- Email: [email protected]
The time for operation in ectopic gestation
AM.
ASSN.
OBST.,
GY?\TEC.
AND
ABD.
BURG.
213
DR. CHANDLER (closing).-1 see that Dr. Pa.ntzer agrees with me #on anatomic irregularities. Dr. Lynch hates to think nature makes any mistake. I dislike to think so myself, but I have called your attention to the circulation around the rectum as being ideal if we walked on all fours. One person out of every four or five is born with the condition of which I have spoken and the qu.estion is what to do for it. 1 am offering a suggestion. Dr. Farr quotes Coffey as saying only about 30 per cent of appendicitis cases get well after operation. I claim that the reason for this is because the surgeon did not do the operation I have described. If surgeons performed thims operation, a much larger percentage of their patients would get well, and that is the object of my paper. 1)~.
ROBERT E. FARR, Minneapolis, Minn., presented. a paper on The Use of Local Anasthesia in Handling Septic Conditiions Within the Abdomen. (For original artieIe see page 152.) DISCUSSION
DR. ROBERT T. MORRIS, NEW YORK CITY.-Personally, I find I have ‘a subconscious sympathy for the patient, and with local anesthesia find m@f working more slowly and deliberately than otherwise I would have done. In typhoid perforation, where a complete operation may occupy less than a minute I use local auesthesia, also sometimes for patients with cardiac disease, but for the most part t.he tendency is to work more slowly and incompletely under local anesthesia.
DR. T. S. WELTON, Brooklyn,
for Operation
N. Y., read a paper entitled The Time (For original article see page
in Ectopic Gestation.
158.) DISCUSSION DR. ROBERT E. FARR, MIN~TEAPOLIS, MINNESOTA.-I know that in all caPes of severe hemorrhage that are in collapse, the injection of novocain and adrenalin will rapidly improve the condition of the patient. It may be partly due to the Wuid, and partly due to the adrenalin and to the novocain. In the cases we have had we have not deferred operation because we have never failed to follow out l;he technic 1 have detailed under local anesthesia, and the patient invariably has jmproved no matter what the condition was in these cases of hemorrhage, unless we had to do a badly traumatizing operation. We simply make an incision in the abdominal wall, check the hemorrhage and do as little operating as possible. We start transfusion at the same time-saline or blood-and make an immediate attack upon the bleeding vessel. I would concur in everything the essayist has said except i.n the points mentioned. DR. HERBERT W. HEWITT, DETROIT, MICHIGAN.-I%thOut going into details of the discussion of the deiayed versus the immediate operation, I wiuh to state that it has been my policy for a long time to do the immediate operation in nearly cjvery case, first of all doing blood transfusion. In these days, when the citrate method may be used by any assistant, the transfusion may be given while preparations are being mado for the operation. By the time everything is in readines#s for the operation the patient is in a much better condition. It is a fact, which I think is known to all, that a patient with ruptured ectopic gestation will stand operation very well. Taking this fact together with the use of blood transfusion, it
seems clear to me that the most advantageous possible moment after diagnosis has been made. be gained by waiting.
