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SOME OF THE ELEMENTS OF SUCCESS IN CELIOTOMY.'

A. LAFTHORN SMITH, M. li., M. H. (,'. S., KN(}.; MONTREAL, CANADA.

Although {ihdoiuinal sections have, on tlie one hand, heen per-
formed much too often, and sometimes when tliere has been no organic
disease of the viscera, yet on the other liand they iiave not heen
performed often enough wlien there has l)een a real necessity for remov-
ing accumulations of virulent pus in the ovaries or tubes, so that while
the mania for removing healthy api)endages by inexperienced operators
is passing away, the (courage of ex})erienced abdominal surgeons is
gradually increasing, and cases which the boldest would have hesitated
to touch a few years ago are now operated upon by the skilled gynecol-
ogist with complete success. Increasing success has encouraged us to
greater boldness, and the greater boldness has itself in turn greatly
increased our success. It is well from time to time to take stock of our
progress, and I have therefore chosen a review of the elements of our
present success in abdominal surgery for the subject of my contribu-
tion. In (!oming to my (conclusions, I have adopted two methods, the
one consisting in impiiring among a great number of honest and f-V.ill-
ful operators wlu.'ther they have ever had any deaths, and if so, what
was the cause of death, and hftw could it have been i)revented; and
secondly, I have observed closely the methods of a great nuudjer of
successful operators whose death-rate had reached the minimum figure,
and I believe that it was easy to see why they were successful. My own
experience has been too small to deserve great consideration, but niy
own three deaths have not been without teaching me valuable lessons
which I shall incorporate in this paper. From the al)ove inijuiries I
found that death following abdomiiuil secti(»n is due to one or more of
the following causes, which [ have placed in th(> (»rder of their fre-
(juency, namely:

First. — Sepsis or peritonitis.

(SeconrZ.— Hemorrhage, either iuunediate (otherwis« called shock) or
secondary.

Third. — Prolonged aiuesthesia.

Fourth. — InterfereiKH^ with the peristalsis of the bowels.

Fifth. — I'rocrastination of the operation.

1. Read before tlie American (•yiiecolotfical Society, May, 1893,

In addition to these causes, which are matters of life and death,
there are other minor accidents, such as mural abscesses, ventral
hernia and wounds of the bladder, which, while not dangerous to life,
yet destroy more or less the success of the operation.

Tfie Avoidance of Sepsis or Peritonitis. — Provided that absolute
surgical cleanliness can l)e obtained in everything pertaining to the
patient, the ojierator and his instruments, including ligatures and
sutures, we have little or nothing to fear from sepsis. It is a mistake
to think that a costly operating room is absolutely essential. I have
frequently successfully performed cirliotomy in the homes of the very
poor, situated in the most unsanitary district of Montreal, while many
of my most ditticult ojjerations have been performed in a small
operating room at the Women's Hospital, where other operations are
performed, including the curetting of foul puerperal fever cases, and yet
case after case has made an uninterrupted recovery without evincing
the slightest sign of sepsis. On several occasions my assistant has
been a general practitioner in active practice, who was at the time
attending cases of diphtheria and scai'let fever, while there have nearly
always been present as spectators many general practitioners and
students. Provided that the rule be strictly observed that no one be
allowed to touch anything used during the operation, except those
whose hands have been properly prepared, I would care very little
whether or not the visitors had been attending puerperal fever or diph-
theria just before coming to the operation. So that we may safely say
that much of the elaborate preparation of visitors carried out at the
German clinics, such as putting on hospital suits or removing their
collars and neckties and spraying them with carbolized steam is quite
unnecessary, provided that the visitors can be placed where it will be
impossible for them to get at or touch anything to be used during the
operation; no other precautions regarding them are necessary, but this
precaution is an absolute necessity. It is an axiom of mechanics that
no piece of machinery is stronger than its weakest part, and all the
elaborate attention to the details of asepsis are of no avail if one
visitor who is not aseptic can get a chance to infect our instruments or
sponges. I can hardly count the number of times I have seen a visitor
try to pick up a knife or forceps or sponge that has fallen on the
ground, and replace it on the tray or dish; and once I saw the practi-
tioner who had sent the case to a leading New York operator, who was
performing a diflicult abdominal operation under the most elaborate
aseptic precautions, walk in during the operation, and without even
washing his hands, suddenly attempt to assist the operator by holding
in the intestines. At other times they will slip in before the operator
and handle the carefully sterilized ligatures or sponges. The notices
seen in many hospitals, warning visitors not to touch anything, are a
good precaution, but it is not suilicient. It would be better to rail

.mtM

them off, so that they cannot possibly get at the sterilized materials.
80 much for the visitors; I hope I have not been too hard on them, but
they always make me anxious for the success of my operation.

