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Deaths in gynecology
Deaths in gynecology A comparative
C.
study
GORDON
(1944,
JOHNSON,
CHARLES
E.
DARLING,
CHARLES
FRANKLIN
19701
M.D. JR.,
McDONELL,
M.D. M.D.
New Orleans, Louisiana This presentation on deaths in gynecology is intended as a comparative study on the same subject, and concerning the same number of fatalities, published by Miller in 1944. His contribution was based, in turn, on a similar paper published by Polak in 1928. Like this paper, the Miller and the Polak pagers stress clinical rather than statistical considerations. The data in this 1970 Qresentation di&r in certain respects from the Miller data, as would be expected at the end of 26 years, but are surprisingly similar in others. The management of benign conditions has imQroved (due in part but by no means entirely to antibiotic therapy), but in malignant disease significant improvement remains to be achieved, AU three of these pagers are directed to one end-could any of these deaths have been prevented? If so, who was responsible for the deaths of these women? The answer is the medical QrofasJion and the solution is the intensifiedinstruction of women in the facts of pelvic cancer.
1 T IS NO w well over 40 years since the late Dr. John 0. Polak’ published what the late Dr. Hilliaxd E. Miller,2 some 16 years later, described as “a very frank and honest, and therefore very troubling, paper” on the lessonsto be learned from a study of “mortalities” (casefatality rates). What Dr. Polak and his co-author, Dr. Donald G. Tollefson, learned was that a very large proportion of the 138 deaths in their 4,270 gynecologic admissionsshould not have occurred, and would not have occurred, if there had been a stricter adherence to their own criteria of surgical safety and a generally better exerciseof surgical judgment. Dr. Miller, in i944, said that ever since he had read Dr. Polak’s article he had had it in his mind to write a similar one when he “thought he had achieved at least a minimum From Charity Hospital of Louisiana at New Orleans. Presented at the Eighty-firs: Annual Meeting of the American Association of Obstetricians and Gynecologists, Hot springs, Virginia, Sept. 10-12, 1970.
of professional wisdom.” He thereupon wrote a paper dealing with the 401 gynecologic deaths that had occurred at Charity Hospital of Lousiana at New Orleans over the 6 year period ending in 1942. I was enormously impressedby that paper and I think it has been my own intention, ever since I read it, to duplicate Dr. Miller’s performance when I thought I had fulfilled his specification concerning “a minimum of professional wisdom.” Mahrlal
and
metheds
The contribution of myself and my coauthors is, like the Miller paper, an analysis of 401 fatalities in which some gynecologic condition was the sole or the principal cause of death. The series includes 106 autopsies. To secure these casesthe necrology books of the New Orleans Charity Hospital were examined and a listing was made of all appropriate deaths. The records of thesecaseswere then examined individually and each record was discarded or was accepted for my pur-
Deaths in gynecology
poses.The result of this effort was a list of gynecologic deaths that (figuring backward) covered the period from January, 1969, through April, 1961, and that was as nearly consecutive as possible.I have no doubt that others, making a similar search, would have selected or rejected at least some different cases. Each of the records selectedfor the investigation was summarized on a form, the entries on which paralleled, as far as possible, the items discussedin the Miller paper. They included: the accuracy and promptness of diagnosis; the correctnessof the surgical procedure and its timing; the adequacy of preoperative preparation; the promptness and vigor (or the lack thereof) of the recognition and management of postoperative complications; the principal responsibility for the fatality (the patient herself, an outside physician, or the hospital staff) ; and general and specific methods of improving gynecolqgic diagnosisand therapy. All of these cases were handled on the gynecologic services of Charity Hospital of Louisiana at New Orleans. This is a teaching hospital, now operated on an equal admission basisby the Tulane University and Louisiana State University Schools of Medicine. When the Miller material was collected, some 20 per cent of the beds were controlled by an independent service which included many excellent gynecologistsbut which lacked the tight organization that is so necessaryfor the best gynecologic results. This service was eliminated’ in 1961 and only a few cakes from it are used in my series. The Polak report is a true analysisof what the authors call “mortalities.” It provides the total picture. Our contribution, like Dr. Miller’s, is not statistical. The material consists only of deaths, and of individual deaths at that. I should like to make it clear, however, that behind his paper and ours is a massof statistical data upon which are based the statementsmade and the conclusionsdrawn. We have made no attempt at a systematic survey of the literature, but even a casual review makes it clear that there is surprisingly little in it under the heading of deaths in
839
gynecology and that most of that is in the foreign literature. Two articles by Greenhill’> ’ are an interesting exception. No doubt a great deal of material on the subject is buried in articles with nonrevealing titles. The material analyzed by Dr. Miller in 1944 consistedof 247 deaths from malignant pelvic diseaseand 154 deaths from benign disease. This 1970 material consists of 35 deaths from benign diseaseand 366 from malignant disease, distributed as follows: carcinoma of the cervix, 209 cases; carcinoma of the endometrium, 50 cases; carcinoma of the ovary, 59 cases; carcinoma of the vulva, 11 cases;carcinoma of the vagina, 8 cases; carcinoma of the tubes, 2 cases; sarcoma of the uterus, 10 cases; and mixed Milllerian tumors of the uterus, 17 cases.As a matter of convenience, the deaths from benign disease are discussed under a single heading, since their small number makes extended comparison with the much larger Miller material rather impractical. General
considerations
Race and age. The disproportionately large number of Negro deaths in the Miller series in both benign and malignant diseaseis duplicated in my own series, in which, in 366 instances of pelvic malignancy, there were 253 Negro casesand 113 white. In 35 deaths from benign disease there were 28 Negro cases.There are a number of explanations, beginning with the basic fact that hospital admissionsfor the periods covered by both studies show similar disproportions. In 1944 Negroes had not shared to any appreciable degree in the general prosperity, which since then had reduced admissionsto charity and public hospitals all over the country. Even if they had shared in it, integration was then not even a theory, let alone a fact, and facilities for Negro care were limited. The 401 deaths in the 1970 study are in general too recent, to be influenced by MEDICARE or MEDICAID. In benign conditions the Negro deaths exceed the white deaths for another reason: As all Southern gynecologists know, both pelvic inflammatory diseaseand uterine fl-
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Johnson,
Darling,
and
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McDonell
broids are more frequent in Negro women than in white and are likely to be seen in more advanced stagesbecauseNegro women are even more inclined than white women to postpone medical consultation in the early, inconvenient stageof symptoms. In the Miller seriesthe age factor showed a gradual rise to 45 years and then a gradual decline. In the 366 malignant casescollected in 1970 the age range was from 13 years (in carcinoma of the ovary) to 100 years plus (in uterine fibroids-the age was verified by a resident staff), and 177 patients were under 50 years of age. The somewhat earlier peak in the Miller seriescan be explained by the large number of benign cases, which represented almost 40 per cent of that series. The higher age peak in the 1970 seriescan also be explained by the fact that women, even more than men, are now living longer and well into the age period in which malignancy-though not invariably-is more likely to develop. Period of investigation. One of the first considerations to impressone in an analysis of the 1970 serieswas that the 8vh years which had to be utilized to collect these 401 cases exceeded by more than 2 years the period necessary for the 1944 collection. The discrepancy is readily explained by the reduction in casefatality rates which occurred in the interim, a reduction which itself is readily explained. It was a far cry from the criteria for safe surgical risks in the Polak paper to those in the Miller paper. Polak was one of the most experienced gynecologists of his day, but one of his minimum preoperative requirements was a hemoglobin of “at least 60 per cent.” The Miller criteria, outdated though some of them are, have a far more modern ring. There are a great many explanations, many of them originating in the World War II experience, to account for the improvement in casefatality rates that has occurred since the Miller paper was written. Resident systems have multiplied. Surgical techniques have improved and new procedures have been developed and made practical. Indications for operation are more clear-cut. Recovery
15, 1971
Amer. J. Obstet. Gym.
