Exploratory Laparotomy.

BY

HENRY O. MARCY, A.M., M.D., EE.U.,OF BOSTON, MASS.

President of the Section of Gynecology, Ninth International Con-gress ; late President of the American Academy of Medicine ;

Member of the British MedicalAssociation ; Member ofthe Massachusetts Medical Society ; Member Bos-

ton Gynecological Society ; CorrespondingMember of the Medico-Chirurgical So-

ciety of Bologna, Italy ; late Sur-geon U. S. Army, etc.

Read in theSection on Surgery, at the Thirty-ninth Annual Meetingof the American MedicalAssociation, May , 188S.

Reprinted from the “Journal of the American MedicalAssociation,’’ January 26, 1889.

CHICAGO ;

Printed at the Office of the Association.ISB9.

Exploratory Laparotomy.

BY

HENRY O. MARCY, A.M., M.D., LE D.,OF BOSTON, MASS.

President of the Section of Gynecology, Ninth International Con-gress ; late President of the American Academy of Medicine ;

Member of the British MedicalAssociation ; Member ofthe Massachusetts Medical Society; Member Bos-

ton Gynecological Society; CorrespondingMember of the Medico-Chirurgical So-

ciety of Bologna, Italy ; late Sur-geon U. S. Army, etc.

Read in the Section on Surgery, at the Thirty-ninth Annual Meetingof the American Medical Association, May, r88&.

Reprinted from the “Journal of the American MedicalAssociation,” January 26, 1889.

CHICAGO :

Printed at the Office op the Association.1889.

EXPLORATORY LAPAROTOMY.

The safety of laparotomy by modern surgicalmethods has so greatly increased the utility ofthe operation, that the time has arrived when itmay be advantageously discussed as a means ofdiagnosis. Although the clinical differentiationof abdominal disease has been much advanced inlater times, it is clearly conceded by those of thewidest experience that many important conditionscan only be approximately determined by all theother means at our disposal.

As if in mockery of my own views, only withinthe week have I made two autopsies upon myown patients which serve pointedly as an illustra-tion. The one, a sufferer from obscure abdominalsymptoms, died from a sudden hemorrhage causedby the rupture of a post-uterine vascular growth,which could have been diagnosticated in no otherway than by exploratory section. The second, achronic sufferer formonths from severe local painsabout the pylorus, where the diagnosis of an emi-nent consultant, as well as myself, lay betweenimpacted gall-stones, or cancer. Symptoms of anacute peritonitis supervened, causing death in afew days. This, viewed in the light of an autopsyof a week previous, where somewhat similarsymptoms had been produced by an activelydeveloping cancer, seemed to settle the case asmalignant. To our utter surprise, the post-mortem revealed an acute apendicitis caused by afoecal concretion which had supervened withulcerative perforation as the cause of the acute

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peritonitis. A stenosis of the pylorus was found,catised by old adhesions about a degenerated gallbladder, full of concretions, but this had nothingto do with the immediate death of the patient.

We have all of us, in our years of experience,more or less often met with abundant illustrationof the uncertainty and obscurity which markedthe progress of the fatal issue from intestinal ob-struction, tuphlo-enteritis, extra-uterine fcetation,abdominal tumors, etc., and, until recently, con-sidered we had exhausted our skill in sympto-matic treatment, where the autopsy has shown,could we have known earlier the changes takingplace, surgical aid might have saved life and re-stored health.

The dangers attendant upon laparotomy arestill considered so great, and the fear of resultsare so fixed in the general opinion of the profes-sion, that it is yet looked upon as a dernierressort.Most of us in middle life have watched the de-velopment of the operation almost from its incep-tion, and some keenly remember the opposition,which assumed even a personal type, in daring toput into execution our convictions.

In the development of modern surgical methods,the experience of the profession is now sufficientlyample to warrant a revision of its teachings, andthe object of this paper will be accomplished byyour active participation in the discussion of thesubject, to which I contribute the following re-port of laparotomies, which includes only and allthe cases where I have opened the abdomen, andfinding conditions which did not warrant furtheroperative measures, closed without surgical inter-ference.

Case i . —Female, set. 30. Opened abdomen in1880. Interstitial myoma. Five years since itfirst gave the patient trouble. Filled pelvic basin.

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On account of the vascular supply, deemed it un-wise to remove ovaries or growth. Recovery easyand rapid. Patient living and far more comfort-able since.

Case 2.—June, 1885. Child, set. 4 years. Seenin consultation with Dr. Adams of Framingham,and aided him in operation two days later. Casesupposed malignant, acute. Temperature 105°,pulse 150. Suffering severe, abdomen distendedwith fluid looking like pus, odorless, creamy,which, on examination, was shown to be a puredevelopment of micrococci (after cultured toseveral generations). Operation determined uponbecause of character of fluid. Abdominal cavitycarefully washed out with a weak mercuric bi-chloride solution. Perfect recovery followed.Patient living and growing finely.