The nurses as well as the assistants must, of course, have their
hands disinfected immediately before the operation just as thoroughly
as the operator, for although their hands do not go into the peritoneal
cavity, yet the sponges directly from their hands do so. I, therefore,
see this done by the assistants and nurses and never accept their state-
ment that their hands are clean; whatever precautions I take, they
must take at the same time. They must scrub their nails with soap
and hot water, rinse them in bichloride, then in water; then they must
steep them in saturated permanganate of potash solution, until they
are mahogany ])rown, and then whiten them in oxalic solution, and
then rinse them in boiled water, 1)ut I do not ask them if they are
menstruating, as does some over-zealous brother, whose name I forget.
I do not think that this makes any difference.

During the years that I used sponges, their proper disinfection
caused me much anxiety, besides being so destructive to their delicate
organism as to put me to considerable expense. I have now done away
with them entirely in my private hospital, and hope soon to do the
same at the Women's Hospital. My nurses now make for me, in their
spare time, hundreds of square six-inch pads of absorbent gauze, sewed
together at their edges, six layers thick, which they sublimate and after-
wards boil for several hours. By this process they are rendered ab-
solutely sterile, nor are they thrown away wlien once used; on the con-
trary, after the operation they are ))oiled for an hour in solution of
washing soda, which dissolves all the H])rin out of them, and they are then
dried in an oven at 212°, from wliich they are at once removed to a glass-
stoppered jar until they are absolutely sterile, then they ai'e wrapped
up in a towel with the instruments and ligatures, and again boiled for
half an hour before the next operation. This towel is only unfolded by
the operator himself at the moment of conunencing the operation; no
antiseptics of any kind are used about the instruments. Carbolic acid
1 to 40 solution is not as good as ])oiling water fop disinfecting, while a
1 to 20 solution is most destructive to the hands, ('arbolic acid is use-
less, costly, and un[)leasant; the first reason alone being sufficient to
make us discard it. A teaspoouful of washing soda in a piiil of water
in which the instruments are boiled [)revents the steel ones from
l>eing rusted; tlu; knives are wrap[)e(l in one of the aforesaid gauze-
jtads in order to protect the edges, ])ut freipient heating and gradual
cooling of steel cutting instruments anneals them or softens their tem-
per, but this can l)e restored by alternately (lip[)ing them into boiling,
and ice waU^r for a few times. The silkworm gut, which I invariably
use for the abdomiiiid sutures, and the silk ligatures, which 1 havt; so
far used for the pedicle, are boiled with the instruments. In future I

intend to use Keller's catgut, rendered antiseptic by soaking for two
weeks in ether, which extracts a few drops of oil from it, and then by
soaking for two weeks in 1 in 200 sublimate alcohol, after which it is
Hnally kept, imtil used, in absolute alcohol.

