THE UNIVERSITY 
 OF ILLINOIS 
 LIBRARY 
 
 From the collection of 
 Julius Doerner, Chicago 
 Purchased, 1918. 
 
 K2.<S3t 
 
Digitized by the Internet Archive 
 in 2017 with funding from 
 
 University of Illinois Urbana-Champaign Alternates 
 
 https://archive.org/details/textbookofabdomi00keit_0 
 
TEXT BOOK 
 
 OF 
 
 ABDOMINAL SURGERY 
 
 A CLINICAL MANUAL 
 FOR PRACTITIONERS AND STUDENTS 
 
 BY 
 
 SKENE KEITH, E.R.C.S.Ed. 
 
 ASSISTED BY 
 
 GEORGE E. KEITH, M.B., C.M. 
 
 WITH ILL [IS TLA TIONS 
 
 PHILADELPHIA 
 
 J. B. LIPPINCOTT COMPANY 
 
 1894 
 
EDINBURGH : PRINTED BY R. AND R. CLARK FOR YOUNG J. PENTLAND 
 II TEVIOT PLACE AND 38 WEST SMITHFIELD, LONDON, E.C. 
 
 All rights reserx'cd. 
 
'fcOa-.V^ERL/Sl'IDSON 
 
 G n.ss 
 
 “All diseases should be described as objects of natural history. In 
 writing therefore such a natural history of diseases, every merely 
 philosophical hypothesis should be set aside, and the manifest and 
 natural phenomena, however minute, should be noted with the 
 utmost exactness.” — Sydenham. 
 
 80197 ? 
 
PREFACE. 
 
 
 
 It is sometimes of advantage to systematise our knowledge 
 of an advancing art, especially when it is one of recent and 
 rapid growth. This has been the case with the Art of Surgery 
 as applied to the Abdomen. 
 
 It may be said that before 1860 abdominal surgery was 
 unknown, or at least was universally condemned. For the next 
 fifteen or twenty years it was almost entirely confined to the 
 removal of tumours of the ovaries ; and it was not until about 
 the year 1880 that operations on other abdominal organs became 
 at all general. Now, such operations have been performed on 
 every organ in the abdomen. 
 
 This volume is intended to show the present state of our 
 knowledge of Abdominal Surgery. In doing this, we might 
 have contented ourselves with making a mere compilation and 
 comparison of the observations and practice of others, for we 
 have seen the abdomen opened by some eighty or ninety different 
 operators ; but we have preferred, while undoubtedly indebted 
 to others, to draw very largely on our own experience and 
 methods. We have done this partly in the belief that personal 
 experience is of more value than the most elaborate and careful 
 a 2 
 
PREFACE 
 
 viii 
 
 compilation, and especially because, owing to the most intimate 
 professional relations with Dr. Thomas Keith, extending over a 
 period of seventeen years, our experience is based on the work 
 of a surgeon whose early results — about 15 per cent, mortality 
 after ovariotomy — were considered, at the time, so remarkable 
 that they were described as “ doubtful,” and whose later results 
 have been called “ phenomenal.” 
 
 We desire to acknowledge our indebtedness to Dr. Douie of 
 Sevenoaks, and to Dr. Simpson of Tunbridge Wells, for much 
 valuable help, and also to Dr. Hepburn, who has been kind 
 enough to revise the greater part of the surgical anatomy. 
 
 42 Charles Street, Berkeley Square, W,, 
 
 June 1894. 
 
CONTENTS 
 
 SECTION L 
 
 THE SURGERY OF THE ABDOMEN. 
 
 CHAPTER L 
 
 INTEODUCTION — THE EXAMINATION OF THE ABDOMEN. PAGE 
 
 Local — General — Phantom Tumours ..... 1 
 
 CHAPTER il. 
 
 TAPPING — ASPIKATION — EXAMINATION OF FLUIDS — EXPLOEATOBY IN- 
 CISION ........ 20 
 
 CHAPTER HI. 
 
 THE PEEPAEATIONS FOE AN ABDOMINAL OPEEATION AND THE 
 OPEEATION. 
 
 Preparation of the Patient — Instruments and Appliances — The Incision 
 — Treatment of Adhesions — Toilet of the Peritoneum — Drainage — 
 
 Closure and Dressing of the Wound — Antiseptics ... 36 
 
 CHAPTER IV. 
 
 AFTEE TEEATMENT. 
 
 Thirst — Food — Stimulants — Management of the Intestine — Septiccemia — 
 The Skin and Kidneys — Temperature .... 
 
 56 
 
X 
 
 CONTENTS. 
 
 CHAPTER V. 
 
 THE PERITONEUM. 
 
 Peritonitis— Ascitic Fluid — Tubercular Peritonitis — Hernia in the Wall 
 — Abscess and Tumours of the Wall — Retro -peritoneal Tumours — 
 Omental Tumours — Hydatid Disease — Mesenteric Cysts . 
 
 CHAPTER VI. 
 
 THE STOMACH. 
 
 Position of the Stomach — Gastrostomy — Gastrorraphy — Gastrotomy — 
 Gastrectomy — Gastro-enterostomy — Pylorectomy — Loreta’s Opera- 
 tion — Pyloroplasty ....... 
 
 CHAPTER YII. 
 
 THE INTESTINE. 
 
 The Anatomy and Connections of the Intestine — Obstruction due to 
 Nervous Exhaustion — Intussusception — Obstruction due to Bands 
 and Adhesions — Volvulus — Enteroliths — Chronic Obstruction — Colo- 
 tomy — Injuries ....... 
 
 CHAPTER VIII. 
 
 THE APPENDIX. 
 
 Position of the Appendix — Simple, Relapsing, and Perforating Append- 
 icitis ......... 
 
 CHAPTER IX. 
 
 THE LIVER. 
 
 Position of the Liver — Abscess — Hepatotomy — Hydatid Disease — Cancer 
 — Gall Stones — Distension of the Gall-bladder — Injuries 
 
 CHAPTER X. 
 
 THE KIDNEY. 
 
 Position of the Kidneys — Movable, Floating, and Displaced Kidney — 
 Renal Calculi — Cystic and Solid Tumours — Injuries . 
 
 CHAPTER XI. 
 
 THE SPLEEN. 
 
 Position of the Spleen — Inflammation and Suppuration — Cysts — Displace- 
 ments — Solid Enlargements — Injuries .... 
 
 PAGE 
 
 76 
 
 103 
 
 143 
 
 205 
 
 230 
 
 255 
 
 302 
 
CONTENTS. 
 
 XI 
 
 SECTION 11. 
 
 THE SURGERY OF THE ABDOMEN PECULIAR TO WOMEN. 
 
 CHAPTER I. page 
 
 TUMOURS OF THE OVARY ....... 317 
 
 CHAPTER II. 
 
 OVARIOTOMY. 
 
 The History of Abdominal Surgery — Position of the Ovaries — Ovario- 
 tomy ......... 341 
 
 CHAPTER HI. 
 
 DISEASES OF THE OVARIES AND FALLOPIAN TUBES . . . 381 
 
 CHAPTER IV. 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 Apostoli’s Treatment — Removal of the Appendages — Hysterectomy . 397 
 
 CHAPTER V. 
 
 DISEASES OF THE UTERUS. 
 
 Displacements — Caesarean Section — Porro’s Operation — Laparo-Electro- 
 tomy — Symphysiotomy — Rupture of the Uterus — Extra-Uterine 
 Gestation — Pelvic Haematocele — Pelvic Abscess . . . 467 
 
LIST OF ILLUSTEATIONS. 
 
 FIG. PAGE 
 
 1. Wells’ Tapping Trocar and Cannula ..... 22 
 
 2. Keith’s Tapping Trocar and Cannula .... 22 
 
 3. Wells’ Cannula for Ascites ...... 22 
 
 4. Dieulafoy’s Aspirator ....... 24 
 
 5. Foulis’ Cells ........ 29 
 
 6. Blunt-Pointed Scissors ...... 40 
 
 7. Keith’s Compression Forceps ...... 41 
 
 8. Keith’s Glass Drainage Tube ...... 42 
 
 9. Lister’s Sinus Forceps ...... 42 
 
 10. Syringe and Cannula for Drainage ..... 43 
 
 11. Silk for Ligatures and Sutures ..... 43 
 
 12. Keith’s Needles ....... 44 
 
 13. Peaslee’s Needle . . . . . . .44 
 
 14. Diagram to illustrate the Continuity of the Peritoneum in the Verti- 
 
 cal Direction. (Cunningham) . . . . .108 
 
 15. Continuous Suture of Stomach . . . . .122 
 
 16. Interrupted Suture of Stomach ..... 122 
 
 17. Diagram to show the Normal Blood Supply of the Kidneys. 
 
 (Hepburn) . . . . . . . .256 
 
 18. Schematic Diagram to show the Nature of certain of the more 
 
 frequent Forms of Accessory Renal Arteries. (Hepburn) . . 257 
 
 19. Sims’ Needle-Holder ....... 263 
 
 20. Diagrammatic Relations of the Normal Ovary . . .317 
 
XIV 
 
 LIST OF ILLUSTRATIONS. 
 
 PAGE 
 
 FIG. 
 
 21. Diagram showing the Relations of a Pediculated Ovarian Tumour 
 
 22. Diagram showing the relations of a Sessile Ovarian Tumour . 
 
 23. Nelaton’s Forceps ...... 
 
 24. Cyst Forceps ....'.. 
 
 25 . ^ 
 
 y Cauteries ....... 
 
 26. J 
 
 27. Cautery Clamp ...... 
 
 28. Pedicle Forceps for Use after the Cautery 
 
 29. Apostoli’s Sound ...... 
 
 30. Keith’s Sound ....... 
 
 31. Keith’s Hysterectomy Clamp ..... 
 
 32. Koeberlee’s Serre-noeud ..... 
 
 33. ) 
 
 V Suture of Uterus after Ciesarean Section 
 
 34. ) 
 
 318 
 
 318 
 
 352 
 
 352 
 
 353 
 
 354 
 
 354 
 
 409 
 
 409 
 
 442 
 
 443 
 
 479 
 
ABDOMINAL SUROEEY. 
 

SECTION I 
 
 THE SUEGERY OF THE ABDOMEN. 
 

ABDOMINAL SUKOEEY. 
 
 CHAPTER 1. 
 
 INTRODUCTIOK 
 
 The General Examination of the Abdomen. 
 
 Surgeons are often prone to give too little heed to the history 
 of the ailments of patients, on the score that so many of the 
 symptoms described are imaginary, or at least have no hearing 
 upon the case as it comes before them. While too much 
 importance attached to such description is apt to lead one 
 astray, much information may often be gained to facilitate a 
 correct diagnosis. 
 
 After inquiring as to the age and state of the general health 
 previous to the present illness, and into the family history, we 
 next find out how long it is since the patient felt quite well, 
 and what first drew attention to the abdomen ; was it dis- 
 comfort, pain, or swelling? If discomfort or pain, what was 
 its character, and what was its situation ; if a swelling, where 
 was it first noticed, did it grow rapidly, or continuously, or 
 rather by fits and starts, or did it alter in size or place at 
 different times ? Has the illness made it necessary to remain 
 1 
 
EXAMINATION OF THE ABDOMEN 
 
 in bed, and if so, for bow long and on how many different 
 occasions ? 
 
 While we are being told this history, we notice the general 
 appearance of the patient, the expression and colour of the face, 
 the state of the breathing, and the position assumed, more 
 particularly when in bed. This leads to the special examination 
 of the abdomen itself, and as there are certain points in this 
 examination common to all cases they must now be shortly 
 considered. 
 
 The abdomen must be thoroughly exposed, the patient rest- 
 ing on a firm bed or couch with the shoulders low and the lower 
 limbs extended. The position usually recommended is that the 
 shoulders be raised and the legs drawn up, but this does not 
 accord with our experience, especially in cases where there 
 is any suspicion of the presence of free fluid in the peritoneal 
 cavity. 
 
 The diagnosis of diseased conditions within the abdominal 
 cavity is not always easy ; in some cases it is well to examine 
 the patient two or evevx three times before making up one’s 
 mind, and no pains must be spared to arrive at an accurate 
 diagnosis. A life may be sacrificed by advising against opera- 
 tion, or it may be unnecessarily endangered when an explora- 
 tory incision is lightly recommended. This is not all, for the 
 misery entailed by an exploratory incision is very great ; there 
 is first the suspense before the operation ; and wdien it is over 
 and nothing achieved, there is the dashing to the ground of all 
 hope, after the courage has been screwed up and great things 
 expected ; and there may be the discomfort of a ventral hernia, 
 in addition to other woes. 
 
 When an abdominal swelling is examined, we must not 
 content ourselves solely with the question of the nature of 
 the growtli and from what part of the body it has sprung ; 
 but an endeavour should always be made to determine the 
 exact connection of the tumour ; and in a great majority of 
 cases it is possible to do this with wonderful exactitude. In 
 
GENERAL EXAMINATION 
 
 3 
 
 itself it may not be often of great importance, but such an 
 examination renders one at least more exact in the matter of 
 diagnosis. 
 
 First notice the general appearance of the abdomen as 
 regards shape, the state and probable thickness of its wall 
 v/hether natural or due to oedema, the appearance of the 
 umbilicus, the presence of a swelling at any one part — including 
 the possibility of the presence of a hernia — as well as the 
 condition of the thoracic walls, and in fact everything abnormal. 
 Continuing the examination, the hands comfortably warm are 
 to be laid gently on the abdomen, bearing in mind that all 
 pressure which may be required must be made steadily and 
 evenly. Extreme gentleness is never more necessary than in 
 the examination of the abdomen ; tumours are not infrequently 
 ruptured, peritonitis lighted up, and even if such serious 
 results do not follow rough manipulation, the patient may 
 be unnecessarily alarmed and may lose faith in the ability 
 of the surgeon. If the swelling .be of such size that it can be 
 easily felt, the first point to determine if possible, is from what 
 part of the peritoneal cavity and from what organ does it take 
 its rise. Next, we ascertain its consistency, whether solid or 
 fiuid or a combination of both ; whether its surface is regular 
 or irregular ; whether fixed or movable ; sensitive or insensitive. 
 When there is difficulty in finding the swelling on account of 
 its small size, the whole abdomen must be carefully gone over, 
 and, as the one hand is moved gently onwards, the other is kept 
 firmly on the abdomen to prevent any small growth slipping 
 over to the part already examined. In our experience rectal 
 examination seldom gives much information, but it must always 
 be resorted to when there is any doubt as to the nature of any 
 growth connected with the pelvis. 
 
 Vaginal examination combined with one hand on the 
 abdomen gives a vast amount of information in cases where 
 growths originate in, or have any connection with the pelvis. 
 Here too, examination must be conducted with great gentleness, 
 
4 
 
 EXAMINATION OF THE ABDOMEN 
 
 especially when the presence of a small inflammatory swelling 
 in the pelvis is suspected. The following incident illustrates 
 well the danger arising from want of this care. An examination 
 of a small tender swelling in the pelvis was made under ether 
 by two gynascologists. l^ext day the abdomen was covered 
 with bruises, there was very great pain, the temperature rose 
 rapidly, and the patient barely escaped with her life from an 
 attack of acute general peritonitis. 
 
 It is rarely necessary to make examinations under ether, for a 
 diagnosis can usually be arrived at without making the patient 
 insensible. If an angesthetic did no harm it might be used for 
 convenience, but, by its administration, the safeguard of pain in 
 the sensitive part is lost, and pressure may be applied which 
 no tender swelling ought to be made to bear. Without an 
 anaesthetic, the patient by tightening the abdominal muscles 
 prevents much injury being done during an examination. 
 
 Percussion, both superficial and deep, is one of the methods 
 to be employed to assist us in diagnosing altered abdominal 
 conditions. While doing this it is sometimes advisable to turn 
 the patient first on one side and then on the other. 
 
 Auscultation is of little value except when there is a doubt 
 between pregnancy, aneurism, or tumour; in other cases it is 
 apt to mislead. 
 
 Such are the usual methods by which we determine what is 
 the condition to be dealt with. In rare cases, an aspirator 
 needle may be used to clear up a doubtful diagnosis, but, as this 
 must always be followed by a tappiug, the method of removing 
 the fluid will be described in the next chapter. 
 
 As regards prognosis we must go wider afield, and study the 
 general condition of the patient, we must examine the state of 
 the heart, lungs, alimentary tract, skin, kidneys, and in doubtful 
 cases, even the nervous system. The following is an interesting 
 example of how disease of the cerebro-spinal nervous system 
 may lead to an erroneous diagnosis. A man with symptoms of 
 locomotor ataxia had a painful tumour in the epigastrium. 
 
THE RIGHT HYPOCHONDRIAC REGION 
 
 5 
 
 wliicli appeared to be connected with the intervertebral discs. 
 This growth had been diagnosed, after an exploratory incision 
 performed in the provinces, as a bony outgrowth from a vertebra, 
 causing pressure on the spinal cord, but it was found after 
 death to be a horse-shoe kidney which had nothing to do with 
 the ataxic condition. It is not sufficient to examine the urine 
 for sugar or albumen, the quantity of urea excreted ought 
 always to be estimated. 
 
 For convenience in describing the position of the various 
 organs, the abdomen has been arbitrarily divided into nine spaces 
 by two horizontal and two vertical lines. The upper transverse 
 line is one drawn across the abdomen at the level of the most 
 prominent part of the ninth costal cartilages, and the lower 
 transverse line joins the crests of the ilia as seen from the front. 
 The vertical lines are drawn upwards from the middle of 
 Poupart’s ligaments. The nine spaces which are thus mapped 
 out are the right and left hypochondriac with the epigastric 
 between them, immediately below are the right and left lumbar 
 with the umbilical in the centre, and the lower three from right 
 to left, are the right iliac, hypogastric, and left iliac regions. 
 
 The consideration of the physical diagnosis of growths of 
 such size that their origin from one or other of those spaces is 
 evident, will now be taken up in detail ; the history does not 
 require to be considered in this chapter, and what is ascertained 
 by physical examination will alone be described. 
 
 In health the right hypochondriac region contains a large 
 part of the liver, the gall-bladder, a part of the right kidney, 
 the suprarenal capsule, and a small portion of the colon at the 
 junction of the ascending and transverse divisions. 
 
 The normal position of the liver in this region is made out by 
 percussion. Almost the whole space is filled by this organ, but 
 it is nowhere to be felt, by reason of its bony covering. In 
 infants it may be felt in the small space unprotected by the 
 costal cartilages. 
 
 Growths and enlargements of this organ must therefore be 
 
6 
 
 EXAMINATION OF THE ABDOMEN 
 
 considered in connection with the epigastric, umbilical, or right 
 lumbar region. 
 
 The gall-bladder is situated underneath the liver with its 
 fundus lying below the ninth right costal cartilage, and it lies 
 entirely in the right hypogastric region. When the stomach is dis- 
 tended and the liver pushed to the right, the fundus of the gall- 
 bladder may not be situated behind the ninth costal cartilage but 
 decidedly more to the right. In a natural state the gall-bladder 
 cannot be felt. When it is abnormally distended, the direction 
 in which it increases is that of a line drawn from the site of its 
 fundus to the umbilicus, and it lies against the anterior abdo- 
 minal wall. When examined between the two hands, the one being 
 in front and the other in the loin, very deep pressure must be 
 made by the latter hand before it pushes the gall-bladder against 
 the hand in front. The shape is oval, somewhat narrow and 
 pointed, or it may be almost globular. The consistency will 
 depend on whether the bladder is filled with fluid or simply 
 with a large number of calculi. When distended with fluid it 
 is usually tense, and, while an indistinct feeling of fluctuation 
 may usually be made out, it sometimes conveys very much the 
 feeling of a solid growth. When distended with calculi, the 
 sensation conveyed to the fingers is that of a solid mass some- 
 what irregular on the surface, and the movement of the calculi 
 on each other may perhaps be detected. Percussion is difficult 
 on account of the bowel being situated on all sides and behind. 
 Very careful percussion, however, along the edge of the liver, 
 will show that the note is at least less tympanitic in the position 
 of the fissure in which the gall-bladder is situated. There is no 
 pulsation, and auscultation gives a negative result, unless the 
 creaking of the stones on each other can be heard. 
 
 The organs which are of interest surgically in the epigastric 
 region are, part of the liver, a portion of the stomach including 
 the oesophageal and pyloric orifices, part of the duodenum, the 
 pancreas, the coeliac axis, and possibly a small part of both 
 kidneys. 
 
THE EPIGASTRIC REGION. 
 
 7 
 
 The liver lies against the abdominal wall, and its lower 
 margin will be found in the position of a curved line passing 
 from the junction of the eighth rib and costal cartilage on the 
 right side, to the junction of the sixth rib and cartilage on the 
 left side. The position is, however, somewhat variable, and 
 will depend on whether the stomach is dilated or contracted. 
 In a perfectly healthy organ, unless the patient be markedly 
 thin, it is impossible to feel this margin, but it may be mapped 
 out by careful light percussion, and the note becomes much less 
 dull as the edge is approached. The liver may be enlarged as 
 a whole, in the early stages of cirrhosis, when it is waxy, when 
 simply congested, in tuberculosis, in fatty liver, in primary 
 cancer, in abscess, and in hydatid disease, if the two latter be 
 deeply situated. In all these conditions the margin of the 
 liver will be found on percussion to be lower down, and along 
 with this lowered position in the epigastric region, the margin 
 of the organ will also be found projecting below the ribs in the 
 right lumbar region. Posteriorly percussion shows an increased 
 area of dulness. N’ot only can the margin be made out on 
 percussion, but it can be felt, and the sharp regular edge is 
 most marked when the organ is waxy. In all these enlarge- 
 ments the swelling seems to be situated immediately beneath 
 the abdominal wall. Similar physical signs are obtained when 
 the liver is pushed down by an effusion in the pleural cavity. 
 
 When the enlargement is circumscribed, it may be due to 
 cancer, to syphilis, and to abscess or hydatid disease situated 
 near the surface. Palpation and percussion show an irregu- 
 larity in the margin of the liver more often than any very 
 prominent alteration in shape. In all these diseases a more 
 or less hard irregular nodule or nodules will be felt projecting 
 from the liver. When the enlargement is due to the presence 
 of syphilitic gummata, a depression may be felt in the centre 
 of one or more of the masses ; in other respects syphilis and 
 cancer have much in common, and feel harder than an abscess 
 or hydatid swelling. A single cancerous mass may be confounded 
 
8 
 
 EXAMINATION OF THE ABDOMEN 
 
 with a distension of the gall-bladder, and as regards the physical 
 signs, one must depend on the exact position of the swelling, 
 and on the regularity of outline of the gall-bladder even if it 
 be distended with calculi, in comparison with the more irregular 
 and solid feeling of a malignant outgrowth. 
 
 The position of the stomach is a very variable one, and when 
 it is distended, or when there is a tumour in its walls or at the 
 pyloric orifice, it is drawn forwards and very much downwards 
 so that the position of the pylorus, even when moderately 
 enlarged, is usually in the umbilical rather than in the epi- 
 gastric region. Tumours of the stomach are practically always 
 malignant, they are hard and solid to the touch, usually freely 
 movable, and may be situated, even when of no great size, 
 about the navel or in the right or left lumbar regions. Tumours 
 in this position, like those of the liver, appear to lie close to 
 the abdominal wall, but they are so surrounded by clear sound 
 that percussion is little to be relied on. 
 
 Tumours of the pylorus are either malignant or consist of a 
 ring of fibrous tissue. The position in which they are usually 
 discovered is not in the epigastric region, but in the umbilical, 
 slightly to the right of the navel. They also feel near the 
 surface, and appear to be more or less annular, and are hard 
 and solid to the touch. In all cases where malignant disease 
 is suspected, the abdomen must be carefully searched for enlarged 
 glands, or for secondary deposits in any situation. Pyloric 
 growths are too small to allow of percussion giving any in- 
 formation except that it shows that they do not have any 
 connection with the liver. 
 
 A foreign body which is known to have been swallowed 
 may be felt through the abdominal wall, and its exact position 
 will depend on the size and shape of the body. 
 
 That a stomach is dilated can usually be seen while it is 
 being artificially distended, and its exact dimensions can be 
 readily mapped out by percussion. 
 
 Enlargements of the pancreas are due either to malignant 
 
THE LEFT HYPOCHONDRIAC REGION 
 
 9 
 
 disease, or to the presence of a cyst ; it is not probable that a 
 cancerous tumour limited to the pancreas could be felt, still 
 less have its position diagnosed ; and by the time a large mass 
 lias formed secondary deposits will be found in various directions. 
 As the situation of the gland is so deep, percussion does not 
 give any information. 
 
 Cysts of the pancreas are rare, and a small one is not very 
 likely to be discovered. Its position will depend on the part of 
 the gland with which it is connected, and the growth may appear 
 to arise from any of the three upper divisions of the abdomen. 
 In a small cyst situated so deeply it is not possible to make out 
 fluctuation. The growth is more or less rounded, smooth, fixed 
 from behind, and but slightly movable. There is a clear sound 
 in front. When the cyst is situated centrally, aortic pulsation 
 is communicated through the growth, but this will not be of 
 an expansile nature. 
 
 An aneurism in the epigastric region will be probably due 
 to a dilatation of the coeliac axis. The position will be fairly 
 median, deeply situated, and the tumour will be found to pul- 
 sate. This pulsation differs from that transmitted through a 
 cyst by being of an expansile nature, and, on auscultation, there 
 will be a well marked bruit, and perhaps the lieart sounds will 
 be heard. 
 
 In the left hypochondriac region are situated the spleen, the 
 remainder of the stomach, the greater part of the left kidney, 
 the left suprarenal capsule, and the tail of the pancreas. The 
 liver and the splenic flexure of the colon may extend into this 
 region. 
 
 As the spleen is protected by the ribs, it is impossible to feel 
 it when it is of normal size. On percussion posteriorly, when 
 the patient is sitting, the position of the spleen may be found 
 lying between the ninth and eleventh ribs. 
 
 The gland may be pushed downwards by a collection of 
 fluid in the pleural cavity. 
 
 Enlargements of the spleen may be due to leucocytluemia. 
 
lO 
 
 EXAMINATION OF THE ABDOMEN 
 
 simple hypertrophy, lymphadenoma, ague cake, waxy disease, 
 inflammation, cysts, and malignant disease. The enlarged spleen 
 appears from underneath the ribs on the left side, feels hard and 
 solid, and when of some size notches may be felt if the enlarge- 
 ments be due to conditions which do not alter its natural shape ; 
 but in malignant disease, when a large cyst is present, or when 
 the enlargement is slight, a distinct notch will not be made out. 
 On percussion, a dull or at least a diminished note can be traced 
 from the posterior area of dulness round to the front ; but when 
 the growth projects only a few inches below the ribs percussion 
 in front will not give any special information. A small amount 
 of consolidation at the base of the left lung, or a collection of 
 fluid in the pleural cavity, has been mistaken, either for an en- 
 largement of the spleen, or for some thickening in the wall or 
 about the diaphragm, posterior to the spleen. Such a mistake 
 may happen when percussion of the back is relied on without 
 sufficient attention being paid to deep palpation underneath the 
 costal margin, but in any case the diagnosis is difficult. Tor 
 example, an aspirating needle has been introduced from the 
 back, to remove fluid supposed to be in the pleural cavity, when 
 on 'post mortem examination it was found that the fluid had 
 been withdrawn from a pymmic abscess at the upper surface of 
 the spleen, and, as the diaphragm had been pushed up, the 
 needle had passed through it. 
 
 The right lumbar region contains the lower part of the 
 kidney, part of the ascending colon, and some coils of small 
 intestine. 
 
 The right kidney lies deeply in the loin, partly covered by 
 peritoneum, and partly lying against the cellular tissue. Though 
 situated principally in the hypochondriac region, it is more con- 
 venient to describe slight enlargements of the organ as if the 
 natural position were in the lumbar region, because an enlarged 
 kidney always sinks downwards. In health it is constantly 
 moving with respiration ; the extent of this mobility may be 
 great, and the range of movement is greater in thin than in 
 
THE RIGHT LUMBAR REGION. 1 1 
 
 stout people. Movable kidney is simply an exaggeration of 
 this normal mobility. In health, except in those who are 
 abnormally fat, the lower end of the kidney can be examined by 
 grasping it between the hands, the one hand being placed flatly 
 on the abdomen outside the rectus, and the other behind, im- 
 mediately outside the erector spinse muscle, and below the mar- 
 gin of the ribs. By approximating the hands, and at the same 
 time telling the patient to inspire deeply, a considerable part of 
 the kidney is felt to come between the hands. 
 
 The kidney may be enlarged and retain its typical shape in 
 waxy disease, and in the congestion caused by the irritation of a 
 stone. It may also do so in the early stages of strumous disease, 
 and in hydro- and pyo-nephrosis. 
 
 In the later stages of these diseases, and also when fluid 
 and solid tumours are found, the distinctive shape is lost. 
 When the kidney enlarges, it inclines at first to bulge out the 
 loin, but its chief direction of increase is downwards and towards 
 the front ; it, however, always retains the feeling of fixation in 
 the loin, unless the growth has originated in a floating or mis- 
 placed kidney. What is discovered on palpation depends on 
 the character of the enlargement, and it may vary from the 
 sensation of an absolutely solid mass, to that of a thin-walled 
 fluctuating cyst. When the enlargement is small, it can be 
 differentiated from a distension of the gall-bladder by its being 
 posterior. Percussion, in all enlargements of the kidney, is of 
 the very greatest importance owing to the situation of the colon 
 in front. As a kidney enlarges, it tends to come from under- 
 neath the ribs, and at the same time it pushes forwards the 
 colon ; the clear note given out when this piece of bowel is 
 percussed is invariably discovered running from above down- 
 wards, unless the bowel be collapsed, or the tumour be of very 
 great size, in which case the colon may be pushed over to the left 
 side. The gut is not always distended, and when this clear note 
 cannot be elicited in front of a growth which may possibly be 
 renal, very careful examination is to be made to discover 
 
12 
 
 EXAMINATION OF THE ABE OMEN 
 
 whether a thick hand-like substance can be felt in the position 
 of the colon. At one examination this band might be found, 
 and, if at a second a tympanitic track were discovered with dis- 
 appearance of the band, a diagnosis might almost be made on 
 this one sign alone. 
 
 In the umbilical region are, the omentum, the transverse 
 colon, the aorta, a small part of the right kidney, and the larger 
 part of the small intestine. None of these organs can be felt in 
 health with the exception of the aorta ; its pulsations are made 
 out because the abdominal wall and the spine are approximated 
 in this situation, — as there is a very short space between the 
 anterior and posterior layers of the peritoneum, — unless the 
 abdomen be distended either by the contents of the intestines 
 or from some pathological condition. 
 
 The omentum may be found to be thickened, due to inflam- 
 mation or to tubercular disease, in which latter case it feels as 
 if it were rolled up into a sausage-shaped mass lying across the 
 abdomen. It may be enlarged from the presence of cysts, 
 hydatid disease, or malignant growths. As the omentum may 
 stretch all over tlie abdomen, the position of the tumour may 
 not be limited to the umbilical region. Enlargements of the 
 omentum will give the feeliug either of solid growths or of tense 
 cysts, and the mobility will be very marked, although scarcely 
 more so than that of a tumour of the stomach. This mobility 
 will serve to differentiate them from enlargements of the 
 pancreas, from retro-peritoneal growths, and in a lesser degree 
 from mesenteric cysts. Percussion will reveal a certain amount 
 of dulness, but this is not likely to be of any diagnostic 
 value. 
 
 The transverse colon runs across the upper part of this space, 
 but it may sometimes dip down in a V-shaped manner. A hard 
 mass may occasionally be found, due either to a fecal accumu- 
 lation or to malignant disease. It is usually said that a fecal 
 tumour pits on pressure, though in our experience this is 
 not always the case, even if the patient be anmsthetised. A 
 
THE LEFT LUMBAR REGLON 
 
 13 
 
 fgecal impaction is more often found either in the right 
 or left iliac region, and this is also the case with malignant 
 disease. 
 
 Tumours of the small intestine are usually of a sarcomatous 
 nature, and they may be found in any part of the abdomen. 
 They are at first freely movable, and the physical diagnosis 
 gives no information beyond the fact that there is a firm solid 
 growth. 
 
 The aorta divides, at a point a little to the left of the middle 
 line and about the level of the umbilicus, into the right and left 
 iliac arteries. An aneurism is not common ; it can usually be 
 diagnosed owing to its proximity to the anterior abdominal 
 wall, through which its typical expansile pulsation can be easily 
 felt, and on auscultation a bruit is to be heard. 
 
 The left lumbar region contains the descending colou, and 
 some small intestine. Even on deep palpation a normal left 
 kidney does not come between the hands in the way the right 
 one does, because the organ is situated higher up, but in all 
 other respects the physical diagnosis of enlargement of the 
 left kidney does not differ on the two sides. 
 
 Malignant disease of the colon is rather more common at the 
 splenic flexure than in the transverse division, and is the gravest 
 condition which may possibly be mistaken for a slight enlarge- 
 ment of the spleen. 
 
 In the right iliac region are the csecum with the appendix, 
 part of the ascending colon, and these cannot be felt in health. 
 The swellings which are met with in this situation are, malig- 
 nant tumours of the csecum, impaction of faeces, infiammatory 
 distension of the appendix, and the various sequelm of an 
 inflammation of this blind tube. 
 
 Malignant disease and fsecal impaction in the ccecum have 
 various physical points in common. The tumours are liard, 
 with a slightly roughened surface, and are not absolutely fixed. 
 The faBcal impaction, as has already been mentioned, pits on 
 pressure when not of too long standing, although this may not 
 
14 
 
 EXAAIINATION OF THE ABDOMEN. 
 
 be evident unless the patient be anaesthetised. When the 
 appendix is dilated and can be felt, its usual position is about 
 the junction of the right iliac and hypogastric regions, and its 
 position is by no means a fixed one, and it may also be dis- 
 covered in the umbilical, or possibly in the right lumbar region. 
 Its shape is that of a cylindrical body of the length and thick- 
 ness of a forefinger, tender to anything but the very gentlest 
 manipulation, and the most sensitive part is a spot on the skin 
 known as M‘Burney’s point. This is situated midway between 
 the umbilicus and the anterioi superior spine of the ilium, and 
 marks the usual position of the junction of the appendix with 
 the caecum. When inflammation of the appendix has led to the 
 formation of an abscess, a tumour usually of an indefinite 
 character is found, and its exact position will vary with the 
 situation of the appendix itself. The feeling of resistance will 
 be marked on comparing the one side with the other, and an 
 examination conducted either through the vagina or the rectum 
 may reach the swelling from below, but bimanually it will be 
 rendered difficult by the tenderness and rigidity of the abdo- 
 minal muscles. 
 
 The hypogastric region contains some of the small intestine, 
 the bladder when distended, the uterus when enlarged, the 
 ovaries when the seat of a growth, the Fallopian tubes when 
 greatly distended either by a foetus or simply by fluid, and a 
 pelvic abscess may be found pointing in the outer part of this 
 region or in either of the lateral ones. 
 
 Temporary distension of the bladder may be caused by any 
 obstruction to the outflow of the urine, and as a secondary 
 result of this, a somewhat chronic condition of atony of the 
 walls due to over-distension may result. Eising immediately 
 above the pubes a globular fluctuating tumour is felt, in close 
 connection with the abdominal wall, and with a very slight 
 amount of mobility. The cyst gives the feeling that it is 
 thin-walled, and is so tense that fluctuation may not be at first 
 apparent. It may be mistaken for pregnancy, for an ovarian 
 
THE HYPOGASTRIC REGION. 
 
 15 
 
 tumour, or, when very much distended, for a retro-peritoneal 
 cyst. Whenever a swelling may possibly be a distended bladder, 
 a catheter must be passed, and it is well not to take any one’s 
 word that this has been done. In the rather rare case when an 
 ovarian tumour is central, it resembles a distended bladder in a 
 very marked way. This was very well seen in a patient who 
 was sent into the Edinburgh Eoyal Infirmary with a tense cyst 
 absolutely central, which extended about four or five inches 
 above the pubes, and came low down into the pelvis in front of 
 the uterus. In appearance and on examination it resembled 
 distension of the bladder so very closely that a catheter was 
 passed, without result, whereupon the patient remarked that her 
 own doctor had already done that twice. In another case seen 
 in the country, where a peculiar abdominal tumour had been 
 discovered in a man, both the doctor and a consultant were 
 puzzled to make out the nature of the cyst, and both had passed 
 a catheter but no water had come away. Acting on the prin- 
 ciple which has been laid down, a catheter was passed a third 
 time, when fortunately it was made to enter the bladder and the 
 cyst very quickly disappeared. 
 
 An enlargement of the uterus in this region will be diagnosed 
 by its central position, by the soft indefinite outline if due to 
 pregnancy, and by its solid and more defined condition if due 
 to a fibroid tumour or to retention of the menses. On bimanual 
 examination the continuity of the abdominal tumour with the 
 cervix will be made out in a pregnancy at this stage of advance- 
 ment, and also when the growth is due to the presence of a 
 fibroid tumour. When the swelling has been caused by an 
 obstruction in the vagina the internal examination will lead 
 to the recognition of the condition. 
 
 An ovarian tumour which does not reach beyond the hypo- 
 gastric region is almost invariably situated more or less to one 
 or other side. Bimanual examination shows at once that the 
 tumour is unconnected with the uterus, unless the broad liga- 
 ments be extensively opened up, in which case the uterus will 
 
EXAMINATION OF THE ABDOMEN 
 
 i6 
 
 be felt to be closely connected to one margin of the tumour, 
 but its shape can be distinctly made out. 
 
 Distension of a Fallopian tube, when large enough to be 
 felt on abdominal palpation, is found not to be central, and to 
 be of a peculiar irregular shape. Bimanually a connection 
 will be found between this tumour and one side of the uterus, 
 or with both, if both tubes be distended. 
 
 Pus may be found pointing above Poupart’s ligament in this 
 or in either of the two iliac regions. A fluctuating tumour is 
 felt closely connected with the pelvic wall, and on rectal or 
 vaginal examination this swelling may be traced down into 
 the pelvis. 
 
 The left iliac region contains the sigmoid flexure of the 
 colon, part of the descending colon, and some coils of small 
 intestine. 
 
 In the sigmoid flexure cancerous tumours, fibroid thicken- 
 ings, and accumulations of fieces are found. ISTothing more 
 need be said about such swellings than has already been said 
 about similar enlargements in the caecum. 
 
 The condition known as intussusception, that is to say, a 
 doubling in of the bowel into itself, may be found in any of 
 the regions below the upper transverse line. What may be 
 felt is an elongated sausage-shaped tumour, usually curved and 
 of variable length. It is tender to the touch, and is more 
 common on the left side of the abdomen. The diagnosis of 
 this condition is made rather by a consideration of the symptoms 
 than by the physical examination. 
 
 Eetro-peritoneal and mesenteric cysts may be found in any 
 part of the abdomen, and when small the physical diagnosis 
 might be made by exclusion, the swelling being evidently not 
 connected with any organ. 
 
 So far the consideration of the physical signs of small 
 tumours has alone been taken up. It will now be necessary 
 to give generally the physical signs presented by enlargements 
 entirely, or almost entirely, filling the abdominal cavity, and 
 
THE ABDOMEN AS A WHOLE. 
 
 17 
 
 where no indication is therefore given with what organ the 
 growth is connected. 
 
 Such large growths are most commonly divided into cystic 
 and into solid tumours, and along with the former will be 
 included those where fluctuation can be made out at one or 
 more points. Cystic growths of this size are rarely seen in 
 connection with the liver and gall-bladder, as rarely with the 
 spleen, occasionally with the pancreas, in hydatid disease of 
 various organs, in the mesentery and the retro-peritoneal tissue, 
 decidedly more frequently with the kidney, and most commonly 
 with the ovary. The natural enlargement of the uterus, and 
 the condition of hydramnios, have always to be considered when 
 the question of diagnosis comes up, and these with fibro-cystic 
 tumours of the uterus, complete the list of large cystic growths. 
 Another condition causing great distension of the abdomen 
 is the presence of ascitic fluid, sometimes encysted, although 
 it is rare to find a large collection enclosed within an adven- 
 titious sac. 
 
 Cysts in the upper part of the abdomen cause a decided 
 raising of the chest wall, and an indication will be given from 
 which side the growth has arisen by the relative amount of this 
 on the two sides. They also, and more especially when in 
 actual contact with the diaphragm, move downwards on deep 
 inspiration, and in this way differ from growths arising from 
 below, for in them the downward descent caused by inspiration 
 either raises up the wall from off the tumour, or pushes down 
 intestine in front of it, unless there be intimate parietal connec- 
 tions in the upper part of the abdomen. Even in such cases 
 the mass is not pushed down. The wave which can be felt in 
 all large collections of fluid in the abdomen, unless perhaps the 
 wall be enormously thick and tense, is the impulse which is 
 given to the hand placed on one side of the abdomen when a 
 slmht blow is given to the other side. When fluctuation is thus 
 obtained the diagnosis of fluid is made very easily. Difiiculty 
 arises in the case of small cystic growths, and when a tumour is 
 2 
 
8 
 
 EXAMINATION OF THE ABDOMEN 
 
 partly solid and partly cystic. In these cases fluctuation as 
 described is not obtained, but there is what may be called a 
 ‘'feeling of fluid.” The two hands are placed firmly on the 
 abdomen, and an impulse is conveyed to the one while the other 
 remains firmly applied to the surface. With practice the differ- 
 ence between a solid growth, a cyst, a cyst with tense thick 
 walls, and a soft solid with an elastic feeling, can be differentiated 
 in this way. When there is a tumour in the upper part of the 
 abdomen a dull note will be got above the growth, and it will 
 not vary on deep inspiration, as intestine is not present to come 
 between the wall and the tumour. 
 
 A renal cyst will be found to bulge more in one loin than in 
 the other, and may not enter into the loin on the other side. 
 Palpation and percussion may show the position of the colon 
 running from above downwards and decidedly on the inner side 
 of the swelling. With cysts in this position, and more markedly 
 in those growing from below, deep inspiration will tend not so 
 much to move the tumour but to move the abdominal wall over 
 the growth, and on percussing along the upper border during 
 expiration a dull note will be elicited, which is altered into a 
 tympanitic one when the patient inspires deeply. In tumours 
 without any pelvic connection it is usual to find a clear note of 
 more or less depth running across the abdomen below the cysts, 
 while the reverse is the case when the growth has sprung from 
 the pelvis. 
 
 Ascitic fluid is differentiated from a cyst by the great 
 difficulty in respiration in comparison to the size of the swelling 
 and by the percussion note, which is more fully referred to in 
 the fifth chapter. 
 
 Solid tumours of the abdomen do not differ, except in their 
 feeling of consistency, from cystic growths. Their position may 
 be the same, they may grow to as great a size, and they may 
 resemble a cystic tumour, except in the want of fluctuation. 
 
