Evening journal., 1908-03-23
MANY SURGICAL
TRAGEDIES
MiShapS That Follow in the
Wake Of Opera
tiOnS

such as forceps. sponges. towels and
gauze pads, are more frequently left in
the human body after operations than
the public is aware Of To be sure. the
number Of operations. in which this
happens is small. 1t occurs perhaps
once or twice in the course Of 1000
operations. Like an eruption Of vesu-
vius. however, it is likely at any time
and has marked the operations of some
Of the best known surgeons Of this
city. They say it may occur again not
/. .wlthstanding the number of schemes
which have been devised to prevent it.
No one knows the number Of these
mishaps. as only In relatively few cases
is death followed by an autopsy. The
announcement that "the operation was
a success, but the patient died." may
cover a multitude Of sins Of omission
and commission so far as any one can
tell. One may find in the files of the
annals Of Surgery" the reports of be-
tween $50 and 200 cases in which OBJ
jects used in operations have been left
In the body. These objects include
tubes, clamps, sponges. towels. forceps,
scissors and finger rings. Usually 1t
is piece of gauze or a sponge that is
left In the wound. In 100 cases re-
ported from Europe thirty-one sponges
and thirty-three pieces Of gauze were
left in wouRds. In forty-three cases
death resulted. In the other sixty-six
cases the articles worked their way out
after remaining in the body for months
and sometimes years or were discover
ed and removed by operations perform
! ed to relieve the pain caused by the
movements Of these objects.
In one case a surgeon lost his seal
ring. 1t finally pushed its way to the
surface of the body Of a person on
/ whom he had operated and was re-
4 turned to its owner. In another a pair
Of forceps circulated about the abdom-
inal cavity Of a ease" for four years
before being recovered. Pieces of
gauze FIVE feet long and a yard wide
have been removed from persons on
whom operations had been performed.
1t seems strange to the layman that
anything should be able to escape the
surgeon in such a small cavity as is
likely to be created In the body in the
course Of an operation. Especially does
1t seem impossible that anything should
be lost in view of the extreme care
taken to prevent it. Many surgeons
have worked out methods of proce-
dure for operations with the intention
Of eliminating the possibility Of the loss
OF anything used Unfortunately even
these have never proved infallible.
The most usual method is to have ev-
erything counted by a nurse before
the operation begins. Before the wound
is closed each article is accounted for
by a recount Some surgeons have had
experiences which led them to triple
the number Of persons responsible for
the appliances, each to check the counts
Of all the others. other surgeons have
the gauze pads In packages of half a
dozen OF a dozen. Only one package
is opened at a time, and its contents
must be accounted for before the next
is opened. Tying tapes to each gauze,
pad or instrument inserted IN a wound
is another precaution. A prominent
Brooklyn surgeon devised a check sys-
tenn similar to that used by baggage
men. A quantity Of glass checks were
numbered, there being two Of each
number, and to each set Of duplicates
was attached a tape. To every article
used in the operation one Of these
tapes with the check attached was fas-
tened. Whenever, for instance, a piece
Of gauze was taken from a basin for
use one of the checks was removed
and placed in the basin. Before the
wound was stitched each article rep
resented by these detached checks had
to be accounted for.
Notwithstanding such precautions, in
four recorded cases large sponges were
torn in half while the operation was
in progress and one Of the halves
placed in the wound and lost sight of.
When the count was made there was
the same number of sponges as at the
beginning Of the operation. The miss
ing half was forgotten and the wound
closed.
A surgeon in describing one Of these
mishaps says:
"a young surgeon, assisted by an
older surgeon, performed the operation.
The older one tore a sponge in half and
tucked half of it in without saying any
thing about 1t. The woman died of
shock, and the sponge was removed at
the postrnortem examination, much to
the surgeons surprise, as a count OF
sponges gave the number with which
the operation had been begun"
Another way in which a reputable
surgeon may be made the victim of
this kind of an accident is illustrated
in this settlement made by an Ameri-
can practitioner:
Il have had two unfortunate expert
ences in regard to foreign bodies re-
naming in the abdominal cavity, one
occurring a few years ago when using
the old fashioned sponges, the patient
dying from general peritonitis. One
occurred about three years ago in which
small gauze sponge was left, the pa
tent making a good recovery, but on a
reappearance of the disease a year
after the sponge was found on explora-
ton. This is an accident to be regret
ted. 1 have always been fortunate in
reference to forceps and instruments
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