- Email: [email protected]
Some gynecological operations in relation to the life assurance
REVIEWS AND ABSTRACTS
439
A further advantage of this prot:cuurc is the prevention of adhesions. Of the 423 patients so treated, 69 per cent were seen again after operation. In only one case could clinical evidence be elicited of postoperative adhesions and this despite the fact that in 15 per cent of the cases, pus had been found at oper:vtion. J. P. GREENHILL. Mayer: Postoperative Paralytic neus. 1924, lxxi, 931.
Miinchener medizinische W ochenschrift,
The author recommends a treatment which he feels has given him the best results with the condition. He introduced from 500 c.c. to 1000 c.c. of saline with 4 c.c. or 8 c.c. pituitary extract intravenously, or if this is impossible, the d:rip method is employed. In 70 per cent of his 52 patients the bowels soon moved and so the existence of a mooha.nical ileus was improibable. E-owever, in spite of the fact that he was able to get the bowels of so many of these patients to move, the majority of them died, but he considers 10 per cent veeoveries as very good. He does not attempt to decide whether the ileus is mechanical or due to sepsis. If after the treatment here recommended no results are obtained, enterostomy is the next t'hing to be considered and should be employed as a last resort. A. C. WILUAMSON. Giles: Some Gynecological Operations in Relat'ion to the Life Assurance. Lancet, 1923, cciv, 884.
The
This address is based on the author's original study of 1,000 cases plus the study of 3,000 additional cases. In general, two questions may be asked: first, what is the expectation of life after abdominal operation, and second, ~at is the state of health after abdominal operation. In formulating an answer to the first question, the exact conditions present at the time of the operation must be available. With re~erence to this, it is most important to know whether or not malignant disease is present. The writer considers the life expectation after operation for carcinoma and for benign tumors, inflammatory conditions and other procedure. In reply to the second question, the author found that 72.5 per cent of patients operated upon expressed themse·lves as being in very good health., It is extremely interesting to know t'hat the highest percentage of cases of very good health occurred in patients where the appendages on both sides were removed. The lowest percentage was in cases where the appendages were removed only on one side. Hysterectomies for benign conditions, ventrofixations, myomectomies, also showed a very high percentage of very good health following the operation. Where a unilateral salpingooophorectomy was done, pathology sufficient to require further operation on the other .tube and ovary occurred in 10.9 per cent of the eases. It was further found that the memory was somewhat affected by operation. The degree of this involvement was determined largely by the dura· tion of the' operation. About 70 per cent of the patients regained normal health. The highest proportion of the eases was found whe·re conservative procedure and complete removal of the organs had taken place. Unilateral operations of the uterine appendages show the lowest proportion of complete recoveries, the chances of complete cure being subordinate to the preservation of the functions of woman· hood. There may be a disturbance of the nervous system, as shown by the affection of the memory. In most cases this is temporary, in a proportion varying from 18 per cent where the operation was of short duration, to 50 per cent where the operation was of long duration. There is a risk that further operation may be required in about ten per cent of cases. This includes the direct sequelae ofl
440
THE AMERICAN JOURNAL OF OBSTE'fRICS AND GYNECOLOGY
the operation and independent conditions in about equal proportions. The risk iR greater after operations for inflammatory disease of the tubes, and after unilateral operations of the tubes and ovaries. Cases where operations for malignant disease have taken place must bo regarded as bad life risks. After operations for inflammatory disease th<> expectation of life is fairly good, but is impaired by the liability of sequelae. Patients who have had benign tumors removed may be considered as good life riskR, aR the chance of complications whirh may lead to a fatal rrsult, is negligiblr. NORMAN
F'.
l\lfiLLRI:.
White, 0.: Instruments Left in the Peritoneal Cavity. The Clinical Journal, Lon· don, 1923, Iii, 553. The case reported is that of a won1an o:f fifty teferreJ because her doctor founU a sharp pointed body in the cervix. She had consulted the physician because of acute pelvic pain. Nineteen years previously an abdominal operation had been performed for an abdominal tumor. Eighteen m(>nths before tho author saw her a second operation had been performed to relieve symptoms but the patient was told that the adhesions were too dense to allow anything extensive to be done. The author removed a hemostat whose points had eroded the uterus above the bladder reflexion and the handles had eroded tho pelvic colon and were in thn cavity of t:he gut. She died some six weeks later from an attack seemingly of anaphylactic origin. In a second case the writer removed a bone penholder from the peritoneal cavity whieJh had been introduced through the vagina and rcmaine·d in the cavity about ninety hours. Recovery was uneventful. A canvass of the surgeons of Great Britain showed that there were forty·fonr cases of this type who had been operated with eleven deaths. Among the thirty· three patients who recovered, the foreign body had remained in the peritoneal cavity up to 7, 12, 15 and 19 years. Twenty-six were treated by second opera· tion, an
A. C.
WILLIAMSON.
Chifolia.u: The Operative Risk in SUigical Treatment of Uterine ribroids, L<· Progres Medical, 1924, No. 42, p. 002. The conclusions of this paper are based on the rcHults of all operations for fibroid tumor of the uterus performed by the author during the last twenty years. The cases are divided into two groups, those from 1904 to 1914, and those from 1919 to 1924. In the first group there wore 145 cases with a mortality of 1:3.7 per cent while in the seeond there was a mortality of lrss than 1 per eent in ] !1-J. cases operated. Of the twenty deaths occurring during the first period, 1:1 were dne to infection, 5 to embolism, 1 to hemorrhage, and 1 to chloroform anesthesia. The hemorrhage occurred following the removal of hemostats on the third day after a vaginal hysterectomy. In this connection Chifoliau points out the necessity for great precaution, believing that it should be done in the operating room and with g<;od vaginal exposure so that the pedicles may be reclamped if necessary.