 Whenever an abdominal tumour could possibly be a 
 pregnancy, auscultation must be most carefully made. Even in 
 
THE ABDOMEN AS A WHOLE. 
 
 19 
 
 very large cystic tumours this may be necessary, from the 
 possibility of an abnormally large amount of amniotic fluid, or 
 from the presence of a cystic growth in addition to the pregnancy. 
 
 Very rarely the abdomen may be distended by a large 
 collection of faeces, the accumulation being distributed generally 
 over the whole of the abdomen. This condition may present 
 the appearance of a distinct abdominal tumour, and it is 
 diagnosed either by feeling that the mass at one or more points 
 pits on pressure, or by careful percussion, when it will be found 
 that the note, if not absolutely tympanitic in the centre of the 
 abdomen, is decidedly less dull. Eectal examination may give 
 no information, as the bowel may be either loaded or empty. 
 When treating such a case it is advisable not to attempt the 
 removal of the accumulation too suddenly, as alarming or even 
 fatal collapse has resulted from too energetic treatment. 
 
 Phantom Tumour. 
 
 A distension of the intestine by gas gives rise to a condition 
 known by the name of phantom tumour. It is almost entirely 
 confined to women, and is usually seen in those who are 
 hysterical, or in others about the time of the menopause. The 
 patient does not seem to be able to diminish the distension 
 voluntarily. On inspecting the abdomen, the appearance may 
 resemble what is seen when an ovarian tumour composed of one 
 or several cysts is present, and even on placing the hands on 
 the abdomen one might be mistaken as to the nature of the 
 swelling until it is percussed. As soon as this is done there 
 can be no excuse for an error being made. To convince the 
 friends of the nature of the enlargement, it may be necessary to 
 administer an anaesthetic and let them see how flat the abdomen 
 becomes as soon as the patient is unconscious. 
 
CHAPTER IL 
 
 TAPPING, ASPIRATION, AND EXPLORATORY 
 INCISION. 
 
 After the ordinary measures of making an examination have 
 been exhausted without a diagnosis having been arrived at, we 
 may adopt one of the two following means to clear up the 
 condition which exists inside the abdomen. These two aids to 
 diagnosis are tapping or aspiration, and an incision through 
 the abdominal wall for the purpose of exploration. 
 
 Tapping. 
 
 Tapping or paracentesis abdominis was at one time the only 
 way of treating collections of fluid inside the abdomen. It 
 was performed in a rough and ready manner : the patient was 
 seated on a chair or on the edge of the bed, a bucket was put 
 between the legs, and a short thick trocar and cannula was 
 thrust through the abdominal wall. It would hardly be 
 expected that any form of treatment carried out in such a 
 way would survive when other methods could be chosen. It 
 was a dangerous way of tapping; a large quantity of warm 
 fluid was withdrawn from the body, and little or no precautions 
 were adopted to keep the patient warm; with the not infre- 
 quent result that the patient caught a chill, and this was 
 followed by an attack of acute peritonitis. This method of 
 
TAPPING. 
 
 2 I 
 
 performing a slight operation has been entirely abandoned, and 
 we have now the choice of two ways of removing abdominal 
 fluid by simple puncture. The one resembles the old method 
 to a certain extent, and the other consists in the removal of 
 the fluid by suction ; the first is tapping, the second aspiration. 
 Tapping is to be employed only for the removal of ascitic or 
 free fluid from the abdominal cavity; and aspiration must 
 invariably be the plan adopted when the fluid from an encysted 
 cavity is being withdrawn. 
 
 The instruments required for a tapping are very simple ; 
 they consist of a trocar and cannula one-twelfth of an inch in 
 diameter ; to the cannula an india-rubber tube can be attached ; 
 or, if Wells’ blunt tapping cannula is to be used, we will require 
 in addition to be provided with a bistoury. 
 
 The patient is to be in bed, lying on his side close to the 
 edge, with a hot water bottle at the feet, and the height of the 
 head is to be as the patient finds comfortable, but not too high. 
 A towel is tucked in below the abdomen, and the spot in the 
 middle line where the trocar is to be inserted is washed with 
 some antiseptic solution. The exact site of the puncture should 
 be wherever it is most convenient and least painful ; and this 
 will be usually through the umbilicus. After having ascertained 
 by percussion that the intestine is not lying against the seat 
 of puncture, the trocar is pushed through the abdominal wall. 
 The point of the instrument should be sharp, so as to penetrate 
 the peritoneum, and not simply push that membrane away in 
 front of it. The trocar is withdrawn, and the end of the rubber 
 tube at once slipped on to the cannula, the small quantity of 
 fluid which escapes falling on the towel. The other end of the 
 rubber tube lies in a basin on the floor, and the fluid is allowed 
 to run until the peritoneal cavity has been emptied. As it 
 comes near to an end the patient is rolled round gently on to 
 the face, so that the opening will be the most dependent part 
 of the abdomen. As soon as the fluid ceases to flow, the tube 
 is closed with the finger and thumb, or the end is kept carefully 
 
22 
 
 TAPPING, ASPIRATION, ETC. 
 
 in the fluid in the basin, and the patient turned round again on 
 
 Fig. 1.— Wells’ Tapping Fig. 2.— Keith’s Tapping 
 
 Trocar and Cannula. Trocar and Cannula. 
 
 (Full size.) (Full size.) 
 
 I 
 
 Fig. 3.— Wells’ Cannula for 
 Ascites. 
 
 (One-half size.) 
 
 to the back. As the cannula is withdrawn, the surrounding 
 skin is pinched up between the finger and thumb ; and, should 
 
TAPPING. 
 
 23 
 
 there be any bleeding from the opening, a little time will be 
 given for it to cease before a piece of sticking-plaster, two 
 inches square, is put on. Should the bleeding not tend to 
 stop, the wall may be transfixed with a needle and pressure 
 made by twisting a thread round it. A broad flannel bandage 
 may be put on to make the patient comfortable, and if the 
 abdomen be very flat, the hollow is filled up with wadding. 
 The after treatment consists in keeping the patient on the back, 
 so that the puncture opening will be at the highest level ; and 
 fluid which may remain behind has thus no tendency to escape. 
 Perspiration must be encouraged, partly to promote absorption 
 of any fluid which may be remaining, and partly to bring the 
 blood to the surface, and thus prevent stagnation in the 
 abdominal blood vessels. The patient is kept in bed for two 
 or three days, after which he can get up as usual. 
 
 When Wells’ blunt trocar is used, a very small incision is 
 made with a bistoury into the peritoneal cavity ; and, if a thin- 
 bladed knife be used, the patient hardly feels the pain of the 
 little cut, which is not more than a quarter of an inch in length. 
 The bistoury is withdrawn, the cannula is inserted into the 
 opening ; and, as the instrument, narrow at the point, and 
 rapidly increasing in size, is provided with several holes, fluid 
 runs away rapidly. A gallon or two can be emptied with this 
 instrument in a very few minutes. The after treatment is 
 exactly the same as when the trocar is used, and the little 
 wound heals as easily. This method is only to be used when 
 the abdominal wall is thin, or when the opening is made 
 through the umbilicus. When this slight operation is per- 
 formed in the way described, and with a clean instrument, 
 there is absolutely no danger. Instead of removing the fluid 
 in a few minutes, a fine trocar with capillary tube is sometimes 
 used to empty the abdomen slowly. There is not any advan- 
 tage to be gained by adopting this plan in preference to the one 
 already described, because the rapid method leaves nothing to 
 be desired when properly carried out. The disadvantages of 
 
24 
 
 TAPPING, ASP/PAT/ON, ETC. 
 
 leaving a patient for many hours with a trocar in the peritoneal 
 cavity are, that the patient has to lie very quietly or run the 
 risk of the trocar slipping out, and there is a certain amount 
 of danger of erysipelas resulting from the prolonged irritation. 
 
 Aspiration. 
 
 For aspiration, the most convenient instruments consist of 
 what may be called an exploring instrument ; and a second 
 with which large quantities of fluid can be removed ; the 
 
 Fig. 4 . — Dieulafoy’s Aspirator. 
 
 principles of both being exactly the same. The first of these 
 instruments is that of Dieulafoy ; it consists of an exhausting 
 cylinder, which can contain fully two ounces, and is provided with 
 two stop-cocks at one end. 
 
 Before the air is exhausted by withdrawing the piston, both 
 stop-cocks are closed ; to one is attached a piece of rubber tube 
 with thick walls to the other end of which a hollow sharp-pointed 
 needle is fitted. It is to be used when there is a doubt as to 
 whether a growth contains fluid or not ; the syringe is exhausted, 
 the needle is rendered aseptic, and is plunged into the most 
 likely part of the swelling. The stop-cock connected with the 
 needle is opened, whereupon fluid, if present in the tumour, 
 flows into the cylinder; should the amount of fluid he evidently 
 small, this stop -cock is closed when the cylinder is full, and the 
 
ASPIRATION. 
 
 25 
 
 fluid it contains is driven out by pushing down the piston, after 
 the other stop-cock has been opened. To refill the syringe both 
 stop-cocks are closed, and the air is exhausted. 
 
 When fluid is evidently present, and the quantity great, a 
 large and more powerful apparatus will be required. This 
 consists of an air-pump fourteen inches long and one and a 
 half inch in diameter, connected by a very thick-walled rubber 
 tube to a rubber cork inserted in a Winchester quart bottle. 
 Through this rubber cork pass two metal tubes, guarded by stop- 
 cocks. One of these is connected with the air-pump, the other 
 to a thick-walled rubber tube, to which the cannula will be 
 attached. The trocar and cannula to be used is the same as that 
 previously mentioned when describing tapping. The patient is 
 to be in the same position as during tapping; the trocar is 
 inserted into the encysted fluid, and as it is withdrawn, leaving 
 the cannula behind, the tube is immediately put on to the cannula ; 
 and, the stop-cocks being both open, the nurse, or whoever is 
 present in the room, steadily works the air-pump so as to keep 
 a constant vacuum in the bottle. When the bottle is filled the 
 contents are to be emptied out, the stop-cock in connection with 
 the cannula being closed ; as soon as the bottle is emptied the 
 cork is introduced, the stop-cock is opened, and the nurse 
 recommences pumping as before. 
 
 When the sac is nearly empty, exhaustion of the air in the 
 bottle must not be very great, simply enough to keep the fluid 
 running, otherwise the lining of the cyst is likely to be sucked 
 into the cannula, and may be injured, or at least may stop the 
 outflow. We must never be satisfied until the cyst has been 
 thoroughly emptied ; and we must never, under any possible 
 circumstances, leave unemptied a collection of fluid through the 
 capsule of which an opening has been made. Nothing can be 
 more dangerous than the not uncommon practice of withdrawing 
 a small quantity of fluid, say a hypodermic syringeful, from a 
 cyst. If the cyst wall be very thick, there may not be any 
 oozing from the puncture opening ; but there is almost certain 
 
26 
 
 TAPPING, ASPIRATION, ETC. 
 
 to be a rupture, starting from the puncture, and, if the contents 
 be malignant, the infection of the peritoneum is certain to follow. 
 When aspiration is performed in the way described — never 
 using a larger needle, though it may be sometimes smaller, and 
 emptying completely any sac that has been punctured — there is 
 no risk, either of extravasation of fluids or of infection of the 
 abdominal cavity. Should a small quantity of fluid be accident- 
 ally left behind, the position of the patient, with the opening at 
 the highest level, would prevent any escape. 
 
 Aspiration has gone very much out of fashion, partly because 
 the operation was badly performed, much too large a trocar 
 being used ; and partly because abdominal operations have come 
 into fashion, for undoubtedly fashion plays a part in surgical 
 matters ; and the misery, which even a simple incision of the 
 abdomen gives to the patient and to all the immediate friends, 
 is very much ignored. Also, when a diagnosis has not been 
 made, it is very easy to say that it cannot be made, but that an 
 exploratory opening will clear up all doubt ; and, at the worst, 
 will do no harm. Tapping is often said to be dangerous ; but it 
 is only so when it is badly performed, and the great argument 
 against it seems toj3e the fear that malignant disease may be 
 spread from the interior of a cyst to the general peritoneal 
 cavity. A very good example of how this opinion, for it is only 
 an opinion, is supported, is shown by the following notes of an 
 operation at which we assisted a number of years ago. A 
 diagnosis of ovarian tumour had been made, in the hospital to 
 which the patient had been sent, after the abdomen had been 
 tapped several times. When the peritoneum was opened a large 
 quantity of ascitic fluid flowed away ; and, on looking into the 
 cavity, the pelvis was seen to be fllled by a papillomatous and 
 apparently solid tumour. There was no appearance of a cyst 
 wall anywhere, the hand could not be passed into the pelvis to 
 make a more thorough examination, and the incision was closed. 
 Some time afterwards this case was reported as showing the dis- 
 astrous effects which may follow the tapping of a malignant 
 
ASPIRATION. 
 
 27 
 
 ovarian tumour, although there was no direct evidence that an 
 ovarian tumour had been tapped, nor that the fluid which had 
 been drawn off had ever been anything but ascitic fluid ; and 
 the evidence seen at the time of operation appeared to us to 
 show that ascitic fluid had alone been withdrawn. 
 
 The reasons why aspiration is not to be used when there is 
 free fluid in the abdominal cavity are, that suction is not 
 necessary, and that the fluid flows away more easily without it, 
 as omentum or bowel is not so likely to become engaged in the 
 opening of the trocar. An encysted fluid must never be tapped, 
 it must always be aspirated, because it is essential that the 
 whole of it be removed ; and besides, it may be so thick that it 
 will not run through a cannula without the aid of suction. 
 
 Tapping is used to remove fluid when there is any obstruc- 
 tion to the circulation resulting in the pouring out of ascitic 
 fluid into the peritoneal cavity. Ascitic fluid, caused by the 
 presence of tubercular disease, or of malignant growths on the 
 peritoneum, or on the surface of an abdominal organ, can also 
 be removed in this way. To clear up a diagnosis it may be 
 necessary to examine the fluid microscopically. The way to do 
 this is to allow the last basinful which has been drawn off to 
 stand for some hours protected from dust ; and to examine the 
 deposit which remains after the top of the fluid has been poured 
 off, or to take what has been sticking to the surface of the 
 basin. 
 
 Aspiration, as distinct from tapping, may be employed for 
 the purpose of clearing up a diagnosis, or to remove fluid from 
 a cyst in a patient in a very much debilitated state of health, 
 thus giving time for some general improvement before any 
 severe operation is performed. In pregnancy also, especially 
 during the later months, a cyst may be aspirated rather than re- 
 moved, so as to carry on the patient until the child is born, 
 without running the risk of inducing premature labour, which 
 commonly follows the operation of ovariotomy when performed 
 at such a time. Broad ligament cysts may be cured in a certain 
 
28 
 
 TAPPING, ASPIRATION, ETC. 
 
 proportion of cases by removing the fluid ; and in exceptional 
 cases an ovarian tumour does not refill after being emptied; 
 but such cases are so rare, that they may be looked upon rather 
 as curiosities than as of any practical importance in the treat- 
 ment of such tumours. By removing fluid from a hydatid cyst 
 a complete and permanent cure may sometimes be obtained. 
 
 Tapping and aspiration must be invariably carried out 
 through the abdominal wall, never by the vagina or rectum ; the 
 risk of haemorrhage from the puncture wound is much greater 
 when the fluid is attacked from below ; and it is almost certain 
 that, when this is done, a leak will result ; malignant disease, if 
 present, will be spread ; or an attack of inflammation accom- 
 panied by the formation of adhesions may be lit up. 
 
 Fluids removed from the abdomen vary in appearance and in 
 consistency. They may be colourless like pure water, or they 
 may vary from that to bright red, or to almost black ; they may 
 be perfectly fluid, or as stiff as a thick jelly, or almost as solid as 
 putty. A positive diagnosis cannot be made from the appear- 
 ance and chemical examination of any of those fluids ; a certain 
 amount of assistance may certainly be obtained, and this will be 
 gone into more fully when the consideration of each special 
 disease is taken up. 
 
 With the microscope a positive diagnosis can be made in 
 two diseases. In the case of hydatids the finding of even a 
 single booklet is pathognomonic. In malignant disease, it is 
 possible to say that the fluid has been thrown off from a malig- 
 nant growth ; but whether the disease is situated in the interior 
 of a cyst or on the peritoneum must be diagnosed by other 
 means. In a fluid thrown off by a malignant tumour blood will 
 always be found ; at first sight this may not be evident ; but, 
 after standing for twelve hours, it will be seen to be deposited 
 on the bottom and sides of the basin. The blood is thoroughly 
 mixed with the fluid, and the appearance is quite different from 
 what is seen when the trocar injures a small vessel. If a small 
 quantity of this deposit be examined under the microscope, large 
 
EXAMINATION OF FLUIDS. 
 
 29 
 
 cells containing one or more nuclei as large or larger than a 
 red blood corpuscle may be seen. Of these there are two 
 varieties ; the one where the outline of the cell is regular, the 
 other where out-growths are forming, and proliferation is rapidly 
 going on. In the latter the disease is much more acutely 
 malignant. 
 
 Dr. Foulis of Edinburgh drew attention to these cells, some 
 
 Fig. 5 .— Foulis’ Cells. 
 
 fifteen or twenty years ago ; the drawings are taken from the 
 original papers ; and they represent exactly what we have 
 frequently seen on microscopic examination. 
 
 The advantage of being able to make a diagnosis in this way 
 is, that it is the only method by which we can apply sound 
 surgical treatment to malignant tumours of tlie abdomen. If 
 these cells be found in fluid which has been withdrawn from the 
 interior of a cyst, the sooner the cyst is removed the better ; the 
 
30 
 
 TAPPING, ASPIPATION, ETC. 
 
 whole organ in which the malignant disease is situated will be 
 taken away, and we may expect that the patient will be free 
 from any return for a number of years, or may be completely 
 cured. On the other hand, if we find the very wildly sprouting 
 cells in a fluid which has been removed from the peritoneal 
 cavity, and more especially if any nodules can be felt, no 
 matter how small, either on abdominal or pelvic examination, 
 it will he unnecessary to advise the patient to undergo an 
 abdominal operation, because we believe that in those cases life 
 cannot be prolonged by any such operation, as the whole of the 
 disease cannot be removed. In a third class, in a free peritoneal 
 fiuid, which has apparently come from the rupture of a remov- 
 able tumour, we may find cells which are not proliferating, but 
 which contain large nuclei. If there be a trace of blood in the 
 fluid, the probability is that the tumour is malignant, but the 
 malignancy need not be of a very active nature. AVhen no 
 nodules are felt removal of the tumour ought certainly to be 
 advised; but the friends may be warned that the disease is 
 certain to recur sooner or later, usually in about one year, 
 the patient being in the meantime in a good state of health. 
 
 It is certainly very difficult to know where to draw the line 
 about operation ; but there is no doubt that there are some cases 
 where the patient has nothing to gain by an abdominal section, 
 and where as correct a diagnosis can be made by the help of the 
 tapping trocar as by an exploratory operation. In the doubtful 
 cases, tapping may be followed by operation; and this is the 
 proper line of treatment to pursue ; for the peritoneum does not of 
 necessity become affected immediately after a rupture has taken 
 place, and a patient may live for some years in perfect health, 
 as happened in the following case. A lady, thirty-six years of 
 age, was seen in the early spring of 1890 ; for about two years 
 she had known of the presence of an abdominal tumour, which 
 had been frequently diagnosed to be a uterine fibroid, although 
 there was a most evident history of rupture followed by five 
 separate attacks of acute peritonitis. The tumour was evidently 
 
EX FLORA TOR Y INCISION. 
 
 31 
 
 an ovarian one, closely connected to the uterus, and the patient 
 was advised to have it removed, but she and her husband could 
 not make up their minds. In the end of March, the cyst gave 
 way for the sixth time ; and, as soon as she had recovered from 
 a sharp attack of peritonitis, she consented to have the tumour 
 removed. This was done in May of the same year. The 
 adhesions in the pelvis were extensive and extremely firm; 
 there was some free fluid in the peritoneum ; there was a laro-e 
 rupture in the cyst, and in its interior a quantity of papilloma- 
 tous masses were seen ; but no deposit was noticed on any part 
 of the peritoneum. Out of curiosity the fluid was examined 
 microscopically ; cells with large nuclei were seen in abundance, 
 and one or two doubtfully sprouting masses. The patient 
 remained in perfect health until the beginning of November 
 1893, when she complained of indefinite abdominal symptoms ; 
 but no return of the growth could be felt on abdominal or 
 vaginal examination. By the end of the same month a mass 
 could be easily made out on the right side of the pelvis, and a 
 second one on the abdominal wall a little to the left of the scar. 
 
 Exploeatory Incision. 
 
 As an alternative to removing fluid from the abdomen for 
 the purposes of examination, an operation has been performed 
 with great frequency in the last ten or twelve years ; it is called 
 exploratory incision, or laparotomy. The object of this opera- 
 tion is twofold : it may be used either when a diagnosis has 
 not been arrived at, or when a diagnosis has been made, but 
 where it is uncertain if the growth can be removed. 
 
 Performed for either of those two reasons the operation has 
 a distinct position in surgery ; it may be that, in exceptional 
 circumstances, it is impossible to say what is the nature of tlie 
 growth inside the abdomen ; and it may also happen that one 
 cannot be sure whether a growth can be removed or not. Still 
 there is probably no operation which has been more tliorouglily 
 
32 
 
 TAPPING, ASPIRATION, ETC. 
 
 abused, and the recklessness with which it has been taught that 
 the abdomen is to be opened, apparently whenever a growth has 
 been discovered, without exhausting all possible methods of 
 making a correct diagnosis, is without parallel in the history 
 of surgery. As many as 10 per cent, of all abdominal opera- 
 tions have been reported as the number of exploratory incisions 
 made by at least one operator ; that is to say, that out of one 
 hundred operations one in ten was found to be unnecessary. If 
 we add the number begun as exploratory incisions, and after- 
 wards placed among the lists under various headings, we get 
 some idea of what can only be called the reckless disregard, if 
 not for tlie life, at least for the comfort of the patients and of 
 the whole circle of friends. The patient places himself in our 
 hands, and it is not right to expose him to the risk, slight 
 though it be, which accompanies an exploratory incision ; nor 
 are we justified in allowing him to run the risk of the future 
 misery which follows a ventral hernia, although this risk ought 
 also to be a very small one ; nor are we entitled to perform an 
 operation entailing a great deal of expense, and which will 
 confine the patient to bed for at least a couple of weeks, simply 
 to save ourselves some trouble. It must doubtless always be, 
 even when every care is taken, that some surgeons will perform 
 more exploratory operations than others ; but this will not justify 
 any one in not availing himself of every possible means which 
 will assist in making a diagnosis, and thus prevent a certain 
 number of unnecessary operations. As an example of an un- 
 necessary case of exploratory incision, the following case which 
 occurred in the practice of a provincial surgeon may be cited. 
 The patient was seen by this operator, some months after the 
 diagnosis of malignant disease had been made, and the opinion 
 expressed that a successful operation was not possible. An 
 exploratory incision, which simply confirmed the previous 
 diagnosis, was made, and the patient of course did not receive 
 any benefit. 
 
 A second case gives an example of an exploratory operation 
 
EXP LORA TOR Y INCISION 
 
 33 
 
 performed after a diagnosis had been made, but where there 
 was a doubt as to whether or not the tumour could be removed. 
 A man, fifty years of age, was seen in consultation, who gave 
 the following history. Fifteen months before, he began to suffer 
 from severe pain in the abdomen, and a hard tumour was 
 discovered in the epigastrium. For some months before this 
 there had been a considerable amount of dyspepsia. During 
 the following fifteen months more than forty physicians and 
 surgeons were consulted, and various opinions were ex- 
 pressed as to the nature of the growth. As a rule, the patient 
 was allowed to choose between two, three, or four different 
 maladies. At length he consulted a well-known physician, being 
 desirous to be told exactly what was the matter. Examination 
 revealed a hard tumour with a regular outline, extremely 
 movable, and situated in the upper part of the abdomen. The 
 growth measured about five inches in breadth and three to four 
 in depth and thickness. The diagnosis arrived at was that of 
 a malignant tumour in the upper part of the omentum; and, 
 as it seemed so very movable, an operation was advised, ex- 
 ploratory in the first instance, to be followed by the removal 
 of the tumour if that were possible. The incision having been 
 made, the tumour was found to be situated, not exactly as had 
 been anticipated in the omentum, but intimately connected with 
 the greater curvature and posterior wall of the stomach ; situated 
 in this position the completion of the operation was not possible, 
 but the patient expressed himself satisfied, as all doubt about 
 the case had now been set at rest. 
 
 This case represents an extreme example of the difficulty 
 which patients experience in obtaining a positive opinion, and 
 while we do not mean to say that such an opinion can invariably 
 be given about every case, still it is not fair to tell a patient 
 that he or she is suffering from one of several diseases ; it 
 would be far better to say, “ I am unable to tell,” and to 
 recommend one or two other opinions — the best that can be 
 got — and then, even if a diagnosis had still not been 
 
34 TAPPING, ASPIRATION, ETC. 
 
 made, an operation need not be performed unless the case be 
 urgent. 
 
 The words of Eicbard Wiseman may well be remembered. 
 “ Thou wilt also learn one necessary piece of Humility — viz. not 
 to trust too much to thy own judgment, especially in difficult 
 cases, but to think fit to seek the advice of other Physicians 
 and Chirurgeons whose long experience hath enabled them to 
 assist thee in preventing the accidents, and encourage thee to 
 go on in the work or forewarn thee of the danger. After thou 
 hast thus defended thyself from the censure of rashness, 
 proceed boldly, and let thy sincerity in thy acting be thy 
 warrant for God’s blessing on thy endeavour.” 
 
 It is not fair to give a patient what is nothing more than an 
 extract from a text-book, and allow him to make the choice of 
 the disease. We came across an amusing example of this not 
 very long ago, where the following diagnosis was given to the 
 friends. “The case may be one of extra-uterine pregnancy, a 
 pyo-salpinx, a hsematocele, an ovarian tumour, or a fibroid 
 tumour of the uterus,” and strangely enough the sequel showed 
 that it was none of them ! 
 
 As an example of what has been said of the advisability of 
 taking two or three opinions, and then, when there is no 
 urgency, waiting for time to clear up the diagnosis, the following 
 case may be mentioned. 
 
 A lady, fifty-two years of age, who had ceased menstruating, 
 began to suffer from pains, and discomfort in the pelvis. Her 
 doctor sent her to a consultant, who made a diagnosis of ovarian 
 tumour, and advised immediate operation. Hot satisfied with 
 this opinion, he sent her on to a second ; on this occasion the 
 diagnosis was made of an old uterine fibroid which did not 
 require any operative treatment. With this opinion the doctor 
 was satisfied, but the friends were not ; and, for the third time 
 within two weeks, another consultation was arranged. Again a 
 different diagnosis was given, the opinion being that the tumour 
 was an old fibroid, but that there were, in addition, several 
 
EXPLORATOR Y INCISION. 
 
 35 
 
 nodules on the peritoneal lining of the pelvis, and that a small 
 amount of ascitic fluid was also present, No treatment was 
 advised, and time proved the last diagnosis to be correct. 
 Surely this was better for the patient and her friends, than 
 rushing into the operation, which time showed to be totally 
 unnecessary. 
 
CHAPTER III. 
 
 THE PREPARATIONS EOR AN ABDOMINAL 
 OPERATION AND THE OPERATION. 
 
 The thought of an operation is always formidable to a patient. 
 All means must therefore be taken to disturb or alter the usual 
 way of life as little as possible consistent with a due regard to 
 safety. Where the patient, especially if a woman, has a com- 
 fortable and well-drained home, let her be operated on in her 
 own room and with her accustomed surroundings. In an ordinary 
 well-kept bedroom it is quite unnecessary to take up carpets, 
 remove curtains and furniture, and so make the room look 
 uncomfortable and unfamiliar. 
 
 The choice of the nurse is of great importance, she has a 
 great deal in her hands, and the life of the patient often depends 
 on her watchfulness and care. She must be endowed with the 
 faculty of observation, she must be absolutely truthful, and 
 must follow her instructions to the letter. It is necessary that 
 she be mentally strong, so as to be able to keep a firm control 
 over the patient. At the same time she must be kind, 
 gentle, a light sleeper, and able to take entire charge for the 
 first few days after an operation. Of course she must be able 
 to pass a female catheter, and to give an enema. Such a nurse 
 is a rare and valuable woman. 
 
 It is not necessary for her to be at the patient’s house the 
 day before the operation ; in a couple of hours everything can 
 be got ready. She must make no preparations in sight of the 
 
PREPARATION OF THE PATIENT 
 
 37 
 
 patient ; all that she requires to attend to is to have at hand a 
 couple of wash-hand basins, a flat dish for the instruments, a 
 bath, several hot water bottles, plenty of hot and cold water, 
 some towels — a dozen will be more than sufficient — half-a-dozen 
 large pins, a flannel bandage, — one yard and a quarter torn 
 down the middle will make two bandages — and some brandy 
 or whiskey. She must also arrange to have her bed ready to put 
 into the room immediately after the operation. A most conveni- 
 ent bed for this purpose is that known as the hammock bedstead. 
 
 The nurse must not attempt to sit up during the whole night 
 with the patient. If she do so she will quickly break down, 
 and many patients do not sleep well when they are watched. 
 
 Preparatiox of the Patient. 
 
 The general health having been attended to if necessary, the 
 special preparations are simple ; a dose of castor-oil, large 
 enough to move the bowels well at least twice, is to be taken 
 two nights before the day of the operation ; an injection is to 
 be given on the morning of the day only if the bowels have 
 not moved well. The food, after this dose, is to be light, such 
 as tea, soup, pudding, etc. ; much milk being avoided. It is 
 almost necessary to explain to the patient what light food 
 means, so as to avoid the danger of an attack of obstruction 
 from faecal impaction, which an old lady went through, from 
 taking the following amount of food after the bowels had been 
 well moved, — an egg for breakfast ; soup, fish, roast-beef witli 
 Yorkshire pudding, etc., for mid-day dinner ; an egg with her tea; 
 a large piece of yellow cheese, bread, and milk, for supper ; and 
 another egg for breakfast on the operation day ; and all to keep 
 up her strength ! 
 
 The patient goes to bed half an hour or so before the arrival 
 of the surgeon. The clothing is to consist of a flannel or silk 
 under vest, if the weather be cold or the patient accustomed to 
 wear one, an ordinary night dress, a flannel dressing jacket, a 
 
38 
 
 PREPARATIONS FOR AN OPERATION 
 
 flannel petticoat, not fastened at the waist ; and stockings. If 
 the patient be a man, he must wear a flannel vest and drawers, 
 stockings, and night shirt. The nurse washes the abdomen 
 thoroughly, first with soap and water, and then with a 1-1000 
 solution of bichloride of mercury. The patient gets up to pass 
 water after the surgeon is in the house, unless it be desired to 
 have the bladder somewhat distended. A catheter is on no 
 account to be used, it is simply teaching a bad habit. 
 
 For the sake of the patient, punctuality on the part of the 
 surgeon and his assistants is very necessary. 
 
 Instruments and Appliances. 
 
 Everything required for the operation must be ordered or 
 brought by the surgeon himself ; he must see after everything ; 
 there must be no divided responsibility. He will have had sent 
 in from the chemist : 
 
 Ether . . . . . . 1 lb. 
 
 Carbolic acid ..... oiii. 
 
 Solution of carbolic acid in glycerine (1-8) . iiv. 
 
 Solution of tartarate of morphia (1 gr. in 12 
 
 minims) ..... 5i. 
 
 Saturated solution of perchloride of iron in 
 
 glycerine ..... 5ii. 
 
 Six yards corrosive gauze. 
 
 Corrosive sublimate tabloids. 
 
 Two sheets of ordinary cotton wadding. 
 
 For an ordinary abdominal section, the following list of 
 instruments and appliances is to be taken by the surgeon. 
 This list does not include instruments for special operations, 
 as these will be mentioned when diseases of the different 
 organs are taken up in detail. 
 
 A portable table, 18 inches broad, 6 feet long, and 40 inches 
 in height. 
 
INSTRUMENTS AND APPLIANCES. 
 
 39 
 
 A belt for fastening the legs. 
 
 Bandages for fixing the hands. 
 
 An india-rubber sheet, feet broad, feet long, with an 
 oval opening in the centre, 8 inches by 4 inches, the edge of 
 which has been smeared on the wrong side, inch in width, 
 with some of the following plaster : — 
 
 ^ 01. oliv8e opt. ..... 3vi. 
 
 Emplast. resinm ..... 3iii. 
 
 Emplast. saponis . . . . 5iv. 
 
 Misce. 
 
 Sig. — Melt and apply as directed. 
 
 An india-rubber sheet of the same size without the opening, 
 to cover the legs. 
 
 A number of the finest Turkey sponges varying from half- 
 a-dozen to thirty. They must be of different shapes and sizes ; 
 a medium one will be about the size of the closed fist ; some 
 for sponging out the pelvis through a small wound will be 
 smaller. The ordinary flat sponge, unless it be unusually thick, 
 is of more trouble than service, for, when thin, the intestine 
 simply pushes it aside. A few sponges large enough to hold 
 a pint of fluid are of great use when there is much fluid in 
 the peritoneum. Before being first used they must be thoroughly 
 purified. There are various ways of doing this, but as satis- 
 factory a method as any is the following : the sponges are 
 thoroughly beaten, so as to get rid of as much sand as possible, 
 and are then to be left for four or five hours in hydrochloric 
 acid, one drachm to the pint. Next they are to be washed 
 many times in hot water, and finally they are placed in a 
 1-40 solution of the best phenol, and are kept there until they 
 are required for use. Before the operation a number, depending 
 on the severity of the case, are wrung out of the carbolic solution, 
 and placed in a thoroughly purified double tin, the outer casing 
 of which is filled with hot water at the patient’s house. It 
 is more than desirable to have the sponges handled by no one 
 
40 
 
 PREPARATIONS FOR AN OPERATION 
 
 except the surgeon and his assistant, and a sufficient number 
 ought always to he taken, to avoid the necessity of their being 
 
 washed during the operation. 
 
 Fig. 6. 
 
 Blunt-Pointed Scissors. (Full size.) 
 
 As the surgeon ought always 
 to see to the cleansing of the 
 sponges after an operation, it is 
 not right to depute this duty to 
 a nurse during its performance. 
 The sponges must be counted 
 before the operation, and it is 
 advisable to mark down the 
 number, so that there may not 
 be any doubt when they are 
 counted before the abdomen is 
 closed. No sponge must be torn, 
 and under no circumstances 
 must one be used which has 
 fallen on the floor, or come in 
 contact with pus or any fluid 
 which may cause irritation. 
 Before they are again used, 
 they must be placed in a solu- 
 tion of carbonate of soda, one 
 liandful to every ten sponges 
 in a gallon of water. After 
 removing most of the blood 
 in this solution, they are to be 
 put into a second soda solution 
 of the same strength, and left 
 there for several hours, being 
 stirred up occasionally. At the 
 end of this time they get a 
 tremendous washing at the warm 
 
 O 
 
 water tap, and are put back into the carbolic acid solution. 
 A good sponge treated in this way will last out many years of 
 liard work. If it be desired to wliiten the sponges, they are 
 
INSTRUAIENTS AND APPLIANCES, 
 
 41 
 
 placed in a weak solution of sulphurous acid (1-5) for some 
 hours, and are well washed in warm water before being placed 
 in the carbolic solution. 
 
 Half-a-dozen towels wrung out of a 1-1000 solution of per- 
 chloride of mercury. 
 
 Fig. 7. — Keith’s Compression Forceps (Two-tliirds size.) 
 
 Two india-rubber aprons for the surgeon and his assistant. 
 One bistoury, light, well balanced, with a 2|-inch blade, 
 and an edge as sharp as it can be made. 
 
 One pair dissecting forceps. 
 
 One blunt-pointed pair of scissors. 
 
 Keith’s compression forceps, in three sizes. 
 
42 
 
 PREPARATIONS FOR AN OPERATION 
 
 Keith’s drainage tubes. A set of five, from SJ to inches in 
 
 Pure india-rubber sheeting, 18 inches square. 
 
 Syringe and cannula for removing fluid from drainage tube. 
 Lister’s sinus forceps. 
 
INSTRUMENTS AND APPLIANCES. 
 
 43 
 
 Silk, — the best make of Chinese twist in two sizes. It is 
 prepared by stretching, then it is boiled for ten minutes, stretched 
 again and kept in a 1-20 solution of carbolic acid until it is 
 required. It will remain for four or five months without be- 
 coming rotten ; for safety, however, it is better to prepare it 
 more often, and in smaller quantities. 
 
 Fig. 10. 
 
 Syringe and Cannula for Drainage, 
 
 Peaslee’s needle. 
 
 Keith’s needles, long and short. 
 
 Eighteen inches of thick silk is to be threaded with a needle 
 at each end ; and the number of stitches required will depend 
 on the expected length of the wound. 
 
 Horse hair for the superficial stitches. 
 
 Ordinary prepared catgut. 
 
 A tray 2-^- inches in depth, into which the instruments and 
 
44 
 
 FI^EFARATIONS FOR AN OFF RATION 
 
 stitches can be placed, and covered with a warm solution of 
 1-30 carbolic acid. Trays made of india-rubber are very 
 convenient. 
 
 A laryngoscopic mirror for throwing light into the pelvis. 
 
 An electric light for operating in foggy weather. 
 
 Clover’s ether inhaler. 
 
 \ Ether is to be preferred to chloro- 
 
 form. Its special advantage in 
 abdominal surgery is, that vomit- 
 ing is much less common than 
 after the use of the latter. At the 
 Samaritan Hospital, for example, 
 they are heard to speak of the 
 “ usual chloroform sickness.” Per- 
 sistent sickness after the admini- 
 stration of an anaesthetic may mask 
 the onset of vomiting from other 
 and more serious causes. Old 
 people, contrary to the opinion of 
 many, take ether well, if the head 
 and shoulders be kept well raised 
 on pillows. 
 
 ^lany patients find a broad 
 bed more comfortable than a narrow 
 one ; the blankets do not feel so 
 heavy, and they do not require so 
 much arranging if tlie patient be 
 restless. It is easy to get pulled 
 over from one side of the bed to 
 
 Keith’s Needles. I’easlee’s Needle, the Other, aild Oil tO a SlllOOtll plaCe. 
 (Full size.) (Full size.) ^ • i l l 
 
 Ihis IS perhaps a minor detail, but 
 everything which gives relief is an aid towards recovery. It 
 is not so convenient for the nurse, however, to work over a broad 
 bed. 
 
 An ordinary abdominal operation will be performed in the 
 
THE INCISION 
 
 45 
 
 following way : the ansestlietist is introduced to the patient, and 
 while ether is being administered, the surgeon and his assistant 
 wash their hands, first with soap and water, and then in a 1-500 
 solution of perchloride of mercury. The patient sees none of 
 the preparations, she falls asleep in bed and wakes up in bed ; 
 and sometimes asks how it is possible to do the oj)eration with- 
 out making any mess. Surely this is better than the common 
 practice of making a woman, nervous and frightened at least for 
 the time, walk into the room, see several strange men, climb up 
 on to the table, see another table covered with a cloth, hiding 
 she knows not what ; and be strapped down perhaps before she 
 is quite unconscious ! It has been described as ‘‘ the most awful 
 moment of my life, just as if I were going to be executed.” If 
 the operation is not to be performed in the dressing-room, the 
 table, instruments, etc., are quickly brought into the patient’s 
 room, as soon as she is unconscious. The table is to stand out 
 from the window, one end being close up to it, the object being 
 to gain as much light as possible. The instruments are placed 
 beside the operator, and when everything is ready, the patient 
 is lifted out of bed and placed on the table, with the head from 
 the window. A hot bottle is placed at the feet ; the night dress 
 is drawn up in front of the abdomen ; and the legs, covered with 
 a blanket, are fixed to the table with the belt placed above the 
 knees. The hands are fastened to this belt by the bandages, 
 and the chest is covered with a shawl. The perforated rubber 
 sheet, which has been previously placed in front of the fire to 
 soften the plaster, is now fixed on to the abdomen, and the legs 
 are covered by the other rubber sheet. It is not necessary to 
 shave the pubes. One of the prepared towels is spread out on 
 the rubber sheeting over the thighs, and another over the chest. 
 
 The Incision. 
 
 The incision will be usually made through the linea alba, 
 and in this situation muscle need not be exposed. In any other 
 
46 
 
 THE OPERATION. 
 
 position it is necessary to divide muscle in addition to other 
 structures. One can usually form a correct idea of the length 
 of the incision which will be required, and the first cut will 
 therefore vary in length from a couple of inches to fifteen or 
 twenty. If the linea alba be not visible the incision is made in 
 a line drawn from the centre of the umbilicus to the centre of 
 the pubes. When cutting down on a tumour which has 
 distended the abdominal walls, it is usual to reach the peri- 
 toneum, or at least the fat superficial to this structure, at the 
 first cut. If the surgeon has not sufficient confidence to do this, 
 or has not a bistoury with a sufficiently keen edge, he will 
 expose only the fascia between or over one or other rectus 
 muscle. The line of separation between the muscles is easily 
 seen on account of its whiteness, and a small opening having 
 been made through this, the bistoury can be dispensed with 
 during the rest of the operation. Blunt-pointed scissors take its 
 place. They take the place also of the director, an instrument 
 which need never be used by the abdominal surgeon. The 
 deeper part of the wound, dowiqto the peritoneum, is opened to 
 the full extent of the skin incision. Should there be any 
 hsemorrhage, forceps are to be put on to the bleeding points, as 
 little surrounding tissue as possible being included in their grasp. 
 The peritoneum is caught up with forceps at the upper angle 
 of the wound, and an opening is made with the scissors large 
 enough to admit the finger, which is passed downwards to guard 
 against injury to a displaced bladder while the peritoneum is 
 being fully opened. When cutting down on intestine the same 
 method is used, except that, if there be any difficulty, a straight 
 line to the abdominal cavity can be kept by catching up the 
 tissues on each side with a pair of forceps, cutting between and 
 catching hold again of a deeper layer, and so on until the 
 peritoneum is reached ; this last structure being divided between 
 two pairs of forceps, which raise it up from off the bowel. 
 
 The question of the long and short incision was debated for 
 long. Before ovariotomy had been performed fifty times, the 
 
ADHESIONS. 
 
 47 
 
 length of the incision had varied from one inch to the whole of 
 the space between the sternum and pubes. A free external 
 incision is a good general rule in surgery, and there is no valid 
 reason why it should not be applied to the abdomen. The 
 incision ought to be long enough to do what is necessary, as 
 easily, as quickly, and with as little exposure and irritation of 
 the intestines as possible, and not one quarter of an inch longer. 
 There is not any advantage to be gained by having the wound 
 half an inch shorter than is convenient ; for the length of the 
 incision has nothing to do with the result of the operation, nor 
 with the firmness of the scar, if the wound be properly brought 
 together. 
 
 Adhesions. 
 
