_SIR SPENCER WELLS AND OVARIOTOMY._
Thomas Spencer Wells, whose career in the revival of the operation
of ovariotomy has attracted very widespread attention and interest,
was born in 1818, being the eldest son of Mr. William Wells of St.
Alban’s, Herts.
Without being formally apprenticed, he enjoyed many of the advantages
of the old apprenticeship system, under an able country practitioner,
Michael Thomas Sadler, of Barnsley, Yorkshire. Subsequently he spent
a year with a parish doctor in Leeds, attending the Leeds Infirmary,
and Hey’s and Teale’s lectures. The session 1837-8 was passed in
Dublin, and there Graves and Stokes largely influenced the young
surgeon. Continuing his course of culture in varied fields, he went
to St. Thomas’s, London, and was a zealous pupil of J. H. Green,
Travers, and Tyrrell. Here he obtained a prize for the best reports
of _post mortem_ examinations. Becoming a member of the College of
Surgeons in 1841, he entered the navy as assistant-surgeon, and spent
six years in the Naval Hospital at Malta.
In 1853 Sir Spencer Wells settled in practice in London, and in 1854
became attached to the Samaritan Hospital, then a dispensary for the
diseases of women. At this time Sir Spencer states he knew less of
this branch of the profession than of any other. In his younger days
he had attended an unusual number of midwifery cases, but latterly
his practice had been almost exclusively surgical, with a strong
tendency towards ophthalmic surgery. It was at this time that he
first became interested in the subject that has made his name so
widely known.
From time immemorial the ovaries of women have been subject to
diseased growths and fluid accumulations, for which there was
scarcely a remedy, except when fluid could be drawn off through one
or more punctures, and fatal results were the almost inevitable
sequel of these diseases. Towards the end of the seventeenth and
beginning of the eighteenth centuries, several medical men proposed
to remove the diseased organ by an incision in the front wall
of the abdomen. William Hunter in 1762 put forward a method by
which this operation, otherwise full of danger, might be rendered
feasible; and John Hunter, lecturing in 1785, favoured the idea
of removal, considering that the opening would not necessarily
constitute a highly dangerous wound. In 1798 Chambon, in a book on
diseases of women, published at Paris, strongly argued in favour
of the operation. Although it does not appear that he ever himself
performed it, he says, “I am convinced that a time will come when
this operation will be considered practicable in more cases than I
have enumerated, and that the objections against its performance will
cease.” John Bell also has a share of credit in this matter, for in
his lectures on surgery at Edinburgh in 1794 he dwelt with much force
on the practicability of removing ovarian tumours by operation. It
was reserved, however, for a pupil of his, Ephraim M’Dowell, from
Virginia, to perform the first modern operation of ovariotomy for
disease. He settled in practice in Kentucky in 1795, and in 1809
carried into effect this novel operation upon a middle-aged woman,
who survived to complete her seventy-eighth year in 1841. Thus an
American had the glory of first boldly starting in the new path.
It was difficult to give the new operation a start in England. “It
must be remembered,” says Sir Spencer Wells, “that, at that time of
day, the mortality from all operations was much greater than it is
now; that the sick and diseased were more passively quiescent under
their maladies and less tolerant of any surgical suggestions, just
as we ourselves find to be the case among the unroused population
of an outlying agricultural district; that they were not buoyed
up, as modern women are, by the histories and promises of painless
extirpations under chloroform or methylene; and that, without any
mawkish sentimentalism, surgeons themselves had to encounter the
_peine forte et dure_ of their suppressed sympathy, and nerve
themselves up to the infliction of the most deliberate and tedious
eviscerative vivisection. The disease was looked upon as a mystery,
and its ending in death as a matter of course; and, instead of being
accompanied, as we now see it, by fretful resistance and chafings to
escape, it only led to stolid endurance or religious submission; and
on the part of the profession, to pity and endeavours to alleviate
the inevitable misery. But M’Dowell was a free man, in a new country,
clear from the conventional trammels of old-world practice, found
his patients in the most favourable conditions of animal life, seems
to have had one of those incomprehensible runs of luck upon which
a man’s fate and reputation so often turn if he has the sagacity
and energy to put such fortunate accidents to good account, and was
happy, as those usually are who can afford or constrain themselves
to wait, in finding suitable time, place, persons, and opportunity
for working into fact the notions of his tutor, Bell. He lost only
the last of his first five cases of ovariotomy, and thus, as it
were, established at the outset what until recently was complacently
regarded as a satisfactory standard of mortality for so serious an
operation.”[9]
As a surgeon M’Dowell was “cautious, calm, and firm, paying great
attention to the details of his operations and treatment, and
selecting and drilling his assistants with great care.” In 1879 a
granite obelisk was raised to his memory in the cemetery where he
was buried, near his home, in commemoration of his courageous and
important work.
