years 5 Recidivation .... < , . J .. After 3 " 13 After 4 " 4 After 5 " 1 I have actually at present 5 patients free from recidivation, who have been operated upon more than four years ago. As will be seen, the most numerous cases of recidivation have occurred only after three years. It seems therefore that it is in the patients' interest for them to undergo an operation of which the dan- gers are slight and which can give them comparatively good health, for a period much longer than that afforded by any other operation or palliative treatment. The extent of the subject I wish to discuss before you forcibly obliges me to be brief; I shall therefore pass straight on to : Charles Jacobs, M. D. 4 B. Uterine Fibroids.-I consider, according to my experience, that it is exceptional for a uterine fibroid to disappear after the meno- pause. We often see, after the critical age, these tumors show their presence by manifold symptoms: metrorrhagia increases in volume, or different forms of degeneration occur. The artificial menopause brought about by bilateral castration, only being able to give, according to actual facts admitted, uncertain results, and on the other hand the medical palliative treatments almost always giving but bad results, our duty is to advise the ablation of the fibrous tumors. The opera- tion being less dangerous according to the smallness of the tumor, I always advise the operation as soon as possible, preferably the vagi- nal hysterectomy, before the tumors have acquired sufficient size to oblige us to interfere by way of the abdomen. I shall not speak to you of the abdominal operations which apply to large fibrous tumors. 4 I have practiced 38 operations of the kind : 23 simple hysterec- tomies with 23 cures; 15 hysterectomies by morcellation with 13 cures; 2 deaths. These 2 deaths have arisen from exhaustion of the patients and cardiac disease. In 5 cases there existed at the same time as the fibrous tumor purulent or bloody tubal collections. C. Extra-uterine Pregnancy.-When all the subjective and objec- tive symptoms permit us to lay down the diagnosis of extra-uterine pregnancy or of abortive tubal pregnancy, our duty is to surgically in- terfere. The great number of cases observed up to the present tend to prove that in the case of extra-uterine pregnancy the appendages are always diseased on both sides; their ablation is therefore absolutely necessary. I consider that in such cases total castration by the vagina fulfills all indications. This intervention should be made as soon as possible, because of the numerous lesions of the uterus and appendages, as well as the peri-uterine diseases, which are unavoidably occasioned by extra- uterine pregnancy. I have operated upon 3 cases-of the sort with 3 positive cures. In the 3 cases tne extra-uterine pregnancy was accompanied by intra-abdominal hcematocele. D. Total Genital Prolapse.-The different ways of treating total genital prolapse give results so little encouraging that in certain cases one may advise the extirpation of the uterus. Such cases are scarce. We will only apply it to aged women whose uteri have become use- Indications for Total Castration by the Vagina. 5 less organs, but which by reason of that infirmity have become the seat of constant pain. I do not advise hysterectomy when the uterus is small, for in such case vaginal plastic operations give very good results. The uterus with thick walls, with swollen cervix surrounded by relaxed tissues, renders doubtful the success of plastic work ; sterility, failure of prior operations, such are the conditions which require rad- ical extirpation. There almost always exists after the cure a degree more or less of vaginal prolapse ; for that reason I am in the habit of completing the treatment by plastic operations on the vagina and perinseum a few week« after. I have operated upon 19 cases of this kind, of which 18 cures and 1 death, due to subsequent intestinal paralysis, resulted. In 12 of these cases I have practiced four or five weeks after the hysterectomy vaginal plastic operations. Excepting in 3 cases, where there still persists a certain degree of anterior vaginal prolapse, I have observed complete cure. E. Inflammatory Diseases of the Appendages.-Two hundred and seventy-two cases of diseased appendages, with 6 deaths-such is my experience; 142 cases of pyosalpinx; 15 cases of abscess of the ovary ; 33 cases of haematosalpinx ; 82 cases of chronic ovaro-salpingitis. The deaths have occurred thus : Three times in cases of pyosal- pinx, 3 times in chronic ovaro-salpingitis. The first 3 cases with exhausted patients; the 3 others with women near their critical age or having gone through such, and whose deaths I attribute to the nervous shock arising from the operation. I have therefore observed 266 cures. I have been able to see again about three fourths of these patients many months after their opera- tions. I have shown them to my students, to my colleagues. I have had undeniably proved their definite and radical cures to have re- mained absolutely the same as after the operations. To all, or mostly all, health has entirely returned, and I can assert that not one of the aforesaid patients has been obliged to again have recourse to me since the operation. There is one danger in hysterectomy of which I will immediately speak to you-that is, subsequent fistulse. They may be classed as follows : 1. Peritoneal fistulae. 