 When there is adhesion beneath the wound, there may be 
 oedema of the wall, or some increased vascularity, though this 
 latter condition, as a rule, seems to go more with adhesions in 
 the pelvis. When the adhesion is very firm there may be some 
 difficulty in telling when one is through the peritoneum, and a 
 little of it may be separated before the mistake is found out. 
 Though experience is the only guide in such cases, it is well to 
 know that the peritoneum may be much swollen, being some- 
 times nearly as much as half an inch in thickness. Should ad- 
 hesions be met with, they can be separated either with the 
 fingers or hand, or with a sponge ; when very firm, tliey must 
 be cut. On to every bleeding point, a pair of catch forceps 
 must be fixed, and left there until towards the end of the opera- 
 tion, when in a bad case fifty or sixty pairs may be lying in the 
 abdomen. All do not require to be ligatured, as the pressure of 
 the forceps has checked the haemorrhage, when the vessels are 
 small. When the adhesions are situated deeply in the pelvis, 
 it is better to tie, without first seeing if the bleeding has stopped, 
 for it is often a matter of great difficulty to get hold of a bleed- 
 ing artery after it has become retracted into the loose cellular 
 tissue of the pelvis. When the bleeding is from a flat or soft 
 
48 
 
 PREPARATIONS FOR AN OPERATION 
 
 surface which gives no hold for a ligature, it may be stopped 
 by the pressure of a sponge wrung out of hot water, or the satu- 
 rated solution of perchloride of iron may be applied to it, either 
 with or without pressure. Oozing of blood will stop of itself ; 
 but the abdomen must never be closed so long as there is a sus- 
 picion that a large vessel is bleeding. It must be found. 
 
 The golden rule in separating adherent growths is, to keep 
 closely to the tumour itself, and not wander off into the sur- 
 rounding tissues. 
 
 The Toilet of the Peritoneum. 
 
 The peritoneum is to be left in as natural a condition as 
 possible ; blood and bloody fluid must be removed by sponging. 
 This is what Dr. Keith learned at his first ovariotomy in 1862, 
 but it was many years before his example was followed. The 
 original notes of the case are given : — 
 
 “’Mrs. E., aged forty-nine, applied to me, last August, on 
 account of a large ovarian tumour filling up the whole abdomen, 
 to which her attention had been first directed about six months 
 before. Previous to this her health had been good, she had 
 married when thirty -six years of age, and had borne two 
 children. The catamenia, after some irregularity, finally ceased 
 in December 1861. For some time the tumour gave rise to no 
 inconvenience, and her general health did not suffer, but, by the 
 time it had attained the size of the uterus at the full period of 
 gestation, her health began to give way : the respiration became 
 impeded, locomotion was a labour to her, she suffered much 
 from abdominal pain, and shortly before I saw her, weary of life, 
 she had taken to her bed, with little prospect of again leaving it. 
 
 “ From the nature of the tumour, which was evidently mul- 
 tilocular, from the extreme rapidity of its growth, from the 
 numerous unmistakable signs that had already appeared of a 
 rapid breaking up of the patient’s health, it was most probable 
 that, if left alone, the disease, with its accompanying suffering. 
 
THE TOILET OE THE PERITONEUM. 
 
 49 
 
 would run its natural course and destroy life in a few weeks or 
 months ; and as nothing was to be hoped for either from tap- 
 ping or the injection of iodine — both dangerous, and but half 
 measures at best — I had no hesitation in recommending ovario- 
 tomy. To this, after due consideration, she willingly gave her 
 consent, and it would have been proceeded with without delay, 
 had not a smart attack of pleurisy with considerable effusion 
 supervened. This yielded to the usual remedies, but a month 
 elapsed before she was in a favourable condition for operation. 
 In the meantime the abdomen had much increased in size, from 
 the presence of a large accumulation of fluid in the general 
 cavity of the peritoneum, none of which existed at the time of 
 my first examination of the tumour. 
 
 With the assistance of Dr. Craig of Eatho, Dr. Howden, Dr. 
 Sidey, and my brother, I removed the tumour on the 18th of 
 September 1862. Before opening the peritoneal cavity, think- 
 ing I had come down on the surface of the tumour, I separated 
 the peritoneum from its loose cellular attachments, to the extent 
 of two fingers’-breadth on either side of the incision. This mis- 
 take happened very easily, but was quickly discovered, and, on 
 opening the peritoneum, there was a sudden gush of a large 
 quantity of straw-coloured fluid. One large cyst containing 
 about eight pounds of fluid was emptied and drawn out, and 
 some cysts punctured ; but as no further diminution of the 
 mass could be obtained, it was necessary to extend the incision 
 above the umbilicus, till sufficient space was gained to allow of 
 the tumour being withdrawn. There was but one small band 
 of adhesion. The pedicle, which consisted of the left broad 
 ligament, was short, broad, and thick. It was transfixed, each 
 side was tied with a double ligature, and then divided little 
 more than an inch from tlie uterus, and so close to the uterine 
 tissue, that a piece of thick cyst wall was left to prevent any 
 chance of the ligature slipping. Owing to the shortness of the 
 pedicle, it was not possible to secure the cut extremity exter- 
 nally. It was, however, brought as near the wound as circum- 
 4 
 
50 
 
 THE OPERATION. 
 
 stances would permit of, by passing a long acupressure needle 
 through the strip of cyst, and then simply laying the needle 
 across the lower angle of the wound. There was thus consider- 
 able tension upon the pedicle, though none upon the ligatures 
 themselves, which were only given a turn round the needle. 
 The edges of the wound were secured by seven needles passed 
 through the whole thickness of the abdominal wall, including 
 the peritoneum. A small quantity of slightly bloody serous 
 fluid was left in the cavity of the pelvis. 
 
 “ The shock of the operation was slight. Towards evening 
 she complained of severe pain in the lower part of the belly, 
 which was relieved by drawing off her water. An opiate was 
 given her, which she vomited almost immediately, and it was 
 not repeated. She suffered for the first three or four days from 
 thirst and occasional severe attacks of vomiting. No food was 
 given, but she relished very much small pieces of ice and 
 occasionally a mouthful of soda-water, for more than that was 
 instantly rejected by the stomach. The pulse rose to 105 on 
 the third day, and then declined, and never again rose above 
 90. The catheter was used every four or five hours till the 
 fourth day, when it became unnecessary, the bowels then like- 
 wise acted spontaneously and without pain. Some of the 
 needles were removed on the fourth day, the rest the day after, 
 when the wound was firmly united, except at the point where 
 the ligatures came out, and required no support or dressing of 
 any kind except a piece of lint dipped in Condy’s fluid laid 
 over the lower angle of the wound. On the fifth day the 
 stomach began to retain some food, which was given in small 
 quantities and of the simplest kind, the treatment being all 
 along strictly antiphlogistic. She was kept very quiet, and 
 was allowed to see no one but her husband and the nurse. 
 The greatest care was taken to keep the air of her room as 
 fresh and pure as was possible under the circumstances of a 
 somewhat limited accommodation, the window being generally 
 open both day and night. 
 
THE TOILET OF THE PERITONEUM. 
 
 5 
 
 “ On the seventh day slight pain was complained of in the 
 left iliac region, where some fulness was felt, as if some pelvic 
 cellulitis threatened. This was accompanied by some consider- 
 able irritability of the bladder, and for the two following days 
 she was restless and uneasy, and again suffered from thirst, 
 but without fever. Thinking some matter might be accumulat- 
 ing, for there was very little discharge coming from the wound, 
 I broke up the adhesions round the ligatures to an extent suffi- 
 cient to admit the finger, and soon after there was a sudden 
 escape of eight or ten ounces of healthy pus. This gave her 
 immediate relief. The ligatures came away with the slough 
 of the pedicle on the fourteenth day, and the day after she was 
 up to have her bed made. After getting into bed she had a 
 good deal of general abdominal pain, and a troublesome irrita- 
 tion in the rectum came on ; considerable quantities of bloody, 
 jelly-like mucus passing several times a day. The opening 
 where the ligatures had come out had almost closed, when, on 
 the evening of the seventeenth day, there was a gush of thin 
 dirty serous-looking very irritating fluid, to the amount of ten 
 or twelve ounces. It was so foetid that it was difficult to 
 enter the room beside her. This discharge continued all day, 
 but during the following night it suddenly ceased after some 
 of the same foetid fluid had passed by the rectum. That this 
 was the same fluid left in the cavity of the pelvis at the time 
 of the operation I have no doubt. On the twenty-second day 
 the fistulous opening in front had quite closed, and the conval- 
 escence after that was rapid and satisfactory. When last seen, 
 in the middle of November, she was going about as usual in 
 the most perfect health.” 
 
 Sponging is preferable to flushing, a procedure of value only 
 in cases where septic fluid is found in the peritoneal cavity, or 
 where such fluid, or even simply irritating fluid, is put in by 
 the surgeon. In such a case he must of course wash up the 
 mess he has made. 
 
 The simplest way of washing out the abdominal cavity is 
 
52 
 
 THE OPERATION. 
 
 to use a funnel and an ordinary soft stomach tube. The water, 
 which must be about blood-heat, is poured into the funnel, 
 while the end of the tube is passed into the bottom of the 
 pelvis, and can be moved into the loins, or elsewhere if necessary. 
 The abdomen should be thoroughly filled before the water is 
 allowed to escape, the wound being temporarily closed with the 
 fingers and thumb. 
 
 Several gallons of water must often be used, and when the 
 water comes out perfectly clean, the peritoneal cavity is to be 
 dried with sponges before the wound is closed, and a drainage 
 tube must be left in. The necessity for washing out in suitable 
 cases is shown by the following notes. Sliortly before the hour 
 fixed for the removal of an ovarian tumour the patient felt as 
 if something had given way, the abdomen was found to be 
 llaccid ; and on opening the peritoneal cavity it was discovered 
 that the tumour had ruptured, and that the intestines were 
 bathed in a large quantity of offensive pus. Before the wound 
 was closed, the cavity was thoroughly washed out with a very 
 large amount of warm water, and the patient made a good 
 recovery. It would have been impossible to cleanse the peri- 
 toneum in any other way. 
 
 In cases where the irritating fluid is confined to the pelvis 
 it is not necessary to wash out the whole of the abdominal 
 cavity ; the water is run in up to the level of the brim only, 
 and then sponged out, and this is repeated until the water 
 comes away quite clean. 
 
 Drainage. 
 
 The idea of draining the peritoneal cavity after operation 
 occurred first to Koeberlee of Strasburg ; his tubes, made of 
 glass, were, however, too short to reach to the bottom of the 
 pelvis. Dr. Keith brought home one of these tubes in 1866, 
 and soon saw that the drainage must be from the lowest part 
 of the abdominal cavity, or not at all. He therefore had tubes 
 made of sufficient length to reach from the bottom of the pelvis 
 
CLOSURE OF THE WOUND. 
 
 53 
 
 to the abdominal wound ; specially toughened glass being used 
 in their manufacture, so as to avoid accidental breakage in the 
 abdominal cavity, an accident which has been known to happen. 
 
 One must use judgment with the drainage tube, and it is 
 impossible to give exact rules for its use. It is* of service only 
 when there is something to be drained ; a simple operation 
 requires no tube; a severe one, where there has been much 
 separation of intestine, and when oozing of blood or serum is 
 expected, ought to be drained. In cases where there has been 
 a rupture of old standing, and consequent chronic inflammatory 
 changes in the covering of the intestine and the peritoneum 
 generally, a drainage tube, though apparently necessary, is not 
 required. The tube is to be put in before the stitches are 
 introduced, two fingers being passed into the pelvis to raise 
 the intestine and allow of it reaching quite to the bottom of 
 the Douglas’s pouch. As will be seen, the glass drainage 
 tube (Fig. 8) is provided with a small flange to prevent it 
 slipping into the peritoneal cavity, and there is no risk of this 
 happening if the tube be fixed in the following manner. It is 
 usually brought out at the lower angle of the wound, but should 
 it be necessary to fix it at any other part, the method is exactly 
 the same. It must be fixed between two stitches introduced 
 so close together, that when they are tied there is not room 
 for the flange to slip inwards. 
 
 Closure of the Wound. 
 
 Before introducing the stitches the omentum is drawn down 
 over the intestines, and a small flat sponge placed beneath the 
 wound, to take up any drops of blood escaping from the needle 
 punctures. For the closure of wounds of average thickness it 
 is more easy to pass the needles from within outwards ; in thin 
 people one can get on more quickly by using a single needle, 
 passing it through the wall on the right side of the wound from 
 without inwards, and in the reverse direction on the left side. 
 
54 
 
 THE OPERATION. 
 
 The whole thickness of the wall is to be included in the stitch, 
 the needle taking in rather less than one-quarter of an inch of 
 peritoneum, and coming out about one-eighth of an inch from 
 the cut edge of the skin. On an average three sutures will be 
 required to the inch, more if the patient be thin. Instead of 
 silk some prefer to use silkworm gut or silver wire ; neither 
 appears to have any special advantage, and they are not so 
 convenient as silk. The flat sponge is removed, the sponges 
 are counted by the assistant, not by the nurse ; the ends of 
 the stitches are drawn tight, and any air which is present is 
 to be pressed out of the cavity. The stitches are to be tied 
 with a slip knot, which is drawn to the side of the wound, so 
 that the knot does not press on the line of union ; they must 
 not be tied tightly ; all that is required is to bring the edges 
 together. The ends of the silks are cut off when all have been 
 tied. Stitch abscesses ought to be unknown. A few stitches 
 of horse-hair are to be employed to bring the skin edges together. 
 
 Dressing of the Wound. 
 
 The wound having been closed, the skin is washed, and the 
 dressing, consisting of ten or twelve layers of gauze thoroughly 
 saturated with the glycerine and carbolic solution, 4 inches in 
 width and somewhat longer than the length of the wound, is put 
 on and covered by dry gauze. If a tube be used, it is carefully 
 surrounded by the dressing, and the 18-inch square of pure 
 rubber is fixed round the top by means of a small opening in 
 this elastic material ; one or several sponges, if much serum be 
 expected, is placed over the end of the tube, and the rubber 
 folded over all. In this way the fluid can be removed from the 
 abdominal cavity without interfering with the wound in the 
 slightest. The abdomen is then covered with one or two sheets 
 of cotton wadding, and the flannel bandage put on. Strips of 
 sticking-plaster are commonly used instead of the bandage ; but 
 it will be found in practice that this plan does not prevent 
 
ANTISEPTICS. 
 
 55 
 
 flatulent distension of the intestine, and is not so comfortable. 
 The patient is lifted back to bed, in which are several hot 
 bottles ; a light shawl is thrown over the head and face, and a 
 dose of morphia, varying from one-eighth to one-quarter of a 
 grain, is given hypodermically. All instruments are removed, 
 the furniture is arranged as before the operation, blinds are 
 drawn down, and the patient is left to the nurse. 
 
 The instruments are scrubbed with a nail brush in soap and 
 water, and each one is to be examined before being put away. 
 
 Antiseptics. 
 
 The foregoing details give our practice in regard to anti- 
 septics. The spra}^, given up by its parent some years ago, is 
 now practically a thing of the past, it having been proved by 
 experiment that living germs can pass througli it unharmed. 
 It has been stated, apparently without any evidence, that the 
 vitality of germs is lessened by their passage through the 
 carbolic acid cloud. Absolutely cleanly surgery is aseptic 
 surgery; it is conceivable that we may fail in our endeavours 
 to be absolutely clean ; why then should we not guard against 
 such possible failure, by using antiseptics for the hands, instru- 
 ments, skin of the patient, and the dressing ? By doing this, we 
 can do no possible harm, and we render chemically clean any 
 filth which may have been overlooked. 
 
CHAPTEE IV. 
 
 AFTEK TEEATMENT. 
 
 The following is a typical history of the satisfactory progress of 
 a patient after an abdominal operation. 
 
 Immediately after being put back to bed at noon, one-sixth 
 of a grain of morphia was given hypodermically. 
 
 4 hours. — The patient has brought up a little frothy mucus 
 on three occasions. T. 98°, P. 84. 
 
 9 hours (evening). — No more vomiting, the skin has been 
 acting freely. Has had a few teaspoonfuls of cold water. 
 Morphia one quarter of a grain. T. 9 9 '2°, P. 100. 
 
 20 hours (morning). — Slept several times for an hour at a 
 time, and once for over two hours. Some rumbling of wind in 
 the bowels accompanied by slight colic. Passed water at 4 a.m. 
 for the first time. Five ounces of hot water have been given 
 through the night ; thirst not excessive. T. 99‘6°, P. 96. 
 
 27 hours. — Wind has begun to pass through the rectal tube. 
 Has had a small cup of tea. T. 9 9 '2°, P. 104. 
 
 32 hours (evening). — Flatus passing freely without the rectal 
 tube. A small cup of gruel once. Morphia one quarter of a grain. 
 
 44 hours. — Slept well. Had tea early in the morning. 
 Pulse and temperature normal. 
 
 Evening. — Has had gruel twice and tea three times. No 
 morphia. 
 
 Seventh day. — Two tablespoonfuls of castor-oil were given 
 early yesterday morning, and the bowels moved well witliout 
 
THIRST 
 
 57 
 
 an injection. The wound was looked at for the first time, the 
 deep stitches were removed, and broad strips of sticking-plaster 
 were put across the abdomen to prevent the wound stretching. 
 For the past three days chicken soup has been given once 
 a day. 
 
 The bowels were moved again on the tenth day, and on the 
 twelfth the patient sat up in bed, getting on to the sofa two 
 days later. In the second and third weeks the food consisted 
 of bread, fish, chicken, and milk pudding. The patient was fitted 
 with a belt on the seventeenth day, and went home on the 
 nineteenth. 
 
 Thirst. 
 
 “ What can I have to drink ? I would like a big drink,” one 
 hears said very often. The quantity of fluid must be limited 
 for the first few hours, a teaspoonfiil of cold water given at long 
 intervals seems to do best ; by night time hot water is found 
 by almost every patient to allay thirst well. It must be drunk 
 very hot, almost boiling, and is best given in a horn spoon, 
 the china of a cup burning the lips. Do not give ice, it allays 
 thirst for a very few minutes, and once begun with, the patient 
 is not content unless he has a piece almost constantly in the 
 mouth ; and if much be given a greater quantity of fluid is 
 taken into the stomach than one is aware of. In a few days 
 the patient will have a dry sore mouth, and he will then regret 
 that his wish for ice had been acceded to. The quantity of 
 fluid which may be given will vary with the amount of perspira- 
 tion ; somewhere about flve ounces will be a fair average for the 
 first night. Should the patient begin to vomit, all fluid by the 
 mouth must be stopped ; and an enema of eight or ten ounces 
 of water, or milk and water, may be given for the thirst if 
 necessary ; a larger injection is apt to be returned, even when 
 put into the rectum very slowly. Until flatus has passed freely 
 from the anus, showing that the intestinal tract is free in its 
 whole course, the quantity of fluid must not be increased. The 
 
58 
 
 AFTER TREATMENT 
 
 craving for a drink, present in almost every case, rapidly passes 
 away after the first forty-eight hours, if the patient be progress- 
 ing satisfactorily. 
 
 Food and Stimulants. 
 
 No food of any kind, unless stimulants be considered as such, 
 is to be given, unless under exceptional circumstances, until the 
 flatus has passed freely. Usually there is not any desire for it, 
 and even when the patient is very weak the strength can be 
 kept up by rectal feeding. After the flatus has passed, a small 
 cup of tea with little milk and sugar, is most grateful and 
 refreshing ; then a teacupful of well-boiled gruel or of Benger s 
 peptonised food or some such easily digested farinaceous food 
 may be taken twice during the day. A little brandy or whiskey 
 seems to help the patient over the first night; from 3ii. to §ss. 
 may be given in an ordinary case; and a somewhat similar 
 quantity may be continued to be given for a few days. For 
 several days the farinaceous food is to be taken two or three 
 times a day ; and towards the end of the week, soup may be 
 added to the diet. Until the bowels have been well moved no 
 solid food must be given. Patients who are accustomed when 
 well to take food often will require to have nourishment more 
 frequently than others ; but an ordinary person can get along 
 easily on this amount of food, especially if it be helped out by 
 a cup of tea occasionally. As time goes on the nourishment 
 will be increased in amount, and during the second week will 
 consist of fish and other light diet. 
 
 When the patient is weak a nutrient enema must be given 
 immediately after the operation, and repeated at regular inter- 
 vals. Fluids are absorbed with great rapidity from the rectum 
 after abdominal operations ; and in practice it is found that it 
 does not matter at such times whether the food be peptonised or 
 not. The quantity injected should be four ounces, and it may 
 consist of an egg beaten up in warm milk and with from 5i. to 
 5SS. of whiskey added ; or of home-made beef-tea, or any good 
 
MANAGEMENT OF THE INTESTINE. 
 
 59 
 
 meat extract, with a similar quantity of stimulant ; or of milk 
 alone with the whiskey. These enemata are to be repeated, at 
 least as often as every four hours ; sometimes they will be 
 absorbed if given every two hours ; though, of course, the rectum 
 will not stand this for more than a few days. Once in every 
 twelve hours the rectum is washed out with warm water. The 
 following case may be given as an example of one requiring 
 rectal feeding : An unmarried lady, thirty-seven years of age, 
 came from Australia to have an ovarian tumour removed. The 
 patient was much emaciated, and the pulse was usually about 
 110. The operation was performed in July 1888. The tumour 
 was found to be universally adherent to the peritoneum and the 
 omentum in front, to the intestine and mesentery behind ; and 
 the right broad ligament was opened up. The tumour weighed 
 28 lbs. The patient was put back to bed with pulse at 142. 
 An enema of Valentine’s fluid beef and two teaspoonfuls of 
 whiskey was given at once, and was repeated fifteen times 
 in the first thirty hours. As the stomach was very irritable 
 little fluid was given by the mouth ; but thirst was not specially 
 complained of. Flatus began to pass thirty-one hours after the 
 operation, and the injections were then discontinued. The 
 stomach was able to retain food in small quantities after the 
 wind passed, and the after progress was satisfactory. 
 
 Management of the Intestine. 
 
 When flatus has passed freely from the rectum after an 
 abdominal operation, the chief danger is past. We watch for 
 this sign with anxiety, and while we must be ready to assist the 
 intestine in expelling the gas, yet in by far the greater number 
 of cases treatment is not necessary, and may indeed be harmful. 
 It is often difficult to wait and watch, to have faith in nature 
 and to hold one’s hand, when it appears that she is likely to 
 fail us. The passage of flatus commences from twenty to thirty 
 hours after the operation ; sometimes it may be sooner, at other 
 
6o 
 
 AFTER TREATMENT 
 
 times later, even as late as 108 hours has been known. In 
 perhaps 90 per cent, nothing requires to he done except to open 
 the sphincter ani muscle with a tube. This tube — an ordinary- 
 glass drainage one will do — is always to he passed into the rectum 
 to the depth of 4 inches or so, occasionally after the first 
 twenty hours ; and especially if there be colicky pains passing 
 down to the region of the sigmoid flexure and stopping there. 
 It may he allowed to remain in the rectum for two hours or 
 even longer, when it does not irritate. A simple ointment with 
 cocaine may be used to lubricate the tube, when there is irri- 
 tability about the anus. Treatment, except by thus opening 
 the sphincter, is to be avoided at first, all that is necessary is to 
 prevent undue irritation of the stomach by not giving too much 
 food or drink. 
 
 When treatment becomes necessary it must be prompt, there 
 is not any time to lose, for a few hours of inactivity at the 
 wrong time may easily result in the death of the patient. The 
 symptoms which call for interference are vomiting; distension 
 of the abdomen, either when accompanied by colicky pains or 
 not, and especially when long-continued windy pains have been 
 followed by intestinal paresis. This brings us to the cause of 
 distension, excluding mechanical obstruction ; two theories have 
 been advanced, the one is, that the distension is due to com- 
 mencing peritonitis; the other, that it is due to a paresis or 
 paralysis of the intestine itself. As a variety of the latter must 
 be included the so-called septic peritonitis, as this may be a 
 septicaemia without any definite inflammation of the peri- 
 toneum. There is truth in both of these hypotheses, though it 
 is probable that the distension is comparatively seldom caused 
 by peritonitis. We do not have opportunities of examining the 
 peritoneum at the time when distension begins, and it is thus 
 impossible to say with absolute certainty what is the exact 
 pathological condition. A careful clinical study leads one to 
 the conclusion that the sympathetic nervous system has much 
 to do with the condition. This conclusion is strengthened by 
 
MANAGEMENT OF THE INTESTINE. 
 
 6i 
 
 the 'post morUni examination of cases of so-called acute septic 
 peritonitis, but which are described more correctly by the single 
 word septicaemia. At such examination no signs of inflam- 
 mation may be seen except in the neighbourhood of the wound ; 
 but some, perhaps very little, red serum will be found. The 
 symptom of distension is common both to these cases of septi- 
 caemia or septic peritonitis, and to those of what is usually called 
 simple peritonitis ; and it is possible that, as there is little 
 inflammation in the one case, there may also be little in the 
 other. Still there cannot be any doubt that cases of simple 
 traumatic peritonitis are met with. 
 
 No two cases of distension ought to be treated by any routine 
 method, and a nurse who has seen the treatment of one case 
 must never be allowed to treat another on her own responsibility 
 and in the same manner. It must be evident to every one that 
 distension, accompanied by increased peristalsis, must not be 
 treated in the same way as when the want of the passage of 
 flatus is due to paresis and cessation of the peristaltic action. 
 When there is paresis, without a previous condition of increased 
 peristaltic action, and consequent exhaustion of the sympathetic 
 ganglia, a stimulant to these ganglia is required. Some hot 
 water may be given ; or a teaspoonful of bicarbonate of soda in 
 warm water ; or a saline mixture, as magnes. sulph. 3i. ; 
 magnes. carb. grs. x. ; aq. menth. pip. 5 ss. ; aq. ad 5ii. Sig. — The 
 dose to be repeated every two hours until the bowels move ; or, 
 and best, the excitement may be given from below. Six grains 
 of sulphate of quinine dissolved in two drachms of whiskey in a 
 couple of ounces of warm water are to be injected into the 
 bowel, and repeated every two hours until three doses have been 
 given. What we have to do is to stimulate the nerve-cells and 
 set up peristaltic action. 
 
 On the other hand, when there are frequent colicky pains 
 showing the existence of peristaltic action, and no appearance 
 of the flatus passing downwards, it is evident that it would be 
 a mistake to increase this action ; the useless movements must 
 
62 
 
 AFTER TREATMENT 
 
 rather be lessened. For this purpose there is no drug like 
 morphia given hypodermically. This was seen very evidently 
 in the case of a thin subject, where the bowel was observed to 
 be adherent to an enlargement of the kidney. Whenever food 
 was taken peristaltic action was set up, and the bowel could be 
 easily seen distending downwards until it came to this adhesion ; 
 here it stopped, an obstruction due to an angle having formed ; 
 and, if nothing were done, vomiting came on. A small dose 
 of morphia invariably gave relief, and the flatus could be seen 
 and heard to pass through the obstruction with a gurgling 
 sound. 
 
 Some surgeons have been in the habit of giving a dose of 
 opium, in some form or other, at stated times and in every 
 case ; others have limited its use to cases of distension, or so- 
 called peritonitis. Naturally, a routine practice of this kind 
 has not proved suitable in every case ; and now the tend- 
 ency is to use this drug rather too little than too much. 
 It is perhaps as great a mistake to use too little opium as it is 
 to give it too often, and especially in too large doses. There 
 is no one drug which is of greater service when given in suitable 
 cases and with a distinct object in view ; and none is capable 
 of doing greater harm when used in a haphazard or routine way. 
 The best preparation of morphia for hypodermic injection is 
 the tartrate, and the dose should seldom exceed a quarter of 
 a grain, and will vary from that down to one-twelfth. Some- 
 times wind will pass after a dose of morphia has been given ; 
 under these circumstances the soothing effect apparently relaxes 
 a spasmodic stricture at an angle. 
 
 A more anxious condition of the intestine is that of paresis 
 following great peristaltic effort. This means that there is some 
 obstruction to the passage downwards of the flatus, which the 
 muscular action of the intestine has failed to overcome. A rest 
 must be given to the tired-out muscular fibres before an effort is 
 made to stimulate them to renewed action. Give a quarter of 
 a grain of morphia, or even in exceptional cases a larger dose, 
 
MANAGEMENT OF THE INTESTINE. 
 
 63 
 
 and stop all fluid by the mouth. After this dose allow a rest 
 of three or four hours, then give the quinine by the rectum ; 
 if the first dose does not set up windy pains let the patient 
 have from one to two tablespoonfuls of castor-oil by the mouth, 
 and continue the quinine until the three doses have been given. 
 Should this fail, give a large enema with turpentine, turn the 
 patient on the side, and if necessary repeat the turpentine 
 injection several times. If there be no septicaemia nor any 
 mechanical block, wind can always be got down, if the proper 
 treatment for the case be used. The following is an example. 
 The operation of hysterectomy was performed on a patient 
 thirty-four years of age on 26th November 1884 : — 
 
 5 P.M. — Quiet, no pain. 
 
 9.15 P.M. — -Ten ounces of urine by catheter, some pain before 
 and a little since in the left side. Morphia one-sixth of a grain. 
 T. 99°, P. 64. 
 
 27th (morning). — Slept well. Pain since 5 A.M., thinks that 
 it is wind. Urine fourteen ounces. Stomach soft. No morphia 
 during the night. T. 9 9 '4°, P. 64. 
 
 11 A.M. — Pains bad. Morphia one-sixth of a grain. 
 
 5 P.M. — Has been very quiet. T. 100°, P. 110. 
 
 9.15 P.M. — Felt very sick about eight o’clock, but did not 
 bring up anything ; now feels better. One pin of the bandage 
 is a little tight. Stomach slightly full and hard. No wind 
 moving about. Urine is coming away involuntarily. Almost 
 no pain. One -sixth of a grain of morphia and six grains of 
 quinine in solution by enema. T. 101°, P. 110. 
 
 11 P.M. — Quinine repeated. 
 
 28th (morning). — Has not been awake for any time during 
 the night. Very little wind moving about, the stomach is hard 
 and slightly distended. Eather more so than last night. There 
 is slight drawing up of the upper lip. Had three injections 
 of quinine during the night and one teaspoonful of magnesia. 
 T. 99-6°, P. 88. 
 
 11 A.M. — Wind is moving about a little. 
 
64 
 
 AFTER TREATMENT 
 
 1 P.M. — A little wind has passed several times, but the 
 stomach is fuller and hard. T. 99’2°, P. 90. 
 
 ' 4 P.M. — Still about as full. Almost total want of expression. 
 Quinine again given by the rectum. T. 99*2°, P. 88. 
 
 6 P.M. — Wind passing very freely. The distension is almost 
 gone and there is no tenderness. A decidedly better pulse. 
 Looks quite natural. T. 99°, P. 84. 
 
 9.30 P.M. — Quiet with some sleep. Not much wind passing. 
 Stomach rather fuller than at six o’clock. One-sixth of a grain 
 of morphia injected, and the quinine to be repeated at 10.30 if 
 necessary. T. 99‘6°, P. 80. 
 
 29th (morning). — Flatus passed freely after the morphia, but 
 quinine was required twice during the night to keep it going- 
 down. T. 99-4°, P. 80. 
 
 The progress of the case after this was satisfactory. 
 
 When there is vomiting an endeavour must be made to 
 discover the exact cause : whether it be due to some derange- 
 ment of the stomach itself; or to mechanical pressure of a 
 distended colon; or to the state of the alimentary tract, as 
 described in cases of distension. When the vomited matter has 
 a sour or sweet taste a half or one teaspoonful of bicarbonate 
 of soda is to be given in six or eight ounces of warm water ; 
 this will either act as an emetic or will remain in the stomach, 
 and neutralise the acidity. Sometimes the stomach is washed 
 out ; but it is doubtful if this does more good than the soda, 
 and it is undoubtedly fatiguing and distressing to the 
 patient. 
 
 Mechanical pressure on the stomach is to be relieved by 
 rubbing the back, or by raising it on a small firm pillow. 
 
 When the vomiting is a part of the general state of relaxa- 
 tion and distension, quinine by the rectum will be found to be 
 invaluable ; and especially so in those cases where the stomach 
 will not retain any medicine. 
 
SEPTICEMIA. 
 
 65 
 
 Septicemia. 
 
 So far, we have dealt with cases where there was not 
 supposed to be any evidence of septicsemia. The first symptoms 
 of this dread condition are noticed about eighteen hours after 
 the operation; there is some difference in the expression and 
 in the manner of the patient. At the very commencement it 
 is difficult to say exactly what is noticed ; there is something 
 not quite natural, and a few hours later this shows itself in 
 the eyes and mouth. There is an appearance of fixation about 
 the face; the eyes have a wild look, and the upper lip is beginning 
 to be drawn up. The manner too has changed, the patient may 
 be elaborately polite, talks in a rapid jerky fashion, and if given 
 a drink, will clutch the cup and put it to the lips quickly and 
 abruptly. There is a look impossible to describe that makes 
 one’s heart sink on first seeing the patient. In the commence- 
 ment it may be passed over, but any one who has seen one well- 
 marked case is not likely ever to forget the appearance. To 
 have the slightest hope of success in the combat with this 
 disease we must throw overboard the good plan of waiting on 
 the natural efforts, for this will lead to but one result. By 
 the time that the first appearance of septiciemia is noticed 
 there may be some, perhaps slight, distension ; and all our 
 efforts must be directed to the elimination of the poison by, 
 if possible, free movement of the bowels, and by the action of 
 the skin. The administration of the saline mixture must be 
 begun immediately, and the quinine added to the nutrient 
 enemata. A small dose of morphia will not interfere with the 
 action of the laxative, and will perhaps cause the skin to act. 
 If taken early enough it is possible to believe that an undoubted 
 case of septicsemia might be cured, provided that the absorption 
 of the poison has stopped, and the patient has sufficient vitality 
 to overcome what has been taken into the system. If absorp- 
 tion be allowed to go on the patient must inevitably die. As 
 5 
 
66 
 
 AFTER TREATMENT 
 
 soon as we find that the bowels will not move nor the skin act, 
 and feel certain that we are dealing with a case of septicccmia, 
 the treatment ought to be to open up the lower angle of the 
 wound; put in a drainage tube to the bottom of the pelvis, 
 if there be not one already there, being quite certain that it 
 does reach to the bottom of the cul-de-sac, and wash out with 
 a large quantity of warm water. It is useless to attempt to 
 wash out by the tube unless an exit be provided for the escape 
 of the fluid. This can hardly be done too soon in a case of 
 septicaemia, but we must be very sure of the diagnosis ; for, if 
 the patient be not relieved by the removal of septic matter, 
 the simple opening up of the wound may be enough to turn 
 the balance against him. A lady thirty -six years of age was 
 seen late one evening, three weeks after the birth of her first 
 child. She was vomiting constantly; the abdomen was enormously 
 distended with flatus ; the temperature was 103° ; pulse 144 ; 
 and there was no movement of intestine. There was a difference 
 of opinion as to what should be done ; one opinion given was, 
 that if the abdomen were not opened the patient would die ; 
 and the other, that such an operation would inevitably kill her. 
 All fluid by the mouth was stopped, quinine was given by the 
 rectum, and within a month the patient was able to be out 
 walking. It is at least probable that no relief would have been 
 given by opening the abdomen, and that the operation would 
 have been sufficient to cause the death of the patient. The 
 following is a typical example of septicaemia : — 
 
 The operation of hysterectomy was performed on a patient 
 thirty years of age on the 8th of March 1886. The weight of 
 the tumour was 10 lbs., and the operation was performed on 
 account of excessive menorrhagia, so great that at one time she 
 was completely blind and deaf simply from the anaemia. The 
 operation lasted forty-five minutes, the patient was in bed at one 
 o’clock, a nutrient enema was at once given, and was repeated 
 every three hours. 
 
 9.30 P.M. — General condition fairly good, tongue moist, little 
 
SEFTICyEMIA. 
 
 67 
 
 thirst. Four ounces of urine passed without the catheter. 
 T. 99*8°, P. 84. 
 
 9th (morning). — Slept fairly well. Stomach slightly dis- 
 tended, feels sick. Quinine to be given in the next enema. 
 T. 99-8°, P. 106. 
 
 N’oon. — Stomach much distended. The patient was set up 
 in bed and the back rubbed ; some flatus came up, but she was 
 too weak to be kept up long. T. 100-6°, P. 120. 
 
 2 P.M. — Much the same, no wind moving about. Has had a 
 third dose of quinine. T. 99-6°, P. 124. 
 
 5.30 P.M. — Great feeling of sickness, but very little vomiting. 
 Gave a teaspoonful of bicarbonate of soda in warm water twice ; 
 some of it and a large quantity of wind came up with friction. 
 Expression dull, and the patient looks distressed. T. 100°, P. 140. 
 
 7.30 P.M. — Still feels sick, but nothing comes up. A turpentine 
 enema was given without stirring up any peristaltic movement. 
 Emptied the stomach and washed it out with a tube passed 
 through the nose. T. 101°, P. 140. 
 
 9.30 P.M. — The skin has begun to act for the first time since 
 the operation, the pulse is stronger, and there has not been any 
 sickness since the washing out. Quinine was given with a few 
 drops of nepenthe. T. 102°, P. 143. 
 
 10th, 4 A.M. — Sickness has recommenced, the stomach was 
 again washed out and a large dose of sulphate of magnesia was 
 poured in through the tube. Expression rather more natural. 
 T. 101-6°, P. 132. 
 
 10 A.M. — After being turned on the side some wind came 
 away. She still feels a little sick. T. 101°, P. 132. 
 
 1 P.M. — Expression rather better. T. 101°, P. 126. 
 
 4 P.M. — Ho change. 
 
 10 P.M. — Ho wind has passed since eleven o’clock, and there 
 is no peristaltic action. Quinine and one-sixth of a grain of 
 morphia. T. 101-6°, P. 126. 
 
 11th (morning). — Some sleep, no wind passing, abdomen dis- 
 tended, feels tired and weak. T. 101-2°, P. 130. 
 
68 
 
 AFTER TREATMENT. 
 
 1 P.M. — Flatus passed several times after the quinine. 
 T. 101°, P. 120. 
 
 6 P.M. — Much the same. T. 101*6°, P. 126. 
 
 Up to this point, although it was evident that some septic 
 absorption was going on, it appeared as if the patient had 
 sufficient strength to counteract it. 
 
 7.30 P.M. — An urgent message was sent by the nurse. Ice 
 was put to the head, and as the patient appeared to be rapidly 
 absorbing the poison transfusion of six ounces of blood was tried 
 with the hope of increasing the vitality, as the woman was so 
 anccmic before the operation. The patient was vomiting, and 
 no wind was going down. Quinine was injected. T. 103*6°, 
 P. 140. 
 
 10 P.M. — No improvement. Vomiting, stomach w^ashed out. 
 Much distension of the abdomen. T. 103*6°, P. 152. 
 
 The patient died early next morning. Eighty-eight hours 
 after the operation. 
 
 Drainage Tube. 
 
 When a drainage tube has been left in at an operation per- 
 formed in the morning, the sponge will have to be changed and 
 the fluid drawn off in the afternoon, and again at night. The 
 rubber sheet is to be opened up without interfering with the 
 dressing, so as to show only the open end of the tube, the cannula 
 is to be passed into the bottom of the tube, and any fluid in the 
 pelvis is drawn out by the syringe. The quantity of fluid sucked 
 up from the abdomen, and what has collected in the sponge, will 
 vary from an ounce or two up to sixteen ounces or more. It 
 will always be more or less bloody, sometimes it will appear to 
 be almost pure blood. At the second dressing the quantity will 
 be much diminished, unless there be h?emorrhage going on, an 
 accident we have never seen. After the second dressing the 
 sponge need not be changed more frequently than once every 
 twelve hours, if the patient be getting on fairly well. At every 
 dressing the tube must be moved by raising, and also by rotating 
 
SEFTICy^MIA. 
 
 69 
 
 it ; this is to prevent the passage of a small piece of omentum 
 or of an appendix epiploica into the tube through the side open- 
 ings. As soon as the fluid becomes of a straw colour the tube 
 can be removed ; or even if it be red, provided that the quantity 
 be not more than a drachm or so. As the tube is drawn out the 
 sides of the wound are pressed together by the finger and thumb, 
 and a fresh piece of dressing is put on. When the rubber sheet 
 fits tightly round the tube and a proper antiseptic dressing has 
 been used, it ought to be impossible to tell through what part of 
 the wound the tube has passed, a few days after it has been 
 taken out. 
 
 An ovarian tumour weighing 45 J lbs. was removed from a 
 patient thirty-six years of age. A free incision was made 
 through an cedematous abdominal wall, and an enormous 
 omentum, consisting almost entirely of connective tissue and 
 blood vessels, had to be separated from off the whole anterior 
 surface of the tumour. It bled freely, and over fifty vessels 
 had to be tied. The mesentery was adherent, and there was 
 some easily separated adhesion to the bowel. As the bleeding 
 was still going on freely from the upper part of the abdomen 
 the incision was enlarged, and six vessels were tied in the peri- 
 toneum, immediately over the aorta. A drainage tube was put 
 in. The patient was in bed at noon. 
 
 5 hours. — Fourteen ounces of very bloody fluid were got 
 away, ten being in the sponges, and four drawn up by the 
 syringe. 
 
 10 hours (evening). — Two ounces of fluid, much the same as 
 before. 
 
 Second day (morning). — One ounce of less bloody serum. 
 
 Second day (evening). — Three ounces of fluid. 
 
 Third day. — Three ounces in the morning, and one and a 
 half at night. 
 
 The fluid gradually became clearer, and the tube was re- 
 moved on the morning of the seventh day. 
 
70 
 
 AFTER TREATMENT 
 
 Movement of the Bowels. 
 
 It is not of great importance when the bowels are moved 
 after an ordinary abdominal operation. Early in the morning 
 of the fifth, sixth, or seventh day, a large dose of castor-oil is to 
 be given. The patient ought not to be told that he is to get it ; 
 while sleepy, the nurse having diluted the dose with soup or 
 hot milk or brandy, simply says “ Drink this.” The patient will 
 often not be aware that he has had oil, and is pleased to find 
 that the bowels move naturally. Sometimes the first movement 
 of the bowels is not so easy, and the nurse may have to give 
 one or more injections before the intestinal tract is thoroughly 
 cleared. 
 
 Eemoval of the Stitches. 
 
 After the bowels have moved the deep stitches can be taken 
 out. The knot is raised by drawing up the ends of the stitch, 
 and the silk is cut below the knot ; by this means a hard end 
 of silk is not drawn through along the tract of the stitch. The 
 horse-hair stitches are not disturbed ; they, assisted by a broad 
 strip of sticking-plaster put across the abdomen somewhat 
 tightly, prevent the scar from stretching. The wound should 
 be perfectly dry; stitch abscesses mean either bad or dirty 
 surgery. 
 
