REVIEWS. A CONSIDERATION OF DR. GOODELL'S STATISTICS OF ABDOMINAL SECTION. BY JOSEPH PRICE, M.D., Philadelphia, Pa. The fallacy that figures are always correct can nowhere be better illustrated than in the statistics of ovariotomy given in the article on that subject in Pepper's "Practice of Medicine," Vol. IV. Appearing as it does in the latest American work on medical science, it were not too much to expect that, in every particular, it would be found thoroughly correct, full, and authoritative. How far it is entitled to be so considered it is the aim of the present inquiry to determine. Ön page 314 of the volume above named, is given the statistics of the operation up to January, 1883. Why a writer should allow the statistics of the three years intervening between this date and the period of the publication of his article to pass without notice is beyond understanding. The table referred to is as follows: Clay. Cases. Recovered. Died. Mortality %. Spencer Wells..1,088 Keith. Without analyzing the table in detail, it is to be remarked that the figures given in the case of Clay are terribly deficient. The statistics of his operations, as given by Mr. Lawson Tait, are 395 abdominal sections with 101 deaths, thus giving an average mortality of 25.5 per cent, or a figure too high according to Dr. Goodell's table, by 6.6 per cent, had the record been brought to as late a date as possible. In the case of Tait, reference is made to the mortality of his last 313 cases as published in the New York Medical Record of January 3d, 1885. In this same number of the journal is the record of 1,000 consecutive cases of abdominal section with 93 deaths, reported by Mr. Tait, thus making an average mortality of 9.3 per cent up to that time. Instead of thus reporting it, Dr. Goodell has chosen for some reason, whatever it may be, to bring his statistics up only to the date as stated above. Further, the remarkable series of operations, 112 in number, reported in the Medical News of September 12th, 1885, is passed over without the slightest mention, notwithstanding the fact that not a single death occurred in it. If these 112 cases be added to the 1,000 already reported, Tait's record up to the date of his last report is 1,112 cases with 93 deaths, or a percentage of 8.36 per cent, in contrast with that stated in the table under examination, as being 11.94 per cent. The difference in the percentage, it will be seen, is one of 3.58 per cent, and certainly worthy of record. Keith's record also suffers by being terminated so far back as the end of 1882, as then, in Dr. Goodell's table, it had a mortality of 10.67 per cent, whereas on December 17th, 1884, it shows a percentage of 9.11, 490 cases having been operated upon with 45 deaths. A further error is made in reference to Keith's success in the statement that he "lately has had a series of 100 cases, with 97 recoveries." Mr. Keith himself distinctly says: "98 of my last 100 cautery operations have recovered, and in one of the two fatal cases, the tumor was malignant, with cancerous matter in the pelvis, practically an incomplete operation." An error of like nature is made also in the following statement. Discussing the use of Listerism in the operation of ovariotomy, Dr. Goodell says: "Tait, of Birmingham, and Keith, of Edinburgh, each with a recent mortality of only 3 per cent, have abandoned the spray." Tait's own record is: "Just as this is written I have completed a series of a hundred cases performed without any of Mr. Lister's so-called antiseptic processes, and in all of which the pedicle was treated with the Staffordshire knot. Only two of these 100 cases have proved fatal," etc. (Dis. of Ovaries, p. 249). In each instance an error is made by which one death too many is attributed to both Keith and Tait. The omissions, in the article under notice, are also as unfortunate as the errors. No reference is made to the fact that the younger Keith performed 37 ovariotomies with only one death; none that Sir Spencer Wells, to the end of 1884, in private practice only, had a series of 247 cases with only 27 deaths, being in the series an average mortality of only 10.9 per cent. Schroeder's cases are carried only to the third hundred, an error moreover entering into the estimate of this third hundred, which should be recorded as containing 7 instead of 8 deaths. Schroeder's cases, it may be remarked, are recorded up to November 30th, 1884, and are in number, 514. In 500 cases his mortality is 13 per cent. In his fourth and fifth hundreds, the mortality was respectively 16 and 7. Nussbaum's cases, altogether omitted, are, up to November, 1884, 415 in number. In his last 115 cases there was a mortality of 8.69 per cent. The