rooms are almost universal. There is a new concept of shock; both hemorrhagic and septic are now recognized. Adjunct therapy, both before and after operation, has becomeone of the accepted facts of surgical life. Blood banks operate around the clock. Early ambulation is now generally practiced. The antibiotics have been introduced and their use has been both standardized and individualized; they have not fulfilled all of their original promise, but they have played an important role in the reduction of the gynecologic death rates between 1944 and 1970. Finally, operation in elderly patients now carries little more risk than the sameoperation in younger women. One or two local considerations might also be mentioned. When the Miller paper was written there were only nine hospitals in Louisiana that provided medical care for the indigent, and difficulties of transportation to them accounted for some poor results. Today there are 17 such hospitals, and with a statewide ambulance service the transportation factor is no longer important. Pathologic categories. In general, the 1970 collection of deaths parallels the 1940 Miller series. There are no instances of chorionepithelioma in the 1970 seriesagainst two in 1944 series, an incidence which can be explained by chance. But the absence of any deaths from surgery for obstetric injuries in the 1970 series is another and significant matter. There were 13 such deaths in the 1944 series, and in Miller’s opinion 11 of them should not have occurred. They were chiefly due to technical errors and inadequate (or totally lacking) preoperative preparation, including one failure to correct a hemoglobin deficiency of 50 per cent. The lessonsof these 1944 caseswere obviously learned before the 1970 caseswere collected. Deaths
from
benign
disease
Ectopic pregnancy. It is ironical that the highest proportion (18 cases)of hospital staff responsibility for some of the deaths in the 1970 seriesshould have occurred in the 35 benign cases, in which conditions for care were generally most favorable. Six patients were in good condition on admission and 10
Volume 109 Number 6
others were in fair condition. Among the conditions represented were ectopic pregnancy (5 cases), uterine fibroids ( 11 cases, 4 degenerating) , and tuboovarian abscesses ( 16 cases, 13 ruptures). Of all emergency gynecologic conditions none responds to operation more promptly and more satisfactorily than ectopic pregnancy. In 699 cases reported from the Tulane service at the New Orleans Charity Hospital in 1965, there was only one death.6 The patient died before any treatment could be instituted, and the diagnosis was made at autopsy. On this service 90 per cent of the patients are now operated on within 8 hours of admission and almost 75 per cent within 3 hours. Nine of the 15 patients with ectopic pregnancy in the Miller series had no operation. Therapy, he stated, was “hesitant and long delayed” and attempts to secure donors were “curiously languid.” This is not the way to manage a condition in which the routine should be to open the abdomen instantly, find and tie the bleeding point instantly, and then consider other matters. In 4 of the 5 deaths from ectopic pregnancy in the 1970 series the patients were beyond help when they were first seen. One died in the admitting room, 2 died on the operating table, and another did not respond to vigorous efforts to correct a renal complication. The fifth patient died because something went seriously wrong with the hospital setup. She was admitted with the diagnosis made, but she was kept in the admitting room, without treatment, for 90 minutes, she was given no blood, and a gynecologic consultant never saw her. She had 3,000 C.C. of blood in her abdomen at autopsy. Uterine fibroids. In the Miller analysis of 154 deaths from benign pelvic disease there were 53 deaths from uterine fibroids, 43 of them in Negroes. Many of these women had had their growths for years and they were enormous, sloughing, and adherent. In 7 cases surgery was out of the question. In Miller’s opinion at least 10 deaths in this group could have been prevented by better preoperative care (it was often poor and sometimes lack-
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ing) and postoperative care (it was also often poor and was also delayed, too brief, or otherwise inadequate). Operation for fibroids, if carried out with the proper safeguards, is attended with fewer risks than any other gynecologic operation, and reliance on that generalization, Miller pointed out, led to a tendency to underestimate potential risks and to develop an unwarranted complacency. Most of this criticism does not apply to the 11 fibroid deaths in the 1970 material. Both preoperative and postoperative care was generally good, and outside, not hospital, management was responsible for 3 patients received moribund after prolonged antibiotic therapy. But the attitude of complacency of which Miller complained was evident in several cases in which treatment was at best perfunctory, and an unwarranted risk, which failed, was assumed in 2 patients who were submitted to cholecystectomy along with extensive pelvic surgery. There was no instance of supracervical hysterectomy in the 1970 series against 12 such operations in the 1944 series. Tuboovarian abscesses. I do not believe that tuboovarian abscesses are treated with the respect they deserve. I regard them as potentially more lethal than appendiceal abscesses. In my own opinion, which is no more than an opinion, their walls are thinner and so they rupture more readily. In the 154 benign gynecoIogic deaths in the 1944 series there were 38 tuboovarian abscesses, 14 of which were proved by autopsy and 21 of which were ruptured. In the 35 benign deaths in the 1970 series there were 16 abscesses, 13 of which were ruptured. The incidence of the condition and of its complications, most notably rupture, has not been reduced by the introduction of antibiotics, and without proper treatment most women who sustain this accident will still surely die of it. Observation in the hospital, under suspicion of the possibility of rupture, is the first step in proper management. The second step, we now believe, is surgical. For many years on the Tulane service at
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and McDonell
Charity Hospital these abscesses were treated conservatively, chiefly under the influence of Dr. C. Jeff Miller, who was influenced, in turn, by Simpson’s dicta on the subject in 1909. Then, as recommended by Te Linde and his associatesat The John Hopkins Hospital,e the policy was changed to one of aggressivesurgery; the ruptured abscesswas regarded as being as true an emergency as a ruptured appendix. The new policy has paid off richly, the death rate being reduced from about 90 per cent in the first reported series to 0 in the last 27 cases.’ In three of the cases in the 1970 series the patients were received moribund and all treatment was unavailing. But in another case both surgical and gynecologic surgeons ruled out a operative problem, and the patient died, with 3,000 C.C.of exudate in the abdomen, while awaiting medical consultation. In another instance of staff responsibility, a ureter that had been severed was not identified at operation. The simple insertion of a catheter would probably have saved this woman’s life. Deaths
from
malignant
disease
Radical surgery. Before proceeding to a discussion of deaths from pelvic malignant disease,certain general statements should be made: Surgery is, justifiably, more aggressive in 1970 than it was in 1944 and the risks that attend it are less, but there is still a delicate line that must be drawn between boldnessand courage, which are commendable, and rashness, for which there is no justification. Also there is an intangible dividing line between a growth which is resectable on one day, or even at one hour, and which the next day or even the next hour is not. There is still another important consideration in this connection: In determining the treatment the patient is to receive the surgeon must not only weigh life against death but must also visualize the kind of life he is providing for his patient. A veritable death in life follows some cancer surgery, and, like Miller, I question the value of most- operations in which metastatic interference with
Amer.
March 15,197l J. Obstet. Gynec.
bowel and bladder function requires a corrective attack upon the urinary tract, the lower colon, or the rectum. However brilliant an occasional result may be, can one really justify such taxing and dangerous surgery upon a patient whose life expectancy, at best, is a matter of months? Some cancers are hopelessfrom their incipiency. Sarcoma of the uterus, for instance, and Mtillerian tumors spread like brush fires. It is often only a matter of months between their first clinical manifestations and the fatal outcome. The fact that in the 1970 cases9 of 17 patients with Miillerian tumors survived a year or more is a tribute to the vigorous and apparently correct treatment they received at Charity Hospital. The survival in this seriesfor this period of time of only one of 10 patients with sarcoma of the uterus is the more usual story. It is a tragic fact that in the 366 deaths from pelvic malignant disease collected in 1970, 90 patients had diseasethat was too far advanced for any measuresexcept those directed to the control of hemorrhage or the relief of pain. Even after rehabilitation they could not have withstood the stressof surgery that held out any hope of cure. The therapy of the individual case of cancer rests, of course, on the circumstances of the individual case and the experience of the surgeon who is handling it. The general opinion is that in cancer of the cervix it makes little difference whether treatment is by surgery or radiation or by the combined modalities. There were a great many radical hysterectomies performed in the 1970 series, many more than in the 1944 series,which covered a period when the Wertheim and similar procedures had suffered something of a decline in popularity. There were only 6 deaths from exenteration procedures in the 1970 cases (the operation was not in use in 1944). These procedures have a very limited use in the type of patient treated at Charity Hospital. They are carried out on the Tulane service by a trained team with competent paramedical help, and with all the
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equipment necessary for elaborate preoperative and post-operative care. Indications are strict and the operation is seldom undertaken unless the chances of cure are estimated at 30 per cent or better. When it is performed under other circumstances, it is seldom justified and is, indeed, likely to precipitate the very results it was planned to prevent or delay. Radical procedures of this type should not be recommended to medical students or taught to interns and residents, most of whom, when their training days are done, are not likely to find themselves so situated as to be able to utilize their knowledge. Causesof death. On the whole, the women in the 1970 series, both statistically and clinically, were in better condition than might have been expected from their evaluations: 45 were rated as in good condition and 79 others as in fair condition. The poor or moribund status of the others was chiefly attributable to their malignant disease. In the 1944 series there was a very considerable overlay of organic disease and an occasional tendency to disregard the opinion of the medical consultant, especially in regard to anesthetic precautions and surgical tolerance. In the 1970 series preoperative preparation was generally good, though in well over half of the cases the patients were not good risks for any therapy. The results of the preoperative situation are evident in the postoperative situation in both the Miller series and our own. There were multiple complications in the 1944 series, some of which were extremely serious and some of which were not well handled. In the 1970 series complications were far fewer and most of them were well handled. Peritonitis, pulmonary complications, and embolus all showed significant decreases. It is shocking, however, to find five patients dying of exsanguination in the admitting room, with hematocrits as low as 13, and a number of others dying there or in the emergency room, chiefly from shock, before any treatment was possible. Aside from the malignant process itself, cardiovascular and renal diseases, particu-
Deaths in gynecology
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larly uremia (46 cases), were the most frequent causes of death. In the Miller series there were seven deaths from the hepatorenal syndrome, which led to the recommendation that preoperative attention to the status of the liver was often a wise precaution. There were no deaths from this cause in the 1970 study, possibly because of the generally good preoperative and postoperative care. The diagnosis was not suspected in any instance in the 1944 series and would probably be overlooked today. In the Miller series 8 patients had presently, or had a history of, multiple malignant diseases. There were 26 such cases in the 1970 series. In each series was a patient who had survived three previous episodes of malignant disease only to perish in the fourth.
Carcinoma of the cervix and the endometrium. In both the 1944 and 1970 studies, as in all similar investigations, carcinoma of the cervix was the major problem. In the 1944 series, the figures for which include both sarcoma of the uterus and carcinoma of the fundus endometrium), it was responsible for 167 of the 247 deaths from malignant disease. In the 1970 series carcinoma of the cervix accounted for 209 of the 366 deaths from malignant disease, and carcinoma of the endometrium accounted for another 50. If, the figures for Miillerian tumors (17 cases) and sarcoma (10 cases) are added, it is seen that all varieties and locations of malignant disease of the uterus accounted for well over three quarters of all deaths from this disease in this series. In the 1970 series the age range for carcinoma of the cervix was from 23 to over 100 years. The time lag from awareness of symptoms to medical consultation ranged from 0 (no time lost) to 9f/2 years (undoubtedly while the symptoms of a chronic benign condition came to represent the symptoms of a malignant process). In this series considerably less than half the patients sought medical advice within a year of the development of symptoms, and in the 1944 series the delay was even longer.
844
Johnson,
Darling,
and
McDonell Amer.