 The patient sits up in bed on or about the twelfth day, and 
 gets up for the first time at the end of a fortnight. The object 
 in keeping the patient in bed for such a long time is to prevent, 
 as much as possible, the risk of phlegmasia dolens ; and, should 
 there be the slightest pain or swelling in the calf of the leg, the 
 patient must on no account be allowed to get out of bed until 
 the symptoms have entirely passed away. 
 
 Before the patient goes home a firm abdominal belt must be 
 fitted, which will have to be worn during the day for at least a 
 year. For evident reasons it must not be discarded at the 
 
MANAGEMENT OF THE SKIN AND KIDNEYS. 7 
 
 beginning of winter. There is not any advantage in hurrying 
 on a patient too quickly, and a fair average time for going home 
 will be three weeks after most operations. Complete return to 
 health and strength need not be expected for some weeks or 
 perhaps for a few months. 
 
 Management of the Skin and Kidneys. 
 
 When a patient is not getting on well none of the bodily 
 functions will be natural, they will be all more or less in 
 abeyance. The action of the skin has often too little attention 
 paid to it ; as a general rule, it may be stated that, if the skin 
 of a patient can be made to act, progress is satisfactory. A free 
 perspiration within the first few hours after an operation is- very 
 much to be desired. It is for this reason that the patient is to 
 be surrounded with hot bottles, and the nurse must see that the 
 hands are kept under the blankets, for there is almost no hope 
 of perspiration if the arms be allowed to lie outside the coverlet. 
 This is certainly irksome to many, but it is of greater import- 
 ance than at first sight appears, for a moist skin gives relief to 
 the kidneys, and also helps to prevent much or any rise in tem- 
 perature. If the condition of the patient be not entirely satis- 
 factory, and the skin be dry, we must endeavour to start the 
 perspiration, — by a small dose of morphia — and the reason why it 
 should not be used, combined with atropine, in abdominal cases, 
 is evident ; by giving some liquor ammonite acetatis by the 
 rectum, either alone, or in combination with a few drops of 
 tincture of aconite, if the pulse be full ; or by fomentations on 
 the arms and legs. If, along with a dry skin there be scanty 
 secretion of urine, dry cupping over the back will at times start 
 a perspiration ; or a small dose of pilocarpine may be injected 
 hypodermically. 
 
 A patient twenty-eight years of age was operated on in 
 the Woman’s Hospital, New York, by Dr. Emmet. The case 
 was one of pyosalpinx, and it was found to be impossible to 
 
72 
 
 AFTER TREATMENT 
 
 remove the tube. The after progress, although flatus had not 
 passed, was fairly satisfactory for the first two days ; then there 
 was a rapid rise of pulse and temperature to 140° and 103° 
 respectively, accompanied by distension, and stoppage of the ex- 
 cretions from the kidneys and skin. The patient sank rapidly, 
 and by the afternoon looked as if she could live but a very few 
 hours. The loins and back of the chest were dry cupped in 
 twelve places at the same time, the patient being then un- 
 conscious. Before the tumblers had been taken off, at the end 
 of fifteen minutes, she was conscious and sweating profusely all 
 over the body, and by next morning the kidneys had recovered 
 their function, and the patient was out of danger. The sequel 
 of this case is also of interest, as Dr. Emmet opened into 
 the tube from the vagina later, and obtained a complete 
 success. 
 
 A non-adherent ovarian tumour was removed from a patient 
 aged twenty-two, at half-past ten in the morning, the operation 
 lasting fifteen minutes. One-sixth of a grain of morphia was 
 given as soon as the patient was in bed. 
 
 5 hours.— Skin very dry. T. 102*2°, P. 122. 
 
 10 hours. — Sweating, urine Sxxii. ; morphia one-sixth grain. 
 
 22J hours. — Sweated little during the night, urine oxxxiii. 
 T. 99*6°, P. 106. 
 
 281 hours.— Urine 3 viii. T. 100°, P. 110. 
 
 30 J hours. — Flatus passing through rectal tube. Says she 
 feels much better, but looks excited. P. 120. 
 
 31 J hours. — Urine 3 x., with a trace of albumen. 
 
 33J hours (9.30 p.m.). — Two ice bags put on. T. 104°. 
 
 34J hours. — No perspiration ; feels weak and tired ; ex- 
 pression natural. Eneniata of beef juice, brandy, and quinine 
 given : sp. gr. of urine, which was 1022 before the operation, is 
 now 1014. Morphia one-sixth grain. T. 102*8°, P. 128. 
 
 35 J hours. — Feels comfortable ; enemata are to be given 
 every two hours and without the quinine, as the flatus is pass- 
 ing freely. T. 102°, P. 128. 
 
MANAGEMENT OF THE SKIN AND KIDNEYS. 73 
 
 39 J hours. — Urine 5vi., albumen ^ on boiling and adding 
 nitric acid. T. 100°. 
 
 41 J hours. — Urine §vi., albumen a trace of blood ; restless; 
 morphia one-eighth grain. T. 101 •6°. 
 
 46 J hours. — Slept well, has had some gruel. T. 101°, P. 120. 
 
 50 hours. — Urine §vi., albumen J, slight increase in the 
 quantity of blood. Face flushed. T. 100‘4°, P. 124. 
 
 52 hours. — Urine 5viii., albumen J. T. 101-4°, P. 124. 
 
 55 hours. — No perspiration ; looks puffy below the eyes. 
 Ordered a mixture of liq. ammon. acet. ; spt. etheris nit. ; 
 and mist, camph. T. 102-8°, P. 138. 
 
 57 J hours. — Skin still very dry. T. 103°, P. 150 ? 
 
 58| hours (9 P.M.). — One-ninth of a grain of pilocarpine in- 
 jected hypodermically ; within a minute the pulse was quickened, 
 and the patient said that she felt her heart beating faster, and as 
 if the blood were “ surging into her hands.” 
 
 9.4 P.M. — Palms of the hands are moist. 
 
 9.5 P.M. — Feels very sick, ice taken off. 
 
 9.8 P.M. — Hands and face are sweating well; the legs are 
 dry. The radial artery, dilated before the injection, is now 
 contracted. 
 
 9.15 P.M. — Face, arms, and body are sweating ; the legs are 
 moist. Urine §x., albumen J, more blood. Feels cold in spite 
 of hot bottles. T. 103°, P. 156 ? 
 
 9.30 P.M. — As the perspiration seemed to be going oft', one 
 tablespoonful of liquor ammonise acetatis was given in hot 
 water. 
 
 10.10 P.M. — Face and hands still wet with perspiration, the 
 legs are moist. 
 
 10.45 P.M. — Sweating all over ; has vomited once. T. 102.6°, 
 P. 150. 
 
 Midnight. — Sweating as before ; pulse weaker, vomited four 
 or five ounces of greenish fluid. Morphia one-sixth of a grain. 
 
 70 hours (9 A.M.). — Sweated all night. Pulse stronger. Urine 
 gviii., albumen J, less deposit and no blood. T. 100-4°, P. 140. 
 
74 
 
 AFTER TREATMENT. 
 
 82 hours (9 a.m.). — The skin has been moist all day. Urine 
 3 viii., albumen J. Feels very weak; pulse intermitting; digi- 
 talis. Ice to head to see if it would soothe and give sleep. 
 Morphia one-sixth of a grain. T. 100°, P. 136. 
 
 94 hours (9 a.m.). — Ice had to be taken off as it stopped the 
 perspiration. Liquor ammonise acetatis was given. 
 
 106 hours (9 p.m.). — Skin moist ; urine during the day Bxxvi., 
 albumen Has felt very weak all day, though rather better 
 than yesterday ; has had some tea and chicken jelly ; morphia 
 one-sixth of a grain. T. 100-8°, P. 128. 
 
 118 hours (9 A.M.). — A fair night, and feels decidedly better ; 
 urine 3 xvii., albumen yy ; liquor ammonise acetatis once during 
 the night ; the enemata are still retained. T. 100-2°, P. 124. 
 
 130 hours (9 p.m.). — A good day ; urine 3xxv., albumen 
 Has had almost no food by the mouth since the operation. 
 T. 100-4°, P. 120. 
 
 142 hours (9 A.M.). — Urine 3 xxii., albumen enemata 
 coming back, and are to be given every six hours. Is taking 
 a little chicken jelly, and equal parts of milk, water, and lime- 
 water. The bowels were moved with an injection. T. 98*8°, 
 P. 112. 
 
 154 hours (9 p.m.). — Enemata are to be stopped. Progress 
 was steady after this point ; the stitches were taken out on 
 the ninth day, and by the twentieth the urine was free from 
 albumen ; sp. gr. 1020. On the twenty -ninth day after the 
 operation the patient was able to take an eight hours’ railway 
 journey. It will be noted that morphia was given in small 
 doses in spite of the presence of albumen in the urine. 
 
 Tempekature. 
 
 It is seldom that the temperature reaches 102°, and if it 
 happen to do so it is usually for a short time only, and the 
 symptom does not require to be treated beyond keeping the 
 skin acting. Should it rise to 103°, rather more active treat- 
 
TEMPERA PURE. 
 
 75 
 
 ment will be called for. What is usually done is to apply cold 
 to some part of the body by passing a stream of iced water 
 through a coil fitting the head or lying on the abdomen. A less 
 cumbersome method is to fill thin sausage-shaped ice bags with 
 small pieces of ice, and place one on the head and one on each 
 side of the neck so as to reach the large blood vessels. 
 
 When the ice fails to bring down the temperature, 
 as in the following case, it will be necessary to apply cold 
 to the limbs and abdomen. In March 1886 a non -adherent 
 ovarian tumour was removed from a patient aged forty -five. 
 Progress was fairly satisfactory until forty-two hours after the 
 operation, when the temperature was 102*6°, and the pulse 130. 
 Ice bags were put on the head and neck at this time. 
 
 46 hours. — Has had fifteen grains of quinine by the mouth 
 in the past hour. T. 103*8°, P. 134. 
 
 47 hours. — Six minims of tincture of aconite. T. 104°. 
 
 48 hours. — T. 105°. 
 
 49 hours. — Feels as if she were being burnt up. In addition 
 to the ice bags, cloths wrung out of iced water were applied to 
 the legs, arms, and abdomen, and were changed every three or 
 four minutes. T. 106'1°, P. 142. 
 
 In half an hour the temperature had fallen to 103*8°, in 
 another half hour to 101*5°, and a quarter of an hour later the 
 temperature was 100*3°, and the pulse 118. The application of 
 the cold cloths was discontinued, the ice bags alone being left 
 on ; the temperature did not again attempt to rise, and the 
 patient made a rapid recovery. 
 
CHAPTER y. 
 
 THE PEPJTONEUM. 
 
 Peeitonitis. 
 
 By peritonitis is understood an inflammation of part or the 
 whole of the peritoneum. The causes of inflammation of the 
 peritoneum are very various. It may result during the course 
 of some acute disease, such as a fever, or the inflammation may 
 pass from the substance of an organ to its peritoneal surface. 
 It may also result as a complication in various diseased condi- 
 tions which we will have to consider later, such as a rupture of 
 the intestine, wounds of the bowel, inflammation and perforation 
 of the appendix, and malignant growths. It may spread from 
 the strangulation of a hernia or an intussusception, from an 
 abscess in the mesenteric glands, or tubercular disease may be 
 an exciting cause. * When none of these diseased conditions are 
 present, it may follow on a chill, and in this condition it re- 
 sembles inflammation in the other great serous cavity of the 
 body, the pleura. It is also described as being a part of puer- 
 peral septicaemia, and as a sequel to various operations on the 
 abdomen, but in both of these instances the condition is often 
 one of acute septic absorption, and the pathological changes do 
 not show much appearance of inflammation of the peritoneum. 
 We will take up here the idiopathic form of peritonitis, and 
 afterwards the tubercular. Inflammation of the peritoneum 
 due to surgical disease in the abdomen will be referred to when 
 these conditions are themselves treated of 
 
SYMPTOMS OF ACUTE PERITONITIS. 
 
 77 
 
 Idiopathic peritonitis is divided into the acute and the 
 chronic varieties. 
 
 Symptoms of Acute Pekitonitis. 
 
 The patient may have been in perfect health before the 
 commencement of the disease. It is ushered in sometimes by a 
 rigor, sometimes by a slight feeling of chilliness, and it is not un- 
 common to find that the patient has caught cold by sitting in a 
 draught, more especially if he has been fatigued and overheated. 
 The feeling of chill may be so slight that it is not noticed at the 
 time, and the first thing observed by the patient is a sudden and 
 acute attack of pain in the abdominal cavity. The pain may be 
 very severe, but it does not cause the symptoms of collapse 
 which are frequently seen when a rupture has taken place. 
 Very quickly the whole of the abdomen becomes tender to the 
 touch, the patient takes up the position which will give the 
 abdominal organs most room, and he draws up the thighs so as 
 to relax the abdominal muscles. Along with the pain and 
 tenderness there is fever, the temperature rising from 102° to 
 103°, and the pulse becomes rapid, wiry, and small. The 
 expression becomes anxious, the patient is terrified to move 
 or to take a long breath, he cannot bear any weight on the 
 abdomen, and is usually afraid when any one approaches or 
 touches the bed. The tongue is coated and dry, there is a 
 bad taste in the mouth, and, if the case progress badly, vomit- 
 ing comes on. 
 
 The patient may die simply from the severity of the 
 symptoms if the case be neglected ; at other times the disease 
 may resolve within three or four days, the temperature falls, the 
 pulse becomes less quick, the pain abates, the bowels move, and 
 the patient is quickly well without any bad results having been 
 left behind. 
 
 Between those two extremes there are some cases where 
 serous fluid is thrown out into the peritoneal cavity, in others 
 
78 
 
 THE PERITONEUM. 
 
 lymph is found without fluid. In pleurisy the fluid may become 
 purulent, and there may he a similar transformation in the case 
 of fluid thrown out by the peritoneum during an attack of 
 inflammation. This alteration in the character of the fluid is 
 always ushered in by a chill. If the pus be not enclosed within 
 a limited space by the formation of adhesions, the patient, 
 though eased sometimes from the very acute pain, rapidly 
 passes into a state of collapse and dies within a very short 
 time. The serous fluid which is thrown out may be quickly 
 reabsorbed, leaving no evidences of its presence. Lymph, on 
 the other hand, may leave its traces behind, as shown by the 
 presence of adhesions, and by the formation of hands between 
 one part of the abdominal contents and another. 
 
 Treatment . — This consists in keeping the patient quiet and 
 warm in bed, and in encouraging the action of the skin. A hot 
 bottle must be kept constantly to the feet, and the hands and arms 
 must be always kept under the bedclothes. It is useless to expect 
 that the patient can be kept safe from the contraction of a chill if 
 these two precautions be not followed. It is absolutely necessary 
 to keep the patient warm, and this is the only way to do it. 
 The abdomen is to he covered by a large fomentation or a 
 turpentine stupe, a poultice being too heavy, unless it is so 
 thin that it does not keep warm for a longer time than a foment- 
 ation, and it gives more trouble. Morphia is to he injected 
 hypodermically, the dose being regulated by the severity of the 
 pain, and it is better to give one-sixth of a grain, and repeat it 
 at a short interval if necessary, than to give a single large dose. 
 If the patient be seen at the very beginning, and if no flatus is 
 passing either naturally or through the rectal tube, then as soon 
 as the pain has been soothed by the morphia, white mixture — 
 sulphate and carbonate of magnesia with peppermint water — 
 should be given every two hours until the bowels move. If 
 this plan of treatment be adopted it must be pushed until the 
 bowels move, but it is to he employed only where nothing is 
 passing per anum. So long as any flatus is coming away there 
 
TREATMENT OE ACUTE PERITONITIS. 
 
 79 
 
 is no necessity to move the bowels until the acute attack is 
 passing off. It is better in those circumstances to give small 
 closes of morphia frequently, just so much as will keep the 
 patient comfortable without paralysing the peristaltic action of 
 the bowels. When the acute attack is over the bowels must be 
 moved by a large dose of castor-oil. 
 
 When vomiting comes on it will be accompanied by a 
 relaxed condition of the intestine, and no flatus will be passing 
 down. Under these circumstances the vomiting will be stopped 
 by treatment directed to favouring the downward passage of the 
 contents of the alimentary canal, and this will be done either 
 by the administration of medicine by the mouth or by medicinal 
 remedies introduced into the rectum. When the vomit has an 
 acid or sour taste the acidity of the stomach may be rectified by 
 giving one teaspoonful of bicarbonate of soda in a tumblerful of 
 very hot water. The effect of this will either be an attack of 
 vomiting which will clear out the stomach, or the soda will 
 remain down, neutralising the effects of the acidity, and often pass- 
 ing out of the stomach. Should the soda be vomited a dose of 
 white mixture is to be given ; should this come back a second 
 dose will probably stop down, and this is to be repeated every 
 two hours until the bowels move, the medicine being stopped as 
 soon as there is the slightest passage from the rectum. When 
 the soda keeps down and there is no peristaltic action going on, 
 six grains of quinine in solution are to be injected into the 
 rectum, and repeated every two hours until three doses have 
 been given. In some cases where the symptoms are very 
 urgent both the white mixture and the quinine may be given. 
 Whenever there is vomiting all fluid by the mouth must be com- 
 pletely stopped, and if the patient be very thirsty eight or ten 
 ounces of warm milk, or of milk and water, may be injected 
 into the rectum. So long as flatus is passing down fluids and 
 fluid food may be given by the mouth ; everything should be 
 hot — hot water, hot tea, hot gruel, hot bread and milk — these 
 are to be given in small quantities, and, with the exception of 
 
8o 
 
 THE PERITONEUM. 
 
 water, not more often than every four hours. When a patient 
 is lying in bed, kept warm, and well nursed, there is compara- 
 tively a small amount of waste going on in spite of the fever, 
 and as the inflammation is in close relation to the intestinal tract, 
 much food is likely to cause serious inconvenience and irritation, 
 for digestion is certain to go on slowly. When the tongue is 
 dry, showing a want of saliva, the food should be peptonised. 
 Stimulants will be required, or at least will be of service in 
 every case of acute peritonitis ; and the quantity and the 
 frequency with which whiskey or brandy is to be given will 
 depend entirely on the general condition of the patient, and 
 especially on the quality of the pulse. It is impossible to give 
 exact directions as to the amount, the only guide being the state 
 of the heart. It is as easy to do harm by over stimulation as it 
 is by giving too little. When the patient is very weak exact 
 directions must be given to the nurse at every visit of the 
 quantity which the patient is to have; that is to say, if the 
 patient is being seen frequently. If the quantity be left to the 
 nurse’s discretion, it is quite likely that she will give either too 
 little or will make the patient drunk. There is one sign, how- 
 ever, which may be given for her guidance : it is when the smell 
 of alcohol is noticed in the patient’s breath continuously too 
 much is being given, for it shows that the spirit is being 
 thrown off by the lungs. After a stimulant has been taken the 
 odour will remain in the breath for perhaps ten minutes, but if 
 it is still there at the end of twenty minutes the quantity must 
 be reduced. 
 
 During the acute attack the urine becomes diminished in 
 quantity and is concentrated. As the attack is passing off it 
 becomes loaded with lithates. Should there be any tendency 
 to suppression the patient must be sweated and dry cupped 
 over the loins and back. 
 
 Should there be during the progress of the acute attack a 
 sudden rigor followed by profuse clammy perspiration and 
 symptoms of collapse, we may feel certain that pus has either 
 
TREATMENT OF ACUTE PERITONITIS. 
 
 8i 
 
 formed in the abdominal cavity or that there has been some 
 escape of irritating fluid, due to a complication ; and the only 
 thing to do is to open the abdomen, wash out, and drain. The 
 chance of recovery under such circumstances must be always 
 extremely small, but if nothing be done the patient will almost 
 certainly die, and the operation adds little or nothing to his 
 dangerous condition. So long as the temperature does not 
 rise above 102*5° or 103° it is not of very great importance ; 
 should it get above 103° ice may be applied to the head and 
 neck. If along with the high temperature the patient is not 
 sweating, eight grains of phenacetine will almost invariably 
 bring down the temperature, and at the same time induce the 
 action of the skin, while it does not seem to cause any 
 depression. 
 
 When the patient is getting better the bowels must be 
 moved every second day with a dose of castor-oil or the infusion 
 of senna pods. The steady action of the bowels must always 
 be attended to, to prevent the formation of adhesions. The 
 abdomen is to be painted with iodine as soon as the skin has 
 recovered from the fomenting. This should be done every 
 second night if the skin will bear it, and may be continued for 
 three or four weeks. To prevent staining of the clothes a 
 broad flannel bandage must be worn, and by the time that the 
 application of the iodine is stopped the patient will be accus- 
 tomed to this belt. He must continue to wear it for at least 
 three months, and must not first leave it off during cold 
 weather. During convalescence the food must be of a non- 
 irritating character, it must be easily digestible, and a return 
 to ordinary diet must not be made too suddenly. The patient 
 must be warned that for a long time he will be liable to a 
 second attack ; he must therefore be careful to see that the 
 bowels act regularly, and that he avoids chills. It is a good 
 plan to encourage any one who has had an attack of peritonitis 
 to wear a warm bandage of some kind for the rest of his life. 
 
 A very acute attack of peritonitis may be mistaken for 
 
 6 
 
82 
 
 THE PERITONEUM. 
 
 appendicitis, or even for some form of intestinal obstruction. 
 The suddenness of the attack, the dilfuseness of the pain all 
 over the abdomen, combined with the elevation of the tempera- 
 ture, will be likely to differentiate this condition from that of 
 obstruction. Appendicitis resembles peritonitis more closely; 
 but in the former there is the localisation of the pain to the 
 right iliac region, a symptom almost always more or less 
 definite ; and, at the commencement, retraction of the abdomen 
 rather than a tendency to distension is seen. 
 
 Chronic Peritonitis. 
 
 The best example of chronic peritonitis is seen where a 
 cyst containing irritating fluid has ruptured into the peritoneal 
 cavity ; this accident is followed by an acute attack of inflam- 
 mation, and it leaves behind a chronic inflammatory condition 
 of the whole of the serous lining of the abdomen. After this 
 acute attack has passed off the patient does not complain of 
 much more than a feeling of discomfort in the abdomen, ac- 
 companied by flatulent distension, the temperature is little if 
 at all above normal, and the patient may feel in fairly good 
 health, especially when it is considered how much peritoneal 
 surface is in a state of irritation. 
 
 The free fluid in the abdomen, originally due to the contents 
 of the cyst, becomes increased in amount, and, when an opera- 
 tion is performed under such circumstances, the parietal peri- 
 toneum is found to be thickened, sometimes having the appear- 
 ance of cartilage, and it may be quite half an inch in thickness. 
 The peritoneum covering the intestine is swollen, rough, and 
 of a grey colour, with dull red patches appearing through the 
 greyness. 
 
 Chronic peritonitis may also follow an acute idiopathic attack, 
 a collection of fluid remaining free in the peritoneal cavity ; or, 
 as is more commonly the case, enclosed in a false sac resulting 
 from adhesions and the matting together of the intestine. 
 
CHRONIC PERITONITIS. 
 
 83 
 
 Symptoms . — The symptoms of an encysted collection of fluid 
 are sometimes by no means deflnite. There may be a history of 
 a previous attack of inflammation in the abdomen, as a result 
 of which some distension has remained, or there may not be 
 any such history. A collection of fluid of this nature is usually 
 found in the lower part of the abdomen ; fluctuation is to be 
 felt, and there is frequently a want of definition in the outline 
 of the swelling due to the close approximation of the intestine. 
 The presence of this adherent bowel gives a clear note on per- 
 cussion, closely surrounding the collection of fluid. Pelvic 
 examination may tend to increase the difficulties of diagnosis, 
 especially in the female, for the fluid may be situated in close 
 relation to the uterus and ovaries, or it may be entirely out of 
 reach. Such a fluid may become purulent, its character being 
 changed either as the result of a chill or of an injury, and it 
 will then resemble an empyema. When this alteration takes 
 place it is accompanied by a rigor or a feeling of chilliness 
 down the back ; the temperature usually rises, there is profuse 
 sweating, and if nothing be done the symptoms of hectic fever 
 come on. A very prominent symptom of suppuration, especi- 
 ally when the swelling is connected with the pelvis, is the 
 free passage of a mucous discharge from the rectum. This is 
 indeed almost a diagnostic sign of a suppurative collection of 
 fluid situated in Douglas’s pouch. 
 
 An encysted collection of fluid has been not uncommonly 
 mistaken for an ovarian tumour, and the differential diagnosis 
 may be one of great difficulty. In addition to the physical 
 examination we shall have to rely chiefly on the history, on 
 the swelling not increasing during menstruation, and on the 
 fact that the thinning of the body is either absent or general 
 in chronic peritonitis, while in the case of an ovarian tumour 
 it is more marked about the chest and arms. 
 
 Treatment . — The treatment of fluid remaining in the peri- 
 toneal cavity after an acute attack consists in rest in bed, in 
 keeping the body warm, in the administration of diuretics and 
 
84 
 
 THE PERITONEUM. 
 
 diaphoretics, with light food, and in painting the whole surface 
 of the abdomen with Churchill’s tincture of iodine. If the fluid 
 be encysted it should be withdrawn by very gentle suction of 
 the aspirator, the foregoing medicinal treatment being also 
 carried out. Should the fluid reaccumulate, or should it 
 become purulent, free incision and drainage is the only course 
 to pursue. 
 
 The Diagnosis of Ascites. 
 
 It is of very great importance that when there is any 
 suspicion of the presence of ascitic fluid the patient should 
 lie with the shoulders low, to allow the fluid to gravitate under- 
 neath the diaphragm, pushing it up and thus gaining more 
 room. The intestines are in this way able to float upwards, 
 and as the height to which they can rise is limited by the 
 mesentery, it is very important to get as much fluid as possible 
 out of the way, especially when the abdomen is much distended. 
 Percussion in the centre of the abdomen will give a clear note ; 
 in both flanks the note will be absolutely dull ; and as the 
 abdomen is percussed towards the middle line it will be found 
 that the note becomes more resonant. Turn the patient on 
 the right side and give the fluid a little time to settle into its 
 new position, and the situation of the clear note will have 
 altered ; in the middle line it may be quite dull, while in the 
 left side the note will be tympanitic ; repeat the experiment 
 by turning the patient on to the left side, and the dull note 
 previously observed on the right side will now have become 
 tympanitic. When a large amount of free fluid is present 
 fluctuation will be easily felt, and the larger the quantity the 
 more easily will this be made out. When the quantity of 
 fluid is so great that the intestine cannot float up to the sur- 
 face, the diagnosis may still be made by percussing deeply ; 
 but when the distension from this cause is enormous, it may 
 be impossible to be sure wliether the fluid is encysted or not. 
 Under such circumstances the size of the abdomen must be 
 
THE DIAGNOSIS OF ASCITES. 
 
 85 
 
 reduced by tapping. As the fluid flows away the intestines 
 will be found to float up against the parietal wall at the 
 highest point; and when the abdomen has been emptied the 
 presence or absence of a tumour can then be detected. 
 
 A patient forty-four years of age was admitted into the 
 Edinburgh Eoyal Infirmary late one night with an enormous 
 distension of the abdomen. She was unable to lie down, and 
 had to sleep propped up in a chair. Next morning, on examin- 
 ing the abdomen, it was found to be enormously distended, and 
 to be dull in every direction, no clear note being obtainable at 
 any point. The abdomen was therefore tapped, over 70 lbs. 
 by weight of fluid being removed; as it was drawn off per- 
 cussion at the highest level gave a tympanitic note, and when 
 all the fluid had been removed two semi-solid ovarian tumours 
 were discovered. At the operation, which was performed a few 
 days later, both of these tumours were found to be ruptured, and 
 the general peritoneum was in a state of chronic peritonitis. 
 
 The shape of the abdomen is a sign on which a considerable 
 amount of stress is laid ; it is usually described as being flatter, 
 more distended in the loins, and less pointed, than when a 
 solid or fluid tumour is present. This appearance is certainly 
 seen in all typical cases where there is a moderate amount of 
 distension ; but it is a sign on which too much stress must not 
 be laid, for in the case of a flaccid cyst, such as a tumour of the 
 broad ligament, the shape of the abdomen is very typical of the 
 presence of free fluid, although percussion will prevent such a 
 mistake being made. When the abdomen is very much dis- 
 tended the appearance and shape is exactly similar to what is 
 seen when a large tumour is present, and percussion may not be 
 able to give any assistance. 
 
 Ascites, the result of general disease, requires to be men- 
 tioned. The cases are due to some obstruction in the portal 
 system, or in the heart. Such cases as a rule belong to the 
 province of the physician, but tapping may be required to 
 give relief when medicines fail. 
 
86 
 
 THE PERITONEUM. 
 
 Tubercular Peritonitis. 
 
 It is evident that there is a considerable amount of doubt 
 about this condition of the peritoneum. Numbers of cases 
 have been related of a cure resulting after an operation and 
 while it is quite certain that some of these cases have been un- 
 doubtedly tubercular, others have evidently been simply cases of 
 chronic peritonitis. The peritoneum has been found covered 
 with small grey masses, and these have been at once called 
 miliary tubercules without further examination, although a 
 similar naked-eye appearance is seen when tubercular disease is 
 not present. Unless a microscopic examination have been made 
 of one of those so-called miliary tubercules, or of the fluid 
 which has been removed, it is impossible to pronounce with 
 certainty whether the disease is tubercular or not. This 
 disease of the peritoneum is more common in children, and the 
 fluid is usually encysted. Suppuration may occur as in ordinary 
 chronic peritonitis. Tubercular disease of the peritoneum is 
 not always accompanied by the presence of fluid, there may 
 simply be caseous masses without any effusion. The fluid 
 resembles that of a simple chronic peritonitis, except that it is 
 more turbid, and little white shreds of tissue are seen floating 
 about in it. 
 
 The method for the examination in this as well as in all 
 other diseases where tubercle bacilli are suspected is by staining 
 with fuchsin. Dr. K. W. Philip’s exact directions are as follows : 
 
 “ Place with a needle a small quantity of the deposit on a 
 cover-glass, and press a second cover-glass gently over it so as 
 to spread the fluid as a thin film. Separate the cover-glasses 
 by sliding them apart, and lay them (deposit upwards) on a 
 sheet of white paper. 
 
 “ Allow the cover-glasses to dry, or gently heat them, and 
 then, with the forceps, pass them three times slowly through the 
 flame of a spirit-lamp (to coagulate the film), taking care not to 
 char the film. Drop the cover-glass (deposit downwards) into a 
 
TUBERCULAR PERITONITIS. 
 
 - 87 
 
 watch-glass containing fuclisin solution. Heat gently until it 
 steams. After two minutes rinse cover-glass in water, and trans- 
 fer to methylene blue solution for one minute, and thereafter rinse 
 in water. If the film is quite blue it may be mounted ; but if 
 red colour remains replace cover-glass in methylene blue for a 
 moment. When the film is blue dry the upper surface of cover- 
 glass, and mount in Tarrant’s medium or glycerine. If balsam 
 be used the blue film must be dried before mounting. The 
 tubercle bacilli are stained red ; all other bacilli, cells, etc., are 
 stained blue.” 
 
 SOLUTIONS. 
 No. I. 
 
 Fuchsin ...... 
 
 Five per cent, solution of carbolic acid in dis- 
 
 1 part. 
 
 tilled water ..... 
 
 100 parts. 
 
 Absolute alcohol ..... 
 
 10 parts. 
 
 No. II. 
 
 Methylene blue ..... 
 
 Twenty-five per cent, solution of sulphuric 
 
 1 part. 
 
 acid in distilled water 
 
 100 parts. 
 
 Symptoms . — These may come on rapidly, but as a rule they 
 advance insidiously, and although the disease may be distinctly 
 chronic, it is more commonly subacute. Pains are complained 
 of in the abdomen, and diarrhoea may be a prominent symptom, 
 though this is most likely to be present when the disease is not 
 limited to the peritoneum but has spread more deeply into the 
 walls of the intestine. 
 
 The constitutional symptoms are those usually seen in 
 tuberculosis, and consist of sweating, evening rise of tempera- 
 ture, with general deterioration in health. The abdomen is 
 distended with fluid, either generally or in some localised 
 position, or it is drawn in, wliile some ill- defined masses can be 
 felt. In children the constitutional symptoms are naturally 
 more acute. The diagnosis resembles that of an ordinary case 
 
88 
 
 THE PERITONEUM. 
 
 of chronic peritonitis, with, in addition, the general symptoms 
 of tubercular disease. 
 
 Treatment . — The treatment will be divided into general and 
 local, and its exact nature will depend on whether fluid is present 
 or not. The general treatment will consist in improving the 
 state of the health, and will not differ from what is described for 
 tuberculosis in any other part of the body. This is all that can 
 be done for cases where caseating masses without any effusion 
 of fluid are present. When fluid is present it must be removed 
 by tapping, or by gentle suction if it be encysted. Incision and 
 drainage is usually recommended, and when the disease has 
 been discovered owing to a mistake in diagnosis this is the 
 proper course to pursue. When a diagnosis has been made it 
 is not necessary to open the abdomen, unless there be suppura- 
 tion, until withdrawal of the fluid by tapping has been tried and 
 has failed. When abdominal section is required the fluid may 
 be discovered either encysted in a more or less irregular cavity, 
 whose walls are formed of intestine, adhesions, and any organ in 
 the neighbourhood ; or the fluid may be free in the peritoneal 
 cavity, the peritoneum and intestines being more or less 
 covered with small grey sago -like tubercles. In neither of 
 these cases is it necessary to wash out the cavity ; drainage is 
 sufficient, and the tube is not to be removed until the fluid has 
 ceased, or almost ceased, to flow. More than twenty years ago 
 a boy eight years of age was tapped for a peritoneal effusion by 
 Dr. Keith. Over a gallon of slightly turbid serum, with large 
 numbers of little grey specks floating in it, was removed, and 
 when the deposit was examined microscopically distinct evidence 
 of tubercular disease was found. Permanent recovery followed 
 this slight operation, and the patient is now a strong and 
 healthy man. 
 
 When the fluid suppurates in an encysted cavity it is best 
 to be content with a simple incision and drainage, the wound 
 being closed as much as possible to lessen the risk of a subse- 
 quent ventral hernia. A large antiseptic and absorbent dressing 
 
THE PRESENCE OF FLUID. 
 
 89 
 
 will be required. This is a better plan than sponging or 
 washing out the cavity, as there would be a considerable risk of 
 injuring the adventitious cyst wall, either by making an opening 
 into the general peritoneal cavity, or by wounding the lining 
 surface, and thus allowing of the possibility of absorption taking 
 place. It is wonderful how quickly a cavity of this nature 
 closes up if efficient drainage be carried out from the lowest 
 part. The pressure of the abdominal wall and viscera evidently 
 assists in this rapid closing of the suppurating cavity. An 
 ordinary rubber tube is the proper form of drain to use ; a glass 
 one, unless in the lowest part of the pelvis, may press against 
 intestine and cause some injury. The practice of using gauze 
 instead of a drainage tube does not appear to possess any 
 advantage whatsoever, a strip or roll of gauze will certainly 
 drain the thin part of a discharge well enough, but a clot, for 
 example, is simply dammed back instead of being removed. 
 Packing with gauze after the method of Mikulicz does not 
 recommend itself. It also prevents the escape of the thicker 
 discharges, while at the same time it distends the cavity instead 
 of allowing it to contract ; besides, its removal may be a difficult, 
 dangerous, and extremely painful matter to the patient. 
 
 The after treatment does not present any special difference from 
 that of an ordinary abdominal operation in a debilitated subject. 
 
 We may sum up the operative treatment of tubercular disease 
 of the abdomen in this way ; when there is absence of fluid an 
 operation is not advisable ; when fluid is present it must be 
 removed by tapping ; should this fail to effect a cure, incision 
 and drainage should be resorted to ; when pus is known to be 
 present, or if it be discovered at a tapping, incision and drainage 
 is the proper course to pursue. 
 
 The Presence of Fluid without any Apparent PiEASON. 
 
 Under this peculiar heading will be described a condition 
 sometimes met with, usually in young women, where the 
 
90 
 
 THE PERITONEUM. 
 
 abdomen distends without any apparent reason, and where on 
 examination a quantity of ascitic fluid is found free in the 
 peritoneal cavity. No history will be obtainable to account for 
 the presence of this fluid. There is either no rise of temperature 
 at any time of the day or night, or there may be a slight 
 irregular elevation ; the pulse is not quickened, and the general 
 health is not much affected, unless the fluid has been allowed to 
 collect for a long time. Were it not for the absence of any rise 
 in temperature, and of any tubercular symptoms or history, 
 these cases would have been included under tubercular disease 
 of the abdomen, and, doubtless, cases are reported where this 
 erroneous conclusion has been adopted. 
 
 Treatment . — The symptom which calls for treatment is 
 simply the increasing size of the abdomen, and what is to 
 be done depends on the amount of fluid which is present. 
 If the quantity be small, estimated at a few pints, an 
 operation is not required ; if it be present in large amount 
 it must be removed by tapping. The appearance of the fluid 
 differs from that which is seen in a tubercular fluid; it is 
 clear, of a light yellow colour, and does not contain any of 
 the grey specks which have been previously referred to. We 
 have never had the opportunity of seeing the inside of an 
 abdomen under these circumstances ; but probably small grey 
 tubercle-like masses would be seen, exactly similar to what one 
 observes when an ovarian tumour complicated by the presence 
 of simple ascitic fluid is removed. It is this naked-eye appear- 
 ance which has doubtless misled many operators. AVhether 
 the case requires tapping or not, the patient must be put to bed, 
 kept warm, restricted almost entirely to a milk diet, given five 
 grains of iodide of potassium three times a day, and the whole 
 of the abdomen must be painted with Churchill’s tincture of 
 iodine. Every one of these cases which we have seen has been 
 permanently cured within six or eight weeks under this treat- 
 ment. It is equally certain that this condition can also be cured 
 by incision and drainage ; but we cannot advise an operation of 
 
HERNIA IN THE WALL. 
 
 91 
 
 this nature — a serious one to the patient, though not so to the 
 surgeon — unless the treatment recommended has not proved 
 efficacious. 
 
 Hernia in the Wall. 
 
 A hernia due to the stretching of an abdominal cicatrix is 
 unfortunately not very uncommon ; its frequency undoubtedly 
 depends on the manner in which an abdominal wound is closed, 
 and on the want of care in providing the patient with a properly 
 fitting and comfortable bandage. The way of suturing the wound 
 has already been minutely described ; but it may be repeated 
 that silk imperfectly purified, and stitches too tightly tied, are 
 the common causes of suppuration in the wound. To these 
 causes may be added the want of a sufficient number of stitches, 
 and in addition the failure to give support to the wound when 
 the stitches are removed, and when the scar is still in a soft 
 condition. The plan of suturing the abdominal wall in layers is 
 not necessary. A wound which can stand the test of time can 
 be made by interrupted stitches passing through the whole thick- 
 ness of the wall, placed at frequent intervals, about three to the 
 inch, and when the stitching is finished the skin edges should 
 be lying as evenly together as if the wound were on the face. It 
 has often been stated that a drainage tube weakens the abdominal 
 incision. We do not know of any evidence in support of this 
 statement, if the drainage tube has been used in the way and of 
 the size recommended by Dr. Keith. When used in the way he 
 has directed it is utterly impossible to tell whether a wound 
 has been drained or not a few days after the tube has been 
 removed. If the tube has been so large that stitches are required 
 to close the opening after it has been removed, or if Mikulicz’ 
 gauze-drain has been used, or if a strip of gauze has been pushed 
 in after a large-sized drainage tube has been removed, it is hardly 
 to be expected that a hernia will not result. The belt used after 
 every abdominal operation should be made of stout unstretchable 
 
92 
 
 THE PERITONEUM. 
 
 jean, and it must not be elastic, thougli this is often inserted to 
 save trouble in fitting. It is to be worn next the skin, and it 
 must be so carefully fitted that straps are not required to go 
 under the thighs. A woman can keep her stockings up by a 
 suspender attached to the belt, and this ought to be quite 
 sufficient to prevent it slipping up round the waist. It is 
 necessary to make the belt fit comfortably, for otherwise the 
 patient will discard it very much sooner than ought to be 
 done. 
 
 If a hernia be seen projecting through the scar it may be 
 prevented from getting worse by fixing to the inside of an 
 abdominal belt such as has been described a hollow distensible 
 pad of indiarubber. Large varieties of trusses have been made, 
 few of which answer the purpose for which they were intended 
 if the scar be a long one. When the belt or truss has failed to 
 keep the hernia from increasing in size an operation can be per- 
 formed if there be not too much gaping of the wall. In an 
 aggravated case it is impossible to bring the wall together 
 properly, and the amount of separation which can be rectified 
 will depend on the size and shape of the abdomen. It is 
 necessary to examine very carefully along the whole length of 
 the hernial opening on both sides, to make certain that the open- 
 ing can be firmly closed in its whole length before an operation 
 is undertaken. Probably the extreme limit of separation which 
 can be united will be about 3 inches, and it is useless to 
 begin the operation unless the whole thickness of the wall can 
 be brought together without much tension. 
 
 The preparations for the operation are similar to those 
 usually employed, and the operation itself consists in the 
 removal of the skin and peritoneum forming the sac, and the 
 refreshing of the edges of the deeper parts of the wound. The 
 stitches must be put in much more closely than usual if there 
 be tension, and the skin edges must be approximated with the 
 very greatest accuracy. When the stitches are removed at the 
 end of a week the abdomen must be thoroughly supported with 
 
TUMOURS IN THE WALL. 
 
 93 
 
 strips of sticking-plaster, which are to he kept on or renewed if 
 required for at least three months, and the patient is told that 
 the belt must be worn for at least two years. When there has 
 been a hernia at the umbilicus the diagnosis is very evident, 
 and the operative treatment consists in relieving the bowel if 
 strangulated, and making certain that the contents have been 
 passed back into the peritoneal cavity. The whole of the sac is 
 to be cut away, and the wound closed very carefully, additional 
 support after the operation being given by sticking-plaster. If 
 the bowel have become gangrenous an artificial opening can be 
 made ; or if the patient be in fairly good condition the divided 
 ends of the bowel can be stitched together after the gangrenous 
 tissue has been cut away ; or the ends may be closed and the 
 continuity of the gut restored by lateral anastomosis, as will be 
 described in the treatment of intussusception. When the 
 omentum has become gangrenous the whole of the injured part 
 must be removed, a chain of catgut or fine silk sutures being 
 used to prevent haemorrhage from the cut surface. 
 
 Abscess in the Wall. 
 
 Abscess situated in the substance of the abdominal wall, 
 unless owing to the improper stitching of an abdominal wound, 
 is a rare condition, but one which is occasionally met with. 
 The symptoms do not differ from those of an abscess elsewhere. 
 The whole wall of the abdomen may be infiltrated, it pits on 
 pressure, is painful, and the skin is red. 
 