time for operation is the earliest 1 do not believe that anything will
DR. OTTO H. BCIIWARZ, ST. LOUIS, MISSO~FG-I mould like to ask Dr. Welton what type of lesion he found in these so-called tragic cases. In a comparatively small service we have had several very interesting tragic eases recently, and, with one exception, the lesion was located in the isthmus of the tube comparatively early, the period. of gestation being eight weeks or less. The lesion in each instance resulted from the fact that the e.horionic villi had corroded the tube wall, with very little coagulated blood around the site of the rupture. We obtained two of our specimens from autopsies in outside cases. DR. CHARLES L. BOKIFIELD, CINCINNATI, ONIO.-This is an eeort to classify these eases and to bring some law out of a chaotic condition; yet there are a great many eases of eetopic gestation that get neil of themselves and are never recognized. I had this point forcibly brought to my attention ten or fifteen year’s ago. I reported a few cases at the Cincinnati Academy of VCedieine, and one of the old doctons asked every one who had had a ease of ectcpic gestation to hold up his hand, and not 50 per cent of the practitioners present held up their hands and yet -very one had had a case of ectopic gestation but had not recognized it. A great many had ruptured, the fetus died, and the patients got along without recognition of the true condition. I agree with Dr. Schwarz regarding the type of cases tha.t die -usually with the first hemorrhage, I do not agree with the essayist that there is so much danger attending these cases. Uis experience has been different from mine. If t.he patient has her first hemorrhage, provided she i.s not moved, and in ;;ho second place nothing is done to try to elevate the blood pressure too rapidly, she may get along all right. In fact, my advice in these cases has been to do nothing except to give them plenty of morphine. I have had a lot of these patients go five or six days, and to the best of my knowIedge I do not regret it. On the other hand, in a large experience extending over many years I have operated on ‘but two cases where there was really active hemorrhage that was dangerous. Jnst lecaruse we have ‘a lot of free blood in the pelvis and can get it out, it does not necessarily mean that the patient is bleeding v,ery much. It means that the patient has bled. If the patient’s condition is improving, well and good. Many of them recover, and I not infrequently run across eases ‘a month or two after rupture, and not being sure of what I had to deal with, I have opened the culdesac and cleaned out a lot of clots, and they got well. It is sometimes wise to err on the side of conservatism. DR. JOHN 0. POLAR, QBOOKLYN, PP’ew Yo&K.--There is one point we till lose sight of, i.e., abortion may occur in ectopic pregnancy as it does in intrauterine ijregnancy, and as in the latter it may be incomplete or complete. When the abortion is complete the bleeding ceases. When inoomplete, the hemorrhage continues. Whether the pregnancy be in the uterus or the tube the analogy is perfect. The type of case Dr. Welton has been discussing is not the kind we meet in office practice, where we make the diagnosis before rupture or after a primary rupture, a.nd operate at our convenience. He is speaking of those severe cases, extremely shocked, that have not died at the time of rupture. Most of t&e cases rupture several times before the linal burst; the rirst erosion through the tube wall is small, and usually closes by blood clot, or the rupture is into the fo1d.s of the broad ligame&, when they may go for four or five weeks before they have another rupture. As we do not know when this next rupture will take place, we operate as soon as the diagnosie is made. In the severe cases where the woman is absolutely pulseless,
AM.
ASSN.
OBXT.,
GYNEC.
AND
ABD.
SURG.
215
operation turns the balance a.gainst her. We where there is no pressure, tl~ansfuse these eases, but we do it coincidentally with the time we place a clamp on the bleeding vessel, and we get results. We do not want to raise blood pressure before we are ready to operate. We want to keep the blood pressure beThere is a type of case referred to by low that point which will blow off the clot. Dr. Welton where we sit alongside the patient and watch her minute by minute. The blood pressure shows what is happening, shows whether she is reacting, or whether the bleeding is still going on. If she reacts, it is folly to go in and add trauma to shock, if we can get her back to a point where she is a relatively safe surgical risk. DR. W. WAYNE BABCOCK, PHILADELPHIA, PENXSYLvANIA.-There is a surgical rule we sometimes forget, which was enunciated by the fathers of surgery, although often omitted from the present day text books, that on the first occurrence of a but if the hemorrhage recurs you must secondary hemorrhage you may operate; operate. This old rule holds good today, and during late years experimental evidence A patient may survive the loss of 20 gives added reason why it should be followed. or 25 ounces of blood but die from a recurrent hemorrhage with the loss of but 6 or 8 ounces of blood. Transfusion is. far from being a perfect antidote, for I have seen a patient die from recurrent hemorrhage despite large transfusions of carefully Likewise, the experimental animal that may survive an enormous typed blood. initial bleeding, may the next day or day after die from the loss of perhaps only one-fifth the quantity of blood previously withdrawn. This I think empha.sizes# the point that we should be very fearful of recurrent secondary hemorrhage, and shows how wise the older