As a result of the prolonged time lag, only 41 patients in the 1970 series were in Stage I of their disease when they were first seen and only 52 were in Stage II, which means that only about half of the patients for whom this information is available (188) were in stages of their disease that were favorable for cure. Just as significant, only 38 patients were in good condition on admission and only 45 others were in fair condition; 34 were classified as moribund. In terms of management, 40 patients were in no condition to tolerate anything but supportive therapy. Miller, reporting on the even bleaker outlook in his series, said that under these circumstances there was little use in discussing histology and response to treatment. In both the 1944 and the 1970 series bleeding was the most frequent first symptom. It usually is. From the standpoint of diagnosis it was the most reliable symptom. It usually is. But because it was usually insidious and painless the tendency was to regard it, for long periods of time, as not more than an inconvenience, and a minor one at that. As these data prove again, the climacteric is the most dangerous period of a woman’s life. The situation in the 1970 cases was somewhat improved over 1944, but even among physicians there was an occasional tendency in the 1970 series to regard spotting and bleeding as a part of the menopausal pattern and to omit the diagnostic measures-the simple diagnostic measureswhich would prove they were not.’ In the 50 cases of carcinoma of the endometrium in the 1970 series, the age range was from 31 to 82 years and the time lag was from 0 in one case to 13 years, also in one case. Only 3 patients were in good condition on admission, only 10 others were in fair condition, and 10 were admitted moribund, though in most instances they had all received such treatment as was possible immediately after the diagnosis was made. In 18 cases no therapy was practical, and only seven patient survived for a year or more. Four, infact, died before any treatment at all could be started. This is a discouraging
March 15, 1971 J. Obstet. Gynec.
picture in disadvantaged women of what is generally regarded as the most favorable of all pelvic malignant diseases. Carcinoma of the ovary. The second largest number of deaths in the 1970 series (59) and in the 1944 series (35) was from carcinoma of the ovary. In the 1970 cases the age range was from 13 to 72 years and the time lag from symptoms to medical consultation was from immediate in 5 cases to 6 years in one. Sisteen of the patients had waited 6 months or longer before seeing a physician, a delay that was peculiarly unfortunate in a condition in which even the earliest symptom is likely to be a late one. The status of these patients, chiefly as a result of their delay, was good in only 3 cases and fair in only 12 others, The condition of the remaining patients was poor in 31 and moribund in 11. Small wonder that in 13 cases no therapy at all was possible. In his 1944 presentation Miller painted a gloomy picture of the “terrible swiftness” of this form of pelvic malignancy and stated flatly that he had never saved a patient with it. Since that time, more aggressive surgery, combined with irradiation and chemotherapy, has wrought considerable improvement. In my private practice I now have 5 patients who are alive and well from 6 months to 11 years after definitive operation; 3 of them have passed the 5 year period. In one remarkable case in this group the patient, in addition to carcinoma of the ovary, presented thrombocytopenic purpura and Boeck’s sarcoid. In another case the diagnosis was missed on the gynecologic service and the patient was transferred to sur?sFYRecommendations A great many of Dr. Miller’s conclusions and recommendations are now standard practice and have been for many years. Several could profitably be repeated here: 1. Total hysterectomy should be routine whenever hysterectomy is done. Sixteen women in these two series lost their lives because that rule was not followed and cancer
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was able to develop in their residual cervices. One of them must have already had it when supravaginal hysterectomy was performed, 9 months before malignant cervical disease became apparent. 2. Attempts at diagnosis of unsuspected cancer, as well as suspected disease, should be intensified, particuarly in the menopausal years. In every instance cancer should be the first diagnostic possibility to be entertained and the last to be discarded. And diagnosis should always be regarded as a matter of extreme urgency. It was far too leisurely in a number of cases in both of these series. 3. There should be careful attention to preoperative preparation, on the principle that under the stress of anesthesia and operation minimal deviations from the normal may become maximal. 4. There should be more alertness to detect incipient postoperative complications, and a quicker resort to parenteral therapy and such other measures as are indicated. Also, these measures should be continued until it is perfectly clear that they are no longer needed. 5. Patients in hospitals should be carefully observed. As several cases in these two series prove, there is no more dangerous time and place to develop one disease than while in the hospital under treatment for another. The responsibility of the profession for deaths from pelvic malignancy The assignment of responsibility for individual deaths always has an element of unfairness no matter how one strives to be objective. It is quite clear, however, why some-indeed most-of the women in these two series lost their lives. In effect, by their delay and, in some instances, by their complete lack of cooperation they signed their own death warrants. In the 1970 series outside physicians could be blamed for the fatal outcome in only 17 of the 366 deaths from malignant disease and the hospital staff for only 47. Both figures represent a decided improvement over the 1944 figures. On the other hand, while a certain per-
Deaths
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845
centage of errors is to be e)xpected on a teaching service, they must be kept to a minimum, as they can be by correct organization and supervision. I treated none of the patients in this series myself, but I supervised the care of many of them and, like Dr. Miller, I found this review a rather chastening experience. Orientation of women-the road to improvement In 1961 the American Cancer Society began a campaign to reduce the death rate in cancer of the uterus. The effort has been highly rewarding, but it has not gone far enough. It is only when one makes such a study as we have just reported that one appreciates the real tragedy of carcinoma of the pelvic organs-the mistakes, the delays, and, above all, the lost opportunities and the deaths that should not have occurred. The basic explanation for the continued high death rate in carcinoma of the cervix and other pelvic malignancy is delay in diagnosis, and delay is explained, in turn, by ignorance. The records for the 1979 series, as well as my personal experience in private practice, suggest a disturbing lack of knowledge on all levels, both professional and lay, concerning pelvic malignancy. In the profession, procrastination and a low index of suspicion are not infrequent. In the Charity Hospital records for the 1970 series are a number of cases in which the diagnosis was unduly delayed, even when the history and physical findings seemed to point to one inexorable conclusion. Our intensified educational effort must therefore begin on the professional level. Students, interns, residents, and practitioners alike must be impressed with certain facts: 1. The lethal potentialities of all types of vaginal discharges and all variants of spotting and bleeding. 2. The urgency of diagnosis and, once it is made, the equal urgency of therapy. 3. The limitations of radical surgery, with emphasis on the fact that mere prolongation of life is not in itself a compassionate achievement.
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and
March 15, 1971 Amer. J. Obstet. Gynec.
McDonell
4. The resfaonsibility of the profession for the terminal Bare of patients for whom death is the only o&come. 5. The r&ponsibility of the profession on all levels f& indoctrinating women in the facts of pe&c cancer, particularly cancer of the cervix, The or&tation of women in this knowledge con&s of stressing to them, at every opportunity, three basic facts: 1. A* kind of discharge and any kind of abnotial bleeding may indicate cancer and requires prompt consultation with a physician fo prove that it is or is not. 2. Pelvic examination should be carried 0uD twice yearly on all women over 30 years of age, whether or not they have symptoms rdferable to the pelvis. 3. The Papanicolaou test should also be carried out twice yearly on women in this age group. It should be used, in fact, wher-
ever and whenever physicians have any contact with women-in private offices, in outpatient clinics, in the wards of public and private hospitals, even, as is the practice at the University of Miami, in emergency rooms. This is a test of great reliability and I deplore the recent action of the Cancer Control Section of the Public Health Service in diverting to other purposes the more than two million dollars previously assigned to popularize this test and to train technicians to perform it. The outstanding lesson which my co-authors and I have learned from our review of 401 gynecologic deaths, 366 of which were due to malignant disease, is (1) that these deaths will continue to occur until women are instructed more intensively and more personally in the facts of cancer and (2) that their orientation in these facts is the responsibility of the medical profession.
REFERWNCES
and Tollefson, J. OBSTET.
D. G.: AMER.
GYNEC. 16: 600, 1928. E.: AMER. J. OBSTET.
2. Miller, H. GYNEC. 48: 824, 1944. 3. Greenhill, J. P.: ADIER. J. OBSTET. GYNEC. 24: 183, 1932. 4. Greenhill, J. P., and Loeff, H. M.: AMER. J. OBSTET. GYNEC. 61: 340, 1951.
Discussion DR. JOSEPH A. HARDY, St. Louis, Missouri. We have been privileged this morning to hear a very courageous and highly philosophical presentation by Drs. Johnson, Darling, and McDonell. After 2 days, during which we have learned how the frontiers of our specialty have been pushed forward, it is appropriate that we be reminded that there remain areas in which WC should not take too much pride in our accotiplishments. Dr. Johnson has emphasized that his a&ysis of 401 deaths is not statistical in its #itent. Nevertheless certain statistical informatih may be drawn from it. It is interesting-thdugh not particularly gratifying--to note that in the Miller series of 1944 there were 247 deaths due to
5. Webster, H. D., Barclay, D. L., and FisGBidlT, C. K.: AIUER. J. OBSTET. GYNEC. !X& f3, 1965.
6. Te Linde, R. W.: Discussion of C&l Nix, F. G., and Cerba, H. T.: OBSTET. GYNEC. 72: 820, 1956. 7. Johnson, C. G.: Unpublished bata.