 The diagnosis is very evident when the case has advanced 
 beyond the initial stages. The treatment consists in poultices, 
 and a free incision as soon as the presence of matter is detected. 
 
 Tumoues in the Wall. 
 
 Tumours of the abdominal wall are sometimes though rarely 
 met with. An enormous deposit of fat, as a part of a general 
 
94 
 
 THE PERITONEUM. 
 
 condition, is not uncommonly seen, and its presence has some- 
 times been taken for an abdominal tumour. The clear note 
 elicited on percussion ought always to prevent this mistake 
 from being made, but a very fat wall renders the diagnosis of 
 small abdominal tumours extremely difficult, and it is often 
 impossible to estimate the size of small growths in very fat 
 people. This was well seen in the case of a lady who was 
 suffering from malignant disease of the uterus; on vaginal 
 examination it was evident that the uterus was enlarged, but a 
 quantity of firm fat on the abdominal wall prevented any further 
 information from being obtained by bimanual examination. 
 During the progress of a vaginal hysterectomy it was found 
 that, in addition to the malignant disease and the enlarged 
 uterus, there was an old fibroid tumour fully 1 lb. in weight. 
 The growth was of such a size that an abdominal incision 
 was required to complete the operation. 
 
 Localised masses of fat or fatty tumours are sometimes seen 
 in the anterior abdominal wall, and when an operation is 
 necessary it does not differ from the removal of such growths 
 elsewhere. 
 
 Malignant tumours are met with growing in the wall. 
 These ought to be removed if the incisions can be made entirely 
 free of the disease, and if the amount of tissue to be removed is 
 not so great as will prevent the edges of the wound being 
 brought together. The following is an interesting case, showing 
 how much of the wall can be removed satisfactorily : — 
 
 A lady forty years of age was seen in the beginning of 1884 
 with a hard indurated and irregular tumour situated in the 
 abdominal wall above the umbilicus, and projecting from the 
 mass were two hard rounded nodules each about the size of a 
 turkey’s egg. These two nodules were red and angry-looking, 
 and several attacks of htemorrhage had been caused by their 
 rubbing together. The base of one of these was divided by the 
 thermo-cautery, and the tumour was examined by Professor 
 D. J. Hamilton. His report stated that the tumour was a round- 
 
TUMOURS BEHIND THE PERITONEUM. 
 
 95 
 
 celled sarcoma, and that its growth was certain to be very 
 rapid; the patient was therefore advised to have the whole 
 mass excised. This was done. The amount of wall taken 
 away measured 11 inches across and 8 inches from above 
 downwards, and part of the sheaths of the recti muscles had 
 to be removed ; the number of large arteries which had to be 
 tied was very great. The wound healed as usual by primary 
 union ; and now, nearly ten years after the operation, there has 
 not been any return of the growth. 
 
 Tumours behind the Peritoneum. 
 
 Excluding an abscess, and the very exceptional case where 
 an ovarian tumour has developed entirely behind the peritoneum, 
 retro -peritoneal growths are either sarcomata or lipomata. 
 Tumours in this situation are rare, and it is almost impossible to 
 make a diagnosis. They may grow to a very large size, may be 
 situated in any part of the abdomen, and they resemble tumours 
 connected with the organs near which they are situated. The 
 growths are either solid or semi-solid, and there is really nothing 
 to go on in making a diagnosis, for it is not likely that any two 
 of these tumours will resemble each other. 
 
 A lady fifty-four years of age was seen with a solid tumour, 
 which had grown within a few months, and which nearly filled 
 the abdomen. Percussion showed that the whole of the growth 
 was uncovered by intestine ; on vaginal examination the uterus 
 was found to be movable, and the tumour could be reached by 
 the examining finger. The patient had got thin, not only on 
 the upper part of the body, but generally, and there did not seem 
 to be any reason to suppose that the tumour was not an ovarian 
 one. The diagnosis was ovarian tumour, probably malignant. 
 At the operation, which was performed in the beginning of 
 August 1889, the tumour was found to be entirely situated be- 
 hind the peritoneum, and to have no connection with the uterus, 
 ovaries, or any other abdominal organ. The posterior layer of 
 
96 
 
 THE PERITONEUM. 
 
 the peritoneum was divided, and the tumour was enucleated 
 without very much difficulty from the surrounding cellular tissue. 
 Pathologically, the growth was found to be a sarcoma. The 
 patient made a rapid recovery, but within six months a second 
 tumour had appeared in the original situation ; nothing further 
 was attempted, and the patient died fourteen months after the 
 operation. 
 
 As we have never seen a lipoma growing behind the peri- 
 toneum, and as such cases are occasionally met with, the follow- 
 ing history of a tumour removed by Dr. Homans of Boston may 
 be given : — 
 
 “ On 8th August 1881 I saw Mrs. Y . I learned that she 
 
 liad always been well and strong, and had had several children. 
 Her father died at the age of sixty-six of cancer of the rectum, 
 and a brother had died of cancer of the liver. On examination 
 I found a large, fluctuating abdominal tumour, without impulse, 
 and containing solid masses. During the previous six months 
 it had grown rapidly. The umbilical girth was 41 inches. 
 I aspirated the tumour in many places where fluctuation seemed 
 most distinct, but got no fluid, not even blood. The abdominal 
 parietes in the pubic region were oedematous, and the lower 
 limbs had been so. Her complexion was somewhat sallow, but 
 had formerly been ruddy. 
 
 “ In March 1882, at her request, I operated at her home. 
 Her umbilical girth Avas now 53 inches, the oedema of 
 the abdominal wall was greater, and her lower limbs Avere much 
 swollen. The tumour Avas exposed by a long incision, and 
 appeared to be an immense lipoma. It had originated on the 
 right side behind the peritoneum, and as it greAV had pushed 
 the bowels before it. It Avas adherent to the peritoneum, from 
 which it was more or less neatly enucleated Avith free haemor- 
 rhage at times. The ascending colon crossed over it, and the 
 caecum, colon, and appendix caeci Avere almost incorporated in 
 the mass. The tumour dipped deeply into the pelvis, Avhich it 
 almost filled, and Avas at length, after considerable haemorrhage 
 
OMENTUM. 
 
 97 
 
 and much shock, removed. The operation lasted about an hour, 
 and the tumour weighed 35 lbs. She never rallied, and died 
 soon after being put to bed. 
 
 “ Dr. Gannet reported that the tumour was a pure lipoma.” 
 
 Cysts of the Urachus are met with so very rarely that 
 they may be classified as surgical curiosities. The presence of 
 such a cyst seems to indicate that there is some very abnormal 
 arrangement of the peritoneum, and occasionally there may be 
 a communication with the bladder. The treatment consists in 
 incision and drainage. 
 
 O 
 
 Omentum. 
 
 Tumours of the omentum are occasionally met with. Those 
 tumours connected with the omentum itself may be either cystic 
 or malignant. Some cases have been reported of cysts con- 
 nected more or less intimately with the omentum, but having 
 the structure of ovarian tumours though unattached to the 
 ovary. These growths on careful examination have always 
 turned out to be ovarian tumours which had lost their pelvic 
 connection by twisting and complete separation of the pedicle. 
 Quite a number of such cases have been reported, and on the 
 only one we have met with the ovarian pedicle could be dis- 
 tinctly seen as a tightly twisted cord. A cyst of this kind can- 
 not be classed as a tumour of the omentum. Cysts actually 
 springing from the omentum are usually of small size and of 
 slow growth ; the symptoms which they give rise to are slight ; 
 they consist in the presence of the tumour, and of a feeling of 
 dragging and discomfort about the epigastrium ; associated with 
 these there may be a certain amount of gastric disturbance if the 
 tumour be situated near the stomach. 
 
 Diagnosis . — The diagnosis will be made chiefly by exclusion. 
 A tense fluctuating tumour situated more or less in the middle line 
 of the abdomen, freely movable and changing its position as the 
 patient moves, with no pelvic connection, and in some cases 
 
 7 
 
98 
 
 THE PERITONEUM. 
 
 moving freely with the respiration, are the more evident signs of 
 the presence of such growths. 
 
 Treatment . — The treatment of omental cysts, when they are 
 giving rise to trouble, consists in their removal. An incision is 
 made over the centre of the growth, in the middle line, if possible, 
 the fluid is withdrawn, preferably wdth the aspirator, and the sac 
 wall is enucleated ; there is usually little difficulty in doing 
 this so long as care is taken to keep close to the cyst. Should 
 there be any difficulty in the enucleation, the puncture opening 
 may be enlarged, and the finger or hand in the interior of the 
 sac acts as a guide during the separation. While the sac is 
 being removed forceps should be put on to any bleeding vessels, 
 and these should be carefully secured with catgut ligatures 
 after the sac has been removed. If the omentum be very much 
 damaged during the enucleation it is better to remove it than 
 to run the risk of the possible formation of a haematocele in its 
 layers. A drainage tube is not likely to be required. 
 
 Hydatid Cysts. 
 
 In addition to these simple cysts of the omentum hydatid 
 disease may be met with, but it is rare. The signs and symptoms 
 resemble those of ordinary cysts, and the only positive diagnosis 
 is the examination of the fluid by the microscope, and the 
 discovery of the booklets. 
 
 Treatment . — The treatment will depend on the exact condition 
 of the omentum ; if a single cyst be present it must be enucleated ; 
 but if this be impossible it must either be stitched to the wall 
 and drained or the omentum must be removed. If the disease 
 be multiple, and the whole can be got rid of by removing the 
 omentum, a chain of ligatures is made above the disease and the 
 omentum below is divided. 
 
HYDATIDS OF THE PERITONEUM. 
 
 99 
 
 Hydatids of the Peritoneum. 
 
 It is probable that there is no such thing as primary hydatid 
 disease of the peritoneum, and that the condition when it is 
 met with has resulted from the rupture of a hydatid cyst in 
 some other organ, such as the liver. The following is an 
 account of a well-marked case of this kind operated upon by 
 Sir Spencer Wells : — 
 
 “The best marked case of hydatids of the peritoneum, as 
 distinguished from hydatid cysts of the liver, which I have 
 seen, was a woman in the Samaritan Hospital in 1870-1871. 
 
 “ The abdomen had all the appearance of a case of multilocular 
 ovarian cyst. Pluctuation was very distinct, but the chief 
 peculiarity of the case was the existence of numerous hard 
 nodules scattered over different parts of the abdominal wall. 
 They were evidently either attached to the abdominal wall or 
 formed part of it, and at first suggested the belief that they 
 must be scattered nodules of cancer. Some of the best marked of 
 these are shown on the drawing near the umbilicus. They were 
 quite as hard as nodules of hard cancer, and some of them being 
 semi-resonant gave rise to the fear that they might be formed 
 on the coat of intestine ; but the fact that the disease was of 
 about twelve years’ duration, that the patient had borne healthy 
 children during its progress, that she was not much emaciated, 
 did not suffer from sickness or diarrhoea, nor from much 
 abdominal pain nor tenderness, showed that cancer might be 
 almost certainly excluded from the diagnosis, even before 
 hydatid fremitus was noticed. This was most distinct, and the 
 diagnosis \fas completed by the puncture of one of the nodules 
 felt in the abdominal wall with a fine trocar. A little clear 
 fluid escaped, in which the booklets of the echinococcus were 
 distinctly seen. Ho very urgent symptoms being present, 
 nothing more was done, and the woman went home. She was 
 afterwards in the Middlesex Hospital under Dr. Murchison, who 
 also pointed out the hydatid fremitus to his class. She again 
 
lOO 
 
 THE PERITONEUM. 
 
 went home, and then, after further enlargement of the abdomen, 
 and some signs of chronic peritonitis, was readmitted into the 
 Samaritan Hospital, and I determined to attempt the removal 
 of the hydatids. After making an incision of 3 or 4 inches 
 in length in the median line below the umbilicus some 
 free peritoneal fluid escaped, with numbers of hydatid cysts of 
 various sizes, some quite free, but most of them having some 
 attachment to omentum or mesentery. Several groups of them 
 were removed with the attached portions of mesentery, a few 
 small mesenteric vessels requiring ligature. Between 3 or 
 4 lbs. of these hydatids, varying in size from a pea to a 
 small apple, were removed. Those in the abdominal wall could 
 not be separated, but 1 punctured several of the largest, 
 hundreds being still left undisturbed. The wound was closed 
 by suture. No bad symptom followed the operation ; on the 
 contrary, considerable relief was given. The patient went 
 home, but I have since ascertained that she died in December 
 1871. Some of the groups of hydatids were shown at the 
 Pathological Society by Dr. Murchison, and it was considered at 
 the meeting that this was the first instance in which an opera- 
 tion for the removal of peritoneal hydatids had ever been under- 
 taken after the diagnosis had been correctly made. 
 
 ‘'Although the origin in this case was not clear, it is extremely 
 probable that it was from the liver. Hydatid cysts of the liver 
 having given way, the dispersed progeny had gone on multi- 
 plying, and formed attachments in various parts of the 
 peritoneum.” 
 
 Mesenteeic Cysts. 
 
 Tumours growing in the mesentery are usually cystic, but 
 may occasionally be solid, and lipomata similar to those described 
 as retro-peritoneal may also be found in, or at the base of the 
 mesentery. Cystic tumours may be mistaken for a cystic growth 
 of any abdominal organ, more especially for cystic tumours of 
 the ovary, cysts of the kidney, or for hydatids. 
 
MESENTERIC CYSTS. 
 
 lOI 
 
 Symptoms . — The symptoms are those of a fluctuating tense 
 cyst, usually of slow growth ; when they are of small size they 
 may he covered by intestine, and are then more easy to diagnose 
 than when they are large and have pressed the intestines to 
 the side. These growths on account of their size cause incon- 
 venience rather than actual danger to life. The contents vary, 
 they may be filled with a somewhat opaque white fluid, or 
 with chyle, or if there should have been a hsemorrhage into 
 the sac almost any colour of fluid will be seen. 
 
 When a tumour which is diagnosed to be one of these 
 mesenteric cysts is discovered in the abdomen it is not necessary 
 to advise immediate operation ; they do not of necessity give 
 rise to any inconvenience so long as they are not very large, 
 and their rate of growth may be so slow that an operation can 
 be safely postponed until symptoms arise which render the 
 operation necessary. 
 
 Treatment . — This consists in enucleation, or, if this be found 
 to be impossible, the sac must be stitched to the abdominal 
 wall. Both these methods of treating a cyst are described under 
 ovariotomy. 
 
 The following case shows how slowly these tumours may in- 
 crease in size, and how little trouble they may give rise to unless 
 interfered with by operation. A patient twenty-seven years of 
 age was seen in May 1883. She complained of some dragging in 
 the left side, and she had discovered a swelling in that situation 
 about three months before. On examination a hard tumour, 
 about the size of a foetal head, was found in the left loin, but 
 too far forward to be mistaken for a typical tumour of the 
 kidney. The growth did not appear to have any connection 
 with the pelvis ; it was quite insensitive to the touch ; it was 
 considerably fixed, entirely covered by the intestine, and it was 
 difficult to say whether it was a solid growth or a tense cyst. 
 A fortnight later the tumour had become much more movable, 
 it could be pushed across the middle line, it felt more elastic, 
 and as if it contained fluid. 
 
102 
 
 THE PERITONEUM. 
 
 By February of the following year there had been no change 
 in the size of the growth. Owing to circumstances unconnected 
 with the case the patient was handed over to another surgeon, 
 who was at first inclined to think that the tumour was connected 
 with the uterus, but changed his diagnosis to that of a renal 
 tumour. The operation was begun under the belief that the 
 kidney would have to be removed, and the ureter was at once 
 divided. Unfortunately this was unnecessary, as the tumour 
 was found to be a cyst of the mesentery, and the kidney was 
 perfectly healthy. Both the kidney and the tumour were 
 enucleated, and the patient recovered after a long and serious 
 illness. 
 
CHAPTER VI. 
 
 THE STOMACH. 
 
 When we enter upon the consideration of the surgery of the 
 intestinal tract, we arrive at what is probably the most difficult 
 part of the surgery of the abdomen. As it is not possible to 
 say where the province of the physician ends and that of the 
 surgeon begins it is well, in difficult cases, and most are difficult, 
 for the two branches of the profession to work in unison, and 
 so to prevent either too prolonged medical treatment or too 
 early surgical interference. In most of the cases, especially if 
 we exclude the stomach, changes take place rapidly. A patient 
 considered to be doing fairly well may, within twenty-four hours, 
 be in a hopeless condition, and past all chance of successful 
 surgical interference. It is therefore necessary to see a patient 
 often, not leaving to the nurse the responsibility of sending if she 
 observe any change. 
 
 The great aim must be to differentiate early the cases which 
 require surgical help from those which do not. To operate 
 unnecessarily is to lessen greatly the chance of recovery; to 
 delay operation too long is a mistake fully as great. Every 
 precaution must be taken to enable us to come to a correct 
 diagnosis of the condition inside the abdominal cavity, for on 
 this naturally depends the line of treatment which will be 
 followed, and we must be prepared to revise the diagnosis, if 
 necessary, at every visit to the patient. The original line of 
 treatment is, however, to be steadily followed, unless a definite 
 
104 
 
 THE STOMACH 
 
 conclusion has been come to, that the diagnosis is wrong, or 
 that there has been a change in the local condition. In 
 attempting to come to a correct diagnosis a careful examination 
 of the history of the patient is of the greatest importance. Not 
 only is it necessary to obtain the precise history of the present 
 attack, but the investigation ought to go back over the whole 
 life of the patient as related to the abdomen. Attention must 
 be paid to any previous attack of abdominal pain which confined 
 the patient to bed ; to the state of the bowels, especially important 
 if usually confined ; to a history of typhoid fever ; and, although 
 it seems hardly necessary to mention that a hernia is a frequent 
 cause of intestinal obstruction, cases have been known where 
 this condition has been overlooked until a surgeon has been 
 called in. 
 
 Malignant disease is frequently found in connection with the 
 intestinal tract in such a position that although it is impossible 
 to remove the disease itself, it may be that life can be prolonged 
 or suffering alleviated by means of an operation. The surgeon 
 ought never to insist on any such interference ; all that it is his 
 duty to do is to explain to the patient that such an operation is 
 possible, while at the same time he clearly brings forward the 
 immediate risk to life. When this is done it is usual to find 
 that a patient who is weak does not desire to have his life 
 prolonged ; he is tired, and willing to go. On the other hand, 
 when the patient is fairly well and is suffering much, he is likely 
 to catch at the idea of anything which offers a fair prospect of 
 relieving him of his suffering. He probably does not wish to die, 
 and feels that life is still worth having if he can but obtain relief. 
 Thus it is that, in cases of cancer of the mouth or the anus, the 
 patient may be clamorous for operation, even although the disease 
 has spread beyond the possibility of a permanent cure. When 
 the disease is situated in the oesophagus, and the stricture has 
 become so complete that the patient is nearly dead from starva- 
 tion, he will likely reject all idea of an operation, the wish to 
 live having passed away. 
 
POSITION OF THE STOMACH 
 
 105 
 
 A number of operations have been performed on the stomach 
 and intestines, some curative, some palliative, and others which 
 may be looked upon somewhat in the light of surgical feats, 
 hardly as triumphs of surgery. According to their situation 
 they may be divided into two classes, those involving the 
 stomach and those having to do with the intestines. 
 
 The difficulty of diagnosis has been briefly referred to, and 
 a few words may now be said on the difficulty of exploring 
 the abdominal cavity after it has been opened. To any one 
 accustomed to perform operations on the abdomen the removal 
 of a simple growth, such as an ovarian tumour, is entered upon 
 with complete confidence ; it is otherwise when the operation is 
 begun for some abnormal condition of the intestinal tract, especi- 
 ally in the intestine. The risk is great, there is often considerable 
 doubt as to the exact diagnosis, and the actual difficulties to be 
 met with in the operation itself may be extreme. 
 
 If possible no one should begin his practice in the surgery 
 of the abdomen with such a case. Some lay great stress on 
 the advisability of operating on the dead body, and to those who 
 have had no surgical training this will be somewhat of a help, 
 though to the touch and the sight the difference is great in the 
 living and in the dead body. Here, as elsewhere, actual experi- 
 ence is clearly necessary before the highest excellence can be 
 reached ; and it is fortunate that this can be gained without at 
 once commencing on the most difficult class of operation. 
 
 Position of the Stomach. 
 
 It is not possible to describe definitely the exact position of 
 the stomach, for it is an organ which is constantly varying in 
 size, and which is only fixed, and that relatively, at one point, 
 viz. at its cardiac or oesophageal orifice. A point in front of 
 the seventh costal cartilage, rather more than one inch from its 
 junction with the sternum, indicates the position of the oeso- 
 phageal opening ; but even this although the most fixed point. 
 
io6 
 
 THE STOMACH 
 
 and more especially the position of the stomach itself, may be 
 materially altered by the pressure of surrounding organs, as well 
 as by new growths. Posteriorly, this opening is on a level with 
 the spinous process of the ninth dorsal vertebra. When com- 
 paratively empty about three-fourths of the bulk of the stomach 
 are situated vertically, the remaining fourth, towards the out- 
 let or pylorus, being placed horizontally. The surfaces look 
 anteriorly and posteriorly ; the borders are upper or right and 
 lower or left, — the former constituting the lesser, and the latter 
 the greater curvature. 
 
 Close to the pylorus there is a slight dilatation, termed the 
 antrum pylori. The pylorus or opening between the stomach 
 and duodenum is situated at the lower end of the stomach. It 
 is directed backwards, and varies much more in position than 
 the oesophageal or cardiac opening. When the stomach is 
 empty the pyloric orifice will be found about half an inch above 
 a horizontal line “ drawn around the body at a level correspond- 
 ing to the most dependent parts of the tenth costal arches ” 
 and ‘'about 4J inches below the lower end of the gladiolus” 
 (Cunningham). As the stomach distends its position alters, it 
 rotates on itself, so that the anterior surface, which bulges more 
 than the posterior, looks forwards and upwards, and the greater 
 curvature turns towards the front, while the pylorus moves 
 towards the right and becomes closely related to the neck of 
 the gall-bladder. 
 
 When the stomach is abnormal, either from a simple disten- 
 sion or when there is a tumour at the pylorus, this orifice may 
 be found at any part of the abdomen, even in the right iliac 
 region. 
 
 Unless the stomach is somewhat distended its anterior sur- 
 face is not in actual contact with the abdominal wall. As it 
 distends it abuts against the parietal peritoneum below the 
 ensiform cartilage, chiefly to the left, the space being bounded 
 by the edge of the ribs on the left side, and the liver on the 
 right, the lower margin, in average distension, being a transverse 
 
THE PERITONEUM. 
 
 107 
 
 line at the level of the junction of the ninth or tenth costal 
 cartilages with their ribs. To understand the surgery of the 
 stomach it is necessary to refer to its peritoneal relations, 
 especially with regard to the posterior surface of the organ, 
 and to the tranverse colon ; to the formation of the transverse 
 mesocolon, and the greater and lesser omenta. 
 
 The Peritoneum. 
 
 From the under surface of the diaphragm to the posterior 
 aspect of the liver the peritoneum is continued as the superior 
 and inferior layers of the coronary ligament of the liver; the 
 former may be traced over the convex surface of the liver to its 
 anterior free border, and from thence on the inferior surface as 
 far back as the transverse fissure ; the latter passes forwards on 
 the inferior surface of the liver to reach the transverse fissure. 
 Along the line of the transverse fissure these two layers come 
 into close contact with each other. From this point they 
 descend to the lesser curvature of the stomach as the gastro- 
 hepatic or small omentum, and having separated to enclose the 
 stomach they again come into intimate contact with each other 
 along the line of the greater curvature, forming the gastro- 
 splenic omentum or ligament in the interval between the stomach 
 and spleen. 
 
 From the great curvature of the stomach they may be traced 
 downwards in front of the transverse colon for a variable distance, 
 — in some cases extending as far as the brim of the pelvis. 
 Doubling backwards upon themselves they pass upwards to 
 meet and enclose the transverse colon, at the upper border of 
 which they again come into contact, but between them there 
 now lie the ramifications of the middle colic vessels, which carry 
 the peritoneum back to the posterior abdominal wall under the 
 name of the transverse mesocolon. Having reached the posterior 
 abdominal wall at the lower border of the pancreas the two 
 layers of the transverse mesocolon separate from each other. 
 
io8 
 
 THE STOMACH 
 
 One passes upwards in front of the body of the pancreas and 
 
 pancreas 
 
 duodenum - 
 
 rectum 
 
 symphysis 
 
 pubis. 
 
 Fig. 14.— Diagram to illustrate the Continuity of the Peritoneum in 
 THE Vertical Direction. (Cunniiigliam.) 
 
 the coeliac axis to reach the diaphragm and become continuous 
 with the inferior coronary ligament of the liver and so complete 
 
THE PERITONEUM. 
 
 09 
 
 the circuit of the small sac of the peritoneum. The other, or 
 lower layer of the transverse mesocolon, descends in front of the 
 third part of the duodenum, and the ramifications of the superior 
 mesenteric vessels, envelops the small intestine and returns 
 to the posterior abdominal wall upon the reverse side of the 
 superior mesenteric vessels, thereby forming the mesentery. 
 Once more this layer of peritoneum passes downwards, clothing 
 the posterior abdominal wall as far as the pelvic brim. Descend- 
 ing into the cavity of the pelvis it forms the mesorectum. 
 Having formed the recto-vaginal and utero-vesical pouches in 
 the female, or the recto-vesical pouch in the male, it reaches 
 the anterior abdominal wall, and continuing upwards to the 
 diaphragm the superior coronary ligament of the liver is reached 
 and the circuit of the great sac of the peritoneum completed. 
 The continuity between the cavities of the great and small sacs 
 is found at the foramen of Winslow, which is situated immedi- 
 ately posterior to the right free border of the small omentum. 
 That part of the peritoneum which is suspended from the 
 inferior border of the stomach is known as the Gastro-colic or 
 Great Omentum, and since it is doubled upon itself prior to 
 investing the transverse colon, it follows that below this part of 
 the colon the great omentum consists of four layers of peritoneum. 
 
 The blood supply of the stomach is derived from all the three 
 branches of the cceliac axis. The gastric or coronary artery runs 
 along the lesser curvature from left to right, giving off transverse 
 branches to both surfaces of the stomach, and anastomosing near 
 the pylorus with the pyloric branch of the hepatic artery. The 
 splenic artery gives off the vasa brevia arteries to the cardiac 
 end, and the gastro-epiploica sinistra to the greater curvature, 
 while the gastro-epiploica dextra, with which it forms an anasto- 
 mosis, is given off from the gastro-duodenal artery, a branch of 
 the hepatic. 
 
 The branches of the pneumogastric nerves can be seen on 
 the walls of the stomach, the left supplying the anterior surface 
 and the right the posterior. 
 
I lO 
 
 THE STOMACH 
 
 Numerous filaments from that part of the solar plexus which 
 surrounds the coeliac axis, viz. the coeliac plexus, are also to be 
 found on the stomach, carried thither by the arteries already 
 mentioned. 
 
 Before leaving the anatomy of this part of the abdomen the 
 gastro-hepatic or small omentum must again be referred to. 
 The right free border of this double layer of peritoneum forms 
 the anterior boundary of the foramen of Winslow. Between 
 these layers the portal vein, the hepatic artery, and the common 
 bile-duct are found, — the artery being in front and to the left 
 side, the common bile-duct in front and to the right side of 
 the vein which is between but on a plane posterior to both. 
 Behind the foramen of AVinslow is the vena cava inferior. 
 At this opening, therefore, it is not possible to do much surgi- 
 cally. 
 
 Opeeations. 
 
 The operations which can be performed on the stomach are 
 the following : — 
 
 Gastrostomy, or the formation of a fistulous opening between 
 the stomach and the outside of the abdomen, is performed when 
 food cannot pass through the oesophagus, the obstruction being 
 caused either by simple cicatricial contraction, from pressure 
 from the outside, or by malignant disease. 
 
 Gastrorraphy signifies the closure of an opening into the 
 stomach, which is the result either of an operation, of a wound, 
 or of ulcerative destruction. 
 
 Gastrotomy, or incision of the stomach, is performed for the 
 purpose of removing foreign bodies, or as a preliminary to the 
 forcible dilatation of a contracted oesophageal or pyloric orifice. 
 
 Gastrectomy means the excision of a part of the stomach. 
 
 Gastro-enterostomy is the operation which is performed 
 when it is necessary to make a fistulous opening between the 
 stomach and some part of the intestine. 
 
 Pylorectomy signifies the removal of the pylorus. The 
 
GASTROSTOMY. 
 
 1 1 1 
 
 last three operations will only be performed when there is 
 malignant disease either of the stomach or pylorus. 
 
 Loreta’s operation and pyloroplasty are performed when 
 there is a non-malignant stricture of the pylorus. The first 
 consists in stretching the contracted pyloric orifice, and the 
 second in dividing the stricture and stitching in the way which 
 will be described later. 
 
 None of these operations are performed frequently, and the 
 mortality overhead is very great. We do not need to go far to 
 seek the reason of this, for the majority of the operations are per- 
 formed for malignant disease ; and, as they are usually only palli- 
 ative, they are often and not unnaturally put off by the patients 
 as long as possible. 
 
 Gastrostomy. 
 
 Gastrostomy is the operation on the stomach which has been 
 performed with greatest frequency. The object of the operation 
 is to make an opening into the stomach after it has been fixed 
 to the abdominal wall for the purpose of introducing food when 
 the oesophagus has been closed by disease. If food cannot he 
 got into the stomach or small intestine it is impossible to keep a 
 patient alive, as rectal feeding always fails to support life for any 
 lengthened period. 
 
 The operation may be called for when the oesophagus is 
 closed by malignant disease, or by simple cicatricial contraction, 
 or when it is closed by pressure from the outside ; and it has 
 been performed for cancerous disease of the mouth and pharynx. 
 It is said that it might he performed for congenital obliteration 
 of the oesophagus, and if this were discovered it might he done ; 
 but whether the patient, if he or she survived, would he grateful, 
 is very doubtful. 
 
 Diagnosis . — The diagnosis of stricture is not a difficult one. The 
 first symptom which is noticed when there is malignant disease 
 may he local or general. The health may have begun to suffer 
 before any difficulty is felt in swallowing. As one would expect. 
 
I 12 
 
 THE STOMACH 
 
 it is solid food which first passes with difficulty into the stomach. 
 The patient finds that he has to be more careful in chewing 
 his food, or he gets into the way of cutting it into small pieces. 
 The difficulty increases, and after a time the patient has to give 
 up solid food entirely, and limits himself to fluids. These he 
 swallows less easily as time goes on, until finally nothing will 
 pass, and the patient then dies of starvation. Before this happens 
 other symptoms will have arisen ; food begins to regurgitate at 
 times, either immediately, or, if a pouch has formed above the 
 stricture, some time after it has been taken. It may be tinged 
 with blood, or mixed with mucus or with pus, and decomposition 
 will often render it most offensive. There is often great irritation 
 of the throat, accompanied by expectoration of mucus, discom- 
 fort in some part of the oesophagus, and sometimes pain between 
 the sternum and spine, especially near the seat of the disease. 
 The diagnosis is confirmed by the passage of a bougie, and by 
 auscultation of the oesophagus. In passing a bougie a soft 
 instrument ought always to be used, as the tissues may be 
 extremely soft and friable, and as any rough manipulation may 
 result in sudden death of the patient by rupture into a large 
 blood vessel The possibility of an aneurism must be excluded 
 by auscultation. When the head is thrown back, the average 
 distance from the incisor teeth to the entrance into the stomach 
 is about 14f inches, and it is not necessarily longer in a tall 
 man ; indeed, height does not seem to have any relation to 
 the length of the oesophagus. Some shreds of tissue may 
 come away with the bougie, and these may be examined 
 microscopically, though there is usually not much difficulty in 
 diagnosing between simple and malignant stricture. Ausculta- 
 tion of the oesophagus is a perfectly harmless method of diagnosis, 
 and gives as satisfactory, and indeed in some cases, more positive 
 results than are derived by the passage of a bougie. The 
 oesophagus is to be auscultated, in the upper part in front, as far 
 down as the sternum. To follow its course onwards to the 
 stomach the stethoscope must be placed on the back, to the left 
 
GASmOSTOMY. 
 
 113 
 
 of the spine and over the transverse processes of the vertebrae, 
 commencing at the second, and ending at the eighth or ninth 
 dorsal. One must be accustomed to recognise the normal sounds 
 made by the passage of fluid through the oesophagus, and atten- 
 tion must always be directed to endeavouring to ascertain what 
 is the usual time the fluid takes to reach the stomach. This is 
 done by placing the fingers of one hand on the thyroid cartilage 
 while listening behind ; the action of the thyroid will show when 
 the fluid starts, and the stethoscope when it has reached any 
 given point. There is a very appreciable length of time taken 
 for fluid to pass between the level of the thyroid and the lower 
 part of the oesophagus. It is not possible to describe in words 
 the sound which is conveyed to the ear in a healthy oesophagus ; 
 when there is a narrowing, one naturally expects to find the 
 sound lessened at that part ; or, if the stricture be complete or 
 nearly so, there will be sudden stoppage of the sound in an 
 abnormal position ; and in some cases it will be even heard to 
 ascend. Minor symptoms consist in general derangements of 
 the stomach and bowels ; flatulence and colic one would expect ; 
 there may be constipation, or a tendency to diarrhoea, or these 
 conditions may alternate. 
 
 There is not much difficulty in the diagnosis of simple 
 stricture ; the history of having swallowed some corrosive or 
 caustic fluid is all-important. This is followed, at a variable 
 length of time, by a gradually increasing difficulty in swallow- 
 ing. There is not so much likelihood of blood or mucus being 
 mixed with the regurgitated food, nor will the microscope show 
 any signs of malignant disease. In other respects the cancerous 
 and non-cancerous strictures resenable each other, except that 
 the cachexia in the latter is not so distinct ; starvation stares 
 the patient in the face in both. 
 
 Outside pressure is usually caused by an aneurism, — probably 
 situated in the left carotid or subclavian artery — or occasionally 
 by a malignant tumour in the neck ; but it is not likely that an 
 operation on the stomach will be called for, as the disease will 
 8 
 
THE STOMACH 
 
 114 
 
 either require other treatment, or the condition of the patient will 
 be such that an operation of this nature will be contra-indicated. 
 
 Treatment . — When considering the treatment one must take 
 into account the cause of the stricture, whether simple or malig- 
 nant, although it is evident that, whenever there is a complete 
 obstruction in the oesophagus, the only way to prolong life is to 
 make an artificial opening somewhere into the stomach or upper 
 part of the intestinal tract, and the stomach is the part that will be 
 chosen for this purpose. When the stricture is not malignant ; 
 when the block is caused by outside pressure ; when the patient 
 is unable to swallow solids, and there is so much difficulty with 
 fluids that he is not sufficiently nourished ; and, in addition, when 
 the treatment by the passage of bougies has failed to prevent 
 increasing contraction of the stricture — then there ought to be 
 no doubt as to the propriety of advising the formation of a 
 gastric fistula, and that without any further delay. When the 
 stricture is due to malignant disease it is impossible to give such 
 definite advice. The disease, be it remembered, is a progressively 
 fatal one; all that we can hope for is relief from death by 
 starvation and from pain and discomfort, by placing the diseased 
 part at rest. If the surgeon be of opinion that the case is a 
 suitable one for operation, he should not wait too long before 
 putting the matter before the patient. When he does bring the 
 subject forward it is not his duty to advise the operation, he 
 ought simply to inform the patient exactly what he has to 
 expect if nothing be done, and how much he may gain or lose 
 by having it performed. In any case the patient has not much 
 to lose, he is suffering and starving, and he knows that when he 
 is unable to take a sufficient quantity of food the end must soon 
 come, even if rectal feeding be carried out with the greatest care 
 and the most scrupulous attention to the selection of the most 
 suitable foods. 
 
 The mortality of the operation is high; this is due un- 
 doubtedly to the fact that it has often been performed too late, 
 and when the patient has been too much reduced by starvation ; 
 
GASTROSTOMY. 
 
 115 
 
 and also, it has frequently been performed by those unaccus- 
 tomed to abdominal work. Overhead the mortality may be 
 roughly put at betweeen 30 and 50 per cent ; but when the 
 operation is performed early enough, and skilfully, this death 
 rate ought to be very much reduced. Suppose the patient to 
 recover from the operation, how long is he likely to live ? If 
 very fortunate he may last out a year, and for at least part of 
 that time he may be in good health ; and, when the end does 
 come, it will come more easily. After these facts have been 
 clearly brought before the patient, and if he choose to run the 
 risk of dying after the operation, with the hope of living a little 
 longer than he would otherwise do, the surgeon is fully justified 
 in performing gastrostomy for malignant disease of the oesophagus. 
 This is, however, a matter of opinion, and the late Professor Spence 
 of Edinburgh wrote : “ To perform gastrostomy in such cases is, 
 I think, absurd, and would bring little credit to surgery.” 
 
 The operation may be performed in one stage or in two. 
 The stomach may be opened either at the time of operation, or 
 after adhesions have formed between it and the abdominal wall. 
 As the incision into the stomach itself is not painful, there is 
 no special advantage in opening the viscus at the time of the 
 operation ; nor is it necessary to wait until the adhesions are 
 very firm. Undoubtedly the proper time for making the open- 
 ing is when it becomes necessary to put food into the stomach. 
 In a very much debilitated subject this will be as soon as all 
 fear of sickness following the administration of the anaesthetic 
 is past, say towards the end of the first twenty-four hours. 
 
 When the patient is in fair condition, and when the strength 
 is well maintained by means of enemata, it is better not to 
 make the opening until the third or fourth day. The advan- 
 tage of waiting a few hours is, that lymph will have been thrown 
 out between the stomach wall and the parietal peritoneum, 
 thus lessening the possible risk of the escape of fluid into the 
 peritoneal cavity. 
 
 The preparation before the operation consists in moving the 
 
THE STOMACH 
 
 1 16 
 
 bowels by injection, and the thorough purification of the skin. 
 In this, and in all operations on the intestine, especially where 
 the patient is much run down, it is of the utmost importance to 
 avoid lowering the temperature. He should be warmly clad, 
 and the indiarubber sheet used in ovariotomy must be made 
 use of, as it not only prevents wetting, but keeps in the warmth. 
 The patient should also be surrounded by several hot bottles. 
 
 The more usual incision is one parallel to the ribs on the 
 left side. It must not be made too close to the costal margin, 
 but about one inch from it ; this is for the purpose of allowing 
 stretching of the wound. The incision should not be made so 
 short that manipulation is rendered difficult, as the time taken 
 in the performance of the operation would therefore be pro- 
 longed. It will probably be nearer three inches than two, and 
 its exact position will depend on the situation of the liver. As 
 the patient is usually emaciated there is no difficulty in mapping 
 out the lower edge of the left lobe of the liver in the epigastrium ; 
 this is fortunate, for the incision ought to commence slightly 
 below the edge of that organ, and be continued downwards and 
 outwards for the desired length. The incision is made in the 
 usual way, the straight line to the peritoneum being kept by 
 forceps. Some prefer to make a vertical incision through' the 
 left rectus muscle ; it is not of great importance which of those 
 two ways is chosen, though the former is, on the whole, the 
 more convenient. When the peritoneum is opened the stomach 
 will in all probability be out of sight behind the ribs, the 
 omentum or transverse colon being found presenting. The 
 stomach is reached either by drawing the omentum downwards, 
 or by passing the fingers underneath the left lobe of the liver, 
 crossing the spine, and there the lesser curvature is come on 
 immediately below the diaphragm. The organ is in this way 
 drawn forward into the wound, and the part which comes up 
 with least traction is fixed on for the opening. It does not 
 matter to which part of the parietal wound the stomach is 
 attached ; as a rule the upper part will be found to be the 
 
GASTROSTOMY. 
 
 117 
 
 nearest point, and where there will be least traction. As soon 
 as the point of opening in the stomach has been fixed on, a silk 
 stitch is passed through its two outer coats, taking a good grasp 
 of the wall; a loop is made of this, and it is used in future 
 manipulation. Various plans are adopted for fixing the stomach 
 to the wall, and here, as in intestinal surgery, too many sutures 
 are commonly used, and too little is left to nature. The principle 
 is to bring as large surfaces of peritoneum as possible into 
 apposition, and to do this by as few stitches as will keep the 
 surfaces at rest and prevent any leakage. As good a method as 
 any is that described in the chapter on ovariotomy for fixing an 
 irremovable sac to the abdominal wall. A round-pointed needle 
 threaded with silk is passed through the abdominal wall, so as 
 to leave a third of an inch or so of peritoneum free ; it then is 
 passed through the stomach wall in a direction parallel to the 
 wound, and excluding the mucous coat, for fully a quarter of an 
 inch ; then it is returned through the parietal wall. The ends 
 of the stitch are left loose until the others have been introduced. 
 Six stitches ought to be sufficient. Should the parietal wound 
 be too long it can now be closed ; this will probably be done 
 most conveniently at its lower end. 
 
 When it is definitely determined not to open the stomach 
 for five or six days, stitches may be altogether dispensed with. 
 The incision is made as before, the loop is put into the stomach 
 wall where the opening is to be, and then a harelip pin is 
 passed through the stomach, taking in the two outer coats for a 
 distance of from one half to one inch ; the direction of the needle 
 will be at right angles to the abdominal wound, and an inch or 
 so below the silk loop. A second pin is passed in the same way 
 as the first, but at an equal distance above the silk loop. The 
 ends of the needles are supported by the skin on both sides, and 
 in this way a considerable amount of the surface of the peritoneum 
 covering the stomach is brought against the peritoneum of the 
 abdominal wall. Below the ends of the needles a small piece 
 of soft dressing is placed, gauze soaked in glycerine and carbolic 
 
i8 
 
 THE STOMACH 
 
 acid being suitable ; and, to guard against all fear of accident, 
 the points of the pins may be broken off. 
 
 The one precaution that must be remembered when incising 
 the stomach is to be careful not to make a large opening. The 
 aperture may be made with a fine tenotomy knife ; as the 
 knife is withdrawn a probe should be passed into the opening, 
 as there may be difficulty in finding it at first, due to bulging 
 of the mucous membrane. A piece of a fine gum elastic 
 catheter, No. 6 or 8, is introduced, and four ounces of warm 
 peptonised milk are run through a funnel into the stomach. 
 The little difficulty of getting a funnel to fit is overcome by 
 fixing a piece of rubber tube to the end of the catheter, and it 
 is usually better not to remove the tube at first on account of 
 the difficulty with the mucous membrane. For the first few 
 days digestion must be made easy by having all food peptonised ; 
 at the end of a week this is no longer necessary. During the 
 first week, food, which ought always to be warm, is to be given 
 not more frequently than every four hours, and the quantities 
 will vary with the necessities of the patient ; as soon as possible 
 regular meals should be taken. No gastronomic pleasure is to 
 be obtained by food passed directly into the stomach, and 
 many attempts have been made to manufacture an artificial 
 oesophagus, so that the patient may masticate his food, and 
 then send it through the outside canal to the stomach. The 
 advantage is that the food is thus mixed with saliva, but in 
 actual practice, the apparatus is not found to work well, as the 
 patient unintentionally swallows some of the food, and this is 
 naturally followed by vomiting. The simple ingestion of food 
 into the stomach is followed by a profuse flow of saliva ; this 
 is always a great inconvenience, but it may sometimes be 
 alleviated by the administration of small doses of belladonna. 
 There is a tendency to protrusion through an abdominal wound 
 which has healed by granulation ; it is therefore well to keep 
 the scar as narrow as possible by drawing it together with a 
 long strip of sticking-plaster. The reason why it is advisable 
 
GASTROSTOMY. 
 