Long after M’Dowell’s operations became known, a case was discovered
as far back as August 1701, in which Robert Houstoun, a Glasgow
surgeon, operated on a woman for a large tumour in a fashion somewhat
anticipatory of modern ovariotomy. She recovered, and lived sixteen
years afterwards. So often are anticipations of great improvements
to be found, that it appears that the merit, like the difficulty of
actually making a thing practicable and practised, is as great as, or
greater than, that of discovery.
Several American surgeons followed M’Dowell, but the operation did
not come rapidly into vogue, partly because anæsthetics had not yet
been introduced. Lizars of Edinburgh had one successful and one
unsuccessful case in 1825. Dr. Granville attempted it in London in
1827, but the operation was abandoned on account of the difficulties
met with: fortunately the patient recovered. In 1836 Dr. Jeaffreson
of Framlingham first operated successfully by means of the short
incision recommended by William Hunter; the patient recovered and
bore a family afterwards. In the same year several other provincial
surgeons were equally successful. In 1840 Mr. Benjamin Phillips
operated unsuccessfully at the Marylebone Infirmary. In 1842 Dr.
Charles Clay of Manchester commenced a long series of operations,
operating four times in the year, three times successfully. The
first successful case in London was by Mr. Walne in November 1842.
From this time operations were not infrequent. In September 1846 Mr.
Cæsar Hawkins proved for the first time that success was possible
in a London hospital; his precautions and his directions were most
excellent. In June 1848 Dr. Charles Clay published a series of 32
cases with only 10 deaths, and he continued to operate for many years
until he had performed 395 operations with only 101 deaths, slightly
above 25 per cent. He used long ligatures. In 1850 Mr. Duffin, in
London, employed an important improvement in procedure.
Sir Spencer Wells’s medical education and study in all these years
had not led to his paying any attention to the subject. It was
evidently outside the prevailing ideas of most of the medical
schools. His opinion in 1848 was certainly against the justifiability
of the operation. In 1853 or 1854 he became acquainted with Mr. Baker
Brown, and in the latter year assisted him at the Middlesex Hospital
in his eighth case of ovariotomy. This was the first time he had seen
the operation attempted, but the patient died. Several unsuccessful
cases led Brown to give up his attempts entirely from March 1856 to
October 1858.
When the Crimean War broke out, Sir Spencer Wells betook himself
to the army in the East. There he learnt much of the freedom with
which the abdomen might be injured and yet recovery take place if
the constitution was good and other things were favourable. He saw
frightful cases of laceration by fragments of shell recover after
careful cleansing and accurate closure of the wounds. He returned to
London much less afraid than before of abdominal wounds. Renewing
his work at the Samaritan Hospital, he at first saw very little of
ovarian disease, and it was not till December 1857 that he made his
first attempt to perform ovariotomy, which, however, on Baker Brown’s
advice, he did not carry to completion. His second attempt was
completed, with Brown’s assistance; but the latter did not recommence
to operate himself until after an interval of more than two years and
a half.