surgeons were when they said you must operate and not delay i.f the hemorrhage returns. A second point-the impression I have is that vaginal section produces very much less shock, and can be carried out in the patient exsanguinated from ectopie hemorrhage with much less risk than can an abdominal section. For over twelve years those patients whom we felt had the tragic form of ectopic rupture have been brought to the operating room a’s quickly as possible and the hemorrhage controlled through the vaginal culdesac. These patients have been given spinal anesthesia, which is in line with Dr. Polak’s argument, for it also lowers the blood pressure. In the ordinary way we simply thrust a pair of curved scissors through the culdesac, tear the puncture widely open with the fingers, quickly introduce two fingers, or even the hand, into the pelvis, locate and free the bleeding tube, pull it down into the vagina and apply a clamp near the cornu. In two minutes the bleeding may be controlled, and if the patient is pulseless or nearly so, merely introduce gauze through the culdesac beyond the points of the clamp, send the patient back to bed as quickly as possible, raise the foot of the bed and use rest, heat, transfusion, hypodermoclysis or other measures that may seem indicated. We do not take time to remove the blood or clot or to wash out the abdomen; we merely locate, bring into the vagina and clamp the bleeding appendage. If the patient is in fair condition and haste is not imperative, we tie o-8” and excise the sffected tube. After the patient goes back to bed, the liquid and coagulated blood continues to escape through the vagina. As the patient improves, a low Fowler position is used. The abdominal operation is marked by low viability and time is lost, and the patient is shocked as blood and clots are baled, sponged or washed out of the abdomen, and the abdominal contents ‘are exposed and manipulated. In the vaginal operation the hemorrhage is quickly controlled without exposure or manipulation of the abdominal contents, and without ‘any effort to remove the escaped blood. The clamp may even be applied through the vagina in the patient’s
own bed in five minutes time. We had three cleat!is in about two years time, after abdominal section for ectopic hemorrhage, before we adopted the vaginal method. For twelve years since we have changed our method of treatment, although our service is not large, we have had enig one death from ectopie pregnancy, and that patient, although in a very serious condition at the time of operation lived several weeks and died from the effects of the catheter cystitis. DR. JAMES E. DAVIS, DETROIT, &Ircamas.-Just one point that has not been mentioned, in regard to the physioiogic adjustment of the fetal and maternal tissue, where the adjustment is not normal, and there is rn the history a number of indications. There is quite a difference in the erosion effect of the fetal tissues upon the maternal tissues. I believe that patients who die quickly and have repeated severe hemorrhages are those in whom the maternal tissue does not offer physiologic resistance to the fetal tissue. The indications for treatment are often obtainable from a carefully taken history, and bearing in mind that the wall of the tube is ~i;hinnecl out very decidedly and that there is much corrosion in the cases where this physiologic adjustment has not taken place. DR. WELTON (closing) .-Dr. Farr ‘s method of local anesthesia with adrenaline has great possibilities and is worthy of a thorough trial. Dr. Hewitt speaks of immediate operation and of transfusing all patients. Unless’ he gets donors quicker than we can, he is not doing an immediate operation but is doing a delayed operation. Dr. 8ehwarz asked regarding the common type of lesions in ruptured ectopie, and where they are located. We fmd most of the lesions located either in the ligamentous or isthmic portion of the tube. There is no coagulation of blood around the lesion due to the chorionic villi. We transfuse these patients coincident with the operation or immediately ‘after the operation. DR.
T.
MORRIS,
in Surgery.
(For
ROBERT
New
original
York, N. Y., read a paper entitled article see page 166.) DISCUSSiON
DR.
CH/&I,ES
p.
NOBLE,
?'IIILADELPMA,
I)ENxSYLvar;lA.-It
Seems
to me,
that
a11 that Dr. Morris has talked about as instituting a new era in surgery’Y, is contained if not in detail. That book was pubin Hilton on ‘(Best and Pain, ” in principle, All the remarks about cleaning ,out milk and letting lished fifty or more years ago. the patient cure himself has been known since the days of Hippocrates, as the ( ( The physician treats, but God heals. ” & medicatrix ?~atwme. Ambroise Par6 said: Time does not permit me to present properly my ideas regarding what has lead to the demonstrated inefficiency of the younger medical men, but it is my opinion that since about IS90 medical education has been miseducation. It has left out a and the constitutional factor in diseasegreat many things-clinical wi:sdom and has taught a goSod deal of the laboratory facts, with a false and exaggerated estimate of their value. I have always used the laboratory in the proper way; but it is not the practice of medicine. It is merely a technical way of getting a quantitative index with reference to certain facts which lone ought to know, not the facts themselves. If you are a good clinician you get both. a qualitative and a quantitative index more accurately than the laboratory man, ‘as a rule, can approximate it. DR. do his
MORRIS surgical
(closing).-In work as quickly
regard to Dr. and as skillfully
Noble’s point, as possible.
every man He should
should do the
ASSN.