 119 
 
 to make the wound into the stomach as small as possible is to 
 prevent the escape of gastric juice. A little will often come 
 away, and it can be absorbed by a pad of wood-wool wadding, 
 or some similar material. The following case illustrates the 
 immense amount of suffering which might be entailed if this 
 precaution were not taken. A poor woman of thirty-nine years 
 of age was kicked in the stomach by her husband. The injury 
 was followed by the formation of a swelling in the upper part 
 of the abdomen. One day the skin ruptured, and a quantity 
 of pus was discharged. The opening became much smaller, 
 but never entirely closed, and when the first reliable informa- 
 tion was obtained there was a small fistula through which 
 milk could be seen at times to pass shortly after it had been 
 swallowed. The patient was in the Edinburgh Eoyal Infirmary 
 on several occasions, and under various physicians, and the 
 unanimous diagnosis seems to have been that of cancer. About 
 a year before the patient’s death the opening began to enlarge, 
 and when seen would admit the tip of the little finger. The 
 skin surrounding the wound was entirely destroyed, it had 
 been digested, and fluid flowed from the fistula almost as soon 
 as swallowed. This digestion of the skin was checked by the 
 local use of bicarbonate of soda. The opening enlarged, and 
 the patient eventually died of starvation. At the post mortem 
 examination it was found that the stomach was closely adherent 
 to the parietal wall round the fistulous opening, which was as 
 large as a shilling, and there was no evidence of cancer. The 
 case would have been a suitable one for an operation on the 
 stomach — that of gastrorraphy. 
 
 To avoid the risk of escape of gastric fluid, modifications of 
 the old operation have been devised, the principle being to 
 bring more of the stomach into the wound than is usual, and 
 thus make the opening at the end of a pucker or funnel. The 
 most satisfactory way of doing this is that described by Witzer. 
 
 A large amount of stomach is drawn out of the wound and 
 is packed round with gauze. A small incision about a quarter 
 
120 
 
 THE STOMACH 
 
 of an inch in length is made into the stomach near the lesser 
 curvature, and a rubber drainage tube thick enough to com- 
 pletely fill the opening is passed into it. A canal about two 
 inches in length is then made round the tube, whose lining 
 will consist of the peritoneal surface of the stomach. This 
 canal is made by drawing the stomach wall over the tube, and 
 stitching together the folds thus brought up. The excess of 
 stomach is returned into the abdomen and is stitched to the 
 parietal wall as usual. The tube is changed once every four 
 or six weeks. 
 
 Gastkoeraphy. 
 
 The next operation to be considered is that of closing an 
 opening in the wall of the stomach ; this may be called gastror- 
 raphy. It may be necessary to perform it for gastric fistula, 
 for gastric ulcer, or for penetrating wounds of the viscus. This 
 operation will never be frequently performed, for gastric fistula 
 is extremely rare, and it will not be often that one will have 
 an opportunity of operating for gastric ulcer, or for penetrating 
 wounds. 
 
 This operation is the most simple of any performed on the 
 stomach. Shortly before the anaesthetic is administered the 
 stomach is to be well washed out with a warm solution of 
 bicarbonate of soda, two drachms to the pint. The length of 
 the incision will depend on the thickness of the abdominal 
 wall, and will probably not be more than three inches. The 
 direction of the wound will vary with the position of the 
 fistula, and must be made in the most convenient situation, 
 without any regard to the usual direction of the abdominal 
 wound in stomach operations. The peritoneum is opened at 
 one side of the fistula, and with the finger in the abdominal 
 cavity as a guide, the incision is prolonged round both sides 
 of the skin opening, and also in the opposite direction to the 
 first part of the wound, so as to make the fistula the centre of 
 the incision. If there be much adhesion, it may be broken 
 
GASTRORI^AFHY. 
 
 I2I 
 
 down before the incision is made entirely through the abdominal 
 wall. The stomach is thus rendered completely free, and several 
 small sponges are packed into the abdominal cavity, in case 
 any gastric fluid should escape during the stitching. The 
 edges of the opening into the stomach are next to be pared, 
 as small a quantity of the wall being excised as is consistent 
 with removing all cicatricial tissue, and making the opening 
 into a long-shaped oval. Various methods of stitching have 
 been employed in bringing together wounds of the stomach, 
 and also of the intestine; the exact details of these different 
 ways are not of extreme importance so long as the general 
 principle of bringing two peritoneal surfaces into apposition 
 is clearly understood and carried out. There must be no doubt 
 about this. A wound of the stomach or bowel must be brought 
 together in a totally different way from a cut through the 
 skin ; the peritoneal edges must be doubled in, for otherwise 
 there is not likely to be union. 
 
 For a wound of this kind in the stomach a continuous suture 
 is to be recommended. A piece of fine silk, which has been 
 thoroughly purified, is to be threaded on an ordinary sewing- 
 needle thick enough to allow the double thread at the eye to 
 pass through the tissues without bruising. The stitching is 
 begun at least a quarter of an inch beyond one end of the 
 opening, and particular care is taken to avoid the inclusion of 
 the mucous membrane. The first stitch makes a pucker of the 
 peritoneum, and is tied. The peritoneum is then picked up 
 on one side, and a little nearer the cut on the other, to make 
 the second stitch ; the next will probably begin to draw the 
 cut edges together, the needle being inserted about a quarter 
 of an inch or rather less from the cut edge, and brought out 
 nearly at the edge on one side ; on the other side the direction 
 is reversed, the needle is inserted close to the edge, and brought 
 out a quarter of an inch away from it. This is in principle, 
 though not actually, the Lernbert mode of stitching. It then 
 zigzags in this way across the whole length of the wound, and 
 
122 
 
 THE STOMACH 
 
 finishes as it began, a quarter of an inch beyond the end of 
 the opening. Somewhere about eight stitches are required to 
 the inch; the peritoneal surfaces are drawn together as the 
 stitching is gone on with, and every care must be taken against 
 drawing the surfaces too tightly together. Additional stitches 
 
 may be required if there seem to be any weakness at any 
 point; these may be interrupted ones, and are also passed so 
 as to double in the peritoneum; or a second doubling in of 
 the peritoneum may be effected by another continuous row of 
 stitches. Some prefer to use the interrupted sutures entirely ; 
 the principle is exactly the same, the peritoneum being turned 
 
 in, and the mucous membrane excluded from the loop. A 
 large number of the sewing-needles must be threaded before- 
 hand to avoid waste of time. At each end of the wound or 
 opening a couple of sutures are introduced beyond the ends 
 of the cut to commence the turning in of the peritoneum. 
 
 If the opening be a short one a stitch should be put in at 
 the middle, so as to be more certain that the sides come accur- 
 ately together; if the opening be large other stitches may be 
 passed through the centre of each half. The needle is intro- 
 duced a quarter of an inch or so from the wmund, and is 
 
GASTRORjRAFHY. 
 
 123 
 
 brought out close to the edge on the same side ; on the other 
 side it enters close to the edge and comes out a quarter of an 
 inch or so away from it ; the interrupted method of suturing 
 does not therefore differ in principle from the continuous. All 
 stitches are introduced before any are tied. When they have 
 been secured an additional row of stitches may appear to be 
 necessary. 
 
 The sponges are withdrawn from the abdominal cavity, and 
 the parietal wall is closed. 'No fluid or food of any description 
 should be introduced into the stomach soon after the operation ; 
 the strength of the patient can be easily kept up for four or 
 flve days by the use of enemata, and by that time the wound 
 in the stomach wall will be firmly united. A small cupful of 
 tea may be given on the fourth or fifth day, to be followed by 
 the same quantity of milk, chicken soup, or well-boiled thin 
 gruel ; and whatever food is given should be peptonised for 
 the next fortnight, the nutrient enemata being continued if 
 required once or twice a day. The bowels should be moved by 
 injection for the first fortnight. 
 
 It might be possible to close successfully a rupture of the 
 stomach caused by a gastric ulcer. It cannot be expected that 
 such an operation will ever be frequently performed ; but it 
 might be justifiable in a case where a patient has been known 
 to suffer from dyspeptic symptoms, with limited or localised 
 pain in the region of the stomach, with perhaps attacks of 
 haematemesis, and followed by sudden and severe abdominal pain 
 and collapse. A gastric ulcer may, however, cause rupture of the 
 stomach without any previous symptoms. The most common 
 seat of an ulcer in the stomach is near the lesser curvature, more 
 usually towards the pyloric than the cardiac orifice ; but it may 
 be found either in the anterior or posterior wall, and, from the 
 operation point of view, the former situation is much more satis- 
 factory, though not so common. The same incision will be used 
 as for gastrostomy, and if the opening in the stomach be not 
 easily found the external wound must be enlarged. When the 
 
124 
 
 THE STOMACH 
 
 ulceration has been on the anterior surface, the contents of the 
 stomach will have passed into the general peritoneal cavity. 
 They must be soaked up at at once, and as soon as the opening 
 has been found and temporarily closed with the finger and 
 thumb to prevent the escape of more fluid, the abdominal cavity 
 is to be thoroughly washed out with warm water. The opening 
 in the stomach is enlarged, if necessary, to show the size of the 
 ulcer and the amount of stomach wall which it will be necessary 
 to remove. This must be done in the transverse axis of the 
 organ, so that the wound when closed will be in the same direc- 
 tion. In a case such as this, where the patient is collapsed, the 
 rapidity with which the continuous suture can be introduced 
 Avill be likely to add much to the success of the operation. The 
 abdomen is again washed out, if there be any fear that this has 
 not been thoroughly done, and the cavity is made dry before the 
 parietal wound is closed. When no extravasation of food is to 
 be seen on opening the peritoneal cavity the anterior layer of 
 the omentum must be divided, and this should be done rather 
 towards the right side on account of the more usual situation of 
 the ulceration. Should the stomach contents be now seen, it is 
 evident that the ulcer has penetrated through the posterior sur- 
 face of the stomach, and the opening into the omentum is to be 
 enlarged by tearing. The posterior surface of the viscus can 
 now be reached, and the opening must be searched for. When 
 it is found, and with care this can, in all probability, be done in 
 every case, the opening is to be closed after the contents of the 
 stomach in the lesser peritoneal cavity have been sponged up. 
 
 Stitching may be extremely difficult, it may indeed be 
 impossible on the living subject. In such a case it has been 
 suggested that the stomach might be opened in front, and the 
 posterior opening be closed from the inside, the anterior open- 
 ing being afterwards closed as usual. This procedure would at 
 least give the patient a chance of recovery. Washing out the 
 peritoneum with warm water must be carried out in every case. 
 In regard to penetrating wounds, nothing need be said beyond 
 
GASTROTOMY. 
 
 125 
 
 what has gone before, except that the operation will be of the 
 nature of an exploratory one, unless food is found to be passing 
 through the external wound. 
 
 Gasteotomy. 
 
 The third operation on the stomach is that of gastrotomy ; 
 this signifies the opening of the stomach itself, and not simply 
 the incision of the abdominal wall. 
 
 It is performed for the removal of foreign bodies from the 
 stomach, from the lower part of the oesophagus, and as a pre- 
 liminary to the stretching of the pylorus, or the lower end of the 
 oesophagus. For practical purposes it may be taken that the 
 cardiac and pyloric openings of the stomach are of equal size, 
 and that a substance that can pass into the stomach can also 
 pass out of it. One reservation must be made, however : it is 
 this, that a long rigid article, as a fork or spoon, may get into 
 the stomach and not be able to pass out ; or such a thing as a 
 set of teeth, when it has hooks, may pass the oesophagus and 
 become caught at the pylorus. To avoid this latter accident, 
 when such a set of teeth has been swallowed, a reel of white 
 cotton may be taken, and the whole thickness of the thread 
 divided transversely to its axis, so as to form numerous short 
 lengths. These threads are mixed up with pudding or gruel, or 
 some such food, and swallowed; the threads wind themselves 
 round the teeth and cover the hooks. 
 
 Two cases are on record where a solid cake of hair has been 
 removed from the stomach ; in one the mass weighed 2 lbs., 
 and the patient confessed that she had been in the habit of 
 eating the combings from her hair. These had become matted 
 together into a solid mass by the help of thick viscid mucus. 
 There is a considerable risk in leaving a foreign body in the 
 stomach ; if it be long there, it must of necessity press against 
 the interior of the organ as it contracts, and ulceration is likely 
 to follow, if the patient do not die in the meantime of the dis- 
 
126 
 
 THE STOMACH 
 
 tressing symptoms which arise. At first the patient feels sick, 
 and there is a constant feeling of distress in the epigastrium ; 
 then follows pain, worse at one time than at others, and not 
 referred to one spot, hut more or less general, over the upper 
 part of the abdomen, or in the bowels. Movements increase the 
 pain, or may bring on a paroxysm ; the patient avoids deep 
 breathing, the downward movement of the diaphragm pressing 
 on the stomach. There is loss of appetite, with general dyspeptic 
 symptoms, though the taking of food often gives relief for the 
 time. All these symptoms become aggravated as time goes on, 
 and eventually the general health breaks down. The patient 
 becomes pinched and thin ; there is vomiting, which often 
 sets up terrible paroxysms of pain ; there may be blood in the 
 vomit and at last the patient dies in great agony of starvation. 
 Symptoms ought not to he allowed to go on so far, when there is 
 a history of something having been swallowed, or when a swell- 
 ing can he felt in the region of the stomach ; and when the 
 symptoms are evidently not due to malignant disease, gastro- 
 tomy ought to be performed. One occasionally meets with 
 hysterical women, who give a history of having swallowed a 
 foreign body, but in such cases the symptoms are not likely to 
 be so severe as to make one believe the story. The irritation 
 of the foreign body may give rise to inflammation, and to the 
 formation of adhesions between the stomach and the parietes, 
 or other viscus, and the substance may be extruded through a 
 fistulous opening : should the opening be, unfortunately, not a 
 fistula, death will very quickly ensue. 
 
 With the idea of facilitating the performance of the operation 
 it has been suggested that the stomach be distended, and this has 
 been carried out by different means and in various ways. The 
 most simple and safe way would be to distend the stomach with 
 hydrogen gas ; other plans, such as distension with ether vapour, 
 or by pouring into the stomach a solution of bicarbonate of soda, 
 followed by one of tartaric acid, have been suggested and carried 
 out. The advantages of distending the stomach are extremely 
 
GASTROTOMY. 
 
 127 
 
 small, and consist practically in bringing the viscus up to the 
 abdominal wound, while the disadvantages are considerable : 
 the contents of the stomach, unless they consist of hydrogen gas 
 alone, may injure the peritoneum ; and in any case the pro- 
 cedure is disagreeable to the patient, unless done after he is 
 anaesthetised, it being easy to pass a tube through the nostril 
 when the patient is unconscious. A disadvantage of distension 
 is said to be that it is more difficult to reach the foreign body, but 
 as the stomach will empty itself as soon as it is opened, this 
 need not be considered. The best plan is simply to wash out 
 the stomach before the anaesthetic is given with a solution of 
 bicarbonate of soda, which must be all carefully withdrawn, as 
 the retention of any fluid is likely to give rise to vomiting. The 
 incision parallel to the costal margin on the left side is the 
 most convenient. The stomach is reached in the way already 
 described, it is drawn forward into the wound, and before it is 
 opened, sponges are carefully packed all round to protect the 
 peritoneal cavity. With the stomach contracted, there is not 
 likely to be much difficulty in feeling the foreign body, and 
 great care must be used especially if it is known to be sharp. 
 The opening into the stomach is made in a transverse direction, 
 and at the spot which seems most convenient for the extraction 
 of the fork or whatever object may be present. The point of 
 opening having been fixed upon, the stomach is grasped on one 
 side by the finger and thumb of the operator, and on the other 
 side by the assistant, and the coats are divided by scissors. The 
 peritoneal edges of the wound are fixed by the pedicle forceps, 
 and the wound is thus kept forward by the assistant. The 
 finger is introduced to make sure that the foreign body has not 
 become attached in any way, and to guide the forceps in its 
 extraction. After it has been removed the stomach does not 
 require to be sponged out unless there be any indication for 
 doing so, as it is better to avoid interfering with an already 
 much irritated mucous surface. If the sponges have got wet 
 they are now to be removed, and dry ones again put into the 
 
128 
 
 THE STOMACH 
 
 peritoneal cavity. The opening into the stomach is closed in 
 the manner described in the previous operation of gastrorraphy 
 the sponges are removed, and the parietal wound is closed as 
 usual, a drainage tube not being required. The after treatment 
 has already been described. 
 
 When a foreign body has become fixed in the lower part of 
 the oesophagus, and has resisted every attempt to push it on- 
 wards with bougies, and where the block appears to be too low 
 down for a successful result by opening the oesophagus, the only 
 thing which can be done is to attempt to clear away the obstruc- 
 tion by operating through the stomach. The operation has been 
 such a rare one that we cannot do better than reproduce Dr. 
 Eichardson’s account of the first successful case. 
 
 “The patient, a man aged thirty - seven, tall and strong, 
 weighing when in health from 160 lbs. to 180 lbs., had swallowed, 
 while eating, a denture of four teeth. The teeth were lodged 
 near the cardiac end of the oesophagus. He was admitted to 
 the hospital, and numerous attempts were made to dislodge 
 them. At one time sufficient traction was used to break the 
 coin probang which had been made fast to the plate. He was 
 finally discharged from the hospital, having gained in weight, 
 and it was thought the foreign body had passed into the 
 stomach. Eleven months after the accident the man came 
 again to the hospital, and the foreign body was found to be 
 in the same place as before, fourteen inches from the central 
 incisors. The patient was reduced to 113 lbs. in weight. He 
 had continual pain, and it was with great difficulty that he 
 was able to swallow enough liquid food to keep him alive. 
 There were two methods of procedure possible, all attempts 
 at removal through the mouth having failed : one by external 
 cesophagotomy, in the manner described by Dr. Leroy Maclean 
 of Troy, and so successfully performed by him ; and the other 
 through the abdominal wall and stomach. I selected the 
 latter method because it had been shown that the plate was 
 very firmly impacted indeed, and that it was very probable that 
 
GASTROTOMY. 
 
 129 
 
 it would be necessary to use the fingers in dislodging it. For two 
 days before the operation the patient was nourished by enemata, 
 and nothing was taken into the stomach but water and stimulants. 
 After etherisation a cut was made parallel to the lower margin 
 of the ribs on the left side, six inches in length, through wdiich 
 the stomach was drawn and held on aseptic towels by assist- 
 ants. A small opening through the stomach wall was next 
 made midway between the curvatures, and forceps introduced 
 for the purpose of grasping the plates. The cardiac opening 
 could not be found. The cut was then enlarged enough to 
 admit the right hand, which was introduced until the oeso- 
 phageal opening was found. The foreign body was detected by 
 the fingers about two inches above the diaphragm ; after con- 
 siderable manipulation with the index and middle fingers the 
 plate was detached and removed. The mucous membrane of 
 the stomach was closed with a continuous silk suture, after the 
 method of Lembert. The patient made a good recovery.” 
 
 Location of the foreign body {or condition reciuiring opera- 
 tion ). — If it is known how far the obstruction is from the 
 central incisors when the head is thrown back, in the position 
 for passing the exploring probang, and if the distance from the 
 same point to the cardiac opening is determined, it is evident 
 that we can tell immediately whether the obstruction can be 
 reached from below or not. If the individual is of average 
 height, and with a neck of ordinary length, it is safe to say that 
 the distance from the central incisors to the diaphragm is about 
 fourteen inches and a half. If the probang is arrested at a 
 point more than thirteen inches from the incisors, the point of 
 obstruction is probably at or near the cardiac end of the oeso- 
 phagus. In all subjects examined this fact was observed ; in 
 some of them it was quite difficult to reach every part, but it was 
 nevertheless possible. The method of making these observations 
 was to do first an external oesophagotomy in the usual way. 
 Then the stomach was opened and the fingers of the left hand 
 introduced into the cardiac opening. With the forefinger of the 
 9 
 
130 
 
 THE STOMACH 
 
 right hand in the upper wound and the forefinger and middle 
 finger of the left hand in the lower end of the oesophagus, it 
 was found possible not only to make the fingers touch, but in 
 many cases to make them overlap quite a distance ; coins 
 and other bodies were passed from one hand to the other with 
 ^ great ease. 
 
 It cannot be denied that these conditions of observation 
 cannot be reproduced on the living subject, and that the results 
 are only approximate. It would be hardly practicable to do 
 both operations on the same patient. If both hands are in use, 
 pushing towards each other, it is of course much easier to bring 
 the fingers together and to push the foreign body from one 
 finger to the other waiting to receive it. 
 
 Yet even in the living I think it is safe to say that there is 
 no point in the oesophagus that cannot be reached by the finger, 
 either from above or below. The other source of error is in the 
 fact that in the cadaver the diaphragm is relaxed. This does 
 not make any appreciable difference, however, because the 
 opening in the diaphragm is so fixed to the bodies of the 
 vertebrse that it does not share to any extent in the contraction 
 of that muscle. It is possible to reach with the left hand three 
 inches above the cardiac opening, that is to say, the length of 
 the left middle finger. From above, through the wound in the 
 neck, one cannot reach quite so far on account of the sternum 
 and clavicle. One can, however, easily reach the arch of the 
 aorta, and even hook the finger round it in some cases. In a 
 few of the dissections the measurement was made between the 
 centre of the incision in the neck to the diaphragm. The dis- 
 tance was a little over six inches. Allowing in the average neck 
 an inch and a half to two inches from the cricoid cartilage to 
 the lower point of the incision in the oesophagus, in external 
 cesophagotomy we have the average distance from that incision 
 to the cardiac opening of five and a half to six inches. The 
 general conclusion at which I have arrived from these measure- 
 
 O 
 
 ments and digital explorations is that the obstruction can be 
 
GASTROTOMY. 
 
 13 
 
 reached by the finger in all or nearly all cases where it is situated 
 more than six inches below the cricoid cartilage. If less than 
 six inches below the cricoid ring, it can be reached best from 
 above, though in some few cases it may be just beyond the reach 
 of the finger. Even in these cases instruments can be easily 
 and intelligently applied. The measurements of the point of 
 inspection or obstruction having been carefully made, and it 
 having been demonstrated that the point in the oesophagus to be 
 reached if necessary by the finger is not less than thirteen inches 
 from the upper incisors and six from the cricoid cartilage, the 
 operation of gastrotomy should be performed. 
 
 Inasmuch as the best argument in favour of gastrotomy 
 is that the fingers may be used to detach the foreign body, if all 
 other means fail, it is evident that the probability of the intro- 
 duction of the hand into the stomach is the most important 
 element in the selection of the incision through the abdominal 
 wall. In the case of the patient on whom I have done this 
 operation it seemed to me best to make an oblique incision 
 under the margin of the ribs on the left side, directly over the 
 stomach. By this incision the stomach can be recognised very 
 easily and drawn out of the wound so far that the subsequent 
 manipulations can be made without the escape of the contents 
 into the peritoneal cavity. From a large number of dissections 
 for the purpose of deciding the question of the incision in the 
 abdominal wall, I have come to the conclusion that the oblique 
 cut is the best on the whole for this operation, although fingers 
 can be introduced into the oesophagus with ease after making 
 the median cut. The incision through the walls of the stomach 
 for the purpose of introducing instruments into the cardiac end 
 of the oesophagus may be made anywhere, provided that it is far 
 enough to the right to avoid the convexity of the lesser curva- 
 ture. All that is necessary is to put the lesser curvature on 
 the stretch, so that it make a straight line to the diaphragmatic 
 opening. The cut through the stomach wall must be far 
 enough to the right to allow the passage of the instrument along 
 
132 
 
 THE STOMACH 
 
 the sulcus between the anterior and posterior walls of the 
 stomach, made tense as above. If the instrument is brought 
 obliquely to this groove and passed upwards, all the time being 
 pressed gently against the straightened lesser curvature, it will 
 glide into the oesophagus every time with the greatest ease. 
 
 The stomach having been exposed by the lateral cut through 
 the abdominal walls, and having been drawn out of the wound, 
 it must be held by an assistant in such a way that the lesser 
 curvature is put on the stretch. It is better for the assistant 
 to hold the stomach in both hands, so that the whole viscus is 
 flattened out. He should stand on the left of the patient, and 
 grasp the greater curvature. The operator standing on the right 
 of the patient, holds the lesser curvature between the left thumb 
 and forefinger, thereby making tense the lesser curvature and 
 assisting in the passage of the instrument. Before doing this it 
 is best to introduce the hand into the peritoneal cavity and ex- 
 amine the diaphragmatic opening externally. With the stomach 
 held as described, the opening in its wall may be made 
 anywhere in its flattened surface so as to avoid the large vessels. 
 It goes without saying that the incisions should first be just 
 large enough to get hold of the stomach with the thumb and 
 fingers and draw it out so as to stretch the lesser curvature. 
 An incision through the stomach wall can then be made large 
 enough to introduce the instrument, by which, I believe, 
 the foreign body can be removed with ease in the majority 
 of cases. 
 
 In the selection of the operation, whether by external 
 cesophagotomy or by gastrotomy, another reason for the choice 
 of the latter operation is that there is less danger of wounding 
 important structures in the thorax, when the traction is down- 
 wards than upwards. If the body is at the orifice it is not in 
 direct relation with pleura, heart, or aorta. There is much less 
 danger of lacerating the oesophageal wall in pulling down the 
 foreign body a short distance than pulling it up a considerable 
 
 one. 
 
GASmOTOMV. 
 
 133 
 
 In November 1893 Mr. Wallace showed a patient at the 
 Edinburgh Medico-Chirurgical Society, upon whom the com- 
 bined operation of external oesophagotomy and gastrotomy 
 had been performed. The following is the account of the 
 case : — 
 
 “ The patient was admitted to Ward 14 of the Eoyal Infirmary 
 on 31st July 1893, and stated that seventeen hours previously 
 a plate with five teeth had passed into the gullet. The plate 
 was caught with a coin catcher, but could not be dislodged. 
 An endeavour was made to remove it through an opening in the 
 oesophagus made as low down in the neck as possible, but 
 although it could be caught with dressing forceps it remained 
 immovably fixed a little way above the cardiac opening. This 
 endeavour having failed, Mr. Wallace at once performed 
 gastrotomy — passed his hand into the stomach, and, having 
 introduced his finger into the oesophagus, grasped the plate with 
 a pair of dressing forceps and readily withdrew it. The stomach 
 wound, 4 inches long, was then stitched (Czerny-Lembert) and 
 the abdomen closed. The whole procedure occupied two hours. 
 The patient made an excellent recovery, and left hospital six 
 weeks after admission. She states (1st November 1893) that 
 she is in perfect health. The wounds are firmly and completely 
 cicatrised.” 
 
 There may be a stricture either at the entrance or exit 
 of the stomach, and the artificial dilatation of either of these by 
 operation is known by the name of Loreta’s operation. Simple 
 stricture of the lower end of the oesophagus has already been 
 discussed. 
 
 When there is a narrowing of the pyloric orifice there will 
 be found more or less thickening, due to hypertrophy of the 
 muscular tissue, which is often so great that a distinct tumour 
 can be felt on abdominal examination. The symptoms caused by 
 this condition resemble to a certain degree those of cancer of 
 the pylorus, but the great point of difference is the length of 
 time the former may exist in comparison with the latter. 
 
134 
 
 THE STOMACH 
 
 What is first noticed is dyspepsia, then dilatation of the 
 stomach, and vomiting. Unless the contraction has existed for 
 a long time, the patient is hungry immediately after he has 
 been sick, showing that there has not been much interference 
 with the glands of the stomach. Examination of the con- 
 tents of the stomach gives, chemically, an acid reaction, with no 
 trace of albumen or peptones ; microscopically, the results are 
 negative. 
 
 Gastrectomy. 
 
 This operation, which signifies the removal of part of the 
 stomach wall, is one which can only be performed under very 
 exceptional circumstances. Any tumour connected • with the 
 stomach, and which can be felt from the outside, will be of such 
 a size that its removal would entail the excision of the greater 
 part of the organ. The diagnosis of the presence of a tumour 
 connected with the stomach wall which cannot be felt through 
 the parietes can never be made with certainty, and it is doubt- 
 ful if this operation ought to be recognised as a legitimate one. 
 
 Gastro-Enterostomy and Pylorectomy. 
 
 The latter offers the possible hope of a cure, the former is 
 only to give relief, the pylorus being put completely at rest by 
 making an artificial channel for the passage of food from the 
 stomach into the intestine. It is difficult to say what ought to 
 be the proper mortality following the operation of removal of 
 the pylorus, but under the best of circumstances it cannot be 
 small. The death rate of the alternative operation ought to be 
 very much less. If it be ever right and projDer to perform 
 either of these operations the one fixed on ought to be that of 
 gastro-enterostomy ; but it should be arranged with the patient 
 that, if there be no secondary deposit and if it be possible to 
 remove the whole of the disease, pylorectomy will be performed. 
 
GASTRO-EN'TEROSTOMY. 
 
 135 
 
 This is the better plan, for one can never know whether there 
 be any secondary deposit or not until the fingers are inside the 
 abdomen. The operation ought therefore to be begun only with 
 the intention of relieving the patient of suffering, for the mor- 
 tality is too high, and the chances of return too great, to justify 
 the performance of a pylorectomy except under the most favour- 
 able circumstances. Of those who are fortunate enough to 
 recover from the removal of the pylorus, it seems that the time 
 they may hope to keep free from the disease is about three 
 years. A large proportion of those who do not survive the 
 operation die of shock, due doubtless to interference with the 
 sympathetic, and to the long time which usually appears to be 
 spent over its performance. 
 
 The symptoms of cancer of the pylorus, other than the 
 general constitutional symptoms of malignant disease, are some- 
 what similar to those of fibrous contraction, but they come on 
 more rapidly and are much more acute. There is first a feeling 
 of discomfort ; then dyspepsia ; loss of appetite ; derangement 
 of the bowels ; dilatation of the stomach ; vomiting — the matter 
 voided being sometimes mixed with blood, and showing evidence 
 on microscopic examination of the presence of malignant disease. 
 Pain is as a rule very severe in the situation of the pylorus, and 
 a definite tumour is usually to be felt. 
 
 Gastro-Enterostomy. 
 
 The incision is made in a transverse direction over the swell- 
 ing, though the operation has also been performed through a 
 median longitudinal one. The stomach, having been washed 
 out as usual, is to be fixed to the highest part of the small 
 intestine which can be brought easily against it. This will be 
 the upper part of the jejunum, and it may be brought in con- 
 tact with the stomach, either by taking it round the omentum, 
 which seems to be the best plan ; or the omentum may be 
 turned up with the transverse colon, and the posterior part of 
 
36 
 
 THE STOMACH 
 
 the stomach attached, probably to the duodenum ; or an opening 
 may be made in the omentum for the passage of the gut. The 
 second plan seems to be a very difficult one, and the last appears 
 to add the unnecessary danger of obstruction. The part of the 
 intestine fixed on, and the stomach about the centre of the 
 anterior wall, are drawn up to the wound. Well warmed sponges, 
 as is recommended in all abdominal operations, are packed into 
 the cavity to prevent any of the contents of the stomach or in- 
 testine from reaching the peritoneum. The stomach and intestine 
 are to be attached to each other, either by Senn’s decalcified per- 
 forated bone plates or by stitches. The former method appears 
 to be undoubtedly the better one. By using the bone plates the 
 time taken in the operation is very much reduced, and there 
 does not seem to be any chance of a leak occurring. We shall 
 describe first how the stitches are put in, and then return to the 
 preparation and mode of use of the bone plates. A constrictor 
 is to be placed on the small intestine a couple of inches above, 
 and one the same distance below the point fixed on for 
 opening. This may be done with clamp forceps, or preferably 
 by passing bands of indiarubber through the mesentery, and 
 fixing them with catch forceps instead of tying, just so much 
 pressure being used as will prevent escape of the contents of the 
 bowel and no more. An incision is then made into the gut one 
 and a half inch in length, in the longitudinal direction, opposite 
 to its mesenteric attachment, and any contents remaining in that 
 part of the intestine are to be emptied out. An incision of 
 similar length is made into the stomach, and in the direction 
 which seems the most suitable. The edges of the openings in 
 the stomach and intestine are then brought together by several 
 continuous silk sutures; several interrupted ones, say four to 
 the inch, being placed beyond to give support. It has been 
 suggested, and the plan has been carried out, that the peritoneal 
 and muscular coats of the stomach and intestine should be 
 divided first, thus allowing of the suturing of the posterior part 
 before the hollow viscera are opened. The rubber ligatures are 
 
GASTRO-ENTEROSTOMY 
 
 137 
 
 removed as soon as the stitching is completed, the sponges are 
 taken out, and the wound is closed. 
 
 When the decalcified bone plates are used the steps of the 
 operation will be the same until the incisions into the stomach 
 and bowel have been made. These will require to be rather 
 longer, as it is desirable to use large bone plates, and the edges 
 must not be bruised by forcing them through too small an 
 opening. Before placing them in position, the four silk threads 
 attached to the ends and sides must be threaded on to round 
 sewing-needles, and as soon as the plates have been introduced, 
 the needles transfix all the coats of the stomach and intestine, 
 passing from the mucous to the peritoneal surface. There are, 
 however, eight threads, four from each plate, to be tied together, 
 and before this is done the peritoneal surfaces which are to be 
 brought into apposition are slightly scarified with the point of a 
 needle. The threads are then tied, each lateral one from one 
 plate to the corresponding lateral one of the other plate ; and so 
 also with the end ones. The threads are cut quite short. Senn 
 has proved by experiment that two parts of the intestinal tract 
 joined together in this way will stand a pressure of 2 lbs. to 
 the square inch, and this far exceeds anything which could 
 result from intestinal distension. The bone plates break up, and 
 in about ten days are passed per anum, usually in fragments, but 
 long before this happens the two pieces of bowel will have 
 become firmly united. Various modifications of the bone plates 
 have been made, but Semi’s appear to be still the best. 
 
 The directions for preparing the decalcified bone plates are 
 as follows : “ The compact layer of an ox’s femur or tibia is cut 
 with a fine saw into oval plates one-fourth of an inch in thick- 
 ness, two and a half to three inches in length, and an inch in 
 width. The plates are then decalcified in a 10 per cent, solu- 
 tion of hydrochloric acid, changed every twenty-four hours until 
 they have become sufficiently soft so that they can be bent in 
 any direction without fracturing. After decalcification they are 
 washed by letting water flow over them from three to six hours 
 
138 
 
 THE STOMACH 
 
 so as to remove the acid. The plates are then covered with 
 porous paper, and compressed between two pieces of tin until 
 they are perfectly dry. If, during the process of drying, the 
 plates are not compressed between two smooth surfaces they 
 become distorted by warping. The hardened plates are then 
 drilled several times in a straight line in the centre, and the 
 openings enlarged and connected with a file, until the perforation 
 is five-eighths of an inch in length and about one-eighth to one- 
 sixth of an inch in width. The sharp margins of the plate and 
 perforations are removed with a file. With a fine drill the four 
 perforations for the sutures are made near the margin of the 
 oblong perforation, one at each end and one at each side. For 
 preservation the plates are kept in absolute alcohol. When 
 the plates are to be used they are washed in a 2 per cent, 
 carbolic acid solution, and the threads or sutures attached by 
 threading two fine sewing-needles, each with a piece of aseptic 
 silk twenty-four inches in length, which are tied together. The 
 threads are then fastened to the surface of the plate by another 
 thread passing through the perforations in the shape of a loop 
 and fastened at the back.” 
 
 Pylorectomy. 
 
 The stomach is washed out, and the incision is usually 
 made in a transverse direction over the pylorus, and is supple- 
 mented, if necessary, by a second one at right angles. When so 
 much muscle is cut through, as must happen when an incision 
 is made in this direction, the bleeding is certain to be free, and 
 it is better to tie the bleeding points at once with fine catgut 
 than to leave on forceps. As soon as the peritoneum is opened 
 the exact condition of the disease is examined, and if it seem 
 possible to remove the whole of the growth the operation is 
 continued. The pylorus, which will be found to be situated 
 lower in the abdomen than usual, is drawn upwards towards 
 the wound, and the exact shape and situation of the disease is 
 
PYLORECTOMY. 
 
 139 
 
 carefully examined so as to indicate where the large and small 
 omentum are to be divided. The large is first cut through to 
 as short a distance as possible, and then the small one is divided, 
 bleeding vessels being tied with catgut. Any adventitious 
 adhesions are now separated, and when this has been done, 
 sponges are packed in all round and below the part to be 
 removed. The exact position of the incisions in the stomach 
 and duodenum will depend on the size of the growth. The 
 stomach is first cut through with scissors, delicate forceps being 
 put on all bleeding vessels. As soon as the first cut is made, 
 fluid from the stomach should be soaked up with a sponge, 
 which must not be used again. The stomach is kept forward 
 by the right hand of the assistant, who also with his left grasps 
 the duodenum as it is divided, and in this way he can prevent 
 haemorrhage, until all bleeding points in the wall of the 
 duodenum have been tied with fine catgut. As the opening 
 into the duodenum is smaller than that into the stomach the 
 latter must be reduced in size. The duodenum is fitted in at 
 the greater curvature of the stomach, the remainder of the 
 opening in that viscus, which will be towards the lesser curva- 
 ture, being closed by a continuous suture. Shock being a 
 frequent cause of death, the time taken in the performance of 
 the operation should be reduced by using the continuous suture, 
 one sufficing for that part of the stomach which is stitched 
 together, and not more than three or four being required for 
 joining the gut together. A little time may be saved by 
 stitching the posterior part from the inside, peritoneal surface of 
 course being opposed to peritoneal surface. A few interrupted 
 sutures may be put in beyond the continuous ones to give 
 support and to take off tension ; these are especially required at 
 the angle where the wound in the stomach meets the circular 
 stitches. The sponges are removed and the wound is closed. 
 The after treatment is the same as after any other operation for 
 closing a wound in the stomach wall. 
 
 Instead of stitching together the cut ends of the stomach 
 
40 
 
 THE STOMACH 
 
 and duodenum, the alternative plan of closing the openings and 
 performing the operation of gastro-enterostomy may be adopted. 
 The open end of the duodenum for fully half an inch is invagi- 
 nated and closed by a continuous silk suture, which brings the 
 peritoneal surfaces together ; the divided end of the stomach is 
 treated in the same way, and the continuity of the alimentary 
 canal is made by connecting the stomach and some part of the 
 small intestine together by means of bone plates. On the whole 
 this latter plan is the better, but there is probably not much to 
 choose between the two methods. 
 
 Loreta’s Operation. 
 
 The stomach is washed out as usual before the operation, 
 and the incision recommended by Loreta is made in the middle 
 line, about four inches in length. The stomach is drawn up to 
 the wound, sponges to protect the peritoneal cavity are packed 
 in, and a point is fixed on between the curvatures on the 
 anterior surface of the stomach, which is to be the site of the 
 opening. The incision is made in a transverse direction large 
 enough to admit two fingers, and at least one inch from the 
 thickened pylorus which can be easily felt. Should it appear 
 more convenient the opening may be made farther away, the 
 whole object being to reach the constriction as easily as possible. 
 Forceps are fixed on to the edges of the stomach wound, and 
 after any bleeding points have been ligatured with fine catgut, 
 the forefinger of the right hand is passed into the stomach, and 
 if possible into the stricture. When this is being done the 
 pylorus is steadied by the left hand, which has been passed into 
 the abdominal cavity. The resistance of the contracted pylorus 
 to dilatation is very great, but with continuous pressure the 
 finger can be gradually and steadily pushed through. As soon 
 as this has been done the pylorus can be hooked forwards and 
 steadied by the fingers of the right hand from within, and the 
 left forefinger is passed into the stomach, and is gradually 
 
PYLOROPLASTY. 
 
 141 
 
 insinuated alongside the other. When both lingers have been 
 got through, they must be separated so as to dilate the opening 
 thoroughly ; Loreta in his first case dilated to the extent of 
 three inches. As soon as all resistance has been overcome, or 
 when the tissues seem as if they might tear, no further dilatation 
 must be attempted; but the opening must not be allowed to 
 contract for some minutes. The incision through the stomach 
 is stitched as usual, the sponges are then removed and the 
 abdominal wound closed. Food is given as after gastrorraphy. 
 
 For dilatation of the oesophagus the incision will be made 
 in the stomach where it is most convenient ; this will usually 
 be somewhere about the middle of the anterior surface. The 
 opening should be made of sufficient size to allow the entrance 
 of one finger, the stomach being invaginated as it is pushed up 
 to the cardiac orifice. If one finger can be got through, the 
 dilatation may be finished by Loreta’s dilator; or this may be 
 used instead of introducing the finger. The extreme amount of 
 dilatation possible by Loreta’s instrument is two inches. 
 
 Pylokoplasty. 
 
 This operation is of use only in cases of simple stricture. 
 It consists in the exposure of the pylorus, and the division of 
 the stricture after the peritoneal cavity has been shut off by 
 sponges. The incision extends from the stomach to the duodenum 
 completely through the stricture. The divided mucous mem- 
 brane and peritoneum are stitched together all round the opening. 
 The centre of the incision on each side is drawn on so as to alter 
 the direction of the opening. It becomes transverse across the 
 bowel, instead of longitudinal, and it is closed in this direction. 
 This is exactly similar to what is done in the vagina or elsewhere 
 when a cicatricial contraction is divided. 
 
 This operation is a more recent one than that of Loreta. It 
 is not more dangerous, and appears to offer a more certain and 
 lasting cure. 
 
142 
 
 THE STOMACH 
 
 Distension of the Stomach. 
 
 In a few cases, a greatly distended stomach has been reduced 
 in size. The abdomen is opened in the middle line, and the 
 stomach is made smaller by taking several pleats in it, stitching 
 the peritoneal surfaces together in layers. The result of these 
 operations appears to have been so far satisfactory. 
 
CHAPTER VII. 
 
 THE INTESTINE. 
 
 The Anatomy and Connections of the Intestine. 
 
