STATISTICS OF ABDOMINAL SECTION.

BY

JOSEPH PRICE, M.D.

TO THE EDITOR OF THE AMERICAN JOURNAL OF OBSTETRICS.

SIR-I wish as briefly as possible to notice a few points in the reply that Dr. Goodell has made to my review of his article on ovariotomy, in Pepper's "System of Medicine." First of all, for a work of the highly scientific and classical character of Dr. Pepper's "System of Medicine," edited as it is by one of enviable national reputation, scholarly attainments, and accuracy in all he performs, I would not have assumed myself to be "the proper person to collate statistics." So far as the article is concerned, for reviewing whose statistics so "ungraciously" I am called to task, my only intention was to point out the fact that the figures therein given do not fairly set forth the status of "Ovariotomy," if you please, as it exists to-day, and as one would of a right expect to find it detailed in the work in which it finds a place. The author of the article excuses its want of completeness, by pleading a lack of time to make it so. In singular contrast to this is the time devoted to the study of statistics in his "reply." The labor here expended, it would seem, would have been more opportune in the original article.

It will be seen by reference to my review in the June number of the AMERICAN JOURNAL OF OBSTETRICS that I there held the mortality attributed to Mr. Tait in his operations to be much too high. For my method of calculating this mortality I am called to task. For my error, if error there was, I am sincerely glad. The result has been that Mr. Tait now gets credit for even better results than I attributed to him. My regret is that justice was not given him in a classic publication, instead of in a magazine article.

While referring to the matter of statistics, I wish now to make brief reference to those of Clay, as given in the paper originally noticed.

The series of operations there reported was performed before the year 1861, with the results stated in the article reviewed (Tait, "Diseases of the Ovaries," p. 245). The series therefore cannot extend up to January 27th, 1883, as is implied in Dr. Goodell's explanation. For the statistics I have given of the results of Clay's operations, Mr. Tait himself is the authority.

He says:-" Dr. Clay continued to operate with very remarkable success for many years, until he had performed 395 operations with 101 deaths, his total mortality being therefore about 25 per cent. Tait, "Diseases of Ovaries," p. 245, Fourth Edition.

و,

I now may briefly refer to the use of the terms "ovariotomy' and "abdominal section " so freely criticised in the "reply." If we examine the reports of Dr. Goodell for the last four years, 1882 to 1885, inclusive, the term "laparotomy " is found used to designate the operations of two of these years, while "ovariotomy" is the term applied in the two others. "Laparotomy" is "abdominal section." (See Agnew, "System of Surgery," Vol. I., p. 407.)

One term, therefore, in accordance with Dr. Goodell's nomenclature, is no wider in its signification than the other. The use of the terms as made in my review was with especial reference to the fashion of our author, of applying either, as best pleases him, to his own operations.

The title of my review, therefore, read in this light, is no "misstatement." Besides, in the very first sentence of the review, the statistics of ovariotomy" are distinctly mentioned.

A word now as to the individual record of Schroeder. In the third and the fifth hundred of this operator's cases, it will be remembered, seven deaths were recorded. Dr. Goodell holds that the correct number is eight, in the third series stating that the eighth death occurred the sixth week in a patient in whom the irremovable part of the cyst had been sewed up. He adds: "Why the eighth case should be excluded from the list of deaths. because the cyst was malignant, and the operation incomplete, I cannot see; nor could my reviewer, I am sure, were this fatal case mine instead of Schroeder's."

If reference is now made to Case 126 in Dr. Goodell's series (Medical News, p. 314, March 21st, 1885), it will be seen that this case is recorded as a recovery, notwithstanding the fact that the patient died thirty-three days after the operation. If this method of estimating mortality is allowable for Dr. Goodell, why is it not so for Schroeder? Dr. Goodell reproaches me for failing to notice the results of Martin, but passes my omission of Bantock, his distinguished friend, justly celebrated in abdominal surgery, without a wail. When he now in his "reply" alludes

'Medical News, April 14th, 1883; February 16th, 1884; March 21st, 1885; January 30th, 1886.

Wells, "Surgical Treatment of Abdominal Tumors," p. 65; Schroeder's letter of November 30th, 1884.

to American and French operators, he simply adds weight to my previous criticism.

As to Peruzzi's statistics, if the best authorities are to be relied upon, I am correct.1

There is no need of further noticing in this connection the mortality list of Tait and Keith. Tait's own expression has already been recorded ("Diseases of Ovaries," p. 249). If I am in error as to my understanding of Keith's statistics, the correction is welcome. I have this to add, however. On the same page of Spencer Wells' book, "On Ovarian and Uterine Tumors," 1882, p. 224, on which Dr. Goodell finds Keith's statistics, as recorded. in his original article, immediately following the statistics he chose for some reason with "the utmost painstaking" to report, occurs the appended statement: "But the mortality has gradually diminished, and of the last 140 cases, 135 have done well. This presents the astonishing result of a loss of only 3.57 per cent. He (Keith) retains his preference for the cautery, and says, "In the treatment of the pedicle the best results by far are still got by the cautery. I much prefer the cautery, and think it the most perfect way. Of the last 120 cautery cases, there were only two deaths (1.6 per cent)."

