INDICATIONS FOR LAPAROTOMY. BY W. O. HENRY, M. D., Gynaecologist and Orthopaedic Surgeon to St. Joseph's Hospital and the John A. Creighton . Medical College. OMAHA, NEB., American Gynaecological ano Obstetrical Journal REPRINTED FROM THE for July, 1895. [Reprinted from the American Gynaecological and Obstetrical Journal for July, 1895.] INDICATIONS FOR LAPAROTOMY* W. O. Henry, M. D., Omaha, Neb., Gynaecologist and Orthopaedic Surgeon to St. Joseph's Hospital and the John A. Creigh- ton Medical College. In complying with the courteous invitation of your secretary to prepare a paper for the present meeting, I have chosen the above subject in order that the suggestions made and the discussion elicited might prove to be a helpful guide both to those of us who do abdominal surgery and to those who are called upon to treat cases which eventually come under the surgeon's knife. I shall not assume to cover in detail all of the possible present and future indications for abdominal section, but rather, from my own expe- rience in part, coupled with the wide and varied experiences of the leading operators at home and abroad, together with the observa- tions of learned physicians (whose opinions I fear are too often ignored by the surgeon), I shall formulate some propositions which, if not now generally indorsed, should, in my opinion, be followed by physicians and surgeons. I shall not stop to discuss the question as to whether laparotomy, cceliotomy, or gastrotomy is the proper term to use, but shall use the first as generally understood by the profession. Laparotomy is indicated- 1. For the removal of all ovarian cysts, fibro-cysts, parovarian and intraligamentary cysts as soon as discovered. Delay is dangerous. Tapping of these cysts is not a justifiable practice. 2. In all malignant diseases of the ovary limited to these parts, and as soon as the diagnosis is determined. 3. In all cases of pyosalpinx. Although a few men advocate catheterization, still it is generally agreed that " tubal catheterization is not found to be practicable." Notwithstanding the opinion of Dorsett, Glasgow, Murray, and others that curettage and packing of the uterus will effectually drain pus-tubes, and, in spite of the fact * Read before the Tri-State Medical Society, St. Louis, April 4, 1895. Copyright, 1895, by J. D. Emmet, M. D. 2 W. O. Henry, M. D. that Vulliet and Landau prefer vaginal puncture in these cases, still the profession, and I believe correctly, holds to abdominal section as the proper way to reach these pus-sacs and effectually get rid of them. Jacobs and Sutton have not been encouraged in their suggestion that the treatment of these cases should be by vaginal hysterectomy. It might be well to mention the fact, too, that even the name of Tait has not been sufficient to lead the profession into that erroneous practice of removing a healthy tube and ovary simply because the opposite tube is distended with pus and therefore demands removal. Let it be said here, too, that many of these cases of pus-tubes are not of gonorrhoeal origin, and we should recognize this fact in justice to our patients and in the interests of science. I am supported in this opinion by the reports of Haultain, Chrobak, Duncan, Martin, Zweifel, Bantock, and Reamy, who hold that these cases are not so frequently of gonorrhoeal origin as is generally supposed ; but that, on the other hand, many times they occur from septic and even simple inflammations by extension from other parts. Then, too, it is known that many times the gonococcus can not be demonstrated. Cheadle reports a case in a girl one year and nine months old with- out a vaginal discharge of any kind. 4. For removal of the tubes and ovaries. When (1) they are so seriously diseased (other than above) as to warrant a grave operation, provided always systematic, intelligent treatment has been tried and has failed to give relief. I wish most emphatically to protest against the removal of these organs for salpingitis, ovaritis, prolapsed ovary, acute retroflexion, or other similar conditions before suitable treat- ment has been given a fair trial. I am sure these organs are being unnecessarily removed. In some cases of prolapsed ovaries with adhesive inflammation and plastic effusion in the pelvic cavity let Dr. Bedford Fenwick's plan of giving three times a day half-drachm doses of solution of per- chloride of mercury be tried, together with suitable local treatment, and many of these cases will entirely recover without operation. Or (2) if not very badly diseased themselves, they keep up serious conditions not amenable to milder measures, as certain cases of in- sanity, dysmenorrhoea, and uterine fibroids. Price, of Philadelphia, and many others have seen insane women cured by removal of the appendages. G. H. Rohe, who has made this subject a special study, says : " The results obtained (from operation) not only encourage us to continue in the work, but require us, in the name of science and hu- Indications for Laparotomy. 