 The first part of the small intestine — the duodenum — extends 
 from the pyloric opening of the stomach to the left side of the 
 second lumbar vertebra. It measures from ten to twelve inches 
 in length, and differs from the jejunum and ileum in being more 
 fixed in position. It has the curve of a horseshoe with the 
 concavity looking towards the left. It surrounds the head of 
 the pancreas, and lies in front of the right kidney and su]3ra- 
 renal capsule, the vena cava inferior, the right psoas muscle, 
 the right crus of the diaphragm, and the aorta. Its relation to 
 the kidney is subject to considerable variation. The first part 
 of the duodenum extends from the pylorus to the under surface 
 of the liver. The common bile duct, and along with it the 
 pancreatic duct, open into the inner and posterior aspect of the 
 second part of the duodenum a little below its middle. This 
 part extends to the right side of the third lumbar vertebra. 
 The third part like the second is immovably fixed in position 
 and does not possess a mesentery, beiug only partially covered 
 by peritoneum. The junction of the duodenum with the jejunum 
 is marked by the duodeno-jejunal flexure, which, together with 
 the root of the mesentery, is held in position by a band of 
 involuntary muscular fibres — the suspensory muscle of Treitz. 
 This muscle descends from the right side of the oesophageal 
 
144 
 
 THE INTESTINE. 
 
 opening in the diaphragm and in front of its left crus to he 
 inserted partly into the duodeno-jejunal flexure and partly into 
 the mesentery. 
 
 The exact relations of the peritoneum to the duodenum are 
 as follows : the first part, two inches in length, is invested by the 
 same two layers of peritoneum which enclose the stomach, and 
 it is thus fairly movable ; the second or descending portion, 
 about three inches in length, is covered by peritoneum only in 
 front, while the posterior surface has a variable relation to the 
 right kidney, the right suprarenal capsule, and the inferior vena 
 cava, being separated only by some areolar tissue, and therefore 
 completely fixed ; the third part, somewhere about five inches 
 in length, is also fixed, being covered by peritoneum on its 
 anterior surface, while the root of the mesentery crosses obliquely 
 downwards from left to right. The superior mesenteric artery 
 and vein also lie in front of this part of the duodenum, the vein 
 being to the right side of the artery. 
 
 The division of the rest of the small intestine into jejunum 
 and ileum is a purely arbitrary one, and, with the exception of 
 the two extremities, it has no fixed position, the one end being, 
 as described, over the left crus of the diaphragm, and the other 
 in the lower part of the right lumbar region close to the iliac 
 crest. The jejunum and ileum are attached to the back wall 
 of the abdomen by a double fan -shaped fold of peritoneum 
 forming the mesentery, which extends from the left side of the 
 second lumbar vertebra across the spine to the right sacro-iliac 
 articulation, and contains blood vessels, nerves, lymphatic vessels, 
 glands, and the gut. The commencement of the large intestine, 
 the caecum, is situated in the right iliac fossa, it is usually 
 entirely surrounded by peritoneum, and is thus somewhat 
 movable. The ileum opens into the caecum on its inner and 
 posterior aspect two and a half inches above its blind end. The 
 ileo-caecal valve, which is situated at this point, is an extension 
 of the end of the ileum into the ciecum, and while it allows 
 of easy passage from the small intestine into the large, it 
 
THE ANATOMY OF THE INTESTINE. 
 
 145 
 
 acts as a barrier in the opposite direction when the csecmn is 
 distended. 
 
 The vermiform appendix opens into the inner and posterior 
 aspect of the caecum below the junction of the ileum and caecum. 
 It consists of a narrow diverticulum from three to six inches in 
 length, and is held in position by a special mesentery. The 
 ascending colon passes upwards as far as the liver. It is usually 
 covered by peritoneum on the front and sides only, leaving a 
 space behind in contact with cellular tissue which separates it 
 from the fascia covering the quadratus lumborum muscle and 
 from the lower end of the right kidney. In some cases a distinct 
 mesocolon is found. The transverse colon runs across the upper 
 part of the abdomen, there being usually a distinct bend down- 
 wards. It is attached by a mesocolon, which permits of great 
 freedom of movement. At its right end, the hepatic flexure 
 unites it to the ascending colon, while by means of the splenic 
 flexure it is continuous at its left end with the descending colon, 
 which resembles the ascending in being usually uncovered by 
 peritoneum posteriorly. It descends upon the left kidney and 
 the quadratus lumborum muscle, being separated from them by 
 areolar tissue. At the iliac crest the descending colon becomes 
 continuous with the sigmoid flexure, which extends to the left 
 sacro- iliac articulation, at which point the term rectum is 
 applied to the remainder of the large intestine. The sigmoid 
 flexure possesses a mesentery — the sigmoid mesocolon — which 
 is continued to the upper part of the rectum, where it is termed 
 the meso-rectum. 
 
 The blood supply of the bowel is very great, the anastomoses 
 are numerous, and the blood vessels run in the mesentery. The 
 duodenum receives its supply from the branches of the coeliac 
 axis, and from the superior mesenteric artery. The rest of the 
 intestine is supplied by branches from the superior and inferior 
 mesenteric arteries, which also spring from the aorta. All these 
 blood vessels are freely supplied with nerve filaments derived 
 from the solar plexus ; and numerous lymphatics are also found 
 10 
 
146 
 
 THE INTESTINE. 
 
 in relation to the mesentery. The veins which return blood 
 from the regions supplied by the branches of the coeliac axis, 
 superior and inferior mesenteric arteries, ultimately coalesce to 
 form the portal vein, which enters the liver at its transverse 
 fissure, along with the terminal branch of the hepatic artery. 
 
 When we come to this, the most difficult part, from a 
 diagnostic point of view, of the digestive tract, it is necessary to 
 lay down some general principles and rules to act as a guide in 
 advising what is best for the patient. What we have to attempt 
 to do is to obtain sufficient information from the symptoms 
 shown by the patient ; from the history derived from himself 
 and his friends, from the physical examination, and also from 
 his general condition, more especially as regards his strength 
 and the state of the heart and pulse, — which will enable us 
 to come to a correct diagnosis and prognosis. In cases such 
 as we are about to consider, the temperature does not give 
 much information, and we must rely on the general appearance 
 and expression, and, above all, on the condition of the pulse. 
 We can afford to delay operative interference, if we have not 
 been able to arrive at a diagnosis, so long as the pulse keeps of 
 good strength, and where it is not increasing in rapidity, or in- 
 creasing very slowly, and when the rate is not above, say, 108 
 or 110. If the pulse rate be coming down, even if there appear 
 to be no improvement in the local condition, it is not right to 
 operate. There is time to wait, for there must be some improve- 
 ment in the local condition, even though it be not evident to 
 account for the diminished pulse rate. But this does not apply 
 when some treatment, such as washing out the stomach, has 
 been lately carried out. When a diagnosis has been made, and 
 when the chances are against the patient if no operation be 
 performed, there is little to be gained by waiting, and the sooner 
 the operation is performed the better. It would be folly to wait 
 for the pulse to rise. This all leads up to what has been said 
 over and over again, that every effort must be made to come to 
 a correct diagnosis. 
 
OBSTRUCTION. 
 
 47 
 
 The common surgical disease of the intestine is a more or 
 less complete obstruction of the lumen of the gut. If the 
 obstruction be complete, death may be due simply to the block ; 
 but death may also occur when there is partial occlusion, due 
 probably to a sudden internal injury, or to acute septic poisoning, 
 or to a combination of these two conditions. 
 
 Generally, an acute obstruction may be due to altered 
 conditions of the wall of the bowel, mural obstruction ; to an 
 obstruction from the outside, extra-mural obstruction ; to an 
 obstruction inside the gut, intra-mural obstruction ; or a 
 combination of any of these conditions may occur in the same 
 subject. 
 
 Mural obstruction is met with when there is a condition of 
 paresis of the intestine. This may be either primary, or it may 
 be secondary to an attack of peritonitis, or it may follow an 
 abdomiual operation. These secondary conditions have been 
 considered elsewhere, and do not require to take up our attention 
 at present. 
 
 A second condition of this form of obstruction is that caused 
 by intussusception, that is to say, a doubling in or invagination 
 of the bowel upon itself. This condition may also be divided 
 into two varieties, the acute and the chronic. 
 
 Another form of this obstruction, fortunately a rare one, is 
 that known by the name of volvolus, i.e. a twisting or rotation 
 of the bowel on itself Under this heading of mural obstruction 
 congenital deficiency of the lower part of the bowel must be 
 included to make the list complete. This condition is treated 
 of in connection with colotomy. 
 
 Extra-mural obstruction is due to a block resulting from the 
 presence of a band either surrounding a knuckle of intestine or 
 under which a coil of bowel has passed, an adhesion of the 
 bowel at an angle, or the passage of part of the intestine through 
 an opening such as the foramen of Winslow, the obturator fora- 
 men, or an opening in the mesentery or omentum. These 
 comprise the extra-mural causes if we exclude the ordinary 
 
148 
 
 THE INTESTINE. 
 
 herniiB which by long use are considered to belong to the works 
 on general surgery. 
 
 Intra-mural obstruction is caused by a gall-stone, or by an 
 enterolith, which is a concretion formed by a secretion of the 
 intestine. 
 
 Combinations of any of these acute conditions, or the com- 
 bination of an acute with a chronic condition, must be borne in 
 mind, so that, when one obstruction has been discovered and 
 dealt with, others may have to be looked for. 
 
 Obstruction due to Nervous Exhaustion. 
 
 This is a condition which has been much overlooked. It 
 consists, at first, in severe cases, of a greatly excited action of 
 the bowels, followed by complete paralysis, and death occurs in 
 from three to four days unless the intestine recover its nerve 
 tone. This condition ought hardly to be classified as an ob- 
 struction ; there is no diminution of the lumen of the gut at any 
 point, but there is a relaxation, and even an increase in size, 
 with complete loss of power in the muscular tissue to pass on 
 the contents of the bowels. In this way it practically comes to 
 be an obstruction, and the symptoms are very much those that 
 are found when there is diminution in the lumen at some part 
 of the intestinal tract. 
 
 History and Symptoms . — The condition is much more com- 
 mon in men than in women, and occurs most frequently in 
 robust patients. In the milder forms it is by no means 
 uncommon, and it is rare to find that life is seriously en- 
 dangered by this condition of the bowel. 
 
 The history of an extreme case is, that a man who has led a 
 more or less sedentary life for some time, suddenly and with- 
 out preparation undergoes great fatigue. He becomes very 
 hungry and eats a large meal, perhaps in the open air. Within 
 a few hours, at latest twelve, he is attacked by severe abdominal 
 pain of a colicky nature, often accompanied by vomiting. In- 
 
OBSTR UCTION D UE TO NER VO US EXHA USTION. 1 49 
 
 testinal movements are distinctly heard. At the very commence- 
 ment a little flatus may be passed, soon this entirely ceases, and 
 within a very few hours the pain has abated and the abdomen 
 has begun to distend. This is quickly followed by return of 
 the vomiting, which had ceased for a time, and its character has 
 now changed. At first it was accompanied by much retching, 
 now the vomited matter comes up with little effort. The 
 extremities become cold, the face is pinched and anxious, and 
 nothing has passed from the rectum. By this time the pulse has 
 become rapid, from 120 to 160, the abdomen is greatly distended, 
 and the patient dies of heart failure. 
 
 A stout, somewhat florid American, aged forty-two, the 
 proprietor of a large cattle ranch, and who as a rule took little 
 exercise, started off before the mid-day dinner to assist at the 
 extinction of a prairie fire some miles away from his house. 
 During the whole of the afternoon he was hard at work beating 
 down the flames with wet sacks. He rode home after sunset, 
 and being very hungry, having had nothing to eat since early 
 breakfast, he ate a large supper, consisting chiefly of cabbage 
 and pork. Four or five hours after, he was awakened out of 
 his sleep by an attack of intense colic, accompanied by vomiting. 
 He took a large dose of laudanum, and as the pain did not abate 
 he had a warm bath, and his wife rubbed laudanum on his 
 abdomen. The pain was entirely relieved by this treatment, 
 but in the morning the abdomen was seen to be much distended, 
 and the vomiting had returned. The pulse was rapid, and 
 within thirty- six hours from the commencement of the attack 
 the patient was dead, no other treatment having been tried. A 
 jpo^t mortem examination was made, but nothing was found 
 except general distension of the bowels. 
 
 Treatment . — The treatment consists in preventing loss of 
 strength by keeping the patient warm and quiet in bed, and the 
 complete stoppage of food and fluids of all kinds by the mouth. 
 The special treatment is directed to the early arrest of the peri- 
 staltic action, and to the soothing of the excited sympathetic. 
 
150 
 
 THE INTESTINE. 
 
 The bowel, in an exhausted subject, has been irritated by the pre- 
 sence of a large quantity of food, it appears to resent this, and 
 to be working in an irregular, excited, and useless manner to get 
 rid of the irritation. 
 
 A fairly large dose of morphia is to be injected hypoder- 
 mically to stop quickly the peristalsis which is going on, and 
 a quarter of a grain must be given, if, as is usual, the patient is 
 a big heavy man. If the pain and intestinal movement do not 
 soon cease a further dose is to be administered. Some four or 
 five hours after complete rest has been given in this way, a 
 large dose, at least an ounce, of castor-oil is to be taken, and, if 
 the bowels can be got to move, the patient is practically well. 
 Should the case not be seen until the bowel has become 
 paralysed and relaxed, the treatment will have to be somewhat 
 different. Only a sufficiently large dose of morphia is given to 
 keep the patient quiet and at rest, not more than one-sixth of a 
 grain, and the stomach is emptied either by a soda vomit or 
 by washing out. The object is to give the bowel rest, and to 
 allow of the recuperation of the nervous system ; while, by 
 emptying the stomach, vomiting is relieved for a time, and 
 there is not so much pressure on the heart. Unfortunately, 
 one cannot afford to wait long, and a short rest must sometimes 
 suffice, but if the general condition be not getting worse, and the 
 distension of the stomach be not increasing rapidly, it is better 
 to wait for four or five hours, and then to give the mixture of 
 magnesia and peppermint by the mouth — I^ magnes. sulph. 5i. ; 
 magnes. carb. grs. x. ; aq. menth. pip. gss. This medicine is 
 more likely to be retained than castor-oil, and the dose is to be 
 repeated if the first should be brought back. Quinine is also to 
 be injected into the rectum, as described under After Treatment 
 in Chapter IV. Here, and also whenever there is any abdominal 
 distension, the rectal tube must be frequently used. 
 
 In all these cases, one-hundredth of a grain of strychnia is 
 to be injected hypodermically every two hours. 
 
 A gentleman, age twenty-five, had travelled from London to 
 
INTUSS USCEPTION, 
 
 151 
 
 Perthshire during the night, arriving on the morning of the 
 12 th of August, which was a Tuesday. He went out shoot- 
 ing at once, ate a heavy lunch, and during the afternoon, while 
 still on the moors, was seized by severe abdominal pain. He 
 became unable to walk, and had to be carried home and put 
 to bed. The pain diminished, the abdomen began to distend, 
 and vomiting became constant. Two days afterwards, on the 
 Thursday, the vomit became stercoraceous, and Dr. Keith was 
 telegraphed for to come prepared to open the abdomen. When 
 he arrived on Friday the patient appeared to be within a few 
 hours of death, he was constantly vomiting faecal matter, no 
 flatus had passed, the hands and feet were cold and blue, and 
 there was much general distension. The treatment consisted in 
 covering the abdomen all over with a large poultice, surrounding 
 the patient with hot bottles, and the administration of a quarter 
 of a grain of morphia hypodermically, followed about flve hours 
 after by a dose of castor-oil. The general appearance quickly 
 improved, there was no more vomiting, and during the next day 
 a small quantity of flatus passed several times. In the afternoon 
 another dose of morphia was given, followed by a dose of castor- 
 oil in the evening. During the night the bowels moved very 
 freely, and there was no further trouble. 
 
 In all cases of simple paralysis of the intestine any operative 
 interference is quite useless, and can only lead to disappoint- 
 ment. Should one be so unfortunate as to open the abdomen 
 in one of these cases, no attempt should be made to remove the 
 contents of the bowel, either by incising or by puncturing with 
 hollow needles, for the less the intestine is interfered with the 
 more chance there is that it will recover its tone. 
 
 Intussusception. 
 
 Although this is the most common cause of intestinal 
 obstruction, it resembles the condition previously described in 
 that there is not necessarily any actual block in the lumen of 
 
52 
 
 THE INTESTINE. 
 
 the gut. What happens in a case of intussusception is, that 
 one part of the bowel is doubled in or invaginated into the 
 bowel immediately below it, so that if a probe were passed 
 downwards through the invagination no obstruction would be 
 met with ; if, however, the probe were passed upwards, unless 
 it should chance to hit the centre of the invagination, it would 
 be arrested where the bowel commences to double in, and it 
 would have to be drawn downwards before it could be passed 
 up to the original starting-point. This condition is found more 
 frequently in the small than in the large intestine, the favourite 
 points being in the one at the ileo-csecal valve, and in the 
 other about the rectum. The relative frequency of the position 
 of this diseased state is, roughly speaking, something like the 
 following. At the ileo-csecal junction a bare half, in the ileum 
 a good quarter, in the colon about one-fifth, and the ileo-colic 
 about half that number. This condition is more common in 
 children below the age of ten or twelve than it is during the 
 whole of the remainder of life. It is very frequently met with 
 during infancy, and in the young it is usually acute ; after the 
 age of twenty it is, as a rule, chronic. 
 
 Causes of Intussusception. 
 
 Intussusception is caused by the irritation of a diarrhoea ; 
 by ulceration of the mucous membrane, as after typhoid fever 
 and dysentery ; by the pressure of a tumour attached to the inner 
 surface of the bowel dragging its connection downwards into the 
 bowel below; and by the irritation caused by the presence of 
 worms. All of these conditions are frequently associated with 
 a chill. In some cases it is difficult, or it may be impossible, to 
 assign a cause for this doubling in of the bowel. As the bowel 
 becomes invaginated the veins running in the mesentery are 
 drawn on and constricted, and the result is the same as is seen 
 in a strangulated hernia. The blood passes more freely into 
 the invaginated portion, the intussusceptum, than it is able to 
 
INTUSSUSCEPTION. 
 
 153 
 
 flow away, and the result is congestion and swelling. The 
 upper part of the outer portion of the howel, the intussuscipiens, 
 plays the part of the constricting ring in an ordinary case of 
 hernia, and the ultimate result is, if the case go on long enough, 
 or he sufficiently acute, that the intussusceptum becomes gan- 
 grenous. It is easy to see that there may be in addition an 
 actual obstruction due to the presence of food, which is unable 
 to pass through the irritated and swollen intussusceptum. Tliis 
 condition is frequently divided into four classes : the ultra-acute, 
 in which death occurs within one day; the acute, where the 
 progress is not so fast, and where the disease may last for about 
 seven days ; the subacute, where the progress of the disease is 
 counted by weeks; and the chronic, which continues for a 
 longer time. For practical purposes, that is, in regard to 
 operative interference, it is amply sufficient to make two classes, 
 the acute and the chronic. In the former, opinions have to be 
 made and acted on quickly, for an acutely strangulated piece of 
 bowel does not give much time for deliberation, the pathological 
 changes occur with great rapidity, and the result of a few hours’ 
 delay may be so serious that any operation ought to be performed 
 as soon as it is decided on, whether during the day or night. 
 
 In chronic cases there is more time to deliberate, and, while 
 all unnecessary delay is to be deprecated, still a day or two is 
 not likely to make any material difference in the result. 
 
 Symptoms of Acute Intussusception . — These are caused, first, 
 by obstruction more or less complete; and secondly, by the 
 pathological changes which take place in the part of the 
 bowel which has been constricted. The first symptom caused 
 by the invagination of a piece of bowel into another is pain. 
 This comes suddenly and without warning, it comes in spasms, 
 and, like most colicky pains, is more severely felt about the 
 umbilicus. Soon it becomes more constant, with acute exacer- 
 bations, and it does not tend to subside until the bowel becomes 
 gangrenous ; then, if there be a perforation, it becomes very 
 acute, and spreads over the whole of the abdomen. 
 
154 
 
 THE INTESTINE. 
 
 Tenderness may be felt at first over the position of the 
 invagination, though this symptom is by no means constant, and 
 after a time the whole of the abdomen becomes sensitive to the 
 touch. 
 
 A most important sign is the passage of blood from the 
 bowel ; there is at first diarrhoea streaked with blood, then 
 bloody mucus is passed, and finally there may be blood accom- 
 panied by occasional scybala. There is a very constant desire 
 to go to stool, more especially if the invagination be into the 
 rectum ; but nothing, or only a little blood, is passed, and the 
 tenesmus remains as distressing as before. Differing from other 
 cases of obstruction, the prominent symptom of distension is 
 absent, unless there be some accidental block ; indeed there is 
 not infrequently retraction of the abdominal wall, and distension 
 may not occur until the bowel has become gangrenous and a 
 perforation has been the result. 
 
 A well-defined tumour is usually found unless the abdomen 
 be accidentally distended. It may be felt either through the 
 abdominal wall or from the rectum. When situated in the 
 abdomen it is more or less sausage-shaped, and may be of 
 almost any length, commonly about five or six inches ; or it 
 may be curved, this being especially the case when it is long. 
 Examination of the rectum must never be omitted. 
 
 An early and usual symptom is collapse ; it is caused by 
 the pain, combined with the injury to the gut, and the htemor- 
 rhage. Nausea and vomiting are met with sometimes, but they 
 are by no means invariably present in the early stages, and 
 hecal vomiting does not occur unless there be actual obstruc- 
 tion. The pulse gradually quickens, and the patient dies of 
 acute septic poisoning. 
 
 In a simple case, uncomplicated by obstruction, there should 
 not be any difficulty in coming to a correct diagnosis of the 
 condition of the bowel ; and doubt arises only when the exact 
 state inside the abdomen is masked by symptoms of actual 
 obstruction. In the very young also it may be by no means 
 
INTUSSUSCEPTION. 
 
 155 
 
 easy to make a correct diagnosis, and when the patient is not 
 old enough to speak, the symptoms will consist chiefly of rest- 
 lessness, with straining, and sudden fits of crying, accompanied 
 by the passage of mucus and blood. When the strangulation of 
 the intussusceptum is rapid, the symptoms will be proportion- 
 ately acute. 
 
 In the acute cases nature has not been able to prepare the 
 way for a spontaneous cure, and the patient dies, because there 
 has not been time for adhesions to take place so as to prevent 
 an opening being formed into the peritoneal cavity when the 
 invaginated piece of gut becomes gangrenous. When the disease 
 is not so acute, adhesions are often met with, and if these 
 connect the gut at the ring firmly, they preserve the continuity 
 of the bowel, when the f^an^renous and now useless intussus- 
 ceptum is thrown off. 
 
 Symptoms of Chronic Intussusception . — These may extend 
 over many weeks or even months, and they resemble generally 
 those of the acute form. The pain is not so severe, nor is it 
 so continuous ; it is still spasmodic ; hut in the intervals the 
 patient does not suffer. As a rule there is neither local nor 
 general tenderness. 
 
 Diarrhoea and the passage of blood, which are such pro- 
 minent signs in the acute cases, are by no means so diagnostic. 
 The bowels certainly may be loose, but they may be confined ; 
 or they may be sometimes the one and sometimes the other. 
 Blood may or may not be present, and the same can be said 
 of tenesmus. 
 
 Distension will not be present unless intestinal contents close 
 the diminished lumen of the bowel at the invaginated part. 
 
 A tumour is made out in about one half of the cases. 
 
 There is no collapse, but nausea and vomiting are likely 
 to be present, especially during the attacks of pain. There is 
 loss of appetite, and symptoms of gastric derangement ; gradually 
 the patient loses ground, becomes weak and emaciated, and 
 may die of exhaustion. 
 
56 
 
 THE INTESTINE. 
 
 When the intnssusceptum slonghs and separates after firm 
 adhesions have been formed round the ring the symptoms are 
 not so much general as local; the dejecta become intensely 
 putrid, due to the admixture of gangrenous debris ; blood is 
 present, and diarrhoea frequently appears. Although this is 
 the way in which nature secures the life of the patient, the 
 ultimate result of the curative process is not always satisfactory, 
 for there may be a perforation formed later, and such an 
 accident must be followed, almost of necessity, by fatal septic 
 peritonitis. Stricture of the intestine may also result from the 
 separation of a piece of intestine in this manner. 
 
 The frequency with which separation occurs is regulated 
 by the severity of the symptoms, and as the disease is com- 
 monly more acute in children than in adults it is found that 
 the older the patient the more likely is separation to take place. 
 
 Treatment of Acute Intussusception. — This must, in the 
 first place, be directed to the general health of the patient, 
 and it is unfortunate that this is apt to be forgotten in 
 tlie interest which is taken in the local disease. The patient 
 is to be kept quiet and warm in bed, the pain relieved 
 by a large poultice and by a small dose of morphia. As it 
 seems useless to hope that an intussusception will return to its 
 natural position, treatment ought not to be delayed. The 
 treatment will lie between insufflation of the bowel from below 
 and operation. The former plan, when properly carried out, 
 is not accompanied by danger, and as few preparations are 
 required, little time need be lost before an attempt is made to 
 reduce the bowel by this means. It must always be tried before 
 recourse is had to operation. 
 
 Water has been used instead of gas to distend the bowel, 
 and it might be satisfactory when the invagination is situated 
 near the rectum. When the mischief is high up in the small 
 intestine a greater amount of pressure is required than is 
 necessary with the gas, and the weight of the water is also a 
 decided disadvantage. 
 
INTUSSUSCEPTION. 
 
 57 
 
 It is now known that gas introduced into the rectum can he 
 made to pass through the whole length of the digestive canal ; 
 the ileo-c8ecal valve does not offer any insuperable obstruction, 
 and a slight additional amount of pressure is all that is required 
 to drive the gas as far as the stomach, after it has reached 
 the lower part of the ileum. The homely plan of blowing air 
 into the rectum with a pair of bellows has been the means of 
 reducing many an invagination ; but it is not altogether safe, 
 and, as one cannot estimate correctly the amount of pressure 
 which is being used, even healthy intestine may be ruptured. 
 In every case where the insufflation method is employed the 
 lower part of the intestine must be cleared out with a large 
 injection of warm water containing soap and castor-oil, and the 
 patient is then ansesthetised. The nozzle of the bellows is 
 inserted into the rectum, and while the anus is held tightly 
 round it by an assistant the air is to be blown in slowly and 
 steadily. A sudden lessening in the amount of pressure indi- 
 cates that reduction has been effected, or that the unfortunate 
 accident, rupture of the intestine, has occurred. To distinguish 
 between these it is necessary to go on with the insufflation 
 carefully, and as gently as possible. If a rupture have occurred 
 the abdomen will become generally tympanitic ; whereas, if the 
 gas be confined to the intestine, the tympanitis will spread more 
 from below upwards. 
 
 Senn states as an absolute fact that healthy intestine does 
 not rupture when the pressure is less than 8 lbs. to the 
 square inch, when the patient is not angesthetised. He advises 
 the use of hydrogen gas, as it is perfectly harmless and is 
 rapidly removed by absorption. The gas is put into a rubber 
 reservoir, to the tube of which a manometer is connected ; this 
 regulates the amount of force which is being used, when the 
 hydrogen is driven out by the pressure of the hand from the 
 rubber bag. Experiment has shown that a pressure of from 
 I lb. to 2 lbs. is sufficient to overcome the resistance 
 offered by the ileo-C£ecal valve, and that a slight increase will 
 
158 
 
 THE INTESTINE, 
 
 drive the gas the whole length of the alimentary canal. The 
 administration of an anaesthetic renders the passage of the gas 
 somewhat more easy by removing the resistance of the muscles 
 of the abdominal wall. All pressure must be made slowly and 
 steadily. 
 
 The hydrogen gas can be prepared without any elaborate 
 apparatus. What is required is simply a Wolff’s, or a large 
 wide-mouthed bottle, in which a couple of ounces of pieces of 
 zinc are placed ; through the cork a short, straight glass tube 
 reaches to nearly the bottom of the bottle, and a longer bent 
 one passes for a short distance only through the cork. The 
 sulphuric acid and water necessary for the completion of the 
 chemical action is to be poured in through the short tube, and 
 the gas finds its way through the bent one, to which the 
 rubber bag is attached. The capacity of the bag should not be 
 less than three or four gallons. It will be filled in about ten 
 minutes, and is disconnected from the bottle after the stop-cock 
 has been closed. 
 
 The ordinary end of an enema syringe, whether of bone or 
 metal, is fixed on to the end of the rubber tube, and is then 
 passed into the rectum. Steady pressure is to be made on the 
 bag after the stop-cock has been opened, and the assistant 
 prevents the return of the gas. The position of the patient may 
 also help in the reduction, as by having the hips high the 
 advantage of the action of gravity is obtained. 
 
 When we are dealing with gut whose vitality has been 
 lowered, as in a case of intussusception, pressure, as shown by 
 the manometer, must never be allowed to exceed 2 lbs. to the 
 square inch for fear of causing rupture ; and it is stated that, 
 should the gut rupture under such a pressure, it shows that the 
 condition of the bowel has been such that the operation was 
 imperatively called for. A¥hen the gas is being injected the 
 hand should be kept on the tumour if it is to be felt, and its 
 altered condition and final disappearance will be easily noticed 
 when the injection is successful. Should there be no tumour 
 
INTUSSUSCEPTION. 
 
 159 
 
 we must remember that two points of resistance have to be 
 overcome, the one at the ileo-Ccecal valve and the other at the 
 intussusception ; these may be close together or far apart, and 
 the pressure diminishes as the gas passes each one. If there be 
 an invagination at two points one only may have been put 
 right ; it is therefore proper to go on with the insufflation of 
 the gas until the whole of the alimentary canal has been 
 distended, always bearing in mind that the pressure must not 
 be raised beyond the 2 lbs. to the square inch. To be 
 sure that the hydrogen gas has traversed the whole length of 
 the alimentary canal a tube is passed into the stomach, when 
 the presence of the gas will be shown if a lighted match be 
 applied. The flame can be easily extinguished by pressing the 
 tube. When the hydrogen has reached the stomach it does not 
 necessarily mean that the intussusception has been reduced, for 
 the gas may travel through the centre of the invaginated bowel. 
 When there is a sudden diminution in the pressure, and there is 
 a fear that a rupture of the bowel has taken place, the insuffla- 
 tion is continued, and the signs are the same as when this 
 accident has happened after using the bellows. Should the 
 insufflation of hydrogen gas fail, or should a rupture occur 
 during its use, nothing remains to be done except to operate. 
 
 Operative Treatment . — After what has been so often said it is 
 perhaps scarcely necessary to repeat that the patient must be kept 
 warm and prevented from getting wet by using the perforated 
 rubber sheet, etc. The incision is always to be made in the middle 
 line, and must be large enough to admit of the passage of the 
 hand into the abdomen. The invaginated portion of the bowel 
 is usually found without much difficulty, and is to be drawn 
 with great care and gentleness into the wound, or as near it as is 
 possible. The next thing is to examine it carefully, and to 
 determine if there be any evidence whether or not the injury 
 has been so acute as to cause death of the intussusceptum, for 
 should there be any signs of gangrene, it would be simply a 
 waste of precious time to attempt reduction. When the bowel 
 
6o 
 
 THE INTESTINE. 
 
 appears to be healthy, careful but not too prolonged attempts 
 must be made to bring it back into its natural position. Before 
 this is done warm sponges are to be arranged so that the 
 cavity of the peritoneum is shut off as far as possible ; exposure 
 of the rest of the abdominal contents is thus avoided, and if 
 rupture should take place during the manipulation, the contents 
 of the bowel are prevented from coming in contact with the 
 peritoneum. The swollen and congested intussusceptum is now 
 to be reduced in size by steady pressure, and when this has 
 been well accomplished, an attempt is made to draw it through 
 the ring, while at the same time the intussuscipiens is to be 
 drawn downwards. Eough traction should be carefully avoided, 
 but the pressure must be kept up very steadily. Should reposi- 
 tion not take place, the bowel is to be again distended with the 
 hydrogen gas, and the traction is to be renewed whenever the 
 gas commences to pass between the invaginated portion and the 
 intussuscipiens, distending the latter. The gas will always 
 pass between these two, as mucous surfaces do not tend to 
 adhere to each other. Should this fail, adhesions will be 
 present, either round the ring or lower down, and these are to 
 be separated, if possible, by passing a probe round between the 
 two pieces of the bowel. If there still be failure, one is apt 
 to be tempted to try to insinuate the tip of the finger, and 
 to break down the adhesions ; but as this implies a decided 
 risk of rupturing the bowel it is well to resist the temptation. 
 Before giving up all attempts at reduction in favour of some 
 form of operation on the bowel itself, a final effort is to be made 
 to sponge off the adhesions ; this is done with a specially soft 
 sponge, the upper part of the bowel being held in the left hand, 
 and pressure being made with the sponge in the right. 
 
 After reduction has been effected there may be reinvagina- 
 tion, and to avoid this risk the mesentery is to be shortened 
 in the neighbourhood of the intussusception. This is done by 
 folding the mesentery on itself, the fold being made parallel to the 
 bowel, and it is made permanent by putting in a few stitches. 
 
INTUSSUSCEPTION. 
 
 i6i 
 
 Before the abdomen is closed we must satisfy ourselves that 
 a second intussusception does not exist, and also that there is 
 not any band or adhesion, which might in itself be a cause of 
 obstruction. Cases have been met with where two intussuscep- 
 tions have been found, and the presence of adhesions is not 
 an unknown danger. When these questions have been settled 
 the sponges are removed and the wound is closed. 
 
 When the gut is found to be gangrenous time must not 
 be wasted in attempting reduction, as it is necessary to remove 
 the dead part. This entails a circular resection of the gut. 
 The bowel is to be removed in the following way : a rubber 
 ligature, passed through a hole made in the mesentery, con- 
 stricts the gut about four inches or so above the ring ; a second 
 ligature is made to surround the intestine below the intussus- 
 ception ; this prevents escape of the contents of the bowel after 
 the diseased part has been removed. Sponges, of course, have 
 shut off the portion of the bowel which is being 023erated upon 
 from the rest of the peritoneal cavity. The entire circumference 
 of the bowel is next removed, between the upper ligature and 
 the constricting ring, so that one half of a V is made, whose 
 apex is in the mesentery, and in this manner, rather more of 
 that part of the bowel farthest from the mesentery is removed. 
 A second similar section of the bowel is made immediately 
 below the ring and through the upper part of the intussuscipiens. 
 The intussusceptum being now disconnected from the rest of 
 the bowel is to be removed, and the divided ends of the bowel 
 may be treated in various ways. That plan is to be chosen 
 which can be performed most quickly, most easily, most satis- 
 factorily, and with the greatest amount of future comfort to the 
 patient. The choice lies between the formation of a faecal 
 fistula, a circular enterorraphy, lateral apposition by means of 
 bone plates, and lateral implantation. 
 
 The formation of a faecal fistula by fixing the open ends of 
 the gut in the abdominal wall is a cruel proceeding, unless it 
 be absolutely impossible to treat the case in any other way. 
 
 11 
 
62 
 
 THE INTESTINE. 
 
 If the patient recover he lives in a more or less miserable 
 condition, and has usually to look forward to a future operation. 
 When this has to he done the cut ends are to be fixed into the 
 most convenient part of the wound ; this is better than making 
 a special opening in the inguinal region, looking to the possi- 
 bility of a second operation in the future. The two ends of 
 gut are to be stitched together at the mesenteric side after the 
 cut in the mesentery itself has been brought together. Stitches 
 are put in the surplus part of the abdominal wound, and are 
 left loose until the bowel has been satisfactorily fixed. This 
 is to be done by passing a stitch through the abdominal wall 
 on one side, taking a good hold of the outer coats of the in- 
 testine at the lower part, and coming out through the other half 
 of the abdominal wall. A similarly placed stitch fixes the 
 upper part of the gut. Additional sutures are passed through 
 the wall and gut on one side, and others through the other 
 side, until the united ends of bowel have been firmly secured. 
 The constricting bands on the intestine need not be removed 
 until all the stitches have been introduced, nor are any of the 
 silks to be tied until all are in position. 
 
 Circular Enterorraphy. 
 
 To bring the ends of the bowel together when they are of 
 equal size is much more easy than when one end has become 
 much dilated, or where small intestine has to be joined to 
 large. Three or four continuous sutures will be required, 
 threaded into the round sewing-needles used in operations on 
 the stomach. The mesentery is first brought together, and 
 the stitches in the bowel are passed through the outer coats 
 only, and do not include the mucous membrane. It is best to 
 begin at the posterior part of the bowel. The peritoneum, as 
 is described in the operation of gastrorraphy, is to be care- 
 fully turned in, so that peritoneal surfaces are in apposition. 
 Additional interrupted stitches are to be introduced at any point 
 
CIRCULAR ENTERORRAPHY. 
 
 63 
 
 that may appear to require them, but they should not be pre- 
 ferred to the continuous for the first row. It need not take 
 long to bring the ends thoroughly into apposition ; at most ten 
 minutes ought to be ample time, unless there be great inequality 
 in the size of the two ends. When there is great difference in 
 the size an alternative operation is to be preferred. 
 
 The third alternative is that of lateral apposition, or 
 intestinal anastomosis by means of the decalcified perforated 
 bone plates. The gangrenous gut is to be removed, and the 
 rubber bands constricting the intestine above and below are 
 put on in the same way as in the previous operation ; the two 
 open ends are to be closed by inverting the wall for about an 
 inch, and then stitching across the end with a continuous silk 
 suture. It is not necessary to put in so many stitches as in 
 circular suturing, a single row is sufficient. The proximal and 
 distal ends being now closed, an incision is made in the longi- 
 tudinal direction, at the side of the bowel opposite the mesen- 
 tery, and a bone plate is stitched into position in the way 
 described under the operation of gastro-enterostomy. A second 
 plate is placed in a like manner in the other end, and in such 
 a position that the two will approximate easily. The stitches 
 from the bone plates are tied as usual, the compressing bands 
 on the bowel and the sponges are removed, and the abdominal 
 wound is closed in the ordinary way. When the operation has 
 been carefully performed it is not necessary to wash out the 
 general abdominal cavity unless there be symptoms of septic 
 absorption, the small part of intestine which has been exposed 
 alone requiring to be purified. 
 
 ^ The operation of lateral implantation of the bowel is per- 
 formed by inserting the proximal end into the distal part of 
 the gut in the following way. The distal end is turned in 
 and closed with a continuous suture, and an incision is made, 
 about two inches distant, in the longitudinal direction, and 
 opposite the mesentery, one inch to one inch and a half in 
 length ; into this opening the proximal and open end of the 
 
64 
 
 THE INTESTINE. 
 
 gut is stitched, first by one row composed of several continuous 
 sutures, and then by a second row of interrupted tension stitches. 
 
 Of these four methods the choice should lie between the 
 second and third. There is probably little or no advantage in 
 the one over the other, unless one end of the bowel be much 
 larger than the other, except when the operator has not accus- 
 tomed himself to work quickly ; in that case he will probably 
 do better with the lateral anastomosis by bone plates. The 
 operation must not be commenced with the fixed idea that 
 any one way is certain to be the best under all circum- 
 stances ; but it is well to be prepared to complete the operation 
 in whichever way seems to be most safe after the gangrenous 
 part of the bowel has been removed. 
 
 When gangrene has not taken place, the removal of any part 
 of the bowel would be running the patient’s life into unnecessary 
 danger. If a channel be made for the free passage from the 
 intestine above the intussusception to another part below, 
 pressure is relieved at the invaginated part, and the intussus- 
 ceptum does not becomie gangrenous. This artificial passage 
 ought always to be made by the help of the bone plates, and 
 no greater length of gut than is absolutely necessary should 
 be excluded from the alimentary canal. It will occasionally 
 happen that on account of the position of the intussusception 
 it will not be possible to approximate the bowel by the help of 
 the bone plates. This will happen when this diseased condition 
 is near the rectum. Here colotomy will have to be resorted 
 to ; and, as it is a simple matter to determine the exact relations 
 of the colon when the hand is inside the abdomen, one will be 
 able to decide whether a lumbar or inguinal incision will be 
 the better. In any case a second incision will be advisable, 
 and, as will be seen later, we are inclined to favour the lumbar 
 operation whenever there is no special contra-indication. 
 
 When a case is not seen until the condition has become 
 chronic there is not any immediate hurry to operate, at least 
 for a few days. The treatment does not vary in any particular 
 
OBSTRUCTION DUE TO BANDS. 165 
 
 detail from that of the acute; inflation by hydrogen gas may 
 be tried, and if it fail operation is to be had recourse to, for 
 it is not advisable to wait in the hope that the intussusceptum 
 will be thrown off and the patient recover. The illness would 
 be a prolonged and dangerous one, and if he survived, the 
 ultimate result is known to be often unsatisfactory. 
 
 Obstruction due to Bands and Adhesions. 
 
 The exact conditions which are met with under this heading 
 are somewhat numerous. In the first place, when a band is the 
 cause of the obstruction, it may be found to be free at one end, 
 and to have twisted round a knuckle of intestine. Sometimes 
 a band may be found to be fixed at both ends ; in such cases 
 a piece of intestine may pass underneath it and so become 
 strangulated. Both of these conditions may also be caused 
 by a diverticulum. At other times the bowel may pass through 
 an opening either in the mesentery, or omentum, or into the 
 obturator foramen, or through the foramen of Winslow. Finally, 
 there may be an adhesion of intestine to a fixed point, and this 
 may cause obstruction by the formation of an angle. 
 
 Symptoms . — It is not possible, and fortunately it is not of 
 any practical importance, to be able to differentiate the symptoms 
 due to the presence of any of the foregoing conditions from one 
 another, for all the symptoms are very much alike. Usually 
 the first thing to be noticed is the sudden onset of pain in the 
 abdomen. This may occur without any previous history of 
 trouble of any kind in that region. In some cases the patient 
 may have previously suffered from an attack of peritonitis, 
 localised or general, or from an injury to the abdomen, or 
 some operation may have been performed. The pain is severe, 
 of a griping character, and like most pain in the intestines, 
 is often referred to the umbilicus rather than to the seat of 
 the obstruction. At first it comes decidedly in paroxysms, 
 with times of complete relief ; later on it loses much of its 
 
66 
 
 THE INTESTINE, 
 
 spasmodic character, and becomes continuous. The abdomen 
 quickly becomes tender, and begins to distend. The tender- 
 ness is sometimes referred to one particular spot; at other 
 times it is felt all over. At the commencement of the attack 
 flatus may pass and the bowels may move ; but this is due 
 simply to the emptying of the gut below the seat of obstruc- 
 tion. Soon flatus ceases to pass. As the abdomen distends 
 vomiting sets in, and after a time it becomes fsecal, unless 
 the obstruction be very high up in the small intestine. There 
 is often collapse when the attack first commences ; the pulse 
 becomes weak and rapid ; the temperature either does not rise, 
 or is subnormal, unless there be acute peritonitis ; the breath- 
 ing becomes quick ; the tongue becomes dirty, and the patient 
 is continually wishing for something to drink. Hiccough also 
 may be present. The urine becomes scanty, and there may be 
 almost complete suppression. 
 