OBST.,
GY?\TEC.
AND
ABD.
BURG.
213
DR. CHANDLER (closing).-1 see that Dr. Pa.ntzer agrees with me #on anatomic irregularities. Dr. Lynch hates to think nature makes any mistake. I dislike to think so myself, but I have called your attention to the circulation around the rectum as being ideal if we walked on all fours. One person out of every four or five is born with the condition of which I have spoken and the qu.estion is what to do for it. 1 am offering a suggestion. Dr. Farr quotes Coffey as saying only about 30 per cent of appendicitis cases get well after operation. I claim that the reason for this is because the surgeon did not do the operation I have described. If surgeons performed thims operation, a much larger percentage of their patients would get well, and that is the object of my paper. 1)~.
ROBERT E. FARR, Minneapolis, Minn., presented. a paper on The Use of Local Anasthesia in Handling Septic Conditiions Within the Abdomen. (For original artieIe see page 152.) DISCUSSION
DR. ROBERT T. MORRIS, NEW YORK CITY.-Personally, I find I have ‘a subconscious sympathy for the patient, and with local anesthesia find m@f working more slowly and deliberately than otherwise I would have done. In typhoid perforation, where a complete operation may occupy less than a minute I use local auesthesia, also sometimes for patients with cardiac disease, but for the most part t.he tendency is to work more slowly and incompletely under local anesthesia.
DR. T. S. WELTON, Brooklyn,
for Operation
N. Y., read a paper entitled The Time (For original article see page
in Ectopic Gestation.
158.) DISCUSSION DR. ROBERT E. FARR, MIN~TEAPOLIS, MINNESOTA.-I know that in all caPes of severe hemorrhage that are in collapse, the injection of novocain and adrenalin will rapidly improve the condition of the patient. It may be partly due to the Wuid, and partly due to the adrenalin and to the novocain. In the cases we have had we have not deferred operation because we have never failed to follow out l;he technic 1 have detailed under local anesthesia, and the patient invariably has jmproved no matter what the condition was in these cases of hemorrhage, unless we had to do a badly traumatizing operation. We simply make an incision in the abdominal wall, check the hemorrhage and do as little operating as possible. We start transfusion at the same time-saline or blood-and make an immediate attack upon the bleeding vessel. I would concur in everything the essayist has said except i.n the points mentioned. DR. HERBERT W. HEWITT, DETROIT, MICHIGAN.-I%thOut going into details of the discussion of the deiayed versus the immediate operation, I wiuh to state that it has been my policy for a long time to do the immediate operation in nearly cjvery case, first of all doing blood transfusion. In these days, when the citrate method may be used by any assistant, the transfusion may be given while preparations are being mado for the operation. By the time everything is in readines#s for the operation the patient is in a much better condition. It is a fact, which I think is known to all, that a patient with ruptured ectopic gestation will stand operation very well. Taking this fact together with the use of blood transfusion, it
seems clear to me that the most advantageous possible moment after diagnosis has been made. be gained by waiting.