3 manity, to give to an insane woman the same chance of relief from disease of the ovaries and uterus that a sane woman has." 5. For uterine fibroids not amenable to electricity or vaginal hysterectomy. 6. For malignant growths of fibro-cysts of the uterus too large for removal per vaginam. 7- For hysteropexy, as advocated and practiced by Thomas Keith since 1869. His method is to stitch the stump of one horn of the uterus into the abdominal wound. And the writer has found it to be a useful procedure in those cases of misplaced uterus not amenable to milder measures. 8. For ectopic gestation. (1) When the foetus is dead and the patient's life is threatened, or the foetus has been dead long enough (two or three weeks) to render the operation comparatively safe be- cause of the atrophied condition of the placenta. (2) Near term, before the child dies, in order, if possible, to save both mother and child. When an ectcpic pregnancy is discovered early the patient should be kept quietly in bed upon low diet until the danger of rupture is past, which is practically the fourth or fifth month, and then by care and an easy life you may tide the patient along until near full term, when your operation may save two lives. I hold that the foetus should not be destroyed, and that the sec- tion should be made at term before the child dies a natural death, as a wise provision of Providence if not removed about this time. Dr. Reed and the late Professor Goodell agree with me in part upon the foregoing, for the latter said shortly before his death that after the fifth month of ectopic gestation he would try to carry the case to full term and then operate to save both mother and child. 9. In all removable tumors complicating pregnancy and liable to produce premature labor or interfere with delivery at term. If done carefully these operations do not disturb the normal course of preg- nancy in the least. The writer has done two of these operations- one at the third month and the other at the fourth-without any trouble. 10. In all cases of labor at term if a living child can not be deliv- ered through the natural channel. In short, embryotomy and other mutilating operations upon the living child are not justifiable. Sym- physiotomy will aid in some of these cases where formerly destruction of the child was practiced ; but Csesarean section or Porro's operation are always preferable to destruction of the child. 4 W. O. Henry, M. D. Please note that Harris gives the results of the first fifty Caesarean sections in this country, and also of the first fifty in Europe, as follows : Women saved 75 Children saved .94 Total 169 So that a total of one hundred and sixty-nine lives were saved out of a possible two hundred. Whereas if embryotomy had been done one hundred innocent children would have been murdered, and possibly some of the mothers would have died from septic or other complica- tions. At all events, here is a positive saving of sixty-nine lives. The physician's business is to save life, not to destroy it. It is more humane, scientific, and moral to let two die (if need be) in an honest, intelligent effort to save both than to deliberately destroy an inno- cent person. Winckel has demonstrated that Caesarean section may save a living child if done within thirty minutes of the mother's death, but results are better if done within ten minutes. 11. In peritonitis not yielding to milder measures Dr. E. E. Mont- gomery saved a patient by this operation who had peritonitis follow- ing abortion. Tait and Baldy also both advocate this operation. Korte records eighteen operations with six recoveries in suppurat- ing peritonitis. Barling, of Birmingham, reports a successful case in a girl aged seven years. Dr. Sutherland reports two cases of traumatic, non-suppurating peritonitis in children which, being obstinate to medical treatment, yielded nicely to abdominal section. So that I hold a patient should not be allowed to die from a peritonitis, whether following labor, abor- tion, or any other exciting cause, without giving them the benefit of this operation. 12. In tubercular peritonitis as a specially curative measure. Kdnig, in a report to the Berlin Congress, gave a summary of one hundred and thirty-one cases thus treated. Twenty-four died, eighty- four were cured, and the remainder were improved by the operation. So many of these operations have now been done successfully with drainage and without it, with flushing the cavity and without it, that it is generally recognized as a valuable treatment in children and adults suffering from tubercular peritonitis. 13. It is indicated in appendicitis: 1. When rupture has oc- curred. 2. When pus is present. 3. When a tumor remains and Indications for Laparotomy. 