The asepsis of the patient is a precaution which gives to some ope-
rators a good deal of anxiety, but not to me. Whenever possible she is
compelled to enter the hospital three days before the operation, and for
three nights she has a hot bath, in which plenty of laundry soap is
used. Hhe is kept soaking in the l)ath for from twenty to thirty niinutes
each time, so as to remove all the dead skin, with its colonies of bacte-
ria, leaving nothing but healthy living epidermis. The nurse gives
special attention to the cleaning of the umbilicus. With the patient
so prepared, with clean clothes and kept in a clean bed, I have very
little anxiety about the cleansing of the field of operation; I merely
scrub the abdomen with soap and brush, especially the navel, then
shsiving not only the pubic hair, but also the fine down, on the
abdomen, rinsing the surface with 1 in 500 bichloi;ide, and then with
boiled water, so as to save my instruments, when she is ready. Two small
precautions now will save much trouble. Many times have I seen the
patient suddenly touch the field of operation at the first cut of the
knife, when it was thought she was entirely under the anaesthetic.
Therefore, her hands should always be wrapped in clean towels, and
gently but firmly bound together with a strip ot gauze. Many other
times have I seen her suddenly raise her knees, scattering on the floor
the pressure forceps, knives and scissors all laid out ready to the sur-
geon's hand; therefore, her knees should be firmly strapped to the table
by a broad belt with a l)uckle, like a surcingle of a horse. Not only
will this prevent her from moving, but in case of the necessity arising
of placing her in the inverted position, on ac(!ount of fainting, the
assistants can perform the manonivre by inverting the table without
touching the patient. But before strapping down her legs, and imme-
diately after placing her on the table and before the nurse has finally
sterilized her hands, she should pass the catheter in the presence of the
operator. I have oifce seen the full bladder cut into by a brilliant
surgeon who had been assured that the patient had passed water just
oefore being placed under the anaesthetic; and the same thing would
once have happened to myself had I not begun my incision pretty high
up and felt a fluctuating tumor on introducing my finger in the region
of the bladder, when I stoi)ped operations until a pint of urine had
been withdrawn l)y the catheter. In this case the nurse had assured
me that the i)atient had just previously emptied her bladder. Some-
times a -great (quantity of urine is secreted in a short time, and some-
times there is retention, so that it is safer to take no tihances, but to see
it done while the |)atient is on the table. By making the first incision
half way between the umbilicus and pubes and only })urely large

enough to introduce one finger, the hladder can surely he avoided,
1)eciuise one finger will act as a director on which the blade of the
scissors can he passed, and the incision can be extended downwards as
far as necessary or as may be safe.

A great deal of stress used to be laid upon the importance of
finding the linea alba and of opening the abdomen exa(!tly in the
middle line. I have seen hundreds of precious seconds wasted in this
search, which, even when successful, in no way increases the success of
the operation. Indeed, it is probable that union is much firmer and
more rapid when the knife goes cleanly through the rectus muscle.
Care should be taken to cut through the peritoneum on a director,
introduced through a tiny hole, which hole is made while the perito-
neum is lifted up by the forceps on either side. I have seen some of
the world's greatest surgeons cut through the intestine while opening
the peritoneum, and I would have done the same thing several times in
cases in which the intestines were glued to the abdominal wall, had I
not taken the precaution of opening the peritoneum on a director. We
now have it in our power to have mural abscesses or to obtain union
by first intention, according to whether we employ pressure forceps to
arrest hemorrhage from the abdominal incision, or whether we content
ourselves with arresting hemorrhage by means of very hot compresses.
If the vessels are large enough to spout, it is much better to cut them
completely across and then to twist each end with a torsion forceps. I
think this is nnich preferable to tying them, as the absorption of the
catgut is so much unnecessary work for the iihagosytes to jjerform.
While infection of the wound will cause mural abscsesses and stitch
abscesses to follow, I l)elieve they are most often due, in tfiese days of
rigorous aseptic precautions, to bruising of tlu; structures, especially the
delicate cellular tissue, with powerful pressure force})s, which are left
on sometimes for a quarter of an hour or more; while stitch abscesses
are more often due to sloughing, from too tightly tying the sutures.
Some operators attribute mural absc(;sses to ca'. rying infection from the
upi)er layers of the skin into the deeper layers by means of the suture;
and they therelbre take all sorts of precautions to avoid this. In my
last ten sections I have had union al)solutely l>y first intention, with the
exception of the drainage tube hole, whi<rb, ol' cour.se, ch)sed up by
granulation; but even at that place there has hardly been more than
one drop or two of moisture.

The next prec^aution for the prevention of sei)sis is the keeping of
the peritoneal cavity clean, or the cleaning of it if soiled. Some of the
most rapidly fatal cases of septic peritonitis have been caused by the
esiuipe of a few drops of ])us from an ovarian ai)scess. Some have
even reconnuen(UHl the as[)iration of pus tubes or ovarian abscesses in
onler to diminish this risk l)y ru[>ture during nMuoval. I have little
fear of this, however, as I have ov'-;r and over again ruptured the most

stinking? jibHceM.ses, n»ul their contents have iiiunrhitefl tlie peritoneal
cavity, and yet the patients have made a splendid recovery. In Huvh
cases, and indeed in every case in which the peritoneum has heen
soiled in the slightest, one element of success, which is absolutely essen-
tial, is the washing out of the peritoneum with plain boiled water
cooled down to 110° F. or 105° F.

