TWENTY CONSECUTIVE CASES OF ABDOMINALSECTION, WITH ONE DEATH.

BY

J. M. BALDY, M.D.,OF PHILADELPHIA

FROM

THE MEDICAL NEWS,

June i, 1889.

[Reprinted from The Medical News, June i, 1889.]

TWENTY CONSECUTIVE CASES OF ABDOMINALSECTION, WITH ONE DEATH}

By J. M. BALDY, M.D.,OF PHILADELPHIA.

This paper embraces the report of twenty abdom-inal sections taken from the surgical experience ofthe writer, and are reported simply as a basis forsome general remarks on this class of surgery. Thecases are taken consecutively, and include the onlydeath I have as yet met with. No case has been re-fused for operation where there seemed a possiblechance for life, and several of them were in such acondition that this chance seemed very small indeed.The general mortality is fully as low as that obtainedby Lawson Tait, as reported in his last one thousandcases. Of the operations themselves I have little tosay. They have been neither harder nor easier thanthose of a similar character done by other operators.The fact becomes daily more and more apparent tome, that all abdominal operations, with complica-tions, are difficult; in fact, each new one seemsmore difficult and delicate than the last. It is im-

1 Read before the Philadelphia County Medical Society, May22, 1889.

2 BALDY

possible to lay down any definite rule of procedurein any class of cases, for the reason that no two arealike; it is simply surprising to find how differentlyeven two apparently similar cases will result. Attimes one has need of all his courage and skill, tomeet therequirements and complications of the case.

Seventeen of the list were complicated by adhe-sions, more or less dense, and the difficulty, nay,almost impossibility at times of breaking these adhe-sions, have convinced me of the folly of evenattempting to cure such cases by either electricity ormassage. In some cases, the electricity would havedestroyed the surrounding tissues much sooner than itwould have even made an impression on the adhe-sions themselves, so extensive, dense, and organizedwere they. It is simple unadulterated nonsense totell me that I could have done with safety, throughthe thickness of the tissues of the abdominal walland vagina, that which I was barely able to do withmy fingers directly on the disease, and the patientfully anaesthetized ; and massage, if carried to theextent advocated by some of its votaries, loses eventhe merit of being harmless, but becomes extremelydangerous. If the patients of the gentlemen whouse this remedy (or say they do) will submit to thepain necessarily incident to this treatment, theymust be dealing with a much less serious type ofcases than it has been my fortune to handle.

In eleven of these cases I have used the drainagetube; nor in any case have I ever regretted its use.On several other occasions I should have used it, butthat the after-treatment was conducted by another

ABDOMINAL SECTION. 3

than myself, the patient residing in the country. Inone case the tube was accidentally displaced by thepatient, before she was completely from under theinfluence of the anaesthetic. In this case the adhe-sions and hemorrhage had been particularly severe,and I was considerably worried over its loss forseveral days; the convalescence progressed, how-ever, without any incident worthy of note. I havesince then several times done without a tube anddepended on purgatives for drainage, with a greaterease of mind, especially in the out-of-town cases.Irrigation with boiled distilled water, and whenthat has become exhausted, simple boiled water, hasbeen a constant resource and of the utmost benefit.There is absolutely nothing which will take its placefor cleaning the abdominal cavity of clots anddebris, as well as for its stimulating effect upon thepatient. Of late, however, two surgeons have ex-pressed the opinion that the flushing is decidedlydangerous, and base that opinion, each upon onecase. Both the patients died after the operation inwhich warm-water irrigation had been used. Therest of the profession seem to be unanimous in theopinion that irrigation is safe and beneficial.

In the fatal case of M. Polaillon, a French sur-geon :

“The patient took chloroform badly, the excited stagewas long and she readily came to, though plenty ofchloroform, out of a new bottle, was administered on apiece of lint. He employed distilled water, previouslyboiled, and containing one part of carbolic acid to ahundred.

“During the flushing, respiration became rapid, then

4 BALDY,

grew feeble and ceased; the face became blue. Theheart continued to beat regularly. The alarming symp-toms began at a quarter past ten o’clock. Artificialrespiration was continued till eleven. Then a few feeblerespirations began, and continued for a quarter of anhour; the pupils were then half contracted. The heartbeat regularly and quickly. The patient continued un-conscious. In spite of stimulants, spontaneous respira-tion could not be permanently maintained. Phlebotomyresulted in the escape of a few drops of very dark bloodfrom the left arm. Gradually the heart’s action becamemore and more feeble, the face grew pale, flatus escapedfrom the anus, and the pupils dilated. She was thirty-five minutes under chloroform, and about an ounce anda half of the anaesthetic had been used.”