time for operation is the earliest 1 do not believe that anything will
DR. OTTO H. BCIIWARZ, ST. LOUIS, MISSO~FG-I mould like to ask Dr. Welton what type of lesion he found in these so-called tragic cases. In a comparatively small service we have had several very interesting tragic eases recently, and, with one exception, the lesion was located in the isthmus of the tube comparatively early, the period. of gestation being eight weeks or less. The lesion in each instance resulted from the fact that the e.horionic villi had corroded the tube wall, with very little coagulated blood around the site of the rupture. We obtained two of our specimens from autopsies in outside cases. DR. CHARLES L. BOKIFIELD, CINCINNATI, ONIO.-This is an eeort to classify these eases and to bring some law out of a chaotic condition; yet there are a great many eases of eetopic gestation that get neil of themselves and are never recognized. I had this point forcibly brought to my attention ten or fifteen year’s ago. I reported a few cases at the Cincinnati Academy of VCedieine, and one of the old doctons asked every one who had had a ease of ectcpic gestation to hold up his hand, and not 50 per cent of the practitioners present held up their hands and yet -very one had had a case of ectopic gestation but had not recognized it. A great many had ruptured, the fetus died, and the patients got along without recognition of the true condition. I agree with Dr. Schwarz regarding the type of cases tha.t die -usually with the first hemorrhage, I do not agree with the essayist that there is so much danger attending these cases. Uis experience has been different from mine. If t.he patient has her first hemorrhage, provided she i.s not moved, and in ;;ho second place nothing is done to try to elevate the blood pressure too rapidly, she may get along all right. In fact, my advice in these cases has been to do nothing except to give them plenty of morphine. I have had a lot of these patients go five or six days, and to the best of my knowIedge I do not regret it. On the other hand, in a large experience extending over many years I have operated on ‘but two cases where there was really active hemorrhage that was dangerous. Jnst lecaruse we have ‘a lot of free blood in the pelvis and can get it out, it does not necessarily mean that the patient is bleeding v,ery much. It means that the patient has bled. If the patient’s condition is improving, well and good. Many of them recover, and I not infrequently run across eases ‘a month or two after rupture, and not being sure of what I had to deal with, I have opened the culdesac and cleaned out a lot of clots, and they got well. It is sometimes wise to err on the side of conservatism. DR. JOHN 0. POLAR, QBOOKLYN, PP’ew Yo&K.--There is one point we till lose sight of, i.e., abortion may occur in ectopic pregnancy as it does in intrauterine ijregnancy, and as in the latter it may be incomplete or complete. When the abortion is complete the bleeding ceases. When inoomplete, the hemorrhage continues. Whether the pregnancy be in the uterus or the tube the analogy is perfect. The type of case Dr. Welton has been discussing is not the kind we meet in office practice, where we make the diagnosis before rupture or after a primary rupture, a.nd operate at our convenience. He is speaking of those severe cases, extremely shocked, that have not died at the time of rupture. Most of t&e cases rupture several times before the linal burst; the rirst erosion through the tube wall is small, and usually closes by blood clot, or the rupture is into the fo1d.s of the broad ligame&, when they may go for four or five weeks before they have another rupture. As we do not know when this next rupture will take place, we operate as soon as the diagnosie is made. In the severe cases where the woman is absolutely pulseless,
AM.
ASSN.
OBXT.,
GYNEC.
AND
ABD.
SURG.
215
operation turns the balance a.gainst her. We where there is no pressure, tl~ansfuse these eases, but we do it coincidentally with the time we place a clamp on the bleeding vessel, and we get results. We do not want to raise blood pressure before we are ready to operate. We want to keep the blood pressure beThere is a type of case referred to by low that point which will blow off the clot. Dr. Welton where we sit alongside the patient and watch her minute by minute. The blood pressure shows what is happening, shows whether she is reacting, or whether the bleeding is still going on. If she reacts, it is folly to go in and add trauma to shock, if we can get her back to a point where she is a relatively safe surgical risk. DR. W. WAYNE BABCOCK, PHILADELPHIA, PENXSYLvANIA.-There is a surgical rule we sometimes forget, which was enunciated by the fathers of surgery, although often omitted from the present day text books, that on the first occurrence of a but if the hemorrhage recurs you must secondary hemorrhage you may operate; operate. This old rule holds good today, and during late years experimental evidence A patient may survive the loss of 20 gives added reason why it should be followed. or 25 ounces of blood but die from a recurrent hemorrhage with the loss of but 6 or 8 ounces of blood. Transfusion is. far from being a perfect antidote, for I have seen a patient die from recurrent hemorrhage despite large transfusions of carefully Likewise, the experimental animal that may survive an enormous typed blood. initial bleeding, may the next day or day after die from the loss of perhaps only one-fifth the quantity of blood previously withdrawn. This I think empha.sizes# the point that we should be very fearful of recurrent secondary hemorrhage, and shows how wise the