I assisted a colleague in a distant town once at an easy operation
of removing the uterus, containing a sloughing fibroid. A corkscrew
was used to extract it from the woman, but the tissues were so soft that
they would not hold, and the result was that the instrument slipped
out, throwing some small pieces of necrosed matter among the intes-
tines. We had forgotten tiie irrigator, whicli would have Hoated these
pieces out; but although carefully si)onged out, some of the minute
particles nuist have remained in and infected the peritoneum, for the
patient died three days later of septic peritonitis. Once the abdomen
is closed and dressed in the way I shall mention, there is no' more
danger as far as infection is concerned. The patient's fate is sealed
when the wound is sutured. Even when the drainage tube is employed
under ordinary precautions, infection is not liable to occur. I employ
one of the longest and narrowest tubes, with very tiny perforations in
it, so that the intestines cannot get caught in them; this accident
having happened to me, and a slight fet-al fistula resulting in on(^ case,
in which the perforations of the tube were too large. The tube is
poiniped out frequently, by a 1)ulb syringe with a long soft rubber
nozzle, and the tube should be gently turned half round several times
a day.

The kind of sutures appears to me to have much to ilo with
the ultimate success. According to many, there is only one material
suitable for the i)urpose, and that is silkworm gut, for as 1 shall show
later on, abdominal sutures shoidd be left in position for one month.
Silkworm gut is as clean and strong at the end of that time as when it
was first i)Jt in. The wound and stitch holes should bo buried in half
an inch thick of boracic acid, and they should not be seen again for a
month, unless the first dressing has been soiled by tlie overflow of the
drainage tul)e, in which case the soiled powder is removed and replaced
by dry powder. Among the arguments used against the extra-})erito-
neal treatment of the stump after hysterectomy, we often hear that
there is great danger of sepsis. This seems absurd to me, f'(»r with the
stump buried in dry boracic acid powder and the peritoneum accu-
rately closed around it by suture, and the abdominal incision also
buried in dr^' boracic acid powder, it is imi)ossible for the peritoneum
to be infected thereby; moreover, as any one knows who has reopened
the abdomen after an abdominal sc(!tion, the j)eritoncal surfaces are
glued together in a k\y hours, or probably in a few minutes even, after

i<4

the oi)eriitifm. As far as iny own small experience goes, T have not
lost a case Iroiu sepsis.

Aroldancc of Hciiiorrhiuje. — From my own expericnicx*, and from
inquiries above rei'erred to, I lind that the second great element of
success is the securing of perfect ha'mostasis, for, after sepsis, hemorrhage
seen)s to have been the principal cause of death following ahdoiiiinal
sections in the practice of a great many tirst-class oi)erators, who have
kindly rej)lied to my (piestion on the subject. Hemorrhage is either
primary or secondary. Some have told me that they lost their piitients
from shock, but tliis term had better be discarded, and all those deaths
formerly classed under that heading should be j>ut down to either
primary or secondary hemorrhage or to prolonged anaesthesia.

