ARE Cicatricial Contraction ■ s O R UTERINE STENOSIS USUAL OR FREQUENT CONDITIONS FOLLOWING EXCISION OF THE CERVIX BY GaLVANO-C AUTERY ? BY J. BYRNE, M.D., Etc., Surgeon-in-Chief to St. Mary's Hospital for Women, Brooklyn, etc. Reprinted from Transactions of New York? Ojsstetei^aii 3q^ety. NEW YORK: JOHN F. TROW & SON, PRINTERS AND BOOKBINDERS, 205-213 East Twelfth Street. 1877. ARE Cicatricial Contractions O R UTERINE STENOSIS USUAL OR FREQUENT CONDITIONS FOLLOWING EXCISION OF THE CERVIX BY Galvano-Cautery ? BY J. BYRNE, M.D., Eto., Surgeon-inrChief to St. Mary's Hospital for Women, Brooklyn, &c. Reprinted from Transactions of New York Obstetrical Society. NEW YOR|K: JOHN F. TROW & SON, PRINTERS-AND BOOKBINDERS, 205-213 East Twelfth Stbeet. 1877. IS STENOSIS UTE III A USUAL OR NECESSARY CONSEQUENCE OF AMPUTATION OF THE CERVIX BY GALVANO-CAUTERY ? As a preface to the consideration of this important question, the following case is submitted : Mi's. A., aged 28, married several years, but sterile, had always suffered from dysmenorrhoea. Had been treated for '•inflammation and ulceration of the womb" by her family physician, at whose request I was called to see her, and by whom the usual active topical applications were had recourse to without benefit. By digital examination the cervix was found to be very vol- uminous and in the centre of its presenting surface conveyed to the touch a fungous sensation, but towards the circumference gradually becoming less spongy, yet uneven and indurated. The whole portio vaginalis seemed to be about one inch and a half in length, and as much transversely, and was exquisitely tender to pressure, or when moved in an upward or lateral direc- tion. On examination by speculum about one-half the cervical extremity was covered by luxuriant granulations, bleeding freely on the most gentle application of the sponge, and grad- ually fading away towards the circumference, which was livid, glistening, and irregular. The cervical canal, for the space of an inch or thereabouts, freely admitted an ordinary sound, but beyond this point nothing larger than a small probe could be passed, even then with some difficulty, and apparently in a tortuous course to the extent of three and one-quarter inches. The existence of carcinoma was surmised, but whether the con- ditions above described might have been due in this particular instance to simple inflammatory processes, or malignant disease, seemed tome to be a question of but little practical importance so far as influencing the treatment. Suffering as she did from obstructive dysmenorrhoea during her whole menstrual life, thereby developing, probably, nutri- tive hypertrophy and elongation of the cervix long anterior to the inflammatory stage, amputation of the cervix offered not alone the only, but a very promising means of permanent relief. This operation was at once proposed, and within a few days 4 thereafter performed by galvano-cautery ; stenosis of the os internum, should such be afterwards found to exist, could be remedied without difficulty. To the subsequent history of this case, I would now call especial attention, as satisfactorily accounting for the condition of parts observable in the specimen before you. So far as could be seen the case appeared to progress favor- ably, and the patient enjoyed that usual immunity from surgi- cal fever and peritonitis so peculiarly characteristic of electro- cautery operations. Such, however, was the shattered condition of her nervous system from long suffering previously, and feel- ing quite satisfied with her already improved physical condi- tion and freedom from pain, that she persistently refused to submit to the necessary inspection of the parts, or any local treatment whatever. The succeeding menstrual period passed over with little if any inconvenience, but the second less so, while the third, then about ten weeks after operation, was ushered in and accompa- nied throughout with dysmenorrhoic symptoms, of a more acute and distressing character than at any previous period, even before her operation. At the urgent solicitation of her medical attendant a proper physical examination was now consented to, and I was requested to see her with that view. By digital exploration the vaginal canal was found con- stricted at about its upper third, at this point barely admitting the index linger, and beyond was felt a puckered depression marking the entrance to the uterine cavity. On introducing the speculum, and by aid of a broad fenes- trated polypus forceps, the circular band of condensed tissues which divided the vaginal canal transversely into two unequal parts, was slightly stretched and the circular conical depression referred to brought into view. This cupping of the cervical stump seemed to be formed by numerous small bands of cica- tricial tissues radiating from the more elevated circumference to the centre, and converging around a minute circular opening. This barely admitted a small probe, which, however, having once cleared the cicatrix, passed freely through the upper canal. At this stage of the examination the patient, who I should state, would not consent to the employment of an anaesthetic, became so nervously restive, that any attempt then to undo the mischief caused