m&gnancy while in the present series this num&r had increased to 366. One might have expected, with increased public acceptance of periodic physical examination and during a decade in which the use of cytologic screening techniques had so greatly increased, that some improvement in the salvage of women with neoplastic disease of the pelvic organs might have been achieved. That such was not the case is discouraging even though the 366 cancer deaths occurred in a period of 8y4 years rather than the 6 years covered by the Miller study. This discouragement is heightened when one notes that in the 1944 series cervix cancer accounted for 167 of the 247 deaths due to malignant disease and in Dr. Johnson’s series the cervix
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was responsible for 209 deaths of the 366 due to malignancy. In other words, cervix cancer deaths in 1944 were 68 per cent of the total due to malignancy. In the ensuing 25 years this figure was reduced-but only to 57 per cent. Stimulated by the concept of attempting to assign responsibility for deaths on the gynecology service, I reviewed the deaths during the 5 year period, 1965-1969, at the hospital where most of my work is done. St. John’s Mercy Hospital is a 600 bed private hospital with university affiliation and a strong teaching service. The bulk of pelvic surgery is done by men who hold faculty appointment at St. Louis University, with perhaps 10 per cent of the patients operated upon by the resident staff either on their own clinic service or under the supervision of the visiting staff. In the 5 years studied there were 6,741 patients discharged and 19 deaths occurred-a gross mortality rate of 0.28 per cent (1 in 354.7 patients). A total of 3,324 operations was performed and 15 of the 19 deaths occurred in patients who were operated upon-a gross operative mortality rate of 0.45 per cent. The autopsy rate was 52.6 per cent (10 out of 19). Of the I9 patients who died 15 had malignancies, divided as indicated-corpus 7, cervix 3, and ovary 5. In some instances multiple malignancies were present but they have been classified according to what was thought to be the primary source of disease. In 13 of the 19 patients who died, the fatal outcome was directIy due to the disease. In 6 instances death was attributed to other factors, such as embolus, cardiac arrest, pulmonary edema, faulty surgical technique, accidental perforation of a viscus, etc. My analysis led me to the conclusion that in 4 of these 19 women death was possibly avoidable. Time will not permit a detailed report but perhaps a few examples will serve to indicate where better judgment or greater care in choice of operative procedure or more meticulous operative technique might have saved a life. A 20-year-old nulliparous patient was admitted with a diagnosis of infertility and ovarian cyst. A curettage and hysterosalpingogram were followed immediately by tramtuba instiation of air. She died in the operating room of air embolism. A 39-year-old patient, para VI, was operated upon for fibromyoma of the uterus associated
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in gynecology
847
with menorrhagia. She died 8 days after operation following multiple transfusions, after developing a lower nephron nephrosis. At autopsy there was massive intraperitoneal and retroperitoneal hemorrhage apparently due to faulty hemostasis of the left infundibulopelvic and broad ligament pedicles. A 49.year-old patient, para 0, was admitted for diagnostic dilatation and curettage which revealed carcinoma of the endometrium. During implantation of radium the uterus was perforated. Laparotomy disclosed an additional perforation of the small bowel which resulted in a vaginal-intestinal fistula with pelvic abscess. She died 43 days after operation for a pulmonary embolus. Autopsy revealed widespread metastases of the primary uterine tumor. There were a number of patients for whom no treatment was available. Several women who had multiple admissions to the hospital for malignant disease and its sequelae came in simply to die in whatever degree of comfort could be afforded them. There remains, however, the bitter truth that Dr. Johnson has pointed out to us-there are women who have died unnecessarily and so long as this situation obtains we cannot afford complacency. DR. JOSEPH H. PRATT, Rochester, Minnesota. Dr. Johnson and his co-authors have performed a service for all of us that should be pertinent and effective. We learn most whp our noses are rubbed into the brutal facts of p&tent ignorance or delay, physician delay, iatTq,genic damage or the inevitable workings of mathematics which, on a percentage basis, tell us that in so many admissions or in so many operations certain unhappy sequelae will rqult. A patient’s death is the ultimate in the po$Gble complications, and therefore the study of a series of deaths will in some instances spotlight the areas where improvement is most needed and could be most effective. Having reviewed the papers of Dr. Polack and Dr. Miller, as well as that of Dr. Johnson, it is quite obvious that their cases deal with all hospital deaths in contradistinction to a statistical study of gynecologic surgical cases by Dr. Williams and myself.* Yet even in our cases, 59 deaths in 26,000 operations, there were deaths, as from loss of blood, that one would think might have been avoided. The past 20 years have brought a substantial improvement in the risks for the patient with malignant lesions. Though Dr. Johnson reported 366 deaths from malignant pelvic diseases out
848
Johnson,
Darling,
and
McDonell Amer.
of 401, as compared to Dr. Miller’s 247, I imagine that the number of malignancies admitted to the hospital during the 8 years of this latter study is substantially greater than those in Dr. Miller’s series, which covered only 6 years of time. Yet in both series, 25 per cent or more of the malignant cases reached the hospital too far advanced for anything other than an effort for symptomatic relief. Dr. Johnson reported 6 deaths from exenterative procedures, and I would be most interested in knowing the pool of cases that resulted in these 6 deaths. In our series of cases covering a 10 year period, the risk of exenteration was 4 in 105 cases, or 3.8 per cent, while in the radical Wertheim hysterectomy it was 3 in 388, or 0.8 per cent. Our approach to the patient for potential exenteration is different from that of Dr. Johnson’s colleagues; ours is basically whether we feel we can remove the recurrent or radiation-resistant tumor. We hope, of course, for eradication of the tumor, but we do not limit ourselves to the more favorable cases in which we might expect a 5 year survival of 30 to 35 per cent. The changes and advances in operative techniques, in pre- and postoperative care, and in knowledge of electrolytes and fluid balance, as mentioned by Dr. Johnson, have made a real difference in our ability to carry out these radical procedures. Though we do not feel an exenteration is a palliative procedure, we will, after frank discussion with the patient and her relatives, make a strenuous effort to remove the tumor. The very knowledge that such procedures are possible, though not necessarily the skill, should be thoroughly disseminated among the residency staff. Two major points brought out by Dr. Johnson should be emphasized. First, that the climacteric years are one of the most dangerous times in a woman’s life, and his study reemphasizes that both the physician and the patient still tend to regard irregular bleeding or discharge as part of a normal menopausal process instead of an indication of malignancy until proved otherwise. This single point would alleviate the often long delays before seeking advice. Second, in this series of cases, as in previous papers, there were several instances of delay of emergency care in the admitting rooms; however, considering the number of admissions to the Charity Hospital in New Orleans, and without specific knowledge of the circumstances
March 15, 1971 J. Obstet. Gynec.
surrounding each case, one can only say that this is in an area where definite efforts for improvement would be rewarding. Though we all regard the benign lesions, such as fibroids and polyps, as carrying practically no risk, 35 deaths from benign conditions from Dr. Johnson’s paper and the 16 postoperative deaths from our study point up the fact that one can never relax in patient care and in attention to detail, and that the unexpected problems or complications will inevitably arise. Even dilatation and curettage and cervical cones, as shown by Dr. Williams and myself, carry some risk. Therefore, it behooves all of us to give each patient the maximum consideration possible, not only to keep the surgical deaths but all gynecologic deaths at a minimum and to avoid the occurrence of any factors of omission or commission that would adversely affect the patient. REFERENCE
1. Williams, OBSTET.
T. J., and Pratt, J. H.: 185, 1966.
AMER.
J.
GYNEC.~~:
DR. J. P. GREENHILL, Chicago, Illinois. This presentation contains an important message for all surgeons. If every hospital would take stock of its postoperative deaths and near-deaths every 5 or 10 years, there would surely be a definite reduction in the serious consequences of operation. Drs. Johnson, Darling, and McDonell mention two analyses of postoperative deaths which I reported. The first appeared in 1932, which was an analysis of the deaths following 6,022 gynecologic operations. The second (written with H. M. Loeff) was published in 1951-19 years later-and represented an analysis of 5,318 gynecologic operations. All of the operations were performed at the Cook County Hospital, an institution almost identical with the Charity Hospital in New Orleans. At the Cook County Hospital, all of the patients are of the low socioeconomic level. There is a preponderance of Negroes, and generally the patients do not seek medical aid until their diseases are far advanced. At the time of the first report we had no residents at all, no physician-anesthesiologists, and we did not have a recovery room until after the second report. The mortality in the first series was 3.5 per cent as compared with 1.3 per cent in the sec-
Volume Number
109 6
ond. In the last 2 years of the second period the rate was reduced to 0.7 per cent. Peritonitis was the most frequent cause of death in both series, being responsible for 48 per cent of the deaths in the first series and 29 per cent in the second. In the last 2 years of the second report the latter figure dropped to 12.5 per cent largely due to the use of penicillin and sulfonamides. There were 35 deaths from hemorrhage and shock in the first period and only 13 in the second. This improvement was due to the establishment of a blood bank, permitting far more blood transfusions. The death rate from malignancy remained about the same because of the advanced stages of the diseases in the patients in both series. There was a marked decrease in the incidence of deaths from pneumonia, because of the use of drugs, improved anesthesia, and early ambulation. Deaths from pulmonary embolism dropped from 18 to 2. The reduced number of deaths in the second series was due to a combination of factors. Among them were the use of penicillin and the sulfonamides, better pre- and postoperative care, more frequent preoperative and postoperative consultations with other specialists, improved operative techniques, a blood bank, and early ambulation. Of great significance also was the development of a comprehensive plan of resident training. We have steadily been reducing our surgical death rate each year by having an excellent
Deaths
in gynecology
849
anesthesiologists’ program and well-equipped recovery rooms. The authors deserve great commendation for having read their paper this morning. Let us hope that as a result of it all hospitals will make analyses of their postoperative deaths at regular intervals. DR. JOHNSON (Closing). Thank you, Drs. Hardy, Pratt, and Greenhill for your discussion. I would like to remind you that at Charity Hospital of Louisiana at New Orleans, patient care since 1962 has been equally divided between the Louisiana State Medical School and the Tulane Medical School. During the period covered by Dr. Hill&d Miller’s report, the two medical schools each took care of 40 per cent of the patients, and the remaining 20 per cent were cared for by an independent unit which consisted of nonfaculty members practicing in New Orleans. In this report, as well as in Dr. Miller’s, no attempt was made, for obvious reasons, to identify the service responsible for the deaths. The main purpose of this report was to compare the causes of individual deaths with those reported by Dr. Miller. I am unable to answer Dr. Pratt’s question concerning the number of malignancies admitted to Charity Hospital or the number of exenteration procedures performed during the years covered by this report.