Sir Spencer Wells has given a graphic account of his early
experiences.[10] “It would be difficult to imagine,” he says, “a
position more disheartening than that in which I was placed when
making my first trials of ovariotomy. The first attempt, as I have
said, was a complete failure, and strengthened not only in the minds
of others, but in my own mind, the fear that I might be entering
upon a path which would lead rather to an unenviable notoriety than
to a sound professional reputation. And if I had not seen increasing
numbers of poor women hopelessly suffering, almost longing for death,
anxious for relief at any risk, I should probably have acquiesced in
the general conviction—have been content with palliative tapping,
or making some further trials of incision and drainage, or of
iodine-injection, or of pressure, rather than have hazarded anything
more in the way of ovariotomy. It may be forgotten now, but it is
true, that at that time everything was against the venture. The
medical press had denounced the operation, both in principle and
practice, in the strongest terms. At the medical societies the
speakers of the highest authority had condemned it most emphatically.
The example of the men who had practised it was not followed; some of
them had given it up. Only once had a successful result been obtained
in any of our large metropolitan hospitals, that by Cæsar Hawkins, at
St. George’s Hospital, in 1846, and he never undertook it a second
time. Every other attempt—at Guy’s Hospital by Morgan, Key, and
Bransby Cooper, at St. Thomas’s by Solly—had ended in death.” In 1858
three cases were undertaken, and all with success, which did much to
confirm Mr. Wells in his new practice. The fourth he lost, and to
explain the cause he made some experiments upon animals, which led to
important improvements in methods, yet during 1859 five out of eleven
operations had fatal results.
The translation in 1860, by Mr. John Clay of Birmingham, of Kiwisch’s
“Diseases of the Ovaries,” with its valuable tables showing the
results of all recorded cases, was of great importance to the
progress of ovariotomy. Since then vast improvements have been
introduced, the mistakes of earlier operators corrected, bichloride
of methylene has been used with gratifying results instead of
chloroform, precautions have been taken to prevent the access of
any taint of infectious disease, every medical man present at the
operation has been put under strict inquiry as to his not having
recently been in a dissecting or _post mortem_ room, and the utmost
possible purification of house, room, bedding, clothing, and
instruments has been practised. Indeed some precautions have been so
stringently insisted on as to give considerable offence at times. The
old vegetable material for ligatures and sutures, coarse whipcord
or twine, has been given up, and after many trials of metallic
wires pure silk has been settled upon as the most trustworthy.
In fact it is entirely absorbed without needing to be pulled out
again. The multitude of intricate details involved precludes our
giving an account of the stages by which the present perfection has
been reached. In 1864 Mr. Wells, in pursuance of a pledge he had
given to record and publish his entire experience, favourable and
unfavourable, published a full account of his first 114 cases. Since
then two extended records, one in 1872 giving an account of 500
cases, and a second in 1882 with 1071 cases, have been published. The
most remarkable thing in the history is the gradual diminution in
mortality. In the first hundred cases the deaths were thirty-four;
in the last they diminished to eleven; in the seventy-one cases
following the first thousand only four died, while sixty-seven
recovered. This is notwithstanding the fact that Sir Spencer Wells
is often called upon to treat patients rejected by other surgeons as
unfavourable cases. A recent record by Thomas Keith, an Aberdeen
surgeon, in which a mortality of only three and a half per cent.
has occurred, even outdoes this astonishing result. It is needless
to relate how the operation has been adopted by most Continental
surgeons of mark, and with excellent results.
We may note that already in 1864 Mr. Wells had treated of hospital
atmosphere, organic germs as causes of excessive mortality, and
commented on the researches of Polli with sulphur and the sulphites,
before as yet the antiseptic treatment had come prominently forward.
When Mr. Lister’s system became established, Mr. Wells gladly adopted
all its essentials in his operations—the spray, carbolised sponges,
instruments, &c. He is convinced that by these precautions those
patients who have recovered have suffered much less from fever, while
convalescence has been more rapid than it used to be. In fact, the
general result of the ovariotomy of the past twenty-five years is
“thousands of perishing women have been rescued from death; many more
thousands of years of human life, health, enjoyment, and usefulness
have been given to the race, and to all future victims of a malady
before inevitable in its fatality, consolation, hope, and almost
certainty of cure.”