Of course, the case died of the chloroform ; thehistory is too complete to admit of any other inter-pretation, nor do I think for a moment that any onebut the operator could think otherwise.

The second case was a patient of Dr. Weir, ofNew York. Of this case, Dr. Jacobus says :

■ “ How the death of this patient can be, even indirectly,attributed to hot douching, I cannot understand, for itwas a case of recurring appendicitis, with several per-forations, general peritonitis and partial collapse, operatedupon on the fifth day, after having been treated by otherphysicians, then removed to a hospital and examinedunder ether, the day previous to the operation.”

This is the flimsy evidence on which the objectionto irrigation is founded. If surgeons will overdosetheir patients with chloroform or wait until theeleventh hour to operate, they must expect them todie. I have repeatedly flushed the abdomen to thediaphragm and have yet to see anything but goodresults. My observations and inquiries amongst my

ABDOMINAL SECTION. 5friends have disclosed the same experience withoutan exception.

A number of these cases were confined to bed witha peritonitis at the time of the operation. All sortsof complications have been met with. In threecases the vermiform appendix had to be freed andthen removed on account of its diseased condition.In one, when torn loose, it was found perforated intwo places; the appendix was simply ligated andcut away. In none of these cases did any unpleas-ant symptom arise from this procedure.

The patients have for the most part been operatedon at their own homes and in several instances werenursed by their friends. This has, of course, neces-sitated an enormous amount of extra work for my-self; but otherwise they would not have beenoperated on, having absolutely refused to go to ahospital. The result only helps to emphasize thefact that hospitals are more luxuries than necessitiesfor these operations, notwithstanding the opinionof some operators to the contrary.

In two of these cases there have resulted ventralhernias. In three fistula tracks have followed. Aligature has recently come away from one of thesefistulas and it will now probably close. The othertwo fistula tracks both followed supra-vaginal hys-terectomies.

The after-treatment has been practically, in manycases, nothing. Unless special indications arisethey recover without having had a single dose ofmedicine, excepting sulphate of magnesium, whichis generally given on the third day. Until the third

6 BALDY,

day they get nothing to eat. Solid food is givenby the fourth or fifth day, if they wish it. If thirstis great, it is relieved by rectal injections, at inter-vals, of about half a pint of warm water ; otherwisetablespoonfuls of soda water are depended on.Opium I have never used and never expect to.

The simpler the details of the operation the better.In ordinary cases my whole armamentarium con-sists of two ligature needles, two or three sutureneedles, a knife, a pair of scissors, a sponge-holder, half a dozen haemostatic forceps, a drain-age and an irrigating tube. Pure silk is usedboth for ligatures and sutures. The dressing con-sists of a few strips of gauze, a pad of absorbent cot-ton and a six-tailed bandage. My bag stands nearby and contains all other necessary instruments, butit is exceedingly rare that I have to resort to them.The less work done with instruments and the morewith the fingers the safer it is for the patient. Oneoften sees operators with six, eight, or even ten pairsof forceps hanging to the sides of the incision. Theseinstruments are not at all desirable and where it isnecessary to use them to control hemorrhage, theycan safely be removed by the time the peritoneumis opened. It is exceptional that I have a singlepair hanging to the vessels when my fingers enterthe peritoneal cavity. They crush and bruise thetissues and only tend to prevent good union. In allthe details of the preparation for the operation andof the operation itself, the most perfect and rigidattempts at cleanliness have been observed. All in-

ABDOMINAL SECTION. 7struments, sponges, dressings, etc., used about anoperation are prepared by myself, when possible.