C.
study
GORDON
(1944,
JOHNSON,
CHARLES
E.
DARLING,
CHARLES
FRANKLIN
19701
M.D. JR.,
McDONELL,
M.D. M.D.
New Orleans, Louisiana This presentation on deaths in gynecology is intended as a comparative study on the same subject, and concerning the same number of fatalities, published by Miller in 1944. His contribution was based, in turn, on a similar paper published by Polak in 1928. Like this paper, the Miller and the Polak pagers stress clinical rather than statistical considerations. The data in this 1970 Qresentation di&r in certain respects from the Miller data, as would be expected at the end of 26 years, but are surprisingly similar in others. The management of benign conditions has imQroved (due in part but by no means entirely to antibiotic therapy), but in malignant disease significant improvement remains to be achieved, AU three of these pagers are directed to one end-could any of these deaths have been prevented? If so, who was responsible for the deaths of these women? The answer is the medical QrofasJion and the solution is the intensifiedinstruction of women in the facts of pelvic cancer.
1 T IS NO w well over 40 years since the late Dr. John 0. Polak’ published what the late Dr. Hilliaxd E. Miller,2 some 16 years later, described as “a very frank and honest, and therefore very troubling, paper” on the lessonsto be learned from a study of “mortalities” (casefatality rates). What Dr. Polak and his co-author, Dr. Donald G. Tollefson, learned was that a very large proportion of the 138 deaths in their 4,270 gynecologic admissionsshould not have occurred, and would not have occurred, if there had been a stricter adherence to their own criteria of surgical safety and a generally better exerciseof surgical judgment. Dr. Miller, in i944, said that ever since he had read Dr. Polak’s article he had had it in his mind to write a similar one when he “thought he had achieved at least a minimum From Charity Hospital of Louisiana at New Orleans. Presented at the Eighty-firs: Annual Meeting of the American Association of Obstetricians and Gynecologists, Hot springs, Virginia, Sept. 10-12, 1970.
of professional wisdom.” He thereupon wrote a paper dealing with the 401 gynecologic deaths that had occurred at Charity Hospital of Lousiana at New Orleans over the 6 year period ending in 1942. I was enormously impressedby that paper and I think it has been my own intention, ever since I read it, to duplicate Dr. Miller’s performance when I thought I had fulfilled his specification concerning “a minimum of professional wisdom.” Mahrlal
and
metheds
The contribution of myself and my coauthors is, like the Miller paper, an analysis of 401 fatalities in which some gynecologic condition was the sole or the principal cause of death. The series includes 106 autopsies. To secure these casesthe necrology books of the New Orleans Charity Hospital were examined and a listing was made of all appropriate deaths. The records of thesecaseswere then examined individually and each record was discarded or was accepted for my pur-
Deaths in gynecology
poses.The result of this effort was a list of gynecologic deaths that (figuring backward) covered the period from January, 1969, through April, 1961, and that was as nearly consecutive as possible.I have no doubt that others, making a similar search, would have selected or rejected at least some different cases. Each of the records selectedfor the investigation was summarized on a form, the entries on which paralleled, as far as possible, the items discussedin the Miller paper. They included: the accuracy and promptness of diagnosis; the correctnessof the surgical procedure and its timing; the adequacy of preoperative preparation; the promptness and vigor (or the lack thereof) of the recognition and management of postoperative complications; the principal responsibility for the fatality (the patient herself, an outside physician, or the hospital staff) ; and general and specific methods of improving gynecolqgic diagnosisand therapy. All of these cases were handled on the gynecologic services of Charity Hospital of Louisiana at New Orleans. This is a teaching hospital, now operated on an equal admission basisby the Tulane University and Louisiana State University Schools of Medicine. When the Miller material was collected, some 20 per cent of the beds were controlled by an independent service which included many excellent gynecologistsbut which lacked the tight organization that is so necessaryfor the best gynecologic results. This service was eliminated’ in 1961 and only a few cakes from it are used in my series. The Polak report is a true analysisof what the authors call “mortalities.” It provides the total picture. Our contribution, like Dr. Miller’s, is not statistical. The material consists only of deaths, and of individual deaths at that. I should like to make it clear, however, that behind his paper and ours is a massof statistical data upon which are based the statementsmade and the conclusionsdrawn. We have made no attempt at a systematic survey of the literature, but even a casual review makes it clear that there is surprisingly little in it under the heading of deaths in
839
gynecology and that most of that is in the foreign literature. Two articles by Greenhill’> ’ are an interesting exception. No doubt a great deal of material on the subject is buried in articles with nonrevealing titles. The material analyzed by Dr. Miller in 1944 consistedof 247 deaths from malignant pelvic diseaseand 154 deaths from benign disease. This 1970 material consists of 35 deaths from benign diseaseand 366 from malignant disease, distributed as follows: carcinoma of the cervix, 209 cases; carcinoma of the endometrium, 50 cases; carcinoma of the ovary, 59 cases; carcinoma of the vulva, 11 cases;carcinoma of the vagina, 8 cases; carcinoma of the tubes, 2 cases; sarcoma of the uterus, 10 cases; and mixed Milllerian tumors of the uterus, 17 cases.As a matter of convenience, the deaths from benign disease are discussed under a single heading, since their small number makes extended comparison with the much larger Miller material rather impractical. General
considerations
Race and age. The disproportionately large number of Negro deaths in the Miller series in both benign and malignant diseaseis duplicated in my own series, in which, in 366 instances of pelvic malignancy, there were 253 Negro casesand 113 white. In 35 deaths from benign disease there were 28 Negro cases.There are a number of explanations, beginning with the basic fact that hospital admissionsfor the periods covered by both studies show similar disproportions. In 1944 Negroes had not shared to any appreciable degree in the general prosperity, which since then had reduced admissionsto charity and public hospitals all over the country. Even if they had shared in it, integration was then not even a theory, let alone a fact, and facilities for Negro care were limited. The 401 deaths in the 1970 study are in general too recent, to be influenced by MEDICARE or MEDICAID. In benign conditions the Negro deaths exceed the white deaths for another reason: As all Southern gynecologists know, both pelvic inflammatory diseaseand uterine fl-
840
Johnson,
Darling,
and
March
McDonell
broids are more frequent in Negro women than in white and are likely to be seen in more advanced stagesbecauseNegro women are even more inclined than white women to postpone medical consultation in the early, inconvenient stageof symptoms. In the Miller seriesthe age factor showed a gradual rise to 45 years and then a gradual decline. In the 366 malignant casescollected in 1970 the age range was from 13 years (in carcinoma of the ovary) to 100 years plus (in uterine fibroids-the age was verified by a resident staff), and 177 patients were under 50 years of age. The somewhat earlier peak in the Miller seriescan be explained by the large number of benign cases, which represented almost 40 per cent of that series. The higher age peak in the 1970 seriescan also be explained by the fact that women, even more than men, are now living longer and well into the age period in which malignancy-though not invariably-is more likely to develop. Period of investigation. One of the first considerations to impressone in an analysis of the 1970 serieswas that the 8vh years which had to be utilized to collect these 401 cases exceeded by more than 2 years the period necessary for the 1944 collection. The discrepancy is readily explained by the reduction in casefatality rates which occurred in the interim, a reduction which itself is readily explained. It was a far cry from the criteria for safe surgical risks in the Polak paper to those in the Miller paper. Polak was one of the most experienced gynecologists of his day, but one of his minimum preoperative requirements was a hemoglobin of “at least 60 per cent.” The Miller criteria, outdated though some of them are, have a far more modern ring. There are a great many explanations, many of them originating in the World War II experience, to account for the improvement in casefatality rates that has occurred since the Miller paper was written. Resident systems have multiplied. Surgical techniques have improved and new procedures have been developed and made practical. Indications for operation are more clear-cut. Recovery
15, 1971
Amer. J. Obstet. Gym.