To begin with, my own case of death from hemorrhage was due to
a tear in the very wide pedicle which was ligatured in segments, the
tumor being so largo that I was coi:;;)clled to cut the i)edicle as I pro-
ceeded with the ligating. The drainage tube revealed the fact that cxnx-
siderable hemorrhage was going on; and on reopening the abdomen, I
found it coming from a tiny artery in the ])road ligament, which had
been opened by this tear, and which was below the line of ligatures.
This death would not have happened if I had, after tying the pedicle
in sections, followed these ligatures by another one en 'ia(t>ise, low
enough to have included the torn i)art. I easily caught u^) the bleed-
ing point and tied it, but the patient had gone too far to stand the
second operation. I have known several other deaths to have occurred
from the slipping of a ligature, in the case of simple removal of the
appendages. It seems dilHcult to understand how this accident can
hapi)en if the pedicle is transfixed with two ligatures, which are
crossed, tied on each side, and the one tied last is again l)rought around
the whole ixnlicle, tying it en, iimMsc It is simply impossible for such
a ligature to slip oil'. If stout catgut of good (piality and properly [ire-
pared be enii)loyed, it is still safer than silk, for the reason that catgut
wh(;n wet contracts. This can be demonstrated by a simple experi-
ment of tying a piece of exi)anded lamiuaria digitata with silk and
catgut, the one a short distance from the other, and then immersing it
in water. The catgut will be found in an hour or two to cause a dis-
tinct constriction of the elastic material, while the silk ligature allows
it to remain the same; as when first applied; fhie catgut sutures on
large adhesions are necessary, but for oozing, irrigation with very hot
water seems to control it effectually. I have many tiuies expected a
very profuse oozing, and indeed closed up the abdomen, after having
l)laced in the drainage tube, with great misgivings, (mly to find that the
total amount sucked from Douglas' cul-de-sac during the next twenty-
four hours did not exceed half an ounce. When the intestines are
torn, hemorrhage in them had better be stopped by Lembert sutures

Fiithor than by the galvjino-cautrry, iia, in one case in which I had
occasion to perform a secondary operation a niontli later for removal of
an ah8o«^ss in the other ovary, I found that a spot on the intestine,
which I had touched with the }j;alva no-cautery in order to arrest the
hemorrhaf>;e, had hecome firmly a<;f<lutinated t(» the surrounding? coilsi
from which it was impossihle to detach it. We may, I think, dismiss
the introduction of astringents, such as perchloride of iron, as in every
case in which I have heard of its being employed, the patient died from
peritonitis. The pnjssure with sterilized gauze is safe and seems to
have been without any marked bad effects. Undoubtedly, most of the
hemorrhage is due to delayed oj)erations, that is to say, operaticms put
ort too long, so that we may under the heading of delayed oj)eration8
include not only most of the cases of deaths from hinnorrhage, but also
the deaths from prolonged anu'sthesia, for it is precisely the dealing
with adhesions and the arrest of the hemorrhage resulting fiom the
tearing of them that makes the operation prolonged; while, on the other
hand, the prolou^^ed an?e4ht'na is itself a very imp:)rtant element in
the unfavorable result. We have in the drainage tube a valuaV)le sen-
tinel to warn us of secondary hemorrhage, and for that reason alone 1
think it is important to continue its use. The ol)jections to it are, of
course, that it keeps open an avenue for the introduction of septic
germs, and that it leaves a weak spot in the abdominal incision, which
is apt to give rise to ventral hernia.

The first of these objecticms may be dismissed, for with ordinary
precautions on the part of the nurse who has charge of the emi)tying
of it, there is very little danger of infection through the tube. As a
proof of this, I may state that I have had no death of a section at the
Woman's Hospital from sei)sis, although most of the abdominal sec-
tions were performed in the general operating roou), and treated
afterwards in the general wards of the hospital, and with ecpially good
results wi.h those treated in special rooms, although most of these cases
had drainage tubes for the first day or two. Apart from that, the drain-
age tube is soon walled in from the rest of the abdominal cavity, as is
seen in cases of fecal fistula in which fleces may come up througii the
track of the drainage tube, a[)i)arently passing among the intestinal
coils without causing any inflammation of the peritoneum. While the
objection that the drainage tube gives rise to ventral hernia nuiy be
overcome by the fact that granulation tissue, if supported for a sufH-
(iient length of time in the manner I shall presently indicate, is as
strong as any other part of the abdominal wall.

Pr(ilon<i<'(l Aiiicxthcmi. — We now come to the avoidance of deaths
from prolonged ana'sthesia, which, as I liave already said, are often put
down under the vague heading of shock. It is a well-known fact that
skillful operators can be found who, having more endurance and dogged
perseverance than judgment, will (.-ontinuy at an operation for as long

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as four houFH. This is more than hmiiiin flesh ivnd blond can stand,
for cvt'i'y one of such cases of which I have had cotjni/ance has died.
Wiien we renieniber the profound deforce of narcosis necessary during
th(! whole continuance of ahdoniinal section, and that the delicate peri-
toneum is heinji rouj^hly handled most of that time, we can hardly
exp(!ct that the result will he otherwise than fatal; so that it has
l>e(!onje pretty fjenerally understood that one of the most important
elements of success is speedy operating. We find that those who hav(!
death rates of three to five per cent, are operators of great skill and
experience, who have reduced the time for a given operation, minute hy
minute, until what would take an unskillful o[)erator an hour, perhaps
they can do in twenty minutes. One nught almost formulate the rule
that any abdominal operaticm which is going to rcMpiire pntfound
ana'sthesia for more than an hour had better not be done at all, or had
better be stopped when the hour is up.