by her own folly, was out of the question, and all subsequent appeals and assurances of success being offered in vain, my connection with the case practically ceased. About three years and a half subsequently 1 was invited to attend the 5 post-mortem, and in order that the specimen here shown may prove the more intelligible, as well as instructive, the foregoing outline of its clinical history is submitted. The uterus, though a large portion had been removed, is still much larger than normal, and its interior is divided into two cavities-the upper and larger one, that of the body proper, and the lower embracing that part of the cervix which is bounded above by the os internum, and below by an opening so small that a probe is passed from below upward with some difficulty, but less so when introduced from within. (In the diagram the constricted external os does not appear, being situated within the gaping canal representing the circular contraction of the upper third of the vagina.) It is proper here to state that, though she died from an acute attack of general peritonitis, her medical attendants, Drs. Geo. K. Smith and Van Harlingen, did not consider menstruation in the light of a direct cause, the final appearance of the latter function having passed over with no more than the usual amount of pain and difficul- ty ten days previous to her fatal attack. The specimen here pre- sented is one of more than ordinary practical interest, first, because it rarely hap- pens that we are afforded an opportunity, post-mortem, to examine uteri, large por- tions of which have been excised by or otherwise sub- mitted to the action of the electric cautery. SecondIv, I can see in it, and the cir- cumstances connected with its history, one of the strongest negative evidences of the correct- ness of certain views and opinions, long entertained and often expressed. The condition of intra-vaginal parts following operations by the electric cautery, and especially of the uterine stump after amputation of the cervix, has been made the subject of remarks from time to time by several members of this Society. Some gentlemen, influenced, probably, by unsatisfactory and perhaps limited experience in the use of galvano cautery, and partly no doubt by having met with one or more examples of great con- traction of tissues, even to total occlusion of the os uteri follow- 6 ing the operations of other gynaecologists, have pronounced ad- versely to this method. Others, again, of large experience in this particular field of uterine surgery, and whose opportunities for accurate observa- tion have been no less extensive, while willing to take into con- sideration certain plausible statements and a priori arguments, were, nevertheless, unable and unwilling to accept conclusions which they believed to be unwarranted and untenable. Under these circufnstances, then, every item in the way of clinical occurrences, and particularly every pathological fact, provided the same be accompanied with a correct history of what was observed to take place in the progress of its develop- ment, must be fairly considered and logically disposed of if we would hope to arrive at any reasonably accurate conclusions. Indeed, without such corroborative aid, abnormal conditions noticed during life are very apt to deceive, and can constitute no sound basis for opinions as influencing practice; while pa- thological appearances, however striking or suggestive, may be oftentimes valueless, if not a mischievous incentive to hoc reasoning. Within the last few weeks Dr. Noeggerath presented a spe- cimen of uterus from which he had, some time previously, ex- cised a large portion of the cervix by galvano-cautery; said operation, however, as in my case, having had no causal con- nection with the patient's death. It will be remembered by those who had an opportunity to examine that specimen, that the closest inspection of the surface from which the part had been excised failed to show any puckering whatever, or any- thing to the eye or touch resembling cicatricial tissue. This case was one of great interest as serving to demonstrate the correctness of certain statements and opinions repeatedly ex- pressed by him, and which I would here venture to endorse in the following propositions, namely : 16^.- That cicatricial contractions, and uterine stenosis, are conditions rarely observed to follow, and never, strictly speak- ing, as direct consequences of amputation of the cervix uteri by the electric cautery. ^d.- That these very troublesome and anomalous states are much less likely to follow amputation of the cervix, by this than by any of the other and infinitely more dangerous methods ordinarily resorted to. Zd.- That when such difficulties do occur, they are to be con- sidered as due to circumstances and conditions, controllable for the most part, wholly independent of the means employed, and calculated in an equal degree to influence the result of any such surgical proceeding, by whatever means conducted. 