rooms are almost universal. There is a new concept of shock; both hemorrhagic and septic are now recognized. Adjunct therapy, both before and after operation, has becomeone of the accepted facts of surgical life. Blood banks operate around the clock. Early ambulation is now generally practiced. The antibiotics have been introduced and their use has been both standardized and individualized; they have not fulfilled all of their original promise, but they have played an important role in the reduction of the gynecologic death rates between 1944 and 1970. Finally, operation in elderly patients now carries little more risk than the sameoperation in younger women. One or two local considerations might also be mentioned. When the Miller paper was written there were only nine hospitals in Louisiana that provided medical care for the indigent, and difficulties of transportation to them accounted for some poor results. Today there are 17 such hospitals, and with a statewide ambulance service the transportation factor is no longer important. Pathologic categories. In general, the 1970 collection of deaths parallels the 1940 Miller series. There are no instances of chorionepithelioma in the 1970 seriesagainst two in 1944 series, an incidence which can be explained by chance. But the absence of any deaths from surgery for obstetric injuries in the 1970 series is another and significant matter. There were 13 such deaths in the 1944 series, and in Miller’s opinion 11 of them should not have occurred. They were chiefly due to technical errors and inadequate (or totally lacking) preoperative preparation, including one failure to correct a hemoglobin deficiency of 50 per cent. The lessonsof these 1944 caseswere obviously learned before the 1970 caseswere collected. Deaths
from
benign
disease
Ectopic pregnancy. It is ironical that the highest proportion (18 cases)of hospital staff responsibility for some of the deaths in the 1970 seriesshould have occurred in the 35 benign cases, in which conditions for care were generally most favorable. Six patients were in good condition on admission and 10
Volume 109 Number 6
others were in fair condition. Among the conditions represented were ectopic pregnancy (5 cases), uterine fibroids ( 11 cases, 4 degenerating) , and tuboovarian abscesses ( 16 cases, 13 ruptures). Of all emergency gynecologic conditions none responds to operation more promptly and more satisfactorily than ectopic pregnancy. In 699 cases reported from the Tulane service at the New Orleans Charity Hospital in 1965, there was only one death.6 The patient died before any treatment could be instituted, and the diagnosis was made at autopsy. On this service 90 per cent of the patients are now operated on within 8 hours of admission and almost 75 per cent within 3 hours. Nine of the 15 patients with ectopic pregnancy in the Miller series had no operation. Therapy, he stated, was “hesitant and long delayed” and attempts to secure donors were “curiously languid.” This is not the way to manage a condition in which the routine should be to open the abdomen instantly, find and tie the bleeding point instantly, and then consider other matters. In 4 of the 5 deaths from ectopic pregnancy in the 1970 series the patients were beyond help when they were first seen. One died in the admitting room, 2 died on the operating table, and another did not respond to vigorous efforts to correct a renal complication. The fifth patient died because something went seriously wrong with the hospital setup. She was admitted with the diagnosis made, but she was kept in the admitting room, without treatment, for 90 minutes, she was given no blood, and a gynecologic consultant never saw her. She had 3,000 C.C. of blood in her abdomen at autopsy. Uterine fibroids. In the Miller analysis of 154 deaths from benign pelvic disease there were 53 deaths from uterine fibroids, 43 of them in Negroes. Many of these women had had their growths for years and they were enormous, sloughing, and adherent. In 7 cases surgery was out of the question. In Miller’s opinion at least 10 deaths in this group could have been prevented by better preoperative care (it was often poor and sometimes lack-
Deaths
in gynecology
841
ing) and postoperative care (it was also often poor and was also delayed, too brief, or otherwise inadequate). Operation for fibroids, if carried out with the proper safeguards, is attended with fewer risks than any other gynecologic operation, and reliance on that generalization, Miller pointed out, led to a tendency to underestimate potential risks and to develop an unwarranted complacency. Most of this criticism does not apply to the 11 fibroid deaths in the 1970 material. Both preoperative and postoperative care was generally good, and outside, not hospital, management was responsible for 3 patients received moribund after prolonged antibiotic therapy. But the attitude of complacency of which Miller complained was evident in several cases in which treatment was at best perfunctory, and an unwarranted risk, which failed, was assumed in 2 patients who were submitted to cholecystectomy along with extensive pelvic surgery. There was no instance of supracervical hysterectomy in the 1970 series against 12 such operations in the 1944 series. Tuboovarian abscesses. I do not believe that tuboovarian abscesses are treated with the respect they deserve. I regard them as potentially more lethal than appendiceal abscesses. In my own opinion, which is no more than an opinion, their walls are thinner and so they rupture more readily. In the 154 benign gynecoIogic deaths in the 1944 series there were 38 tuboovarian abscesses, 14 of which were proved by autopsy and 21 of which were ruptured. In the 35 benign deaths in the 1970 series there were 16 abscesses, 13 of which were ruptured. The incidence of the condition and of its complications, most notably rupture, has not been reduced by the introduction of antibiotics, and without proper treatment most women who sustain this accident will still surely die of it. Observation in the hospital, under suspicion of the possibility of rupture, is the first step in proper management. The second step, we now believe, is surgical. For many years on the Tulane service at
842
Johnson, Darling,
and McDonell
Charity Hospital these abscesses were treated conservatively, chiefly under the influence of Dr. C. Jeff Miller, who was influenced, in turn, by Simpson’s dicta on the subject in 1909. Then, as recommended by Te Linde and his associatesat The John Hopkins Hospital,e the policy was changed to one of aggressivesurgery; the ruptured abscesswas regarded as being as true an emergency as a ruptured appendix. The new policy has paid off richly, the death rate being reduced from about 90 per cent in the first reported series to 0 in the last 27 cases.’ In three of the cases in the 1970 series the patients were received moribund and all treatment was unavailing. But in another case both surgical and gynecologic surgeons ruled out a operative problem, and the patient died, with 3,000 C.C.of exudate in the abdomen, while awaiting medical consultation. In another instance of staff responsibility, a ureter that had been severed was not identified at operation. The simple insertion of a catheter would probably have saved this woman’s life. Deaths
from
malignant
disease
Radical surgery. Before proceeding to a discussion of deaths from pelvic malignant disease,certain general statements should be made: Surgery is, justifiably, more aggressive in 1970 than it was in 1944 and the risks that attend it are less, but there is still a delicate line that must be drawn between boldnessand courage, which are commendable, and rashness, for which there is no justification. Also there is an intangible dividing line between a growth which is resectable on one day, or even at one hour, and which the next day or even the next hour is not. There is still another important consideration in this connection: In determining the treatment the patient is to receive the surgeon must not only weigh life against death but must also visualize the kind of life he is providing for his patient. A veritable death in life follows some cancer surgery, and, like Miller, I question the value of most- operations in which metastatic interference with
Amer.
March 15,197l J. Obstet. Gynec.
bowel and bladder function requires a corrective attack upon the urinary tract, the lower colon, or the rectum. However brilliant an occasional result may be, can one really justify such taxing and dangerous surgery upon a patient whose life expectancy, at best, is a matter of months? Some cancers are hopelessfrom their incipiency. Sarcoma of the uterus, for instance, and Mtillerian tumors spread like brush fires. It is often only a matter of months between their first clinical manifestations and the fatal outcome. The fact that in the 1970 cases9 of 17 patients with Miillerian tumors survived a year or more is a tribute to the vigorous and apparently correct treatment they received at Charity Hospital. The survival in this seriesfor this period of time of only one of 10 patients with sarcoma of the uterus is the more usual story. It is a tragic fact that in the 366 deaths from pelvic malignant disease collected in 1970, 90 patients had diseasethat was too far advanced for any measuresexcept those directed to the control of hemorrhage or the relief of pain. Even after rehabilitation they could not have withstood the stressof surgery that held out any hope of cure. The therapy of the individual case of cancer rests, of course, on the circumstances of the individual case and the experience of the surgeon who is handling it. The general opinion is that in cancer of the cervix it makes little difference whether treatment is by surgery or radiation or by the combined modalities. There were a great many radical hysterectomies performed in the 1970 series, many more than in the 1944 series,which covered a period when the Wertheim and similar procedures had suffered something of a decline in popularity. There were only 6 deaths from exenteration procedures in the 1970 cases (the operation was not in use in 1944). These procedures have a very limited use in the type of patient treated at Charity Hospital. They are carried out on the Tulane service by a trained team with competent paramedical help, and with all the
Volume 109 Number 6
equipment necessary for elaborate preoperative and post-operative care. Indications are strict and the operation is seldom undertaken unless the chances of cure are estimated at 30 per cent or better. When it is performed under other circumstances, it is seldom justified and is, indeed, likely to precipitate the very results it was planned to prevent or delay. Radical procedures of this type should not be recommended to medical students or taught to interns and residents, most of whom, when their training days are done, are not likely to find themselves so situated as to be able to utilize their knowledge. Causesof death. On the whole, the women in the 1970 series, both statistically and clinically, were in better condition than might have been expected from their evaluations: 45 were rated as in good condition and 79 others as in fair condition. The poor or moribund status of the others was chiefly attributable to their malignant disease. In the 1944 series there was a very considerable overlay of organic disease and an occasional tendency to disregard the opinion of the medical consultant, especially in regard to anesthetic precautions and surgical tolerance. In the 1970 series preoperative preparation was generally good, though in well over half of the cases the patients were not good risks for any therapy. The results of the preoperative situation are evident in the postoperative situation in both the Miller series and our own. There were multiple complications in the 1944 series, some of which were extremely serious and some of which were not well handled. In the 1970 series complications were far fewer and most of them were well handled. Peritonitis, pulmonary complications, and embolus all showed significant decreases. It is shocking, however, to find five patients dying of exsanguination in the admitting room, with hematocrits as low as 13, and a number of others dying there or in the emergency room, chiefly from shock, before any treatment was possible. Aside from the malignant process itself, cardiovascular and renal diseases, particu-
Deaths in gynecology
843
larly uremia (46 cases), were the most frequent causes of death. In the Miller series there were seven deaths from the hepatorenal syndrome, which led to the recommendation that preoperative attention to the status of the liver was often a wise precaution. There were no deaths from this cause in the 1970 study, possibly because of the generally good preoperative and postoperative care. The diagnosis was not suspected in any instance in the 1944 series and would probably be overlooked today. In the Miller series 8 patients had presently, or had a history of, multiple malignant diseases. There were 26 such cases in the 1970 series. In each series was a patient who had survived three previous episodes of malignant disease only to perish in the fourth.
Carcinoma of the cervix and the endometrium. In both the 1944 and 1970 studies, as in all similar investigations, carcinoma of the cervix was the major problem. In the 1944 series, the figures for which include both sarcoma of the uterus and carcinoma of the fundus endometrium), it was responsible for 167 of the 247 deaths from malignant disease. In the 1970 series carcinoma of the cervix accounted for 209 of the 366 deaths from malignant disease, and carcinoma of the endometrium accounted for another 50. If, the figures for Miillerian tumors (17 cases) and sarcoma (10 cases) are added, it is seen that all varieties and locations of malignant disease of the uterus accounted for well over three quarters of all deaths from this disease in this series. In the 1970 series the age range for carcinoma of the cervix was from 23 to over 100 years. The time lag from awareness of symptoms to medical consultation ranged from 0 (no time lost) to 9f/2 years (undoubtedly while the symptoms of a chronic benign condition came to represent the symptoms of a malignant process). In this series considerably less than half the patients sought medical advice within a year of the development of symptoms, and in the 1944 series the delay was even longer.
844
Johnson,
Darling,
and
McDonell Amer.