5 the patient grows worse rather than better after five or six days' treatment of rest to the body, mind, and intestinal tract. I am inclined to think too free catharsis is often practiced in these cases and that they are really aggravated thereby. Dr. J. B. Murphy says : " The rule first, last, and always should be to operate in every case of appendicitis, promising or unpromising, at the earliest possible moment." Dr. Deaver and Dr. McBurney both advocate early operation in all cases. In contrast with these opinions we have Treves, Ashhurst, Osler, Hare, and Meigs, who all oppose early operation and believe that too many appendices are being removed. Dr. Lange, of Ohio, reports very carefully eighteen cases treated without operation, and all recovered. Dr. Grandin, of New York, reports eighteen cases. Upon ten he operated and had two deaths. The others all recovered but one with- out operation. In addition to these experiences and opinions we have the com- bined testimony of the great mass of general practitioners who have for years treated many of these cases successfully without any opera- tion. 14. In rupture of the stomach, bowels, gall, or urinary bladder and uterus when any of these viscera pour their contents into the peritoneal cavity. Kriege and Barling each report a successful case of laparotomy done for perforating ulcer of the stomach. Kyewski reports two cases of rupture of the intestines from ab- dominal contusion, in which laparotomj was done, the bowel sutured, and recovery followed. Dr. Richard Braun von Fernwald has recently saved two women by abdominal section and repairing a ruptured uterus. Rupture of the urinary bladder shows about ninety-five per cent, of deaths if left to Nature, but only sixty-eight per cent if section be done and the rupture repaired. Perforation from typhoid ulcer shows about twenty per cent, of recoveries from section and suturing of the ruptured point. 15. In all penetrating wounds of the abdominal and pelvic cavi- ties. Since the very elaborate paper of Dr. Nancrede in 1887 the consensus of opinion has been more and more in this direction. Rapetto reports recovery from a stab wound of the stomach after laparotomy and repair of the wound with Lembert-Czerny sutures. 16. In obstruction of the bowels under the following conditions: i. It should be done at once when obstruction is due to intussuscep- 6 W. O. Henry, M. D. tion, gallstone, enterolith, foreign body, or morbid growth. 2. If due to volvulus, constricting bands, or other undetermined cause, it should be done as soon as alarming symptoms develop (such as collapse, stercoraceous vomiting, peritonitis, greatly increased frequency of the pulse, or high grade of fever), or when relief does not come after one week's judicious treatment. 17. In stenosis of the oesophagus tending to speedy death, carci- noma of the stomach as soon as discovered, and cholelithiasis when- ever any serious or distressing symptoms arise. Billroth's wonderful successes in more than fifty per cent, of his one hundred and twenty-four cases of direct anastomosis of stomach with bowel, and gall bladder with intestine, together with the many favorable reports from the use of Abbe's catgut rings, Senn's bone plates, and the Murphy button, encourage us to believe that now the surgeon is master of the situation in many of these stomach, gall bladder, and intestinal troubles formerly beyond his control. 18. As an exploratory and diagnostic measure in all other serious conditions in the abdominal and pelvic cavities which do not yield to less heroic measures. The suggestion of Dr. Morris that these cases be diagnosed by di- viding the tissues between the anus and coccyx so that the hand may be passed through the rectum and colon for such purpose has not met with favor from the profession, and I think should be condemned as being unreliable and therefore unjustifiable. Let a word or two of warning be spoken here. In the first place, do not wait too long in recommending and doing this exploratory operation, for an early diagnosis may make the removal of disease or tumors possible and thus indefinitely prolong life and prevent suffer- ing, which if neglected may render operation entirely useless. As a case in point note the cysto-sarcoma of the kidney reported in a re- cent Lancet-Clinic. Hence in obscure cases after due consideration, if not cleared up, then make your diagnostic operation early. In the second place, if it be found upon exploratory operation that your patient will probably live longer and suffer less to leave the morbid condition as found than by removing it, then by all means leave it, sew up your abdominal wound, and give Nature a chance. It is bad surgery and worse morals to complete an operation mere- ly for the sake of being able to say that you have done such and such operation ; therefore stop immediately at the point where you find you can do nothing more for your patient's recovery.