Vol. XI.

Original Articles.

TO BEGINNERS IN LAPAROTOMY.

BY F. BYRON ROBINSON, CHICAGO.* There are too many laparotomies done to-day by unskilled men without proper facilities. It is criminal to learn laparotomy by beginning on the patient. A few days ago a young man walked into a restaurant and sat down opposite me to lunch. He had graduated about two months previously from a medical college, and he soon made himself acquainted with me. He felt elated over the acquisition of his recent M.D., and to my astonishment he vigorously announced himself on a "hunt" for a laparotomy. He said he was determined to find a laparotomy soon, and that he should do it himself. He told me (significantly) that his professors had said that laparotomy was one of the easiest of surgical operations. Now, as this young physician was in such dead earnest in his "still hunt' for a laparotomy, I thought I would try the effect of reasoning with him. Fortunately Dr. Gillette, of Toledo, another gynecologist, sat by me, who could add to my words that laparotomy is a very serious operation and should be done only by one trained in the work. I said to the bright young doctor: "Have you ever done five post-mortems?" "No," he replied. I said: "Have you ever done one post-mortem?" He said he had never done one post-mortem. He absolutely He absolutely acknowledged that he had only superficially dissected one abdomen. I then asked him how he expected to do the "coming laparotomy." He replied that he would read up for a few weeks. After a half-hour of talk the young doctor said to me: "Why! no doctor ever told me that a laparotomy was so serious a matter as you say. I am glad I had this

* Professor of Gynecology, Chicago Post-Graduate School; Gynecologist to Woman's Hospital, to Post-Graduate Hospital, to Chicago Charity Hospital, and to Columbia Dispensary.

No. 17.

talk, and I will study before I operate." But the young doctor could not help thrusting at me the idea that I had to begin once, and that I was doing laparotomy, which he said he had just as much right to perform as I had. I replied: "Doctor, you have just as much right to laparotomize as anyone. But simple justice to a patient demands that you should be properly prepared to accomplish what you undertake."

This young physician is simply a type of what I will denominate the "new school of specialists." specialists." I mean by this new school of specialists men who graduate from a medical college and enter immediately into the practice of abdominal surgery and gynecology or some other specialty. The specialist may have no training and attempt to learn what to do from observing the patients and from reading.

More ambitious young men place themselves under masters for a longer or shorter time.

The older plan of becoming a specialist was to be a general practitioner or a general surgeon for five to ten or more years, and then gradually to limit practice to some single line of work.

McDowell was a well-tried surgeon before he deliberately did laparotomy in 1809. Atlee did hundreds of operations before he carefully diagnosed and successfully operated for ovarian tumor. All the famous laparotomists of England for the past twenty-five years have been well grounded in general surgery. The same is true in Germany and Austria.

inal surgery that he asked my friend how he would do a laparotomy. Finally he said he would like to know how anyone expected to drain the abdomen with the tube standing straight up. Dr. G― performed four laparotomies on four young women. The sad sequel was that three of the women died. Mortality was 75 per cent. He had never learned to do abdominal surgery. It is reported, now, that he became discouraged or afraid and does other work than laparotomy.

Dr. B has been a general practitioner for eight years. He never was trained in surgery beyond the range of ordinary collegiate clinics. He has studied the nervous system, and knows something of it in a special

Dr. B has performed two laparotomies lately; one was on a beautiful young woman. Both women died. These were the only two laparotomies he ever did. Mortality in this case, 100 per cent.

Is this not woman-slaughter in the first degree.

My friend Dr. Lwas a general practitioner. He did a little surgery, but only common cases such as amputation of a leg or an arm. Dr. L studied gynæcology out of the books to some extent, but had no training in abdominal surgery. Like Drs. G. and B, he knew relatively nothing of the anatomy of the abdomen and pelvis. Like them, he would not know how to mend a gut if he had torn it apart. Dr. L-performed four laparotomies, and two of the women died. His mortality was 50 per cent.

I am acquainted with two more good general practitioners who have had no training in abdominal surgery, but who did two laparotomies. Both women died. Mortality 100 per cent. Another general practitioner did three laparotomies, and one died. Mortality 33 per cent.

My friend Dr. H- told me a few days ago that he tried laparotomy in four cases, and two died. Mortality, 50 per cent. But the Doctor said he quit because the patients died too easily. Dr. H- is a general practitioner.

My friend Dr. A is a general practitioner and does some surgery. He performed laparotomy for bowel obstruction. On opening the abdomen he said the ascending colon was "black looking" from a band having

stretched over it and obstructed it. He said he simply cut the band, bnt did not know what to do with the colon as he thought it was gangrenons. He did not know enough surgery to attempt to make an artificial anus. The patient died promptly. His mortality in abdominal surgery was 100 per cent.