As a result of the prolonged time lag, only 41 patients in the 1970 series were in Stage I of their disease when they were first seen and only 52 were in Stage II, which means that only about half of the patients for whom this information is available (188) were in stages of their disease that were favorable for cure. Just as significant, only 38 patients were in good condition on admission and only 45 others were in fair condition; 34 were classified as moribund. In terms of management, 40 patients were in no condition to tolerate anything but supportive therapy. Miller, reporting on the even bleaker outlook in his series, said that under these circumstances there was little use in discussing histology and response to treatment. In both the 1944 and the 1970 series bleeding was the most frequent first symptom. It usually is. From the standpoint of diagnosis it was the most reliable symptom. It usually is. But because it was usually insidious and painless the tendency was to regard it, for long periods of time, as not more than an inconvenience, and a minor one at that. As these data prove again, the climacteric is the most dangerous period of a woman’s life. The situation in the 1970 cases was somewhat improved over 1944, but even among physicians there was an occasional tendency in the 1970 series to regard spotting and bleeding as a part of the menopausal pattern and to omit the diagnostic measures-the simple diagnostic measureswhich would prove they were not.’ In the 50 cases of carcinoma of the endometrium in the 1970 series, the age range was from 31 to 82 years and the time lag was from 0 in one case to 13 years, also in one case. Only 3 patients were in good condition on admission, only 10 others were in fair condition, and 10 were admitted moribund, though in most instances they had all received such treatment as was possible immediately after the diagnosis was made. In 18 cases no therapy was practical, and only seven patient survived for a year or more. Four, infact, died before any treatment at all could be started. This is a discouraging
March 15, 1971 J. Obstet. Gynec.
picture in disadvantaged women of what is generally regarded as the most favorable of all pelvic malignant diseases. Carcinoma of the ovary. The second largest number of deaths in the 1970 series (59) and in the 1944 series (35) was from carcinoma of the ovary. In the 1970 cases the age range was from 13 to 72 years and the time lag from symptoms to medical consultation was from immediate in 5 cases to 6 years in one. Sisteen of the patients had waited 6 months or longer before seeing a physician, a delay that was peculiarly unfortunate in a condition in which even the earliest symptom is likely to be a late one. The status of these patients, chiefly as a result of their delay, was good in only 3 cases and fair in only 12 others, The condition of the remaining patients was poor in 31 and moribund in 11. Small wonder that in 13 cases no therapy at all was possible. In his 1944 presentation Miller painted a gloomy picture of the “terrible swiftness” of this form of pelvic malignancy and stated flatly that he had never saved a patient with it. Since that time, more aggressive surgery, combined with irradiation and chemotherapy, has wrought considerable improvement. In my private practice I now have 5 patients who are alive and well from 6 months to 11 years after definitive operation; 3 of them have passed the 5 year period. In one remarkable case in this group the patient, in addition to carcinoma of the ovary, presented thrombocytopenic purpura and Boeck’s sarcoid. In another case the diagnosis was missed on the gynecologic service and the patient was transferred to sur?sFYRecommendations A great many of Dr. Miller’s conclusions and recommendations are now standard practice and have been for many years. Several could profitably be repeated here: 1. Total hysterectomy should be routine whenever hysterectomy is done. Sixteen women in these two series lost their lives because that rule was not followed and cancer
Volume 109 Number 6
was able to develop in their residual cervices. One of them must have already had it when supravaginal hysterectomy was performed, 9 months before malignant cervical disease became apparent. 2. Attempts at diagnosis of unsuspected cancer, as well as suspected disease, should be intensified, particuarly in the menopausal years. In every instance cancer should be the first diagnostic possibility to be entertained and the last to be discarded. And diagnosis should always be regarded as a matter of extreme urgency. It was far too leisurely in a number of cases in both of these series. 3. There should be careful attention to preoperative preparation, on the principle that under the stress of anesthesia and operation minimal deviations from the normal may become maximal. 4. There should be more alertness to detect incipient postoperative complications, and a quicker resort to parenteral therapy and such other measures as are indicated. Also, these measures should be continued until it is perfectly clear that they are no longer needed. 5. Patients in hospitals should be carefully observed. As several cases in these two series prove, there is no more dangerous time and place to develop one disease than while in the hospital under treatment for another. The responsibility of the profession for deaths from pelvic malignancy The assignment of responsibility for individual deaths always has an element of unfairness no matter how one strives to be objective. It is quite clear, however, why some-indeed most-of the women in these two series lost their lives. In effect, by their delay and, in some instances, by their complete lack of cooperation they signed their own death warrants. In the 1970 series outside physicians could be blamed for the fatal outcome in only 17 of the 366 deaths from malignant disease and the hospital staff for only 47. Both figures represent a decided improvement over the 1944 figures. On the other hand, while a certain per-
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centage of errors is to be e)xpected on a teaching service, they must be kept to a minimum, as they can be by correct organization and supervision. I treated none of the patients in this series myself, but I supervised the care of many of them and, like Dr. Miller, I found this review a rather chastening experience. Orientation of women-the road to improvement In 1961 the American Cancer Society began a campaign to reduce the death rate in cancer of the uterus. The effort has been highly rewarding, but it has not gone far enough. It is only when one makes such a study as we have just reported that one appreciates the real tragedy of carcinoma of the pelvic organs-the mistakes, the delays, and, above all, the lost opportunities and the deaths that should not have occurred. The basic explanation for the continued high death rate in carcinoma of the cervix and other pelvic malignancy is delay in diagnosis, and delay is explained, in turn, by ignorance. The records for the 1979 series, as well as my personal experience in private practice, suggest a disturbing lack of knowledge on all levels, both professional and lay, concerning pelvic malignancy. In the profession, procrastination and a low index of suspicion are not infrequent. In the Charity Hospital records for the 1970 series are a number of cases in which the diagnosis was unduly delayed, even when the history and physical findings seemed to point to one inexorable conclusion. Our intensified educational effort must therefore begin on the professional level. Students, interns, residents, and practitioners alike must be impressed with certain facts: 1. The lethal potentialities of all types of vaginal discharges and all variants of spotting and bleeding. 2. The urgency of diagnosis and, once it is made, the equal urgency of therapy. 3. The limitations of radical surgery, with emphasis on the fact that mere prolongation of life is not in itself a compassionate achievement.
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4. The resfaonsibility of the profession for the terminal Bare of patients for whom death is the only o&come. 5. The r&ponsibility of the profession on all levels f& indoctrinating women in the facts of pe&c cancer, particularly cancer of the cervix, The or&tation of women in this knowledge con&s of stressing to them, at every opportunity, three basic facts: 1. A* kind of discharge and any kind of abnotial bleeding may indicate cancer and requires prompt consultation with a physician fo prove that it is or is not. 2. Pelvic examination should be carried 0uD twice yearly on all women over 30 years of age, whether or not they have symptoms rdferable to the pelvis. 3. The Papanicolaou test should also be carried out twice yearly on women in this age group. It should be used, in fact, wher-
ever and whenever physicians have any contact with women-in private offices, in outpatient clinics, in the wards of public and private hospitals, even, as is the practice at the University of Miami, in emergency rooms. This is a test of great reliability and I deplore the recent action of the Cancer Control Section of the Public Health Service in diverting to other purposes the more than two million dollars previously assigned to popularize this test and to train technicians to perform it. The outstanding lesson which my co-authors and I have learned from our review of 401 gynecologic deaths, 366 of which were due to malignant disease, is (1) that these deaths will continue to occur until women are instructed more intensively and more personally in the facts of cancer and (2) that their orientation in these facts is the responsibility of the medical profession.
REFERWNCES
and Tollefson, J. OBSTET.
D. G.: AMER.
GYNEC. 16: 600, 1928. E.: AMER. J. OBSTET.
2. Miller, H. GYNEC. 48: 824, 1944. 3. Greenhill, J. P.: ADIER. J. OBSTET. GYNEC. 24: 183, 1932. 4. Greenhill, J. P., and Loeff, H. M.: AMER. J. OBSTET. GYNEC. 61: 340, 1951.
Discussion DR. JOSEPH A. HARDY, St. Louis, Missouri. We have been privileged this morning to hear a very courageous and highly philosophical presentation by Drs. Johnson, Darling, and McDonell. After 2 days, during which we have learned how the frontiers of our specialty have been pushed forward, it is appropriate that we be reminded that there remain areas in which WC should not take too much pride in our accotiplishments. Dr. Johnson has emphasized that his a&ysis of 401 deaths is not statistical in its #itent. Nevertheless certain statistical informatih may be drawn from it. It is interesting-thdugh not particularly gratifying--to note that in the Miller series of 1944 there were 247 deaths due to
5. Webster, H. D., Barclay, D. L., and FisGBidlT, C. K.: AIUER. J. OBSTET. GYNEC. !X& f3, 1965.
6. Te Linde, R. W.: Discussion of C&l Nix, F. G., and Cerba, H. T.: OBSTET. GYNEC. 72: 820, 1956. 7. Johnson, C. G.: Unpublished bata.