I never had occasion more than once to admire the judgment of
celebrated operators, who, in the presence of adhesions which it was im-
possible to detach within an hour, had the courage to stop the opera-
tion and save the patient's life; while more than once I have felt sorry
to see what would otherwise have been a fairly su(H*essful oper lion
turned into an inevitably fatal one in the hopeless endeavor to make it
perfect at the expense of the [)atient's life. An}' saving in time, there-
fore, which can be attained through skill in techniipie and strict atten-
tion to business, contributes greatly to the success of the results; and
for this reason conversation or anything else on the part of visitors and
assistants which would take up a single moment of the operator's atten-
tion or distract it from the work he has on hand, or even the delivering
of a practical lecture during the course of an abdominal operation is to
be deprecated, for there are few people who, like Julius ('avsar, can do
seven things at once; and while they are telling a story or listening to a
joke or delivering a lecture, they are losing at least a few precious
moments, and add so much to the risks from prolonged ana'sthesia.
When the patient's abdomen is sewed up, and the aniesthetic discon-
tinued, then and not till then should a single word be uttered.

The Care of (he InteMina. — The fourtli element of success is the
care of the intestines, the most important point in which is, in the
words of one of America's most ceh^bratcd o[)erators, that one should
never see them; and I have luany times tested the truth of his i)roverb.
If I do not see the intestines once during the o[)eration I feel very
little anxiety about their management afterwards; while if the intes-
tines are seen during the operation, or still more so if they escape from
the abdomen and are laid out on the abdominal wall or on the table, no
matter how they are protected with hot towels or oiled silk, I know
that there will be great trouble in managing them afterwards. Whether
this is due to paralysis of the great sympathetic nerve by exposure to

the air or to injury to the peritoneum from over muoh hiintllinfi;, it is a.
well-known fact that intestines which have been handled a jj;reat deal
give a great deal of trouble, and cause a great deal of anxiety after-
wards. Although deaths from interference with the functions of the
Ijowels are not so common as those from sepsis or hemorrhage or pro-
longed anaesthesia, yet quite a few operators have t>Id me that they
have lost cases from this cause. Many of them have even re-opened
the abdomen several days later, and found the obstruction and saved
their patient; but in many other cases the intestines absolutely refused
to act. It will generally be iound that where the intestines have been
subjec'ted to handling, either outside of the abdomen, or even to a great
deal of sponging in the abdominal cavity, there will be some tympa-
nitic distension and paralysis afterwards; while if no sponging be
employed, and the abdominal cavity cleansed by means of hot water
irrigation, the intestiuos act naturally in a day or two after the oi)era-
tion. This is a strong argument in favor of irrigation instea<l of
sponging, for the cleansing of the peritoneum. Not only is sponging,
as I have aln id, an inefKcient means of removing every particle

of ase[)tic m .t also if some of the water be left to float in, the

lymph which .. ^ ,,iired out from the raw surfaces is diluted so much
that it fails to act as a glue or cement to bind the coils of intestines
together. For this reason it seems to me that it would be well in every
case to leave a little water in the peritoneum, which is quite able to
absorl) it, when it is no longer recjuired for this purpose, if it does
not flow out, as I have generally found it to do, by the drainage tube.
In some desperate cases of ahdominal distension, when everything else
has failed to relieve the tynq)anitis, I have been indebted to Professor
Skene's prescription, which 1 think should be generally known, which
is as follows; Six or eight grains i>f (piiniuc; dissolved in aromatic
sulphuric acid, with about half an ounce of watt.'r, with acacia enough
to mak<! the mixture biaiul; is administered by enema. WIkmi about
to administer it, warm water enough is added to raise the temperature
of the mixture to that of the rectum. This, he says, he has found will
relieve llatulenee if it can be relieved at all, and is at tiie same time a
good way ol" sui)porting the jiatient; in fact, he thinks its action in re-
lieving flatulence is by nistoring the tone of the intestine, llatlierthan
allow the [)atient to die from obstruction of the bowel, wv of course
must reopen the abdomen. In one case I know of this having ))een
done, and the patient's life saved, the intestine having been found
adherent to the abdominal incision. This, of course, could be pre-
ventfil by drawing tlu' omentum down over the bowels, before closing
the incision.