439
A further advantage of this prot:cuurc is the prevention of adhesions. Of the 423 patients so treated, 69 per cent were seen again after operation. In only one case could clinical evidence be elicited of postoperative adhesions and this despite the fact that in 15 per cent of the cases, pus had been found at oper:vtion. J. P. GREENHILL. Mayer: Postoperative Paralytic neus. 1924, lxxi, 931.
Miinchener medizinische W ochenschrift,
The author recommends a treatment which he feels has given him the best results with the condition. He introduced from 500 c.c. to 1000 c.c. of saline with 4 c.c. or 8 c.c. pituitary extract intravenously, or if this is impossible, the d:rip method is employed. In 70 per cent of his 52 patients the bowels soon moved and so the existence of a mooha.nical ileus was improibable. E-owever, in spite of the fact that he was able to get the bowels of so many of these patients to move, the majority of them died, but he considers 10 per cent veeoveries as very good. He does not attempt to decide whether the ileus is mechanical or due to sepsis. If after the treatment here recommended no results are obtained, enterostomy is the next t'hing to be considered and should be employed as a last resort. A. C. WILUAMSON. Giles: Some Gynecological Operations in Relat'ion to the Life Assurance. Lancet, 1923, cciv, 884.
The
This address is based on the author's original study of 1,000 cases plus the study of 3,000 additional cases. In general, two questions may be asked: first, what is the expectation of life after abdominal operation, and second, ~at is the state of health after abdominal operation. In formulating an answer to the first question, the exact conditions present at the time of the operation must be available. With re~erence to this, it is most important to know whether or not malignant disease is present. The writer considers the life expectation after operation for carcinoma and for benign tumors, inflammatory conditions and other procedure. In reply to the second question, the author found that 72.5 per cent of patients operated upon expressed themse·lves as being in very good health., It is extremely interesting to know t'hat the highest percentage of cases of very good health occurred in patients where the appendages on both sides were removed. The lowest percentage was in cases where the appendages were removed only on one side. Hysterectomies for benign conditions, ventrofixations, myomectomies, also showed a very high percentage of very good health following the operation. Where a unilateral salpingooophorectomy was done, pathology sufficient to require further operation on the other .tube and ovary occurred in 10.9 per cent of the eases. It was further found that the memory was somewhat affected by operation. The degree of this involvement was determined largely by the dura· tion of the' operation. About 70 per cent of the patients regained normal health. The highest proportion of the eases was found whe·re conservative procedure and complete removal of the organs had taken place. Unilateral operations of the uterine appendages show the lowest proportion of complete recoveries, the chances of complete cure being subordinate to the preservation of the functions of woman· hood. There may be a disturbance of the nervous system, as shown by the affection of the memory. In most cases this is temporary, in a proportion varying from 18 per cent where the operation was of short duration, to 50 per cent where the operation was of long duration. There is a risk that further operation may be required in about ten per cent of cases. This includes the direct sequelae ofl
440
THE AMERICAN JOURNAL OF OBSTE'fRICS AND GYNECOLOGY
the operation and independent conditions in about equal proportions. The risk iR greater after operations for inflammatory disease of the tubes, and after unilateral operations of the tubes and ovaries. Cases where operations for malignant disease have taken place must bo regarded as bad life risks. After operations for inflammatory disease th<> expectation of life is fairly good, but is impaired by the liability of sequelae. Patients who have had benign tumors removed may be considered as good life riskR, aR the chance of complications whirh may lead to a fatal rrsult, is negligiblr. NORMAN
F'.
l\lfiLLRI:.
White, 0.: Instruments Left in the Peritoneal Cavity. The Clinical Journal, Lon· don, 1923, Iii, 553. The case reported is that of a won1an o:f fifty teferreJ because her doctor founU a sharp pointed body in the cervix. She had consulted the physician because of acute pelvic pain. Nineteen years previously an abdominal operation had been performed for an abdominal tumor. Eighteen m(>nths before tho author saw her a second operation had been performed to relieve symptoms but the patient was told that the adhesions were too dense to allow anything extensive to be done. The author removed a hemostat whose points had eroded the uterus above the bladder reflexion and the handles had eroded tho pelvic colon and were in thn cavity of t:he gut. She died some six weeks later from an attack seemingly of anaphylactic origin. In a second case the writer removed a bone penholder from the peritoneal cavity whieJh had been introduced through the vagina and rcmaine·d in the cavity about ninety hours. Recovery was uneventful. A canvass of the surgeons of Great Britain showed that there were forty·fonr cases of this type who had been operated with eleven deaths. Among the thirty· three patients who recovered, the foreign body had remained in the peritoneal cavity up to 7, 12, 15 and 19 years. Twenty-six were treated by second opera· tion, an
A. C.
WILLIAMSON.
Chifolia.u: The Operative Risk in SUigical Treatment of Uterine ribroids, L<· Progres Medical, 1924, No. 42, p. 002. The conclusions of this paper are based on the rcHults of all operations for fibroid tumor of the uterus performed by the author during the last twenty years. The cases are divided into two groups, those from 1904 to 1914, and those from 1919 to 1924. In the first group there wore 145 cases with a mortality of 1:3.7 per cent while in the seeond there was a mortality of lrss than 1 per eent in ] !1-J. cases operated. Of the twenty deaths occurring during the first period, 1:1 were dne to infection, 5 to embolism, 1 to hemorrhage, and 1 to chloroform anesthesia. The hemorrhage occurred following the removal of hemostats on the third day after a vaginal hysterectomy. In this connection Chifoliau points out the necessity for great precaution, believing that it should be done in the operating room and with g<;od vaginal exposure so that the pedicles may be reclamped if necessary.