ANOTHER TWELVE MONTHS OF PERI- TONEAL SURGERY-FIFTY-SEVEN CASES. BY HENRY T. BYFORD, M.D., PROFESSOR OF DISEASES OF WOMEN AT THE POST-GRADUATE MEDICAL SCHOOL OF CHICAGO, GYNECOLOGIST TO ST. LUKE'S HOSPITAL, SURGEON TO THE WOMAN'S HOSPITAL OF CHICAGO. Reprinted from "The Journal of the American Medical Association," March 15, 1890. Having, at the annual meeting of the Chicago Gynecological Society, October, 1888, reported my peritoneal sections for the year ending June 30, 1888, I have thought it best to commence this report with July 1, 1888, in continuation with the old one. MORTAIJTY. Perhaps the most interesting subject for us to examine is the mortality, and our first inquiry will be, what kind of cases usually get well, and in what kind do most of the deaths occur ? All abdominal sections in which there were no adhe- sions (sixteen in number) recovered. All vaginal sections (sixteen in number), with and without adhesions, got well, excepting one in which the death depended upon general conditions, viz: de- lirium tremens and its complications. In the series of forty-eight cases of last year, all abdom- 2 inal sections without adhesions (sixteen in num- ber; got well, excepting two cases of haemorrhage due to the employment of the prevalent imperfect methods of tying the pedicle.1 This accident ought not to have occurred, and has not occurred to me since. As far, therefore, as these 105 cases are determinative, I feel justified in inferring that cases of abdominal section for removal of the uterus or appendages in which there are no ad- hesions or development in the broad ligament (the patient being in good condition for opera- tion), ought to recover in all except rare cases of unavoidable accidents. Of the twenty-one cases of vaginal section of last year all recovered, mak- ing, with those of the present year, thirty-seven cases with one death, or a mortality of 2.7 per cent. Hence I also infer that vaginal section, in the cases in which it is indicated, is at present safer than abdominal section. When extensive adhesions, development in the subperitoneal tissue, or pus accumulations occur, we have desperate cases to deal with, and get a high death-rate after our operations. Of the eight deaths in this series five belonged to this class, viz: one malignant and four developed in the broad ligament. Another cause for a high mortality is the de- bilitated and often septic condition of the patient at the time of the operation. One patient was so nearly destroyed by a pyosalpinx that the opera- tion was done as a last resort. In one case the abdominal cavity was at the autopsy found healthy, and the death caused by exhaustion and suppuration of hypodermic needle punctures in the thigh. This was also a last resort case. In another case of carcinoma of the cervix the opera- 1 I am including exploratory incisions in which the adhesions were not interfered with. 3 tion (vaginal hysterectomy) was the easiest and most perfect operation I had yet done, but the patient had taken morphine and alcohol to such an extent that she died of their effects. In another case a patient with uterine sarcoma died, three weeks after the operation, of inanition. This case I have not included in the mortality, as no connection between the operation and the death could be found by the pathologist at the autopsy -the wound was healed. One of the most important things in the devel- opment of peritoneal section must be the elimina- tion of the accidental. But for a sponge left in the abdominal cavity in one case, the infection by an assistant in another, and an accidental and unnoticed rupture of the stump sac in another case, the general mortality would be 8.77 per cent., instead of 14 per cent. Yet the experience derived from these eight fatal cases has been of much more value to me than that derived from the forty-nine recoveries. Indeed, I regard it about as difficult to become a first class peritoneal surgeon without an extensive experience with fatal cases, as for a rich man to go to heaven. DIAGNOSIS. If what I have said should prove to be in ac- cord with the experience of others, then, by means of an accurate diagnosis of the local and general conditions, we can speak thus to our patients: To one, "Your chances of surviving the operation are 98 or 99 in 100; the danger need not deter you from seeking its benefits;" to an- other, "Your chances are 90 in 100, but your dis- ease will not shorten your life-do not take the risk ; " to another, "Your chances are from 80 to 4 90 in 100, but the remote risk is greater; take your chances now, lest they be worse hereafter." Accuracy of diagnosis is difficult, but not im- possible of attainment, and will perhaps only be attained by those who have opportunities for verifying and correcting the diagnosis by peri- toneal section. Its want is one of the most con- spicuous imperfections of abdominal and pelvic surgery, yet one of the most valuable attainments. SUBSEQUENT HISTORY. The determination of the utility of these opera- tions depends largely upon the remote results. In a few of the cases of oophorectomy for diseased appendages the cure has been immediate and complete, but in the majority the improvement has been gradual. As months pass by the reports become more and more favorable. It has been an agreeable surprise to note the excellent results in hystero-epilepsy and mental failure. I