2. Vesical fistulae. 3. Ureteral fistulse. 4. Intestinal fistulae. In the 403 cases of hysterectomy I have observed 9 fistulae after 6 Charles Jacobs, M. D. the operation, which gives me the conviction that however complicated may be the operation subsequent fistula is an excessively rare thing. I have observed : Five intestinal fistulse. Three vesical fistulae. One ureteral fistula. Intestinal Fistula.-In most of the cases these fistulae existed prior to the operation, that is to say, they were fistulous passages which communicate the pelvic purulent pockets to some part of the intestine. These passages were so large, and with coats so well organized, that the disappearance of the purulent pockets did not suffice to bring about the subsequent and spontaneous cure. The first case I observed was of this kind. It was in a person attacked by a long-standing pelvic suppuration, communicating with the intestine. The fistulous passages, for there were several of them, gave, after the hysterectomy, issue to faecal matters, by way of the vagina. I tried to cure this infirmity by the vaginal plastic operations, but in vain. About a year after the operation the patient died from intestinal tuberculosis. In the second case, an intestinal fistula took place during the operation by the rupture of the adhesions. I observed a spontaneous cure after a few days. The third intestinal fistula took place a year after hysterectomy by morcellation in uterine fibroid. A pad of wadding had been left in Douglas's pouch up to that time ; after having caused a small local abscess, it issued by the vaginal wound. There persisted in this place a small intestinal fistula, which I succeeded in curing by means of a plastic operation. The fourth case of intestino-vaginal fistula caused me to make use of the Murphy button. It was a very serious pelvic suppuration, with intestinal communication. The adhesions of the appendages were so solid that I could not complete their extirpation. There subsequently persisted a large fis- tula, connecting the vagina with the iliac S at its upper part. I let the patient gain strength, and three months after the operation I made her undergo a coeliotomy. I easily detached the iliac S from its adhe- sions, and found a very large and lengthened fistula. I attempted to suture by means of catgut, in separate stitches, but the passage of the intestine absolutely closing, I was obliged to practice intestinal resection. I cut away about eight or ten centimetres of the intestine, and rapidly applied Murphy's button. Seventeen days after, the but- Indications for Total Castration by the Vagina. 7 ton was evacuated with pain by the patient. Yet after the tenth day normal defecation re-established itself, and the patient is now abso- lutely cured. The last case of intestino-vaginal fistula is quite recent. It was a tuberculous disease of the appendages, with strong intestinal adhe- sions. The detaching of these brought about an entire rent of the intestinal coats. Four days after, the faecal matters issued by way of the vagina. Three weeks after the operation, in the presence of per- sistence of the infirmity, I performed a coeliotomy. The search after the fistula was easy ; in this case again, by reason of the extent of the wound, I resected a few centimetres of the intestine and placed Murphy's button. This patient died. A peritonitis declared itself after the escape of Murphy's button. I attempted, without result, a second coeliotomy with a fresh application of Murphy's button. Vesical Fistulce.-The wounding of the bladder in consequence of pelvic lesions. The above was a case of serious pelvic suppuration, in which I was obliged to abandon a part of the appendages in the pelvis. Some time after the operation, the patient complained of being constantly wet. The micturition took place in a natural way. Vesi- cal injections allowed no liquid to issue by the vagina. At the bottom of this passage there was to be seen a small orifice, by means of which the urine issued drop by drop. We had before us a ureteral fistula. I catheterized the ureters and was easily able to ascertain the integrity of the right ureter, which showed me that the wounded ureter was the left one. I performed a coeliotomy with the intention of curing this infirmity, by the suture of the renal end of the ureter to the bladder. But notwithstanding the most attentive searches, I could not find the left ureter. I then performed nephrectomy. The patient is cured. I have made in these three cases of coeliotomy, consecutive to very laborious total vaginal castrations, a proof of the greatest importance. In the three cases, the visceral adhesions which, at the time of the operation, were such that the total ablation of the appendages was, if not impossible, at least very laborious, had almost disappeared, and in three cases I easily reached the wounded intestines, which were at the bottom of the pelvis. The hopes put forth, respecting the later consequences of total vaginal castration in pelvic suppurations, seems to be demonstrated in these examples. Let us add to the above the 33 cases of intestinal fistulse after 8 Charles Jacobs., M. D. ablation of the appendages by way of the abdomen, spoken of by