I could multiply this list of tragic laparotomies where beginners have started to do this delicate work without reasonable training or without any training in abdominal surgery. The cases of tragic deaths, now, in laparotomies, generally occur in small towns with insufficient hospital facilities, with hardly any trained nurses, and with beginners in abdominal surgery who have had but little or no training in laparotomy.

Mortality of 30 per cent., 50 per cent., or 100 per cent. in laparotomy must be viewed to-day as woman-slaughter. Laparotomy of to-day rests upon the accumulated experience of fifty years, and it is almost a science. Fifty per cent. of deaths to-day in laparotomy is criminal. Let me assert the terrible fact that beginners and amateurs in laparotomy will average a death rate of about 25 per cent., while skilled abdominal surgeons will average about 5 per cent. In my last forty laparotomies, which represented as severe pathological conditions as man ever saw, I really only lost one from the operation. These were bad cases and had filtered through other hands. I will say that a second in this list of forty cases died from a pure accident; five days after the operation she was doing well, when suddenly she died from an embolus which floated into the lung.

Dozens of skilled abdominal surgeons can now present one hundred cases with five deaths. Tait did one hundred with one death. Stansburg Sutton told me last week that he did one hundred with two deaths. Now I want to ask the beginner: What makes the difference between Mr. Tait's result and that of the man who is just starting without the reasonable training, without the trained nurse or the hospital facilities? The reader can answer. You will all remember that in Shakespeare's masterpiece Hamlet handed a flute to Guildenstern and told him to play. Guildenstern says: "I can't play." Hamlet insisted that he should play, that all he had to do was to blow with his mouth and

lift his fingers up and down on the flute-holes. But Guildenstern pointedly replied that he could not play because he had not the skill. Now the difference between high and low mortality in laparotomy is simply a question of acquired skill. Skill means superior practical and theoretical knowledge on any subject.

But the young doctor says: "I must have patients to begin on. I must have patients on which to learn laparotomy." No, Doctor, you are wrong; you are unjust; you are not doing to another as you would be done by. You are wronging yourself and the patient; and the profession gets a black eye every time you lose a patient. Doctor, please allow me to give you some advice as to beginning to perform laparotomies. It may be you will listen to me more carfully if I tell you that I have studied abdominal surgery and gynæcology for eight years, that I went to Europe three times and studied a year each time, that I spent six months as a pupil of Mr. Tait. I have dissected carefully about 50 cadavers and experimented on the abdominal viscera of over 200 dogs. I have seen hundreds of operations, and done many myself. In the first place, if you ever do laparotomy skillfully, you will have to learn it. Remember, laparotomy is no more a pioneer field, but well tested and tried. It is now a

science.

Allow me to illustrate how to learn the subject, by my assistants. I have three assistants in the work. One of them went to Europe and remained a couple of years. She had a good hospital training. She assisted me many times.

Now during the past eight months she has performed eight successful laparotomies herself, without a death. She takes her patients to a hospital, and then requests me to assist her and stand by if any severe difficulty arises, but I have only had to really help her in one very bad case.

Is this all she does, simply assist? No. She has carefully dissected and studied for weeks the abdomen and pelvis of many cadavers. She has put in a whole year in study and dissecting the abdominal viscera in order to learn what to do when the abdomen was opened.

One of my other assistants has helped me in some twenty-five laparotomies, and I let

her do many things during the operation. She is also steadily pursuing the study of the abdominal viscera. When she begins on her first laparotomy, she will have enough skill to know what to do.

My other assistant is demonstrator of anatomy in a college. She had four years in a good hospital where abdominal surgery was a specialty. She brings a case to a hospital and requests me to assist her, and so far she has not lost a case. She knows exactly the pelvic and abdominal structure, and when pathology rings in its changes she is not lost.

These three women will in a few years be skillful laparotomists, simply because they are properly learning how to do it.

But the young doctor says: "I have no time to go away to learn. I have paid for a college education already." This remark is not just. A patient's life cannot be bought and sold like bread and butter. Young physician, you can never be a skillful laparotomist unless you go under a master, unless you experiment on animals' abdomens. You must dissect the abdomen of the cadaver, and you must study the book on abdominal surgery. Laparotomy cannot be learned in a twelvemonth. It will require systematic experiment, systematic observation and reasoning. (Remember, I am not talking of an emergency care of strangulated hernia where immediate operation is demanded, but of laparotomy, where there is ample time for deliberation.)

I would like to say to the beginner that half the battle in laparotomy is with the intestines. Now, the young doctor can learn much that is good in any small town by experimenting on the intestines of dogs. He can learn how to mend wounded bowels, and how repair acts on bowels. He can learn what peritonitis really is, by the post-mortem on the dog. He can learn very much by practicing on the dog's abdominal viscera. He can very soon learn how easily a dog can be killed by opening his abdomen. And a woman will die just as easily. I would like to say to him that one of my most valuable experiences in abdominal surgery was gained on the abdominal viscera of 230 dogs during five years' experments. It is fascinating work.