Case j.—May, 1886. F., set. 60. Slow devel-opment of an enormous abdominal distention.Uterine myoma filled the pelvis, but diagnosisuncertain. Fifty pounds of fluid removed. Re-covered from operation and was greatly relieved,but died a few weeks later.

Case 4. —Nov., 1886. Male. Subject to fre-quent attacks of illness, with great pain in regionof appendix. Temperature reaching to 104°.Focalized soreness and tenderness. Appendixnot involved, but bands of adhesion at head ofcoecum were divided. Recovery complete, fol-lowed by a gain in weight of over thirty pounds.Remains well.

Case 5.—Nov., 18S6. F., set. 30. Under ob-servation in hospital for some months. Severepain and emaciation. Uterus fixed. Perhaps acase of old tubal disease. Laparotomy showeddisseminated tubercle mesenteric and over theabdominal walls. Resected a small portion forexamination. Washed out with mercuric bichlo-

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ride solution and closed the abdomen. The mili-ary masses proved to be colonies of tubercular ba-cilli, and cultivations were made which reproducedtrue. Recovery followed, with an improvementof all symptoms. Patient sailed for Europe thefollowing spring, and in a letter under date ofAugust, 1887, she writes, “Am enjoying atpresent very good health, being able to workagain.”

Case 6.—February, 1887. Female, set. 28.Patient confined to bed with severe abdominalpains, Tumor on right side, reaching nearly toumbilicus, accompanied with many of the symp-toms of pregnancy. Uterus evidently merged inthe growth. Proved an ectopic pregnancy.Closed the wound. Miscarriage followed. Re-covery complete and patient remains well.

Case 7.—April, 1887. F., set. 30. Patient illfour weeks. Tumor on right side, growing rapid-ly, Exploration revealed cancer of omentum.Closed wound. Autopsy later showed round cellsarcoma. Thought result not materially changedby operation.

Case 8.—April, 1887. F., set. 33. Pulse andtemperature high, with severe pains caused by atumor of right side extending to umbilicus. Al-though from subsequent history probably cystic,it was found everywhere adherent and judgedmalignant. Patient still living, but for the mostpart confined to the bed for the year. Tumor in-creasing in size, and again I have advised explora-tion with the hope of removal.

Case p. —July, 1887. Dr. W., set. 72. Suffererfor years from gall stones. Now in extremis frombiliary obstruction. Eaparotomy and found adhe-sions to ascending colon and the parts about.Could feel and probably dislodged, in a measure,a calculus, size of a walnut. It was thought not

7

safe to proceed further, so closed the abdomen andimprovement followed for a short period. Woundhealed perfectly. Symptoms of obstruction re-turned and death supervened within a month.Autopsy showed a large impacted calculus andconditions which warranted the conclusion thatthe duct adhesions prevented a safe removal.

Case 10. —August, 1887. Boy, set. 12. Peri-typhilitis. Freely separated adhesions. Patientrecovered well from operation. Wound healed.Death about six weeks later from undeterminedcause. Autopsy showed the intestine unobstruct-ed, and only delicate bands to determine place ofthe extraordinary plastic effusion.

Case 11.—October, 1887. Child, set. 2. Tem-perature 104° and pulse 140 to 150. Opened andwashed out a large pus cavity involving appen-dix, drained. Improvement most marked fromtime of operation. Some weeks later enlarged theincision on account of return of fever, etc. Closeda fistula of the bladder by a continuous tendonsuture and two openings in the large intestinewhich admitted finger, also the abdominal wall.Recovery complete and rapid. Child growingfinely, and seems as strong as before her long ill-ness.

From this report it will be seen, although thelist of cases is small, that life was not seriouslyendangered by the operations, and in more thanone instance, although seemingly only explora-tory, therecovery was dependent upon the surgicalinterference. To write the opposite side of myexperience would be to narrate a long seriesreach -

ing over more than years of active clinica 1study, where the post-mortem revelations havetaught the shortcomings of our art, and withregretful sadness caused us, at least, the contem-plation of what might have been.

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I am well aware that I am not alone in theconsideration of exploratory laparotomy as to theviews taken of the subject in this brief paper.Prominent among the contributions upon thissubject, I take pleasure in citing an able articlerecentty written by Dr. T. Gaillard Thomas, ofNew York City. In the light of the criticisms ofa certain considerable and highly respectable classof the profession, raising the protest against whatthey deem an unjustifiable resort to laparotomyfor abdominal disease, I can but believe that itemanates, as a rule, from men only theoreticallyinterested in the subject. Of the quite largenumber of surgeons, in Europe as well as America,with whom I am personalty acquainted, I knowof no men more conservative in opinion, or whoreview with greater care and precision the prem-ises upon which they base the advisability of op-erative interference, and only a long experienceand extended observation has led them to acceptexploratory laparotomy as, at times, the onlymeans of a correct diagnosis.

Eet us hope those younger in the professionwho have entered upon its labors under more fa-vorable auspices, will take heed to such warning,profit by the lesson it teaches, and remember thatthe future, if not the present, will regard the sinsof omission in the same stern light as those ofcommission.