Other I'Hciiu'nlx of Sii,('ce.<s. — In addition to the elements of success
which an- necessary for the avoirliuice of the a)><'ve four prineijial
causes of death, there are other minor accidents which must be avoided
if we wish the cases to be successful. Thus wc; can harilly call thu

result satisfiictorv if, in the place of an achinji ovary, we leave a painful
ventral hernia. A few words, therefon;, on the prevention of ventral
hernia may be opportune. When the edges of the abdominal incision
are brought together clean and not bruised, and with corresponding
layers of tissue in exact apposition, we obtain union by first intention.
Under this term we may include all cases of union in which there is
no suppuration or granulation, although it does not necessarily follow
that there is an exudation of plastic lymph. The ideal union by first
intention is, of course, one in which the cut oi)enings of vessels and the
cut libnjs of other tissues exactly correspond and unite; but this prob-
jibly never occurs after an abdominal section. The imion is rather due
to the exudation of plastic lymph from the o[)p()site surfaces, which
.brms a gelatinous glue .uul which evenlualiy l)ec()mes organized into
white fibrous tissue. We can obtain a good idea of this process by
observing what tiikes phun; when the tendon Achilles is cut by the ortho-
pedic sm-geon, for the cure of tnlipes ecpiinus. After the subcutaneous
division of the tendon, the foot is kept for three days in its former
i'aulty position, so that the divided ends of the tendon shall become
joined again by the fusion of plastic lymph. When a sullieient (pian-
tity of this has exuded, and while still in a soft and stret(^hal)le
condition the surgeon gradually brings the foot to right angles with the
leg, until there is perhaps a space of two inches between the cut ends
of the tendon, which are united, however, by this baud of soft plastic
lymph. The foot is then left in position until this material has become
thoroughly organized, when the patient will be found to have full use
of the part. The same thing, 1 take it, occurs after an abdominal
section, and it is owing to the too early removal of the sutute while the
l)lastic lymph is still soil and stretchable, and before it has become
organized into white fibrous tissue, that we owe the great frequency of
ventral hernia. By leaving in the sui)porting silkworm gut sutures for
one month after the operation, we can avoid not only the risk of ventral
hernia, but we are also saved the anxiety of the incision being torn
open during a fit of coughing or other efi'ort, and the intestines escap-
ing out of the abdomen, as has occurred in several recorded cases. If
the silkworm gut sutures are left iu for a month, as I have done in my
last fifteen or eighteen cases, they can do no harm, and this accident is
absolutely ))revented from occurring, although I am not positive as to
the exa(!t tim(^ it re((uires for conversion of this i)lastic lymph into
dense white fibrous tissue, yet T will (je in favor of leaving in the sutures
at least until this process has had time to lie completed. In my last
few cases I have been introducing a few l)uri(Ml i^ilkworm gut sutures
through the cut edges of the abdominal fascia, which of course remain
during the whole of tlu; patient's life, and which therefore render the
occurrence of ventral hernia im[)ossi!)le. These wow introdiu'cd nftcr
the through and through sutures hadj been' [)laced in position, and
before the latter were tied.

We may, therefore, sum up the elements of sueeess in cn^liotomy,
as far as we know them at the present time, in the avoidance of sepsis
or peritonitis, tlie avoidance of hemorrliage, the avoidance of prolonged
anaesthesia, the avoidance of injury to tlie bowels and bladder and the
avoidance of ventral hernia and mural abscesses. From the expe-
rience of a great number of operators, we may infer that if wo lost no
patients from any of these causes we could do a thousand abdominal
sections ns well as a hundred without a death.