It is daily becoming more apparent that inexperi-enced and untrained men should not be temptedlightly to enter into the abdominal operation. Analarmingly large number of operations have latelycome to my notice, by men who have presumablynever attempted the procedure before, and who havebeen assisted by men equally inexperienced and in-capable of dealing with possible complications. Aconsiderable number of these cases have, of course,ended fatally—cases which should have all recoveredhad a skilled operator undertaken them. I do notmean to say that a physician with only a limitedexperience should never attempt an abdominal oper-ation, because I am very decidedly of the opin-ion that every surgeon in the land should be pre-pared in an emergency to open the abdominal cavityand attempt to deal with what he finds. Our coun-try is so large, and the different settlements andtowns so wide apart, that it is an impossibility alwaysto obtain skilled assistance; even where it couldbe obtained there are times when physicians haveno moral right to wait long enough for its arrival.If a tubal pregnancy has ruptured and the patient isbleeding to death, that belly should be opened atonce, and by the first man with any respectableamount of surgical experience who may first see thepatient. Any physician attending a case of labor,perhaps in the country, may meet with a ruptureduterus, and will give his patient a much better chancefor life if he open the abdomen immediately. Andso it is with many cases of intestinal obstruction,

8 BALDY,

gunshot and stab wounds. A delay of even a fewhours in these cases is responsible for their terriblemortality, and it would be better for any one withgood general surgical judgment and skill to open theabdomen, than to leave it unopened or even todelay. It is full time that members of the professionhad learned the importance of this and realized theirown individual responsibility in allowing such pa-tients to die, without an effort to save them.

But excepting as an emergency and life-savingprocedure, I am just as decidedly of the opinionthat men without special experience should neveropen the abdominal cavity, both for their patient’ssake and for that of their own reputation. If a sim-ple ovarian cyst is found the operation is easy enoughand any tyro could finish it successfully; but just assurely as serious complications are met with both thepatient and doctor are in trouble.

I may mention some of the more recent cases ofwhich I am cognizant, which will serve to illustratesome of the points.

Case I.—A young married woman with a good-sizedcystic tumor of the abdomen; in good general health;within one hour's ride of Philadelphia. Operationundertaken by several young men, but without even agood knowledge of general surgery. A long time waswasted in obtaining entrance into the peritoneal cavity.The cyst was found adherent and adhesions bled onbeing freed. Operation lasted over two hours, and finallyended by leaving it only half finished, with part of thecyst in situ. Death on the following day.

Case II.—Young healthy married woman with cysticdisease of abdomen. Operator’s first case. Cyst adhe-rent. Bleeding profuse, and large haemostatics plungedblindly into pelvis in hopes of controlling it. Operationover three hours. Death in a few days.

ABDOMINAL SECTION. 9Case III.—Young healthy married woman. Unrup-

tured tubal pregnancy diagnosed. Patient lived in atown which could have been reached in a short time byan expert. The ambitious attendant put the woman tobed, took several days to prepare for the operation, andtogether with four friends opened the abdomen. Opera-tion lasted for five hours ; not finished; patient bled todeath on the table.

This is the only case of tubal pregnancy I haveever known to be killed by an operation. I couldrelate many more equally as distressing, but thesecases tell all that is necessary and will justify theremarks I have already made.

There are two complications in abdominal surgeryconstantly met with, and in dealing with which menshow their skill and judgment or display their totalunfitness for such work: these are adhesions andhemorrhage. They are, moreover, constant com-panions ; where there are adhesions to be dealt with,there is also nearly always, of necessity, bleeding.Adhesions are not things to be blindly torn loose. Indealing with them, the utmost care and judgmentmust be constantly exercised, and the almost instinc-tive knowledge of when to break and when to ligatethem, must be ever present. Nor are adhesionsthings to be afraid of. It matters not how densethey are, it is exceptional that they cannot be suc-cessfully disposed of. The man who loses his headand becomes frightened because of tight adhesions,had better never attempt this class of surgery, asthey are almost sure to be met with in greater orless degree.

A careful survey of the whole field should first betaken by the surgeon, for the most part with his

10 BA LDY,

fingers, and a decision carefully arrived at as towhether or not it will be possible and safe to removethe disease. The decision once made in the affirma-tive and the enucleation once begun, it shouldnever, but under very exceptional circumstances,be stopped. The worse results obtained in abdom-inal surgery are in these unfinished operations. Thegreat danger of this half work was sounded someyears ago by Lawson Tait, and is to-day acceptedas sound teaching by all who have a right to anopinion on the subject. There is constant dangerattending the breaking up of adhesions. One mayat any time open an intestine and have the ques-tion of a resection to decide ; a ureter may be tornout at any moment and a nephrectomy must ofnecessity follow. I have known of the whole cir-cumference of the sigmoid flexure of the bowelbeing torn away and a closure of the two ends ofthe gut necessitated ; often the coats of the intestineare torn away down to the mucous lining, and aperforation may occur some days subsequently. Thebladder has been opened a great number of times.With these dangers ahead, it can readily be seenwhy untrained men should keep their hands off,unless absolutely necessary.