Dudley, in the American Journal of Obstetrics of 1892. Another danger, which I shall also avoid in the discussion, is that of haemorrhage. The security of the haemostasis evidently depends upon the instruments, but would one dare undertake a serious opera- tion with imperfect instruments? No ! I have only seen one case of serious haemorrhage after the taking away of the instruments, but not a fatal one. I must add that it was a haemophilic patient. Con- secutive haemorrhage is therefore a bugbear which will only stop the timid. It has been said as a reproach to total castration by the vagina that danger might exist in complicated cases of leaving in the ab- domen the remains of suppurating pockets. There are certainly cases of suppuration, wherein the fusion of the pockets with the neighboring organs is such, that complete ablation is impossible. In the 157 cases of serious suppuration upon which I have operated, I have left twenty-one times parts of the appendages in the pelvis, and I have never been obliged to have recourse to a supplementary •operation by reason of tardy complications. Besides is not that what happens in laparotomies for very adherent purulent diseases of the appendages? Lawson Tait, Pozzi, Fenger, would they not have advised the opening of the pockets, their cleaning and drainage ? Have they not observed definite cures ? It is at least remarkable that it is precisely in these serious cases that vaginal castration has given its greatest successes, which have gained to it confirmed laparotomists, such as Pozzi, Terrier, Sanger, and others. If a few operators have been obliged to have recourse to supplementary operations after vaginal hysterectomy, how many times have they not been obliged to fall back upon supplementary liysterectomy after a check sustained by the laparotomy ? As far as I am concerned, I have performed 14 hysterectomies of this kind, 5 times after laparotomies practiced by me, and which have remained incomplete when looked at in a therapeutic light, 9 times .after laparotomies practiced by Belgian or French colleagues. I have obtained 14 definite cures. If we admit that all diseases of the ap- pendages which put woman's life in danger or which render her life miserable in consequence of constant pains and continual impotency necessitate surgical intervention, viz. : the ablation of the diseased organs, we will absolutely put aside all discussion as regards the abuse of operations. I wrote, however, on that subject a few months ago in the American Journal of Obstetrics. Indications for Total Castration by the Vagina. 9 Then let us now examine, before going into definite particulars of vaginal castration in the disease of appendages, what is the impor- tance of the operation compared with that of the laparotomy. I do not wish to go far into this question, the mathematical expres- sion of operative mortality being always very relative. If we take into consideration the French laparotomists of incontestable renown,, such as Terrier and Pozzi, in the cases of suppurated diseases of ap- pendages, they obtain 6 and 8 per cent, of deaths in 96 and 99 cases. My own statistics give, in 157 cases 3 deaths-that is to say, 1.9. per cent. ; Leopold, in 14 cases, no death ; Pean, in 350 cases, 7 deaths, 2 per cent. ; Richelot, in 56 cases, 5 deaths, 8.9 per cent. ; Segond, in 114 cases, 13 deaths, 11.2 per cent. ; Doyen, in 125 cases,, 8 deaths, 6.4 per cent. ; so we find in 816 cases 36 deaths-that is to say, 4.5 per cent. Therefore in cases of suppurative diseases of the appendages the operation of Pean victoriously maintains the comparison with laparot- omy ; it is incontestable that the former is much superior. In cases of non-suppuration : Segond, in 82 cases, obtains no- deaths ; in 115 cases, I have had 3 deaths; Pdan, in 100 cases, 2 deaths; Leopold, in 30 cases, 1 death; Sanger, in 17 cases, 2 deaths; Richelot, in 40 cases, 2 deaths ; making, in a total of 584 cases, 10 deaths, or 1.7 per cent. Laparotomy in these cases, equally, gives very brilliant results. One may even say that its dangers are very little. Thus in 461 cases operated upon by Pozzi, Terrier, Schauta, there has been a mortality of 3.6 per cent. I have therefore the right to conclude that the operation of Pean is less dangerous than laparotomy in cases of suppurative diseases of the appendages; it gives as good results in cases of non-suppurative lesions. If the experience and the careful examination of our patients dur- ing several months after operation give us the conviction that the tardy results are much more brilliant after hysterectomy than those ghen after laparotomy, we shall remain convinced that total cas- tration by the vagina is certainly the preferable operation in cases of bilateral disease of the appendages ; it is less dangerous and gives more perfect cures. Indications for Total Vaginal Castration in the Diseases of Appen- dages.