7 As to the example now before ns, it might, at first sight, ap- pear strange and inconsistent on the part of an advocate for galvano-cautery to call attention to a specimen so directly the opposite, in all its pathological features, to that exhibited by Dr. Noeggerath, and one so suggestively at variance with the views and principles set forth in the foregoing propositions. In this connection I would simply remark that the question is not whether cicatricial deformities after excision of the cer- vix uteri through the agency of the electric cautery, and serious disturbances and obstructions to menstruation consequent thereon, do or do not occur, for the specimen before us is affir- mative evidence of the fact, so that we know and freely admit that such conditions can and do occasionally supervene. But if, in a large experience of many years with this particular agent, both in hospital and private practice, and during which every intra-vaginal operation where it could be judiciously sub- stituted for the knife, scissors, " vitality modifying" escarotics or strong caustic applications, I have employed the electric cautery, and carefully observed its effects; if, in nearly fifty amputations of the cervix for non-malignant conditions alone, mainly hypertrophy, by this means, 1 have noticed but four similar to and including the one to 'which this specimen refers; and finally, if to this I add the statement that the clinical his- tory of that one case, as here given, would apply, in all its main features, to either or all four, I cannot look upon such experi- ence in any other light than that of positive and convincing proof that my conclusions are correct. I am well aware that when a case of this nature is to be in- vestigated we are confronted, at the very outset, in our search after causal connections, with two prominent and startling cir- cumstances, viz., the operation by galvano-cautery and the specimen before us. It is needless to say, however, that if we proceed to reason from such disjointed materials, a single oc- currence and an isolated fact; if, in any case the first and the final links only in a long chain of clinical testimony are to constitute the sole basis of our reasoning, though once in a while, and by the merest accident, our inferences may happen to be correct, the chances are infinitely greater that any con- clusions or opinions so reached will be absurd and untenable. And yet this "rapid transit" style of argument is precisely what we are constantly asked to accept as conclusive. Indeed, the "method" usually adopted, though not in accordance with the modern conception of certain phenomena, is, nevertheless, so attractively easy that a sample of the article may not be out of place here, and in substance, may be expressed thus: " 1st. Amputation of the cervix uteri by galvano-cautery pro- 8 duces cicatricial obliteration of the uterine canal and a radical impairment of the menstrual function." 2d. " Interruption to this important physiological process necessarily predisposes to pul- monary tuberculosis." Ergo, in the majority of cases where amputation of the cervix has been performed by electro-cau- tery instead of the ecraseur, scalpel, or scissors, the patients die of consumption! " Had my patient at any time during the last three years of her life consulted any gynaecologist, however skilful and trustworthy in other respects, yet having not only little or no practical experience in electro-cautery-but, as we often find in regard to every department of knowledge, either a correspond- ingly high estimate of his fitness to sit in judgment, or a total dis- belief in its claims and merits-the examination of such a case would hardly fail to have confirmed him in his peculiar notions. Moreover, if, added to this preliminary disqualification on his part, we consider that nine times out of ten every fact and cir- cumstance at all calculated to threw light upon and account for certain abnormal conditions noticed, had been carefully con- cealed from him or misrepresented, there can be but little doubt that the unfortunate representative of this " modern surgical innovation" would have fared badly. Much worse, however, would it have been had the patient sought counsel and relief at the hands of some obscure and unprincipled practitioner; because, whereas in the first instance, a partial consciousness of incompetency, or in legal parlance, "a want of jurisdiction," if no higher motive, might render criticism more guarded; in the latter case, not even such ob- stacles would be permitted to stand in the way of a free ex- pression of his " opinion." Flattered at the very thought of being deemed competent to pass judgment on matters of which he knew he had no knowledge, practical or otherwise, and thoroughly imbued with a contemptuous disregard for " golden rules," or " codes of ethics," why should he hesitate ? Others might think it worth while to put in an appearance of going into details, but as for him, conclusions would be reached by a less circuitous route; as for example, the aforesaid " rapid transit " line. In a word, he would doubtless have promptly declared the case to be one of unwarrantable mutila- tion. Need more be said as proof negative of the appositeness of this case and specimen to the main question-namely, When cicatricial contraction and structural impediments to men- struation are observed after amputation of the cervix by gal- vano-cautery, are such conditions mainly or at all chargeable to this method of operating ? "