In addition to all this, bleeding is constant, as Ihave said, and may be of two kinds, either venousor arterial. Fortunately, the vast majority Of it issimply venous or a general oozing. Where an arteryof any size is torn, is must be at once secured andligated, but otherwise the bleeding had better be leftalone or controlled by skilful handling of sponges;it will not be often that this cannot be done.* But

ABDOMINAL SECTION.

whether controlled in this manner or not, there isno time to be wasted over it. The very best chanceof stopping it is to finish the enucleation quicklyand apply the ligature to the pedicle, then there istime and room enough to deal with what may beleft, which does not often amount to much. Ithas lately been proposed and found necessary tothrow a ligature around the uterine artery on eachside, by passing a threaded needle deep through thesides of the uterus and thus include the artery. Ihave never seen a case where I even had to thinkof this procedure, and I have seen some very freebleeding ; surely it would take very rough and care-less handling often to necessitate a resort to it.However, an uncontrollable case may at times occur,and it is a point well worth bearing in mind. Oftenthe mere bringing together of torn peritoneal edgesover a denuded and bleeding surface is sufficient tocontrol an otherwise troublesome point. Much ofit may safely be left to the drainage tube. I neverlike to use s'yptics when it can be avoided. It is thepremature attempt to control bleeding which is oftenso disastrous. Men find a pretty free flow of blood,and, not being accustomed to it, become frightenedand stop everything in the endeavor to control it.This they find oftentimes impossible ; the indicationthen is to finish quickly and stop the bleeding at itsroot. The pedicle ligature will stop it all, or what isstill left is not alarming. Had such been the coursepursued in the tubal pregnancy case mentioned, theoperation would most probably have been finishedand the patient survived. The one redeemingfeature of that case is, that the same men and their

12 ABDOMINAL SECTION.

friends will never be tempted into another suchoperation; but, unfortunately, the woman’s friendsand acquaintances will also never be tempted intoone. And so indirectly that one case will probablybe responsible for the death of half a dozen or moreothers, who might be saved did they not refuseassistance.

Abdominal surgery, of necessity, has enoughlegitimate deaths to answer for, withoutbeing loadeddown by such unnecessary and frightful examples.

Note. —Since the above was written I have had apatient die of apoplexy,- on the seventeenth dayafter operation. The case was one of intra-liga-mentous papillomatous cyst. Second operation.Had done well from the first. Small quantity ofpus from tube. Tube had been perfectly dry andclean for some days, pulse and temperature normal.Said she never felt better in her life. Had sleptsoundly all night, ate a good breakfast and was talk-ing and joking with nurse when she suddenly hada convulsion ; became unconscious and died withintwenty minutes. Post-mortem revealed a calcareouscondition of the mitral valves of the heart. At thebifurcation of two vessels in the fourth ventricle, apiece of the calcareous plate was found lodged, oneof the vessels was ruptured and the ventricle halffull of blood-clot. Everything else in the bodywas healthy. A full report of the case will beshortly published. Of course, I do not considerthis a death from operation, but have thought itproper to speak of it in connection with this paper.

328 South Seventeenth Street.

No. Pathological condition or symptoms. Drainage. Adhesions. Result. Effect of ope-ration. Remarks

I Pelvic inflammatory disease; ovariancyst.

No. Dense anduniversal.

Recovery. Great relieffrom symp-

toms.

Adhesions so great that it was impossibleto reach pelvis; nothing removed.Ventral hernia.

2 Constant local pain ; convulsions dur-ing menstruation; impossible coitionfrpm pain ; chronic salpingitis ; smallcirrhotic ovaries.

No. Yes. Recovery. Only gradualrelief; not yet

complete ;convulsions

seldom;coition pos-

sible andeasy.

From being a chronic almost bedriddeninvalid, is now able to attend to herhousehold and marital duties.

3 Left puerperal pyosalpinx. Yes. Dense anduniversal

Recovery. Cure. First case of the kind ever operated onin which life was saved.