mortality in all of his operations at the date given above, was 21.4 per cent. Professor Olshausen's cases, also omitted, were reported December 26th, 1884, as being 270 in number. Of these 28 died. Of his last hundred, but four cases proved fatal. Professor Billroth's cases, also omitted, number 327 operations with 101 deaths, the average mortality being 31.5 per cent. This list was completed early in 1885, and includes all his cases to the end of December, 1884. Possibly the most remarkable list of operations on record in the field of abdominal surgery-that of the elder Keith-comprising 38 consecutive hysterectomies with three deaths, is passed unnoticed. The data concerning the results of all Italian operators, collected by Peruzzi, is also incomplete, being brought by him as far as the fifth hundred, while from Dr. Goodell's statement it would seem that, at the given date, June, 1884, only the third hundred had been reached. The results, as given by Peruzzi, for the fourth and fifth hundreds, respectively, are 26 and 23 deaths. Moreover, Spencer Wells gives the results of the same authority in the first 100 cases, as 37 recoveries to 63 deaths, thus making the mortality of this series 2 per cent greater than that given by Dr. Goodell. A little variety in error, however, as in other matters, savors of spice. Statistically, Dr. Goodell's discussion is woefully deficient. its only fulness being that of error. It is certainly a matter of regret and disappointment that its data were not brought up to at least a near remoteness. If that were impossible, wherefore fail in accuracy ? 1317 SPRING GARDEN ST., PHILADELPHIA, DISEASES OF THE OVARIES AND OVIDUCTS. By WM. GOODELL, M.D. Pp. 155. A chapter from Pepper's "System of Medicine," Vol. IV. Clear, concise, correct, embodying in the plainest languagesimplicity is a beauty-those facts which are most necessary and valuable, and omitting all superfluous matter, it is difficult-considering that it is a part of a whole which is written, not for the pathologist or the specialist in ovarian diseases, but for the general mass of the profession-to say where it could be changed for the better. A lapse is made on the first page in speaking of the function of the ovaries as "that of secreting the Graafian follicles," developing being evidently the word that was meant. Chronic oöphoritis, its diagnosis and treatment, a subject about which the average medical man has a rather misty conception, is described most clearly and succinctly. In discussing Battey's operation, the author, as do most advanced gynecologists of the present era, condemns the vaginal section, for the reasons that by this method adherent ovaries cannot be safely dislodged or often even reached, the vaginal wound is difficult to dress antiseptically, and the abdominal "incision is more simple and less dangerous. Cysts of the parovarium, of the tubes, of the hydatid of Morgagni are next described, then the solid and the cystic tumors of the ovary and their surgical treatment. Exploratory puncture with a hypodermic needle is considered very bad practice and is condemned, this and the microscope being scarcely at all considered as a means of differentiating, by exami nation of the contents, the various forms of cystomata. While I will admit that puncture, even with the finest needle, may be dangerous, yet there are cases, as in suspected malignancy, where it and the microscope would be invaluable, and I should have liked to have seen a fuller exposition of this method of diagnosis. Palliative treatment of ovarian tumors by tapping in any of its forms is condemned, and rightly so, except to convince a woman of the futility of the trocar; or it may be tried once in a thinwalled, flaccid, slow-growing monocyst; or where a cyst develops during pregnancy or complicates labor; or as a preliminary to ovariotomy where the cyst is excessively large; or where the radical operation is deemed impracticable. The statistics of ovariotomy which Dr. Goodell gives need no mention, having already been discussed pro and con. The author does not accept the views of some recent writers upon early operation, believing that in most cases late removal gives the best results. The indications for ovariotomy, the preparatory treatment, the procedure itself, and the after-treatment are handled as are the other subjects of the chapter, clearly and well. The author believes in drainage when any material from a purulent or colloid cyst has escaped into the abdominal cavity; when the cyst contents are putrid, and septic symptoms or peritonitis are present; when a large amount of ascitic fluid is found; when four drachms or more of blood or sero-sanguinolent fluid can be squeezed from the