-The indications of hysterectomy are the same as those of bilateral ablation of the appendages by coeliotomy. The bilateral- ity of the lesions, the uselessness of palliative measures alone make 10 Charles Jacobs, M. D. legitimate our intervention by way of the vagina. The diagnosis is of great value, but it is necessary not to make a bugbear of it. For if, since our efforts to popularize the vaginal method, the diagnosis has suddenly become difficult, it is at least singular to find that it is precisely those who found the diagnosis so easy when justifying the abdominal way, who pretend to-day that it is full of difficulties by the former method. It is incontestable that one can always make the diagnosis whether the appendages are diseased or not, with or without anaesthesia. What does it signify whether the tubes contain pus or blood- whether these collections be in the ovary or in the tubes? We must have before us the idea of perfecting a diagnosis as much as possible ; but these points are secondary as regards our intervention. Besides, at the first time of intervention by the vagina, which should always be the opening of the pouch of Douglas, the real exploring point, the sur- geon must always practice exploration by that way, although he may have to confine his operation to a simple elytrotomy, should such be necessary. These in doubtful cases I When the diagnosis is certain, the exploration is superfluous, but it always constitutes an argument sufficiently strong for vaginal cas- tration to be no longer an operation which unavoidably causes the ablation of the uterus as soon as it is attacked. Finally bilateral lesions require total vaginal castration. Those I esions are suppurative or non-suppurative. 1. Suppurative Lesions.-When the pockets are very adherent ac- cording to the opinion of all surgeons of to-day, vaginal hysterec- tomy is the operation that should be chosen. If the pockets are free, then the operation of Pean is superior to laparotomy, for it per- mits an easy drainage, it is more complete, and never leaves any cica- trix. For my part I never hesitate. If the adhesions of the lesions do not permit the complete ablation, we have seen that we should be wrong in fearing the possible reap- pearance of inflammation of the remains left in the pelvis. In all cases wherein I have been obliged to act thus, I have never seen tardy complications. It is not the same with abdominal operations. 2. Non-suppurative Lesions.-They comprise : i. The non-suppu- rative salpinx. 2. The parenchymatous salpingitis. 3. The catarrhal salpingitis. 4. The degeneration of the ovary. When the lesions are bilateral, they require the complete ablation of the appendages. All agree upon this point. Indications for Total Castration by the Vagina. 11 In these cases vaginal castration is as benign as is laparotomy, and it is more complete, the total ablation being the rule. In all cases the cure may be called radical by our operation, whereas laparotomy leaves the woman exposed to uterine diseases, to persistent pelvic pains, on a level with the pedicles, and to nerv- ous disorders. F. I arrive at my last category : Chronic and incurable diseases, and among them pelvic neuralgias, and tuberculosis. All those who have practiced laparotomy a great deal know the very little encouraging results that may be expected from bilateral castration in serious pelvic neuralgias, in cases where the most attentive examination does not succeed in discovering very clearly the lesions. It is established to-day that the results acquired by the operation of Pean in these cases give more brilliant results than does lapa- rotomy. Out of the six cases of the sort I have operated upon I have five times seen the radical cure follow and maintain two, three, and four years after the operation, with women whose nervous systems were so shaken that they became morphinomaniacs. Two of the above patients, hysterical persons, have had their at- tacks completely disappear. With the sixth person the therapeutic result is too recent to be affirmed. Lastly, I have applied total vaginal castration in six cases of con- genital tuberculosis. I have obtained five cures-one death. Four of the patients cqred by the operation enjoy very good health, with the fifth patient pulmonary disease has set in since the operation. The number of these cases is too limited to deduct precise conclusions from. However, the results I have obtained are most encouraging and will guide me in cases of this kind, more toward vaginal castra- tion than toward laparotomy. I shall not enter into the details of the operation ; that would carry me too far. Besides, they have been given to those among you who have had occasion to see applied the operation of Pean, in Europe. Permit me in finishing to submit to you the following conclusions : A. i. Total castration by the vagina is indicated in uterine cancer at its beginning. 2. In uterine fibroid. 3. In extra-uterine preg- nancy and total abortion. 4. In complete genital prolapse, accord- ing to the indications I have put before you. B. It is the best operation in bilateral purulent or non-purulent •diseases of the appendages. 12 Charles Jacobs, M. D. C. It finds its indications in uterine and in chronic incurable diseases of the uterus and its appendages. D. Complete vaginal castration is not a more dangerous operation than is laparotomy. The most Recent Statistics.*-Landau, 141 cases, 2 deaths; Leopold,. 44 cases, 1 death ; Sanger, 17 cases, 2 deaths ; Pfian, 450 cases, 12 deaths ; Richelot, 219 cases, 11 deaths ; Doyen, 253 cases, 18 deaths; S£gond, 200 cases, 14 deaths; Gallet, 29 cases, 2 deaths; Jacobs, 403 cases, 12 deaths. Total, 1,756 cases, 74 deaths, 4.2 per cenL mortality. * Unpublished.