The good influence of this success has, Sir James Paget says,
extended to every department of operative surgery, and will always
continue to be felt. It has led to an extension of the whole domain
of peritoneal surgery, leading surgeons to attempt and persevere
until successful in many operations formerly considered quite out of
reach.
Sir Spencer Wells is by no means content with promoting the progress
of operative surgery; he looks forward to prevention with the
greatest hope, and advocates measures calculated to promote accurate
research in pathology. He is a strong supporter of any possible
action by the College of Surgeons in this direction. He says: “While
we modern surgeons congratulate our science on its liberation from
the trammels of tradition; upon its working in an atmosphere cleared
of the mist of superstition; upon the changing of its mode of action
from a blind grappling with the phantom entities of a disease to a
study and manipulation of overnourished or degenerating tissues; upon
its having laws which can be understood and rules of practice which
can be followed, we ought not to overlook one fact, which perhaps
is more evident to outsiders than to ourselves, standing as we do
in the dust and turmoil of the arena of our work. I mean that that
work, good and useful as it is, has too much the character of what is
technically called ‘salvaging’—is too much in correlation with what
is done by the lifeboat service.”
Mr. Wells had long been a member of the Council of the College of
Surgeons when in 1882-3 he became its President. In 1882 he was
created a baronet. He has by no means limited himself to questions
of operative surgery. His public efforts have been frequently
directed towards important subjects of state and municipal polity,
sanitary matters, the abatement of the smoke nuisance, the securing
of the health of passengers on board ship, the hygienic condition of
hospitals, and perhaps most important of all, the mode of disposal of
the dead. His views on the evils of the present system are well set
forth in a letter he addressed to the _Times_ on March 3, 1885, from
which we make the following extract:—
“In this metropolitan district in the twenty-five years 1859-1883,
the deaths registered number 1,896,314. Of course, the dead have
been buried, and with scarcely an exception, in and around London.
Grant that in ten years a body may become harmless—although I do not
at all believe that it does so within twenty years in our soil and
climate—can any imagination conceive the enormous mass of decaying
animal matter by which we are surrounded? Could any one be surprised
at the outbreak of some devastating pestilence a hundredfold more
destructive than the plague or black death of the Middle Ages? And
ought not every sanitary reformer to aid the revival of the ancient
practice which would convert the existing cemeteries, so rapidly
becoming sources of danger to the public health, into permanently
beautiful gardens, receptacles for vases and cinerary urns, which
would encourage sculpture, mural decoration, and coloured glass-work;
while in our country churches the ashes of the people might again
repose in death near the scene of their work in life perfectly
harmless, instead of polluting the earth of the church-yard and the
water drunk by the surviving people, or being carried far from their
homes and places of worship to some distant cemetery, which before
long must become overcrowded and pestilential. Public sentiment may
for a time revolt at an innovation, but a very little reflection will
bring most people to agree with part of the Bishop of Manchester’s
address on consecrating a new cemetery. He said:—
“‘Here is another hundred acres of land withdrawn from the
food-producing area of the country for ever.... In the same sense in
which the “Sabbath was made for man, and not man for the Sabbath,” I
hold that the earth was made, not for the dead, but for the living.
No intelligent faith can suppose that any Christian doctrine is
affected by the manner in which, or the time in which, this mortal
body of ours crumbles into dust.’”
Sir Spencer Wells in his frequent communications on the subject lays
much stress on the fact that such undoubted proofs of natural death
are required by the Cremation Society before cremating a body that no
murderer or poisoner would think of getting the forms filled up. At
the Milan Crematorium a death from poison was actually discovered in
this way, when natural death only was believed to have taken place.
FOOTNOTES:
[9] Ovarian and Uterine Tumours: 1882.
[10] Address to Midland Medical Society, Birmingham, November 5,
1884.