last sponge removed from Douglas' pouch before the closure of the wound, and "when in doubt as to what to do." In cases where the question arises we are advised, provided it brings no additional risk, to remove the second ovary where there has been sterility, where there is malignant degeneration of one ovary, and when the menopause is near or passed, also when a fibroid is present or it is desired to hasten the climacteric. Following and qualifying this is the concluding sentence-it should be impressed on the mind of every surgeon-in the prime of menstrual life the sound ovary should be left untouched unless there exist grave reasons for its removal. BROOKS H. WELLS. CORRESPONDENCE. A REPLY TO DR. PRICE'S "CONSIDERATION OF DR. GOODELL'S STATISTICS OF ABDOMINAL SECTION." EDITOR OF THE AMERICAN JOURNAL OF OBSTETRICS. DEAR SIR: I admit that the reviewer of the statistics in my article on Ovariotomy has some grounds for legitimate criticism, but none for the ungracious manner in which he makes it. I am also willing to admit that a less busy man than myself would have compiled these statistics better, although, as I expect shortly to show, my reviewer would hardly have been the proper person for this purpose. But I am not wholly without excuse; for, in the first place, I was limited in my article as to space, and I therefore gave what seemed to me statistical research enough to establish the point proposed-viz., that the fatality in ovariotomy lessens in proportion to the increase of the operator's experience. In the second place, had my critic ever been invited, as I hope he will be some day, to write an article for so large a work as Dr. Pepper's System of Medicine, he would have known that the author parts with his manuscript many months before the work is published. When the "proof" came to me, I was so run down by overwork, having indeed to leave home for my health, that I corrected it perfunctorily, being too worn out to make any additions to it. I am, indeed, not sure that I had then read of Mr. Tait's phenomenal series of one hundred and twelve cases of ovariotomy without a death, for my medical journals had accumulated for several months without being unwrapped. But why, let me ask while on this subject, did my reviewer neglect to mention Tait's later series of one hundred and thirty-two cases without a death, which were reported only two months later? (British Medical Journal, November 14th, 1885, p. 937.) If I am to be called to account for omissions, why should not he? Concerning other statistics in my article, let me call your attention, Mr. Editor, to the fact that I have, in every instance but one, given full references to my authorities, and if my figures are wrong, my authorities are in error. This is more than Dr. Price has done, and this grave omission, especially grave when he wishes to prove my incompetency, makes most of his statistics valueless to any one who would like to utilize them. With all deference to my reviewer's superior accuracy, I hold that I am right in attributing to Tait and to Keith, at the time specified, a mortality each of three per cent in their ovariotomies, and not two per cent as he contends. The former says (AMERICAN JOURNAL OF OBSTETRICS, Vol. XV., p. 547), "The mortality of Dr. Keith's practice and my own is now as low as three per cent." Further, I am the more willing to admit the unsupported statement of my reviewer, for he, as usual, gives no references, that "Keith himself distinctly says, ninety-eight of my last one hundred cautery operations have recovered,"" because, elsewhere, and even so far back as four years ago, Keith makes the statement which my reviewer, so jealous of Keith's reputation, has most carelessly omitted to mention: "Of my last one hundred and twenty cautery cases, there were only two deaths." (Ovarian and Uterine Tumors, by Sir Spencer Wells, Am. ed., 1882, p. 224.) But Dr. Keith does not use the cautery in every case of ovariotomy, for in many cases he cannot use it; and I, on the other hand, was recording not his "last one hundred cautery operations," but his last hundred operations. So, unless my critic can furnish better evidence, and fortified by available references, I shall not yield my statement, backed as it is by Tait, that Keith lost three cases out of his last one hundred, at the time specified. With regard to Peruzzi's Italian statistics of ovariotomy, I am right, and my reviewer is wrong, if my authority quotes correctly. The Italian surgeons lost sixty-one cases out of their first one hundred, and not sixty-three (British Medical Journal, September 16th, 1882, p. 528, from Raccoglitore Medico, July 20th). Let me also, Mr. Editor, respectfully submit that I was not |