older surgeons were when they said you must operate and not delay i.f the hemorrhage returns. A second point-the impression I have is that vaginal section produces very much less shock, and can be carried out in the patient exsanguinated from ectopie hemorrhage with much less risk than can an abdominal section. For over twelve years those patients whom we felt had the tragic form of ectopic rupture have been brought to the operating room a’s quickly as possible and the hemorrhage controlled through the vaginal culdesac. These patients have been given spinal anesthesia, which is in line with Dr. Polak’s argument, for it also lowers the blood pressure. In the ordinary way we simply thrust a pair of curved scissors through the culdesac, tear the puncture widely open with the fingers, quickly introduce two fingers, or even the hand, into the pelvis, locate and free the bleeding tube, pull it down into the vagina and apply a clamp near the cornu. In two minutes the bleeding may be controlled, and if the patient is pulseless or nearly so, merely introduce gauze through the culdesac beyond the points of the clamp, send the patient back to bed as quickly as possible, raise the foot of the bed and use rest, heat, transfusion, hypodermoclysis or other measures that may seem indicated. We do not take time to remove the blood or clot or to wash out the abdomen; we merely locate, bring into the vagina and clamp the bleeding appendage. If the patient is in fair condition and haste is not imperative, we tie o-8” and excise the sffected tube. After the patient goes back to bed, the liquid and coagulated blood continues to escape through the vagina. As the patient improves, a low Fowler position is used. The abdominal operation is marked by low viability and time is lost, and the patient is shocked as blood and clots are baled, sponged or washed out of the abdomen, and the abdominal contents ‘are exposed and manipulated. In the vaginal operation the hemorrhage is quickly controlled without exposure or manipulation of the abdominal contents, and without ‘any effort to remove the escaped blood. The clamp may even be applied through the vagina in the patient’s
own bed in five minutes time. We had three cleat!is in about two years time, after abdominal section for ectopic hemorrhage, before we adopted the vaginal method. For twelve years since we have changed our method of treatment, although our service is not large, we have had enig one death from ectopie pregnancy, and that patient, although in a very serious condition at the time of operation lived several weeks and died from the effects of the catheter cystitis. DR. JAMES E. DAVIS, DETROIT, &Ircamas.-Just one point that has not been mentioned, in regard to the physioiogic adjustment of the fetal and maternal tissue, where the adjustment is not normal, and there is rn the history a number of indications. There is quite a difference in the erosion effect of the fetal tissues upon the maternal tissues. I believe that patients who die quickly and have repeated severe hemorrhages are those in whom the maternal tissue does not offer physiologic resistance to the fetal tissue. The indications for treatment are often obtainable from a carefully taken history, and bearing in mind that the wall of the tube is ~i;hinnecl out very decidedly and that there is much corrosion in the cases where this physiologic adjustment has not taken place. DR. WELTON (closing) .-Dr. Farr ‘s method of local anesthesia with adrenaline has great possibilities and is worthy of a thorough trial. Dr. Hewitt speaks of immediate operation and of transfusing all patients. Unless’ he gets donors quicker than we can, he is not doing an immediate operation but is doing a delayed operation. Dr. 8ehwarz asked regarding the common type of lesions in ruptured ectopie, and where they are located. We fmd most of the lesions located either in the ligamentous or isthmic portion of the tube. There is no coagulation of blood around the lesion due to the chorionic villi. We transfuse these patients coincident with the operation or immediately ‘after the operation. DR.
T.
MORRIS,
in Surgery.
(For
ROBERT
New
original
York, N. Y., read a paper entitled article see page 166.) DISCUSSiON
DR.
CH/&I,ES
p.
NOBLE,
?'IIILADELPMA,
I)ENxSYLvar;lA.-It
Seems
to me,
that
a11 that Dr. Morris has talked about as instituting a new era in surgery’Y, is contained if not in detail. That book was pubin Hilton on ‘(Best and Pain, ” in principle, All the remarks about cleaning ,out milk and letting lished fifty or more years ago. the patient cure himself has been known since the days of Hippocrates, as the ( ( The physician treats, but God heals. ” & medicatrix ?~atwme. Ambroise Par6 said: Time does not permit me to present properly my ideas regarding what has lead to the demonstrated inefficiency of the younger medical men, but it is my opinion that since about IS90 medical education has been miseducation. It has left out a and the constitutional factor in diseasegreat many things-clinical wi:sdom and has taught a goSod deal of the laboratory facts, with a false and exaggerated estimate of their value. I have always used the laboratory in the proper way; but it is not the practice of medicine. It is merely a technical way of getting a quantitative index with reference to certain facts which lone ought to know, not the facts themselves. If you are a good clinician you get both. a qualitative and a quantitative index more accurately than the laboratory man, ‘as a rule, can approximate it. DR. do his
MORRIS surgical
(closing).-In work as quickly
regard to Dr. and as skillfully
Noble’s point, as possible.
every man He should
should do the