Laparotomy has passed through different periods of development, just as so many major operations, particularly ovariotomy, have done. Lizars (1825), Dieffenbach (1826), Atlee and others, opened the abdominal cavity for the purpose of performing ovariotomy when, really, only uter ine fibroids were present. Considering it impossible to remove such tumors in this way, those observers simply closed the abdominal cavity. Out of fourteen cases of this kind, in which the operation was not per formed, five died from the effects of the surgical Chas. Clay, in August, 1843, and Heath, in November, 1843, went a step farther: Having opened the abdomen, for the removal of what they sup posed to be an ovarian tumor, they found uterine fibroids alone present and removed them through the abdominal wound. Both patients died. • Chas. Clay (1844) and Parkmann (1848) had similar cases. Burnham (1853) having committed a like diagnostic error, removed the uterus, with its contained fibroids, and saved his patient's life.
Peaslee (1835), Boyd (1856), Spencer Wells (1869), and Sawyer (1860), having made similar mistakes in diagnosis, performed the same operation without success.
Kimball • was the first to extirpate a previously diagnosticated uterine fibroma, with the uterus, in 1853. This case ended in recovery. Koeberh: (1863), was the next to perform this operation, which was now removed from the domain of accident, and received among approved surgical measures, although it was reserved for later times to show in how far it is justifiable.
All the statements made in our remarks on enucleation, regarding the uncertainty of deductions concerning the value of operations, as based on statistical evidence, apply equally to laparotomy in cases of uterine fibromata. In order, however, to give a point of departure for an estimate of the danger attending the operation I here append the statistics, pub lished until 1878, without criticism, although many require it very much.
It is not, as a rule, clearly stated in these reports, whether only the tumor was removed through the abdominal wound, the uterus and ovaries being left behind, or whether the latter were also extirpated. Moreover, all operations, of this kind, done on cysto-fibromata, are in cluded in the tables. Pean (loc. cit.) collected 44 operations with 30 cures. The mortality here amounted to 68.2 per cent. Marion Sims (on intrauterine fibroids) found, among 11 extirpations done in Eng land, 2 cures, i.e., a mortality of 82 per cent.; among 11 operations per formed in America, 4 cures, i.e., a mortality of 64 per cent.; among 18
operations, in France, 11 cures, i.e., a mortality of 39 per cent.
Koerberle found, up to 1864, 50 laparotomies, performed for the purpose in question, 35 of which were completed. 12 cures were attained, and 23 deaths occurred.
Caternault ' found among 20 gastrotomies, in which only the tumors were removed, 12 deaths, or 60 per cent. Among 12 extirpations of the uterus with the fibroids, he found 32 deaths, or 76 per cent. Routh' collected 48 laparatomies, performed on account of uterine tumors; 15 of these were not completed (with 7 deaths), and 33 were completed (with 23 deaths.) Gaillard Thomas's' statistics are the most unfavorable of al:. According to Storer, he cites 24 operations, with 18 deaths, or 75 per cent., and in addition quotes 10 other operations, done in America, all of which had a fatal termination. Schroder found, among 108 laparotomies, per formed for uterine fibroids, 16 cures and 78 deaths, i.e., cures in 14.7 per cent. and death in 85.3 per cent. of the cases. Of these 108 lapa rotomies, 73 were combined with extirpation of the uterus. Among these cases there were 55 deaths and 18 recoveries. The tumor alone was re moved 35 times, death occurring in 23, and recovery in 12 cases. . Pozzi (loc cit.) collected, up to 1875, 119 cases of this kind, among which there were 77 deaths, i.e., a mortality of 64.7 per cent.
All these statistics furnish, on the whole, a comparatively uniform and very unfavorable result. I have endeavored to prepare a more useful statistical table, which I now append. In the first place, I have omitted all cases in which laparotomy was done for the removal of a cysto-fibroma, because these tumors will be separately considered in the next chapter. Then, the laparotomies in which the uterus was not exsected have been carefully separated from those in which both uterus and tumor were re moved.' I. Laparotomies for the Removal of Pediculated Sub-serous fibromr faata, without extirpation of the uterus.
Koeberle 3 cases (2 reported by Caternault, Mc. cit., 1 in Gazette lad. de Strasbourg, 1866, No. 5). Two fatal results.
Sands 1' case. Death 5 minutes after the operation, from laceration of the common iliac vein.
Gillespie.' Large fibroma with many adhesions. Pedicle attached'by clamp at lower angle of the wound. Death on the 2d day, from perito nitis.
Hackenberg.' Pedicle separated by ecraseur. The tumor was con sidered ovarian. Death on 3d day, from peritonitis.