One word further as to the adequacy of Dr. Goodell's statistics. He says: "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."

On the contrary, it is easy to prove that the results of the younger operators, at home and abroad, without great personal experience, compare very favorably with those obtained by veteran ovariotomists. The younger Keith, who now counts his operations by the hundred, should have due credit for his wonderful skill and success. (In his first one hundred cases he had only 6 deaths, 4 hysterectomies being included in the series.) To deprive him of mention and credit, simply because he has a father who himself has become famous in the field of abdominal surgery, does not appear reasonable.

Why the full number of the elder Keith's operations was not set down ought to be apparent, for the reason that it would be unreasonable to criticise an article in the light of statistics not accessible to Dr. Goodell at the time of its production.

And now for the consideration of a point, vital in this relation. "The reply" states: "The whole stock in trade of my reviewer

Spencer Wells, "Abdominal Tumors," 1885, p. 66.

consists solely of Spencer Wells' last work on 'The Diagnosis and Treatment of Abdominal Tumors,' which was published in England in the spring of 1885, and republished in this country in the following summer, and from this book he has taken all his telling statistics, without acknowledgment-statistics which, being embodied in personal communications to the distinguished author, appear nowhere else. This work I did not see until too late. Yet the lumped ovarian statistics of personal communication, however recent, cannot have the same weight as the older statistics which I have given in my article, etc." Let us look into this matter, and weigh the value of all this wrath. First of all, the book from which these statistics were taken is well known to all the reading profession. Second, Spencer Wells' name appears twice on the same page in connection with my statistics. Verbum sat.

Were these statistics accessible at the time of writing of the original article under discussion? This article appeared in February, 1886. Spencer Wells' book was published in the spring of 1885, was republished in this city, and was for sale on Walnut Street, May 23d, 1885, nearly a year before Dr. Goodell's article on "Ovariotomy." A long time surely for a production to be out of the hands of its author and out of the reach of correction.

But, to repeat: "The lumped ovarian statistics of personal communication, however recent, cannot have the same weight as the older statistics, etc." What wealth of resource! What skill in logic! First, these statistics appear too late (nearly an entire year before the publication of Dr. Goodell's article), and now, when at hand, they are not as valuable as those of an earlier date. History repeats itself, with sop for its writer: "At nunc acerbæ sunt "-the fox will not eat the grapes.

Therefore, as the criticism under question was meant to show what was wanting in Dr. Goodell's statistics, rather than to be an exhaustive and elaborate exposition of all the results of all operators, as it was meant to show what omissions Dr. Goodell made when data were present to supply such deficiency at the time of his writing, it seems evident that Dr. Goodell has done very honestly for the AMERICAN JOURNAL OF OBSTETRICS What he failed to do for Dr. Pepper's "System of Medicine," to wit: -striven for accuracy even at the expense of his time.

1317 SPRING GARDEN STREET, Philadelphia, Pa.

JOSEPH PRice.

TRANSACTIONS OF THE OBSTETRICAL SOCIETY OF PHILADELPHIA.

Special Meeting, April 15th, 1886.

The President, B. F. BAER, M.D., in the Chair.

DR. M. PRICE reported two cases of

EMMET'S BUTTON-HOLE OPERATION.

I desire to call the attention of the Society to a novel operation for the diagnosis and treatment of urethral and vesical diseases, and accidents incident to parturition, devised and practised by Dr. Emmet, of New York, for the past six years. In the last edition of his gynecology, he treats the subject elaborately, and gives it as, in his judgment, the most rational treatment for prolapsus of the mucous and submucous tissues, urethrocele, lacerations of the urethra from dilatation or injuries in labor, gonorrheal inflammation, and abscess in the urethral wall.

I desire to report two cases of this operation, where no other treatment, in my judgment, would have been of the slightest benefit to the patient. The operation recommended by Dr. Emmet is what he designates as his "button-hole operation of the urethra," and may be performed either in the Sims' position or in the lithotomy position. The operation consists in opening the urethra from three-quarters to one inch, midway between the urethral orifice and the neck of the bladder, thus giving ample room for inspection of the canal for any growth or condition requiring drainage or operative procedure. In those cases where the opening is made for diagnostic purposes simply, the opening may be closed with sutures, or be allowed to close in its own way. Many cases of urethral irritation are wonderfully benefited and most of them entirely cured simply by the free drainage it allows. The mucous membrane of the urethra and vagina are tacked together in these cases to prevent retraction. In the operation for urethrocele, the urethral opening is made through the pouch or dilated portion of the urethra, while a block-tin bougie is held in the bladder. The opening is continued down into the mucous membrane covering the sound, and a sufficiently large piece of the mucous membrane of the vagina removed to insure the removal of the pouch. The mucous membrane is then taken under the sound and drawn through the button-hole opening, so as to obliterate the redundancy of mucous membrane. Sutures are then passed from the vaginal surface to the block-tin sound, and back on the opposite side in the same position; all the sutures being thus introduced before cutting away the redundant mucous membrane held by a tenaculum in the hands of an assistant. This