m&gnancy while in the present series this num&r had increased to 366. One might have expected, with increased public acceptance of periodic physical examination and during a decade in which the use of cytologic screening techniques had so greatly increased, that some improvement in the salvage of women with neoplastic disease of the pelvic organs might have been achieved. That such was not the case is discouraging even though the 366 cancer deaths occurred in a period of 8y4 years rather than the 6 years covered by the Miller study. This discouragement is heightened when one notes that in the 1944 series cervix cancer accounted for 167 of the 247 deaths due to malignant disease and in Dr. Johnson’s series the cervix
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was responsible for 209 deaths of the 366 due to malignancy. In other words, cervix cancer deaths in 1944 were 68 per cent of the total due to malignancy. In the ensuing 25 years this figure was reduced-but only to 57 per cent. Stimulated by the concept of attempting to assign responsibility for deaths on the gynecology service, I reviewed the deaths during the 5 year period, 1965-1969, at the hospital where most of my work is done. St. John’s Mercy Hospital is a 600 bed private hospital with university affiliation and a strong teaching service. The bulk of pelvic surgery is done by men who hold faculty appointment at St. Louis University, with perhaps 10 per cent of the patients operated upon by the resident staff either on their own clinic service or under the supervision of the visiting staff. In the 5 years studied there were 6,741 patients discharged and 19 deaths occurred-a gross mortality rate of 0.28 per cent (1 in 354.7 patients). A total of 3,324 operations was performed and 15 of the 19 deaths occurred in patients who were operated upon-a gross operative mortality rate of 0.45 per cent. The autopsy rate was 52.6 per cent (10 out of 19). Of the I9 patients who died 15 had malignancies, divided as indicated-corpus 7, cervix 3, and ovary 5. In some instances multiple malignancies were present but they have been classified according to what was thought to be the primary source of disease. In 13 of the 19 patients who died, the fatal outcome was directIy due to the disease. In 6 instances death was attributed to other factors, such as embolus, cardiac arrest, pulmonary edema, faulty surgical technique, accidental perforation of a viscus, etc. My analysis led me to the conclusion that in 4 of these 19 women death was possibly avoidable. Time will not permit a detailed report but perhaps a few examples will serve to indicate where better judgment or greater care in choice of operative procedure or more meticulous operative technique might have saved a life. A 20-year-old nulliparous patient was admitted with a diagnosis of infertility and ovarian cyst. A curettage and hysterosalpingogram were followed immediately by tramtuba instiation of air. She died in the operating room of air embolism. A 39-year-old patient, para VI, was operated upon for fibromyoma of the uterus associated
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with menorrhagia. She died 8 days after operation following multiple transfusions, after developing a lower nephron nephrosis. At autopsy there was massive intraperitoneal and retroperitoneal hemorrhage apparently due to faulty hemostasis of the left infundibulopelvic and broad ligament pedicles. A 49.year-old patient, para 0, was admitted for diagnostic dilatation and curettage which revealed carcinoma of the endometrium. During implantation of radium the uterus was perforated. Laparotomy disclosed an additional perforation of the small bowel which resulted in a vaginal-intestinal fistula with pelvic abscess. She died 43 days after operation for a pulmonary embolus. Autopsy revealed widespread metastases of the primary uterine tumor. There were a number of patients for whom no treatment was available. Several women who had multiple admissions to the hospital for malignant disease and its sequelae came in simply to die in whatever degree of comfort could be afforded them. There remains, however, the bitter truth that Dr. Johnson has pointed out to us-there are women who have died unnecessarily and so long as this situation obtains we cannot afford complacency. DR. JOSEPH H. PRATT, Rochester, Minnesota. Dr. Johnson and his co-authors have performed a service for all of us that should be pertinent and effective. We learn most whp our noses are rubbed into the brutal facts of p&tent ignorance or delay, physician delay, iatTq,genic damage or the inevitable workings of mathematics which, on a percentage basis, tell us that in so many admissions or in so many operations certain unhappy sequelae will rqult. A patient’s death is the ultimate in the po$Gble complications, and therefore the study of a series of deaths will in some instances spotlight the areas where improvement is most needed and could be most effective. Having reviewed the papers of Dr. Polack and Dr. Miller, as well as that of Dr. Johnson, it is quite obvious that their cases deal with all hospital deaths in contradistinction to a statistical study of gynecologic surgical cases by Dr. Williams and myself.* Yet even in our cases, 59 deaths in 26,000 operations, there were deaths, as from loss of blood, that one would think might have been avoided. The past 20 years have brought a substantial improvement in the risks for the patient with malignant lesions. Though Dr. Johnson reported 366 deaths from malignant pelvic diseases out
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of 401, as compared to Dr. Miller’s 247, I imagine that the number of malignancies admitted to the hospital during the 8 years of this latter study is substantially greater than those in Dr. Miller’s series, which covered only 6 years of time. Yet in both series, 25 per cent or more of the malignant cases reached the hospital too far advanced for anything other than an effort for symptomatic relief. Dr. Johnson reported 6 deaths from exenterative procedures, and I would be most interested in knowing the pool of cases that resulted in these 6 deaths. In our series of cases covering a 10 year period, the risk of exenteration was 4 in 105 cases, or 3.8 per cent, while in the radical Wertheim hysterectomy it was 3 in 388, or 0.8 per cent. Our approach to the patient for potential exenteration is different from that of Dr. Johnson’s colleagues; ours is basically whether we feel we can remove the recurrent or radiation-resistant tumor. We hope, of course, for eradication of the tumor, but we do not limit ourselves to the more favorable cases in which we might expect a 5 year survival of 30 to 35 per cent. The changes and advances in operative techniques, in pre- and postoperative care, and in knowledge of electrolytes and fluid balance, as mentioned by Dr. Johnson, have made a real difference in our ability to carry out these radical procedures. Though we do not feel an exenteration is a palliative procedure, we will, after frank discussion with the patient and her relatives, make a strenuous effort to remove the tumor. The very knowledge that such procedures are possible, though not necessarily the skill, should be thoroughly disseminated among the residency staff. Two major points brought out by Dr. Johnson should be emphasized. First, that the climacteric years are one of the most dangerous times in a woman’s life, and his study reemphasizes that both the physician and the patient still tend to regard irregular bleeding or discharge as part of a normal menopausal process instead of an indication of malignancy until proved otherwise. This single point would alleviate the often long delays before seeking advice. Second, in this series of cases, as in previous papers, there were several instances of delay of emergency care in the admitting rooms; however, considering the number of admissions to the Charity Hospital in New Orleans, and without specific knowledge of the circumstances
March 15, 1971 J. Obstet. Gynec.
surrounding each case, one can only say that this is in an area where definite efforts for improvement would be rewarding. Though we all regard the benign lesions, such as fibroids and polyps, as carrying practically no risk, 35 deaths from benign conditions from Dr. Johnson’s paper and the 16 postoperative deaths from our study point up the fact that one can never relax in patient care and in attention to detail, and that the unexpected problems or complications will inevitably arise. Even dilatation and curettage and cervical cones, as shown by Dr. Williams and myself, carry some risk. Therefore, it behooves all of us to give each patient the maximum consideration possible, not only to keep the surgical deaths but all gynecologic deaths at a minimum and to avoid the occurrence of any factors of omission or commission that would adversely affect the patient. REFERENCE
1. Williams, OBSTET.
T. J., and Pratt, J. H.: 185, 1966.
AMER.
J.
GYNEC.~~:
DR. J. P. GREENHILL, Chicago, Illinois. This presentation contains an important message for all surgeons. If every hospital would take stock of its postoperative deaths and near-deaths every 5 or 10 years, there would surely be a definite reduction in the serious consequences of operation. Drs. Johnson, Darling, and McDonell mention two analyses of postoperative deaths which I reported. The first appeared in 1932, which was an analysis of the deaths following 6,022 gynecologic operations. The second (written with H. M. Loeff) was published in 1951-19 years later-and represented an analysis of 5,318 gynecologic operations. All of the operations were performed at the Cook County Hospital, an institution almost identical with the Charity Hospital in New Orleans. At the Cook County Hospital, all of the patients are of the low socioeconomic level. There is a preponderance of Negroes, and generally the patients do not seek medical aid until their diseases are far advanced. At the time of the first report we had no residents at all, no physician-anesthesiologists, and we did not have a recovery room until after the second report. The mortality in the first series was 3.5 per cent as compared with 1.3 per cent in the sec-
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ond. In the last 2 years of the second period the rate was reduced to 0.7 per cent. Peritonitis was the most frequent cause of death in both series, being responsible for 48 per cent of the deaths in the first series and 29 per cent in the second. In the last 2 years of the second report the latter figure dropped to 12.5 per cent largely due to the use of penicillin and sulfonamides. There were 35 deaths from hemorrhage and shock in the first period and only 13 in the second. This improvement was due to the establishment of a blood bank, permitting far more blood transfusions. The death rate from malignancy remained about the same because of the advanced stages of the diseases in the patients in both series. There was a marked decrease in the incidence of deaths from pneumonia, because of the use of drugs, improved anesthesia, and early ambulation. Deaths from pulmonary embolism dropped from 18 to 2. The reduced number of deaths in the second series was due to a combination of factors. Among them were the use of penicillin and the sulfonamides, better pre- and postoperative care, more frequent preoperative and postoperative consultations with other specialists, improved operative techniques, a blood bank, and early ambulation. Of great significance also was the development of a comprehensive plan of resident training. We have steadily been reducing our surgical death rate each year by having an excellent
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anesthesiologists’ program and well-equipped recovery rooms. The authors deserve great commendation for having read their paper this morning. Let us hope that as a result of it all hospitals will make analyses of their postoperative deaths at regular intervals. DR. JOHNSON (Closing). Thank you, Drs. Hardy, Pratt, and Greenhill for your discussion. I would like to remind you that at Charity Hospital of Louisiana at New Orleans, patient care since 1962 has been equally divided between the Louisiana State Medical School and the Tulane Medical School. During the period covered by Dr. Hill&d Miller’s report, the two medical schools each took care of 40 per cent of the patients, and the remaining 20 per cent were cared for by an independent unit which consisted of nonfaculty members practicing in New Orleans. In this report, as well as in Dr. Miller’s, no attempt was made, for obvious reasons, to identify the service responsible for the deaths. The main purpose of this report was to compare the causes of individual deaths with those reported by Dr. Miller. I am unable to answer Dr. Pratt’s question concerning the number of malignancies admitted to Charity Hospital or the number of exenteration procedures performed during the years covered by this report.