have altogether removed ovaries for such mental con- ditions in twelve cases, with immediate or rapid recovery in five cases, gradual improvement in six cases, and a persistence of symptoms in one case. I am in consequence inclined to regard it as an operation of great value not only in cases entirely dependent upon pelvic disease, but in those in which ovulation or menstruation is only an exciting cause. It is often a necessary step to the cure, and makes the cure by other means possible. SHALL WE EXHAUST ALL OTHER THERAPEUTICAL RESOURCES BEFORE PERFORMING PERI- TONEAL SECTION FOR DISEASED APPENDAGES ? I would answer, if that means to try all reme- dies, decidedly no-not any more than I should 5 try version, embryotomy, symphisiotomy, ergot, etc., before resorting to Caesarean section in a case of labor at term with a conjugate of one inch. After examining and studying my case I would claim the same right of judgment, and not wait until too late to operate in the one case any more than in the other. CURE OF RETROVERSION. I have to report the cure of four cases among the eight of retroversion and retroflexion in the vaginal ovariotomies and oophorectomies. This was accomplished by leaving an iodoform gauze tampon under and in front of the replaced cervix uteri for forty-eight hours after the operation. The exudates and adhesions about the stumps and between the anterior and posterior walls of the recto-uterine pouch often fixes the uterus in the position in which it was tamponed. If the uterus fall back into retroversion when the tam- pon is removed, it may tear loose a recent adhe- sion and cause some disturbance, as it did in three cases ; but this is of course only temporary. AFTER-MANAGEMENT. I seldom give opiates, and consider them often injurious. Yet, after the bowels have moved the main objections to their use have subsided, and indications for them may arise. There are cases in which they are required almost immediately after the operation, to insure quiet. The time when they are contraindicated is, I think, from the end of the first to the end of the fourth twelve hours P. O. By paralyzing peristaltic action they favor adhesions of the intestinal loops in the positions in which they were placed or pushed at 6 the operation, and which may be such positions as will prevent the intestines resuming normal functions. The most valuable and striking action of salines is when they are administered during the second and third twelve hours for symptoms of intestinal obstruction, viz : tympanitis and regurgitation, without nausea, of all fluid taken, often following a few hours of gastric quiet. In such cases the saline acts by filling the intestinal loop with fluid and favoring normal peristalsis, tearing them loose from their adhesions and forcing the fluid through them. It has been supposed by many, as well as my- self, that twenty-four hours was long enough to leave the forceps on the broad ligaments in vagi- nal hysterectomy ; yet I report a case of almost fatal haemorrhage following their removal in thirty-six hours (No. 7). With regard to the advantages of forceps, the question is not whether in the concrete case the forceps or ligatures are better or safer, but rather, which can in the given case be best applied. When the uterus can be pulled down, five ligatures can be applied to each broad ligament quite rapidly and safely ; when the uterus can not be pulled well down the forceps reach better. The quintuple ligature, when the parts can be pulled down, is safer than the for- ceps, because the broad ligament is not of equal thickness throughout, and portions of it are liable to receive too little pressure by the forceps and either bleed or slip out. A number of the charity cases were done before classes ranging from thirty to fifty students, and recovered without a bad symptom. In one case, Sophie N., three sections were made upon the same patient, a vaginal oophorec- tomy, a laparo-hysterorrhaphy, and an inguinal 7 oophorectomy. The ovary having been drawn forward by the hysterorrhaphy, I at last entered the abdominal cavity by way of the inguinal canal.2 In the few abdominal hysterectomies the stump was treated extraperitoneally, and each time with success. In one case (No. 2) I adopted a new method by separating the bladder and anterior vaginal wall from the cervix and fixing the stump extraperitoneally in the vagina.3 When practi- cable I should call it, as far as the subsequent condition is concerned, preferable to abdominal fixation. I have since employed it successfully in two other cases, and to my utmost satisfaction'4 SUMMARY. i Whole No. Recov- ered. Died. Per cent. Recov- ered. Ovariotomies-Abdominal. Intraperitoneal tumors II IO I 90.9 Subperitoneal tumors 7 3 4 42.8 Ovariotomies-Vaginal 3 3 IOO. Oophorectomies-Abdominal. For diseased appendages 15 13 2 86.6 For general conditions 2 2 IOO. Oophorectomies-Vaginal. For diseased appendages 5 5 IOO. For general conditions I I IOO. Hysterectomy-Abdominal " Vaginal 4 4 IOO. 7 6 I 83-3 Laparo-Hysterorrhaphy I I IOO. Exploratory incision I I IOO. Summary 57 49 8 86. Mortality, excluding subperitoneal ovarian tumors, is 8.7 per cent., viz.: 5° 46 4 91-3 2 See Transactions of Chicago Medical Society for Dec. 16, 1889. 3 See Transactions of American Gynecological Society for 1889. 4 See Transactions of Chicago Medical Society for Dec. 16, 1889.