4 Pyosalpinx. Yes. Universaland dense

Recovery. Cure. Three weeks in bed with peritonitis ;disease seven years’ standing

5 Cirrhotic ovaries, prolapsed and ad-herent.

No. Yes. Recovery. Cure. Relief gradual but complete; convulsiveattacks, which were cured.

6 Ovarian cyst; retro-peritoneal cyst;enlarged cirrhotic ovary.

No. Yes. Recovery. Pelvic ab-scess.

Fourth day walked to kitchen and ateher dinner, sitting at table ; out ofbedfrequently.

7 Pelvic abscess. Yes Yes. Recovery. Cure. Ventral hernia.

8 Fibroid uterus; enormous distentionfrom ascites; hysterectomy, extra-peritoneal.

Yes No. Recovery. Cure Fistula track ; ventral hernia; had beentapped eight times.

9 Ovarian cyst; ventral hernia. No. No. Recovery. Purulentperitonitis.

IO Purulent peritonitis. Yes. Yes. Death. Same as Case 9. Lived six days. Anearlier operation would have saved her.

II Double pyosalpinx. Yes. Dense anduniversal.

Recovery. Cure. Almost died ofhemorrhage on the table.

12 Right pyosalpinx and ovarian abscess ;

left hsematocele.Yes Universal. Recovery. Cure Peritonitis at time of operation.

13 Prolapsed and adherent ovaries, fourtimes natural size.

No. Yes. Recovery. Cure. For a few months complete cure ; latelysome pain, probably from adhesions.

14 Fibro-cystic uterus; supra vaginal hys-terectomy.

Yes. No. Recovery. Cure. Fistula track; had been diagnosed andtreated for hernia.

is Extra-uterine pregnancy Yes. Universal. Recovery. Abscess. Of a month’s rupture and commencinggangrene.

l6 Multiple abscesses. Yes. Yes. Recovery. Cure. Fistula track; ligature recently cameaway, and track will probably close

17 Left ovarian cyst; right pyosalpinxand ovarian abscess.

Yes. Universalbut light.

Recovery. Cure. Had severe attack of peritonitis duringconvalescence.

18 Right ovarian cyst; left cirrhotic ovary No. Yes. Recovery. Cure. Peritonitis at time of operation.

19 Ovaries greatly enlarged, prolapsed,adherent, and painful.

No. Yes. Recovery. Cure. Inversion of uterus had been reduced,but constantly tended to re-invert;operation to correct this tendency.

20 Pyosalpinx and chronic salpingitis. No. Yes. Recovery. Cure. Right tube adherent to uterus from overfundus to vaginal vault.

THE MEDICAL NEWS.ANationalWeeklyMedicalPeriodical, containing 28-32 Double-

Columed Quarto Pages of Heading Matter in EachIssue. $5.00 per annum, post-paid

UNITING in itself the best characteristics of the magazine and the news-paper, The MedicalNews renders a service of exceptional value to theprofession. It presents original articles, hospital notes and clinical lecturesby the ablest writers and teachers of the day, discusses living topics editor-ially in a clear and scholarly manner, and employs all the recent andapproved methods of medical journalism—the telegraph, reporters and acorps of special correspondents covering all the medical centres of theglobe. It thus imparts, without loss of time, all advances of knowledgeattained in the medical sciences. In short, it is the effort of all concernedin the publication of THE News that it shall be indispensable to everyphysician in active practice.

The American Journal of the Medical Sciences.Edited by I. Minis Hays, A.M , M.D.

Published monthly, beginning with 1888. Each numbercontains 112 octavo pages, amply illustrated. Price

reduced to $4.00 per annum, post-paid.In his contribution to A Century of American Medicine, published in

1876, Dr. John S. Billings, U. S. A., Librarian of the National MedicalLibrary, Washington, thus graphically outlines the character and servicesofThe American Journal — " The ninety-seven volumes of this Journalneed no eulogy. They contain many original papers of the highest value;nearly all the real criticisms and reviews which we possess; and such care-fully prepared summaries of the progress of medical science, and abstractsand notices of foreign works, that from this file alone, were all other pro-ductions of the press for the last fifty years destroyed, it would be possibleto reproduce the great majority of the real contributions of the world tomedical science during that period.”

COMMUTATION RATE.—Postage paid.The Medical News, published every Saturday,The American Journal of the Medical

Sciences, monthly, .....

in advance, $7.50.

LEA BROTHERS & CO., 706 & 708 Sansom St, Phi,a.