 All these conditions occur more frequently in men than in 
 women, and the most usual age is between twenty and forty. 
 The constriction is to be looked for, as a rule, in those parts of 
 the abdomen most prone to be the seat of inflammation, as, for 
 example, in the right iliac region, and in the pelvis. The cause 
 of death is due either to exhaustion with failure of the heart ; 
 or to peritonitis ; or to septic absorption ; or more usually to a 
 combination of these conditions. 
 
 Treatment . — Operation must follow the diagnosis, for medical 
 treatment cannot rectify a mechanical wrong. The operation 
 will always be somewhat of the nature of an exploratory 
 incision, as an absolutely precise diagnosis is quite impossible. 
 The preparations are to be made as usual, special attention 
 being paid to keeping the patient warm. It is not necessary 
 to wash out the stomach ; this sinq^ly exhausts the patient, 
 and does not help us in any way. The whole of the surface 
 of the abdomen is to be scrupulously washed with a strong 
 solution (1 in 1000) of the perchloride of mercury, and the 
 perforated rubber sheet ought always to be used. 
 
OBSTRUCTION DUE TO BANDS. 
 
 67 
 
 The incision is to be made in the middle line, between the 
 umbilicus and the pubes, rather nearer to the former, and with 
 ordinary care there is no risk of injuring the distended coils of 
 intestine. The first incision should be long enough to admit 
 two fingers easily, unless the abdomen be much distended, for 
 in that case the opening must be large enough to admit the 
 hand. As soon as the peritoneum is opened the two fingers 
 of the left hand, or the whole hand, as the case may be, are 
 passed down to the right iliac fossa ; if nothing be found there 
 they explore the left iliac region, unless the ascending colon 
 is found to be contracted ; and, if the obstruction has not been 
 found, the incision is to be enlarged to the extent of admitting 
 the whole hand. This length of incision is likely to be enough 
 for all purposes, but there is no objection to making it longer if 
 that appear to be more convenient ; but it must not be made 
 too long, unless it be intended to turn out the intestine e7i masse, 
 i.e. eventration. If an obstruction be not found in the two most 
 likely situations, the best plan is to go systematically over the 
 intestine until the obstructing point is reached. This is to be 
 done by making a fixed point of the most swollen piece of gut 
 within sight ; either by passing a ligature through the mesentery, 
 the ends of which are held by the assistant ; or the gut itself 
 may be held with the finger and thumb without employing any 
 ligature. This is the better way. The surgeon then commences 
 to draw out the bowel, and as it is drawn out at one end it is 
 pushed in at the other. This may be begun either towards the 
 obstructing point or away from it ; after passing two or three 
 feet of bowel through the hands in this way one is enabled to 
 judge whether the obstruction is being approached or not by 
 noticing the size of the gut, the amount of congestion, the 
 thickness of the wall, and the state of the contents, these be- 
 coming more fluid the nearer the obstructing band is reached. 
 When it is found that the examination has been made in the 
 wrong direction the advantage of having a fixed point of com- 
 mencement is seen, for one can begin again in the opposite 
 
i68 
 
 THE INTESTINE. 
 
 direction without having to go over a second time the bowel 
 already examined. The obstruction having been reached, its 
 treatment will depend on the exact cause, and on the condition 
 of the gut. It will only be possible to indicate generally how 
 the conditions are to be treated ; they vary to such an extent 
 that every case will have to be treated by the surgeon in the 
 way which, under the circumstances, appears best. Bands of all 
 kinds, whether free at one end or adherent at both, must be 
 divided near their base, and tied with catgut. 
 
 A diverticulum, not uncommonly seen in those who have a 
 malformation elsewhere, as a hare lip, cleft palate, etc., will 
 require a little more care ; sometimes the base of one of these is 
 as large, or nearly as large, as the intestine, and when this is 
 so, the cut end should be invaginated, and the peritoneal surfaces 
 brought together with a continuous suture of fine silk. When 
 the bowel has passed underneath a band fixed at both ends, the 
 whole length of gut which has been obstructed must be care- 
 fully examined, so as to be certain that there are no secondary 
 adhesions of one part to another. The band is to be ligatured 
 at both ends and then divided. 
 
 Should intestine have passed through a slit in the mesentery 
 or omentum, or through the displaced ring of a hernia, the open- 
 ing is to be enlarged and the bowel reduced, the whole amount 
 which had passed through the opening being examined for a 
 second obstruction or for gangrene. The opening must be closed 
 with fine silk, peritoneal surfaces being brought into apposition. 
 One case is recorded by Treves, who has had a large experience of 
 intestinal cases, where the bowel had passed into the lesser bag 
 of the peritoneum through the foramen of Winslow, and several 
 others have also been reported. In all it was found to be im- 
 possible to withdraw the bowel through the foramen, and it was, 
 of course, impossible to enlarge that opening. One of these cases 
 recovered spontaneously after the abdomen had been closed. 
 
 When a part of the circumference of the bowel is fixed at 
 one point there will always be a certain amount of obstruction. 
 
OBSTRUCTION DUE TO BANDS. 
 
 169 
 
 This will not necessarily be complete if the bowel be healthy, as 
 it will often stretch at this point ; but should there be in such a 
 case any condition of the intestinal wall which will prevent 
 dilatation, a complete stoppage may be the result, the block 
 being caused by the pressure of the proximal part of the gut on 
 the distal. The indication here for the treatment of the bowel 
 is very simple, and consists in separating it from its fixed 
 position, and in covering both the raw surfaces so formed by 
 bringing the peritoneum together by stitches. 
 
 An obstruction caused in this way may result from the 
 passage of an appendix epiploica through the side holes of a 
 drainage tube ; but this is only likely to occur when the holes 
 have been made too large. We have only seen one case of this 
 kind ; it occurred after the removal of a double pyosalpinx. ISTo 
 flatus passed for forty-eight hours, the abdomen was beginning 
 to distend, the pulse to quicken, and the patient complained 
 of pain in the position of the tube ; and, as only a little clear 
 serum could be withdrawn, it was removed. Although it could 
 be rotated freely it did not come out easily, and before it had 
 been half withdrawn the patient complained of great pain. As 
 the lower end came out it was seen that a little piece of fat, 
 evidently an appendix epiploica, had passed into the tube 
 through one of the side openings. It was firmly fixed, and a 
 considerable amount of force was required to pull it out of the 
 tube. Within an hour flatus was passing freely, and the patient 
 made an uninterrupted recovery. 
 
 In all cases of obstruction by a band through an opening or 
 at an angle, we must never be satisfied until the whole length 
 of gut which has been in any way interfered with has been 
 carefully examined, and until it has been determined that no 
 other obstruction exists in the abdomen. When the bowel 
 is found to be healthy the abdomen is closed, and a drainage 
 tube is not required. 
 
 In some cases the peritoneal covering of the intestine has 
 been injured during the separation of an adhesion, or from great 
 
170 
 
 THE INTESTINE. 
 
 distension ; and as this may lead to a future adhesion of the 
 part, the peritoneum on each side of the crack or tear must be 
 drawn over it by a continuous suture. The direction of this 
 kind of union ought to be made as much as possible transversely 
 to the axis of the bowel, for in this way the lumen is not 
 narrowed. Should there be one or more gangrenous spots, the 
 rest of the wall being undoubtedly healthy, they may be cut 
 out, an oval incision being made in the transverse direction, 
 and closed with the continuous suture. A small opening made 
 in the course of any abdominal operation is to be closed in a 
 similar way. When a considerable portion of the bowel is 
 gangrenous, a resection of the whole circumference must be 
 made ; before this is done a rubber band is fixed on above and 
 below, as described in intussusception, to control the contents 
 of the intestine. They must not be put on too near to the 
 gangrenous part, for the obvious reason that the vitality of that 
 part of the bowel is likely to be lessened. The gangrenous 
 portion is now to be cut out, going thoroughly clear of any 
 doubtful or injured part ; the direction of the section is to be 
 V-shaped, the angle being in the mesentery, and the very 
 greatest care is taken to prevent soiling of the peritoneum. 
 Bleeding vessels are secured by fine catgut ligatures ; the 
 proximal opening being kept well forwards outside of the 
 wound, the constricting rubber band is loosened to allow of 
 the intestinal contents being emptied out. If bone plates are 
 to be used, the end of the gut may be washed out with warm 
 water after it has again been constricted. The two cut ends 
 may now be stitched together, or the continuity of the bowel 
 may be restored by lateral apposition and the use of decalcified 
 bone plates. Of these two methods the choice will always be 
 made of the latter when the one end of gut is much larger than 
 the other ; where the openings are of somewhat similar size 
 there is not much to choose between the two methods, and 
 the one will be adopted which the surgeon feels he can do 
 more easily. Both of these operations have been described in 
 
VOLVULUS. 
 
 171 
 
 connection with intussusception, and nothing further need be 
 said. 
 
 In all cases where the bowel is found to be gangrenous, and 
 also in those where its vitality is evidently deteriorated, the 
 abdomen must be thoroughly washed out with warm water, and 
 a drainage tube left in^ as in those cases some septic infection 
 may have passed from the intestinal tract into the peritoneal 
 cavity. 
 
 Volvulus. 
 
 This is the rarest cause of intestinal obstruction, and is 
 always acute. It is a twisting of the bowel on itself, causing 
 obstruction in the blood supply passing through the mesentery, 
 and followed by oedema of the wall of the part of the intestine 
 involved in the twist. A twist of this nature can occur only 
 when the mesentery is abnormally long ; it is therefore usually 
 met with in those situations where this is naturally the case, 
 viz. in the sigmoid flexure and in the lower part of the ileum. 
 In addition to this elongation of the mesentery, which appears 
 to be invariably present, there may be found a somewhat con- 
 stricted portion of the intestine. In other cases there may be a 
 history of persistent constipation ; this condition is usually met 
 with about middle life. 
 
 Sy mptoms . — These consist in the history of constipation, though 
 this is not always present ; and in cases where there is narrowing 
 of the gut, there may have been some antecedent abdominal 
 symptoms, such as dyspepsia, slight distension, and attacks of 
 pain about the navel. The formation of the volvulus is accom- 
 panied by a sudden and severe attack of pain of a colicky nature, 
 referred to the neighbourhood of the umbilicus ; and along with 
 this there is usually some distinct evidence of collapse. Soon 
 the pain spreads over the whole of the abdomen, and is accom- 
 panied by tenderness, at first over the situation of the twist, and 
 later on becoming general. Vomiting then commences, and the 
 abdomen begins to distend. Tenesmus, which is complained of 
 
72 
 
 THE INTESTINE. 
 
 when the volvulus is situated at the sigmoid flexure, is not so 
 likely to be a prominent symptom when the twist is farther 
 from the rectum. The pulse becomes rapid and small, there 
 are the usual symptoms following any great general injury, and 
 the patient may die within two days of the onset of the attack. 
 
 Treatment . — In this condition, more than in any other of acute 
 obstruction, treatment must not be delayed. The first thing to do 
 is to attend to the patient’s general condition, and to obtain a good 
 nurse. It is impossible to rectify the twist by any action from 
 above, and it is said that it cannot be rectified by inflation from 
 below ; still it would be right to make the attempt with hydrogen 
 gas if the patient be seen shortly after the first onset, for one 
 cannot say with certainty that it will not succeed in undoing 
 the twist, and it is possible to conceive that a case may be cured 
 if treated early, although the doubt would always arise in such 
 instances as to what had really been the nature of the obstruction. 
 
 When a case of obstruction has been diagnosed to be due to 
 the presence of a volvulus, and when inflation by hydrogen gas 
 has failed to bring relief, the sooner the operation is performed 
 the more likely is the patient to recover, and nothing can 
 possibly be gained by delay. 
 
 The Oj^eration . — The incision is to be made in the middle line, 
 between the umbilicus and the pubes. When the volvulus has 
 been brought into view, it can be easily untwisted if the operation 
 have been performed sufficiently early. If this fortunate result be 
 obtained, a recurrence of the condition must be prevented. It has 
 already been said that there is invariably a long mesentery, and 
 this will require to be shortened. It can be done very simply by 
 making a fold in the mesentery parallel to the bowel, and 
 keeping it in this condition by a few stitches. Eemoval of any 
 part of the mesentery must not be thought of, for a very evident 
 anatomical reason. Eeduction may not be effected so easily; 
 there may be considerable matting together and adhesions in 
 addition to the simple twist ; or more than one loop of 
 intestine may be affected. Should it be impossible to return the 
 
ENTEROLITHS. 
 
 73 
 
 gut to its natural condition, the contents must be emptied out 
 through an incision made in the most prominent part of the 
 bowel, in the longitudinal direction, and at the opposite side to 
 the mesentery ; care must be taken to prevent any soiling of the 
 peritoneal cavity, which is closed by sponges, so as to prevent, 
 as far as possible, infection from intestinal gases. After the 
 bowel has been fairly well emptied, the incision may be closed 
 by a continuous silk suture, or the lips of the wound may be 
 kept together by the fingers of tlie assistant. Should it still be 
 impossible to rectify the volvulus a lateral anastomosis by means 
 of decalcified bone plates should be made, connecting the gut 
 above and below. This is undoubtedly better than making an 
 artificial anus as a routine practice. When gangrene has super- 
 vened, the dead tissue must be removed, and a lateral anastomosis 
 or a circular enterorraphy may be made, or both ends may be 
 fixed into the wound, as may seem best at the time. 
 
 Enteroliths. 
 
 One more acute form of intestinal obstruction remains to be 
 noticed. In the lumen of the gut may be found a foreign body, 
 or, what is practically the same thing, a substance known by the 
 name of an enterolith. The latter is secreted by the intestine, 
 the former is usually a biliary calculus. Quite a large concre- 
 tion may be present within the intestine without creating an 
 obstruction ; the actual block appears to be formed partly by the 
 mass and partly by the irritation it sets up in the bowel, so 
 that in this way a comparatively small stone may cause complete 
 obstruction. 
 
 Symptoms . — They may be those due to a sudden obstruction as 
 by a band, or there may be a history of previous intestinal trouble, 
 sometimes of long standing. When a gall stone is the cause, there 
 will be probably a history pointing to some liver disturbance, 
 jaundice perhaps ; or when the nucleus of the blocking substance 
 consists of a gall stone, there will have been antecedent biliary 
 
74 
 
 THE INTESTINE. 
 
 colic. A single gall stone of sufficient size to close the bowel 
 can only have reached the intestine by a process of ulceration. 
 When the obstruction is high up in the intestine there cannot 
 be much abdominal distension ; vomiting would be the more 
 prominent symptom. 
 
 Treatment . — Operation holds out the only hope of relief in all 
 cases when purgation has been tried and has failed. The steps of 
 the operation are the same as those previously described up to the 
 point where the obstruction is reached. It is useless to attempt 
 to push on such a concretion ; but as it can sometimes be broken 
 up, a strong round needle is to be inserted through the coats 
 of the intestine below the obstruction, traversing the wall in an 
 oblique direction ; and with the needle an attempt is to be made 
 to break up the mass, which is fixed with the left hand. The 
 part of the bowel with which the mass is actually in contact 
 will have had its vitality lowered by the pressure upon it. It 
 must be handled therefore with great gentleness ; and, if the 
 needle do not manage to reduce the size of the block easily, a 
 prolonged effort must not be made, but the obstruction must be 
 removed through an incision. 
 
 It is usually recommended that the stone should be pushed 
 onwards or backwards to allow of the incision being made 
 through a healthy piece of intestine, and v/hen this can be easily 
 accomplished it is right to do so. A stone can seldom be pushed 
 onwards, and, unless the case has been operated on very early, 
 a healthy part of intestine may be several feet from the proximal 
 side of the block, and nothing but harm would be done^by pro- 
 longed manipulation of the stone, if it be firmly fixed. The rule 
 must be to push on the stone if it will go easily ; if this be not 
 possible, it must be pushed backwards if healthy gut be near ; 
 and, if neither of these can be managed, an incision will have 
 to be made over the concretion itself. .In any of these three 
 situations the incision is to be made in a longitudinal direction, 
 and through the convexity of the gut. The opening is to be 
 kept well forwards, and the fluid contents are allowed to flow 
 
DIAGNOSIS OF ACUTE OBSTRUCTION. 
 
 175 
 
 into a basin; this action being assisted by raising the coils 
 and allowing the contents to pour out. The opening is closed 
 by a continuous suture, and when the incision has been made 
 through swollen tissue, two rows, or perhaps three, will be 
 required, and a good grasp must be taken of the peritoneal and 
 middle coats. When the pressure has been so great that the 
 bowel has become gangrenous, resection must be made, and the 
 divided ends treated either by the bone plates with lateral 
 anastomosis, or by fixing both ends in the wound, either of these 
 being preferred to the circular stitching, as the proximal end of 
 the bowel will be much dilated and softened. 
 
 The Differential Diagnosis of Acute Obstruction. 
 
 The importance of coming to a correct diagnosis can hardly 
 be exaggerated, and before attention is given to what may exist 
 inside the abdomen, the possibility of a hernia must invariably 
 be excluded. With this proviso it is fortunately only necessary 
 to differentiate those cases which require operation, and those 
 which can recover without operation ; but to do this with any- 
 thing approaching certainty one has to arrive at as correct a 
 knowledge as possible of the exact condition which exists inside 
 the abdominal cavity. This is not always possible, indeed one 
 must sometimes open the abdomen without this knowledge, 
 being induced to do so by the general condition of the patient, 
 and by the fact that all treatment has failed to remove the 
 obstruction. An excellent example of such a condition is the 
 following. A lady fifty-four years of age, of gouty constitution, 
 was seized suddenly with intermitting abdominal pain in the 
 region of the umbilicus ; at first there was no sickness, and the 
 abdomen distended but slowly. In the position of the splenic 
 flexure of the colon there was some slight tenderness, and the 
 surgeon who first saw the patient after the abdomen was some- 
 what distended thought he felt a swelling in that position. Five 
 days after the onset of the attack vomiting commenced, and this 
 
176 
 
 THE INTESTINE. 
 
 continued about once or twice in the twenty-four hours until 
 the day she died. When seen ten days after the beginning of 
 the illness the appearance was fairly good, pulse 108, temperature 
 normal, general distension of the abdomen not very great, colicky 
 pains at the navel, no general pain, slight tenderness at the splenic 
 flexure of the colon and nowhere else, no dulness. The bowels 
 had moved slightly the night before. There was a history of two 
 slight former attacks of obstruction, the second of which, two 
 months before, gave way under treatment for gout. The patient 
 was seen again on the thirteenth day, the condition was much 
 the same as before, flatus had passed occasionally, a considerable 
 quantity in the morning, pulse was 96, and temperature remained 
 normal. N’ext day the patient’s aspect was not so good, 
 there was more distension, and the pulse had risen to 108. It 
 was determined to open the abdomen, and several hours before 
 this could be done there was severe pain all over. The condition 
 found was that of perityphlitis, with pus in the abdomen, and 
 there was in addition a rupture of the ascending colon. With 
 the exception of the two previous attacks there was nothing 
 whatever which pointed to this condition. For the purpose of 
 diagnosis we may divide the conditions of acute obstruction into 
 the three groups : of paresis due to nervous exhaustion ; of intus- 
 susception ; and of obstruction due to bands, adhesions, twist- 
 ing, hernise, and to the presence of concretions. The following 
 table shows how little difference there is between these conditions, 
 and how frequently, even in typical cases, the symptoms of one 
 class resemble those of another. So true is this, in the more 
 indefinite cases, that too much attention must not be paid to 
 book knowledge when at the bedside ; experience is sometimes 
 the only guide ; and especially must we remember that the 
 general condition of the patient must not be allowed to fail 
 while we are seeking for a correct diagnosis. 
 
 [Table. 
 
TABLE COMPARING THE SYIVIPTOMS OF THE DIFFERENT FORMS OF OBSTRUCTION. 
 
 COMPARISON OF FORMS OF OBSTRUCTION. 177 
 
 12 
 
78 
 
 THE INTESTINE. 
 
 There is a certain amount of similarity in the operations 
 which can be performed to relieve an acute obstruction, no 
 matter what is the exact cause. Before opening the abdomen 
 it is essential that arrangements be made for keeping the patient 
 warm, so as to reduce the shock as far as possible. The patient 
 must be both warmly dressed and warmly covered, hot bottles 
 must be kept to the feet, and if he be much reduced others may 
 be put round about him. In addition the body is to be entirely 
 covered with indiarubber sheeting. A slow deliberate operator 
 is out of place in such operations, and so also is one who cannot 
 manipulate gently, for the gut is often soft, and may be easily 
 torn. As such operations may have to be performed at very 
 short notice, it will often fall to the part of the surgeon to 
 disinfect the skin of the abdomen after the patient is on the 
 table, and he must not fail to inquire if the bladder has been 
 emptied before the administration of the anaesthetic has been 
 begun, for every morsel of space gained is an advantage. The 
 incision is always to be made in the middle line below the 
 umbilicus, and in every case where the abdomen is not much 
 distended, one long enough to admit two fingers will be at first 
 sufficient. The fingers are to be passed to the right iliac region. 
 If that part be found to be healthy, and the ascending colon 
 contracted, one need not examine the sigmoid flexure, but must 
 withdraw the fingers and enlarge the wound to the extent of 
 admitting the hand. 
 
 When there is much distension, a four or five inch incision 
 is made at once, as the two fingers are not long enough to 
 examine much of the abdomen. If nothing be found amiss in 
 the right iliac fossa, and the ascending colon be found contracted, 
 and if the examination of any tender spot have not revealed 
 anything, the gut is to be gone over, drawing it out at one end 
 and pushing in at the other in the way already described. The 
 obstruction having been found in this way, or possibly after 
 eventration has been resorted to, the next thing will be to 
 remove it if possible without injury to the gut ; or to make an 
 
OPERATIVE TREATMENT OF OBSTRUCTION. 179 
 
 artificial anastomosis if the gut be fairly healthy ; or to resect a 
 part if it be seriously damaged. Bands are to be divided and 
 removed ; openings are to be enlarged and the prolapsed gut 
 withdrawn, the rent being then closed with sutures ; a volvulus 
 is to be untwisted and the mesentery shortened ; and an 
 invagination is to be reduced by taxis and the mesentery again 
 shortened. 
 
 In the more serious cases where it is not possible to relieve 
 the obstruction in any of these ways, and where the gut has not 
 become gangrenous, a connection is to be established between 
 the intestine above and that below, so as to cut out from the 
 intestinal tract, at least for a time, the obstructed part. By 
 doing this rest is given, and in some cases nourishment may 
 pass through both the old and the new channels ; but if the 
 obstruction remain permanent that part of the bowel which has 
 been cut off by the short circuiting becomes atrophied. 
 
 In adopting this plan of treatment one precaution must 
 never be lost sight of : it is not to remove too much of the gut. 
 It must be evident that digestion and proper nutrition cannot 
 go on if too much of the small intestine be cut out of the 
 alimentary tract, and that when this is done the patient will 
 inevitably die of marasmus. At present statistics are wanting 
 which would tell us how much and what part can be removed 
 with safety. The removal of four feet of small intestine has 
 resulted in death from marasmus, and the same result would 
 have occurred if an equal amount had been cut out by the 
 formation of an anastomosis, unless the obstruction became 
 removed and the gut returned to its functional activity. 
 
 When the bowel has become gangrenous at a single point, 
 an oval incision may be made completely free of the dead part, 
 and the opening thus formed closed by a continuous silk suture. 
 The direction of the opening must be transverse, so as to prevent 
 any diminution in the size of the gut. 
 
 When the gangrene is more extensive the whole of the 
 injured part must be removed by incisions made completely 
 
i8o 
 
 THE INTESTINE. 
 
 free of the disease and through entirely healthy tissue. The 
 divided ends of intestine may be treated in one of the three 
 following w^ays : the openings may be inverted and closed with 
 a continuous suture, and the continuity of the bowel preserved 
 by lateral anastomosis by means of bone plates ; the ends may 
 be sutured together; one or both ends may be fixed in the 
 wound, or in an incision made for the purpose. 
 
 Lateral anastomosis is to be preferred when the proximal 
 end has become much larger than the distal. When there is 
 not much difference in size, the choice between lateral anasto- 
 mosis and circular stitching will depend on the inclination of 
 the surgeon, and also on the ease or difficulty in bringing the 
 bowel together by either method. When the patient is very 
 much debilitated, the cut ends may be fixed in the wound if it 
 be expected that the continuity can be restored at some future 
 time ; or, when this cannot be hoped for, the proximal end is 
 brought through an opening made at a convenient spot, and the 
 distal end is stitched across, and either fixed into the wound or 
 allowed to drop back into the abdomen. 
 
 During the performance of any of these operations the 
 peritoneal cavity and the rest of the intestines must be shut off 
 by warm sponges, and whenever the bowel has been found to be 
 gangrenous the cavity must be washed out, and a drainage tube 
 introduced to drain from the bottom of the pelvis. The after 
 treatment will not vary from any other ordinary abdominal 
 operation, and it is not necessary to wash out the stomach 
 either before or after. 
 
 Enough has been said in the foregoing pages to show how 
 gangrenous bowel, discovered during an operation for hernia, and 
 usually recognised as belonging to general surgery, is to be 
 treated. The principle to act on is to consider the life of the 
 patient first, and his future comfort second. In a debilitated 
 subject an artificial anus must be made, and it can be closed at 
 some future time ; but when the general condition is good, the 
 wound is to be enlarged, the gangrenous gut removed, and the 
 
CHRONIC OBSTRUCTION. 
 
 i8i 
 
 continuity restored either by circular enterorraphy or by lateral 
 anastomosis. 
 
 Puncture of the Intestine. 
 
 An additional method of treatment which has been exten- 
 sively revived of late years requires to be mentioned. 
 
 When an abdomen is greatly distended with wind one is 
 inclined to think that by making a small opening into the 
 bowel with a hollow needle the distension will be relieved, at 
 least for a time. Unfortunately this is not the case ; and unless 
 a large number of punctures are made, no appreciable difference 
 is seen in the size of the abdomen, a few inches of gut only 
 being emptied by each puncture. Even when an incision is 
 made into the gut, it is remarkable how little gas comes away 
 naturally. It is actually unsafe to puncture a distended coil of 
 intestine, for even the opening made by a fine needle may allow 
 of the escape of gas or faecal matter into the peritoneal cavity 
 This risk would not be sufficient to condemn the practice if 
 much relief were obtained, but when we consider that little 
 reduction in size can be expected, the practice is one which 
 ought not to be recommended. 
 
 Chronic Obstruction. 
 
 Cases of this form of obstruction are most conveniently 
 divided into two groups ; the one where the obstruction is due 
 to a simple cause, and the other where it is due to malignant 
 disease. These forms of chronic obstruction may be divided in 
 the same way as the acute, into mural, extra-mural, intra-mural, 
 and combinations. 
 
 Chronic mural obstructions are caused by fibrous strictures 
 due either to hyperplasia, or to a cicatricial contraction follow- 
 ing ulceration, intussusception, or any other injury to the bowel. 
 A second cause is congenital stenosis, and the last is the thick- 
 ening resulting from malignant disease. 
 
i 82 
 
 THE INTESTINE. 
 
 The extra-mural causes are those due to the outside pressure 
 of a tumour, of an abscess, or of an hsematocele. 
 
 The intra-mural causes are the presence of fsecal accumula- 
 tions, or of polypi, although the latter might also be classified 
 under the head of mural obstruction. 
 
 Symptoms . — These are very much alike in all the different 
 forms of chronic obstruction, and at the commencement, and for 
 a long time, may indicate nothing more than some derangement of 
 the digestive system. At times the patient may be perfectly 
 well, or he may suffer from attacks of colic situated in the usual 
 region at the umbilicus. These attacks may be accompanied by 
 vomiting, though this symptom is not often present ; in addition 
 there may be some distension accompanied by constipation, 
 which is, however, easily relieved by an aperient. The pain 
 usually commences some hours after food is taken, and between 
 the attacks there may be constipation, or diarrhoea, or these 
 conditions may alternate. There is always dyspepsia. As the 
 disease progresses and the obstruction becomes more marked, 
 all of these symptoms become increased, and the patient begins 
 to lose flesh. Some time or other there is an acute attack of 
 obstruction, and if it be not relieved the patient dies quickly, the 
 general condition having been impaired by the previous derange- 
 ments of digestion, etc. These symptoms are common both to 
 simple and to malignant stenosis, the only difference being that in 
 the latter emaciation is likely to be more rapid than in the former. 
 
 The dangers of chronic obstruction are twofold ; there is first 
 the risk that the diminution in the lumen of the gut may be the 
 cause of a complete block, and that death may result from 
 acute obstruction ; and secondly, as the bowel on the proximal 
 side of the narrowing becomes dilated, a pouch is formed as we 
 have already seen is the case in stricture of the oesophagus, the 
 vitality of the dilated part becomes diminished, the contents lie 
 there and undergo putrefactive changes, and a combination of 
 these two conditions leads to ulceration of the mucous membrane, 
 and eventually it may be to perforation. 
 
CHRONIC OBSTRUCTION 
 
 183 
 
 The most common situation of the fibrous variety of stricture 
 is at the pylorus ; here it consists of an annular ring of thickened 
 fibrous tissue, which gradually closes the canal, and at the same 
 time forms a distinct tumour. Its treatment has already been 
 considered. Fibrous stricture in other parts of the intestinal 
 canal is the result of a contraction due to the healing of an ulcer, 
 and it differs from the pyloric variety of fibrous stricture in that 
 it is not circular. When there has been a history of dysentery, 
 followed by slowly increasing symptoms of obstruction, one 
 would expect to find one or more contractions in the large 
 intestine, or possibly in the ileum. The stricture caused by a 
 syphilitic ulceration will usually be in the rectum, while that 
 due to tubercular disease will be situated about the caecum. 
 
 Another form of cicatricial contraction, and one which is 
 more likely to be circular, is that which follows injury to intestine 
 which had been damaged at the time of an invagination resulting 
 in a spontaneous cure after sloughing, or following the injury 
 which may be received when a piece of bowel has passed into a 
 hernial sac, and which has not been so far destroyed as to prevent 
 an apparently successful primary operation. When there is a 
 history of this kind followed by symptoms of obstruction, the 
 diagnosis is likely to be easily made. 
 
 Malignant disease of the intestines is most commonly found 
 in the rectum. It is almost invariably an epithelioma when in 
 this position or in the large intestine. When the disease is 
 situated in the small intestine it is usually of a sarcomatous 
 nature. In cases of carcinoma the disease commences either in 
 the mucous membrane or in the glands ; when it is a sarcoma, its 
 origin is in the connective tissue of the wall. 
 
 Chronic obstruction may also be caused by the presence of a 
 tumour in such a position that the gut is caught between it and 
 some fixed point. This is more likely to be found in those parts 
 of the intestinal tract where there is little movement, and the 
 growth is likely to be of such a size that the probable diagnosis 
 is by no means difficult. Such a condition is much more likely 
 
1 84 
 
 THE INTESTINE. 
 
 to occur in women, for the reason that tumours are more common 
 in them ; but it is wonderful how easily the bowel seems to 
 accustom itself to being displaced unless the tumour has suddenly 
 altered its position. 
 
 [N’on- malignant tumours in the interior of the bowel are 
 usually polypi growing from the mucous or submucous tissue ; 
 or more rarely the growth may be a cyst. A polypus or pedi- 
 culated adenoma is not usually large enough to form a complete 
 obstruction ; it is more likely to be the cause of danger by be- 
 coming the exciting cause of an invagination. The diagnosis of 
 the presence of a tumour inside the intestine might be made, 
 but usually it is only discovered after the abdomen has been 
 opened on account of symptoms of obstruction. Cysts as a rule 
 act by completely blocking the lumen of the gut. 
 
 An accumulated mass of faeces is usually met with in the 
 large intestine, and as a rule either in the caecum or at the 
 sigmoid flexure. This condition seems to be due to some pro- 
 longed over-distension of a part of the intestine. The result of 
 the long-continued presence of a faecal mass is that inflammation 
 is set up, and eventually an opening through the bowel may be 
 formed. The symptoms not infrequently resemble those of 
 malignant disease, and there may be alternating attacks of 
 constipation and diarrhoea. A very distinct and well-deflned 
 tumour may be felt. 
 
 Diagnosis . — The differential diagnosis of chronic obstruction, 
 due either to a simple cause or to malignant disease, will be 
 made by considering the previous history of any condition 
 which may have left behind an injury of the intestine ; and by 
 the deterioration in the general health being more marked in 
 malignant disease, while the abdominal symptoms are less 
 noticeable. The position where the obstruction seems to be 
 situated, and the presence or absence of a tumour, will also 
 prove of assistance. The importance of making a diagnosis of 
 what is the cause of a chronic obstruction is that it enables us 
 to give a more correct prognosis than would otherwise be possible. 
 
CHRONIC OBSTRUCTION 
 
 185 
 
 for in the one class we can hold out the certainty of a complete 
 recovery if the operation be successful, while in the other it is 
 at least very unlikely that a permanent cure can be effected. 
 In cases where the disease is not malignant, and where there is 
 a history of one of the conditions which may have given rise to 
 cicatricial contraction, and more especially where there have 
 been one or more attacks of acute obstruction, it is advisable not 
 to wait until the life of the patient is endangered by an absolute 
 block; but we are justified in advising an operation when the 
 patient is in fairly good health, unless there be any special reasons 
 which contra-indicate the performance of any serious operation 
 except as a last resource. 
 
 Treatment . — When an acute attack threatening to prove fatal 
 is superadded to the chronic condition of partial obstruction, the 
 operation that will have to be performed does not differ from that 
 which is required when there is no history of gradual diminution 
 in the lumen of the gut. The indications for operation, and the 
 exact line of treatment to be followed, will be determined with- 
 out reference to the previous chronic obstruction. When there 
 is a contraction caused by the healing of a cicatrix, the continuity 
 of the intestine should be made by lateral anastomosis by means 
 of bone plates. This is undoubtedly the proper course to pursue, 
 and the only special precaution is, one must be certain that 
 there are no other strictures present due to the same cause, before 
 the incision in the bowel has been made and the bone plates 
 stitched into position. Under every circumstance this ought to 
 be better than excision ; and as long as there is not an absolute 
 and permanent obstruction, there need be no fear of marasmus 
 even should the bone plates be situated some feet apart. 
 
 The treatment of a sarcoma of the small intestine is not 
 likely to be satisfactory. If the diagnosis of the presence of 
 such a growth be made, no operation should be undertaken, 
 because, as the disease advances quickly, infiltration of the 
 surrounding tissues is almost certain, and it is therefore nearly 
 hopeless to expect to be able to remove the whole of the disease. 
 
i86 
 
 THE INTESTINE. 
 
 Even if this were done there would he a quick return. If, how- 
 ever, this disease be found during the performance of an operation 
 for acute obstruction, a lateral anastomosis by means of bone 
 plates may be made ; or if the disease be situated far down in 
 the ileum, the proximal end of the intestine may be fixed in the 
 wound. This will give the patient a chance of getting over the 
 acute attack of obstruction, and may prolong his life for a more 
 or less short period of time. 
 
 In cancer of the large intestine, which is too high up to be 
 removed from below, the progress of the disease is often very 
 slow. When a well-defined tumour can be felt and a diagnosis 
 of cancer has been arrived at, and when there does not appear 
 to be any surrounding infiltration nor infection of glands at a 
 distance, and if in addition the health be fairly good, an operation 
 should be proposed to the patient. The intention of this opera- 
 tion will be to remove the whole of the disease, and then to close 
 the divided ends of the intestine and make a lateral anastomosis, 
 or to bring the ends directly together by circular stitching. This 
 certainly goes against the fundamental general principle that it 
 is useless to attempt the removal of a cancerous tumour unless 
 the whole organ in which it is situated be taken away. But, as 
 the surgery of the abdomen differs in some respects from general 
 surgery, it may be that this sound surgical principle need not be 
 carried too far in the case of a slow growing carcinoma of the 
 intestine. 
 
 Before the operation is determined on, the alternatives which 
 the patient will have to face if the disease cannot be entirely 
 removed must be put before him, and the general decision as to 
 what is to be done ought to rest with him. These alternatives 
 are either a lateral anastomosis by means of bone plates, a 
 colotomy, or closure of the wound, nothing having been effected. 
 
 When a lateral anastomosis can be made, this is the proper 
 course to follow. It may not be possible, and in such a case 
 colotomy may prolong the life of the patient by preventing the 
 irritation from the cancerous stricture ; but the patient might 
 
COLOTOMY 
 
 187 
 
 prefer that the wound should be closed if the obstruction be not 
 giving much trouble, leaving the opening into the bowel to be 
 made when it becomes absolutely necessary. The difference 
 between lateral anastomosis and colotomy is, that in the first the 
 diseased part is put at rest, and the operation thus gives all the 
 advantages which may be derived from a colotomy ; and at the 
 same time it does not offer the disadvantage of having the end 
 of the intestinal canal in a novel situation. 
 
 When there is a tumour inside the intestine, a longitudinal 
 incision must be made along the convex surface of the gut either 
 above or below the swelling, large enough to allow of the removal 
 of the growth and the ligature of its pedicle after it has been 
 transfixed. The incision in the gut is then closed in the usual 
 way with a continuous silk suture. If the intestine be found to 
 be gangrenous, it is to be dealt with in the way described in 
 the treatment of acute obstruction. 
 
 The treatment of fgecal impaction consists chiefly in injec- 
 tions, as of bicarbonate of soda and water, syrup and water, etc. 
 These injections are to be put up slowly, and retained as long as 
 possible. Attempts may be made to tone up the wall by the 
 administration of strychnia, and the use of the faradic and 
 galvanic currents, and well-applied massage. 
 
 Colotomy. 
 
 By colotomy is understood the formation of an artificial 
 communication between the colon and the surface of the body. 
 The operation may be performed through the flank, or in the 
 inguinal region on either side. The first is commonly known as 
 lumbar colotomy or Amussat’s operation, and the other as the 
 operation of Littre. Until within the last few years lumbar 
 colotomy has been the operation which was practically always 
 performed. The old fear of the peritoneum was the chief factor 
 in the choice of the lumbar operation, it being supposed that the 
 colon could always be reached from behind without having to 
 
i88 
 
 THE INTESTINE. 
 
 open the peritoneal cavity. It is now known that both at the 
 sigmoid flexure and at the ascending colon the large intestine is 
 in a certain proportion of cases not only entirely surrounded by 
 peritoneum, hut is also provided with a mesocolon, and observa- 
 tions show that this is rather more likely to he the case in the 
 left than in the right side. With the amount of distension of 
 the colon, the number of cases where the operation can he per- 
 formed without opening the peritoneum will vary ; the greater 
 the distension the more frequent will this he possible. 
 
 As the great dread of the peritoneum passed away the older 
 operation of Littre began to be practised. It differs from the 
 lumbar colotomy in this, that the peritoneum must be opened, 
 and that the intestine must be stitched to the abdominal wall in 
 front. 
 
 One of these two operations is performed either for the 
 purpose of putting the lower part of the bowel completely at 
 rest, or to prevent a fatal termination in the presence of 
 obstruction in the large intestine. The first of these purposes is 
 carried out either with the object of effecting a cure, or, when 
 the disease is of a malignant character, with the intention of 
 giving a patient ease and prolonging life, by removing a source 
 of irritation. The cases where we may expect a cure are those 
 where there is either ulceration of the rectum, or excessive 
 distension of the colon, or where a non-malignant recto-vesical 
 fistula is present. In addition to these, Littre’s operation may 
 require to be performed in some cases of volvulus, intussus- 
 ception, or other forms of intestinal obstruction. 
 
 In severe cases of ulceration of the rectum, where the disease 
 has resisted all treatment, and where it seems to be evident that 
 the ulcerated condition is prevented from healing by the irri- 
 tation due to the passage of feces, both directly and by reflex 
 action, the opening of the bowel above the seat of the disease 
 will give complete rest, and may thus allow the ulcerations to 
 heal. The opening will be made usually on the left side, or on 
 the right occasionally if there be any reason to suspect that the 
 
COLOTOMY, 
 
 189 
 
 ulcerations are high up in the descending colon ; and especially 
 if in addition there be excessive distension of the colon. It may 
 be that the operation will become necessary for this latter 
 condition alone when purgative medicines, enemata, and the use 
 of electricity have failed, and symptoms of intestinal obstruction 
 are threatened. With a two or three months’ rest the colon 
 becomes contracted, returns to its normal size, and recovers its 
 muscular power. 
 
 In cases of recto -vesical fistula an attempt may be made 
 to allow the fistulous opening to close, or to give relief from 
 distressing symptoms by emptying the bowel above, and thus 
 preventing the passage of faeces into the fistula. The alternative 
 to this procedure is resection of the bowel, an operation which 
 entails a considerable amount of danger ; and as a general rule 
 the simpler operation of colotomy will be preferred. In such 
 cases colotomy does not offer an absolute certainty of success ; 
 but should it fail resection can be resorted to later, and it is 
 well that the patient should be told before the first operation 
 that the simple colotomy may result in failure. It will be 
 impossible to tell beforehand for what length of time the 
 external opening in the colon will have to be kept open ; but in 
 any case it must not be closed until all bladder symptoms have 
 subsided, and have been absent for several weeks. 
 
 The suffering due to malignant disease of the rectum can 
 be relieved in many cases by removing the constant irritation 
 which is caused by the continuous passage of faeces. This gives 
 not only relief, but prolongs life, as the disease advances more 
 slowly when it is allowed to lie quiescent. It is impossible to 
 estimate the amount of time which is gained by the operation, 
 it will depend in large measure on the stage to which the 
 disease has progressed; but in any case the end comes more 
 easily and with less sufiering. If it were not that the discom- 
 fort and misery resulting from the opening of the bowel, either 
 in front or behind, is always present, Bryant’s suggestion that 
 the disease should be put at rest as soon as it is discovered, if it 
 
THE INTESTINE. 
 
 190 
 
 cannot be entirely removed, would be a very proper line of 
 treatment to adopt. One can hardly advise this plan in the 
 circumstances. To have an artificial anus prevents any one, 
 almost invariably, from living like ordinary people and this 
 being so, some very definite advantage must be expected before 
 the patient can be advised to undergo the operation of colotomy 
 for malignant disease. Undoubtedly there are numerous cases 
 where the operation is perfectly justifiable and right, but it 
 would be difficult to realise that one would consent to have an 
 artificial anus made in oneself unless it were with the expecta- 
 tion of gaining some definite relief from suffering. Ultimately, 
 the decision must rest with the patient, and as a rule it will be 
 given against the performance of the operation unless the disease 
 be giving rise to great distress and misery. 
 
 When there is actual obstruction of the colon, colotomy 
 ought to be performed to save life. Volvulus at its common 
 situation at the sigmoid flexure may have to be treated in this 
 way, if untwisting or lateral anastomosis by means of bone 
 plates cannot be effected. This is by no means a satisfactory 
 termination to such an operation, and it ought never to be the 
 operation of election. Colotomy will also be performed to save 
 life in cases of imperforate anus after an attempt to reach the 
 bowel from below has failed; and for this purpose Littre’s 
 operation is to be preferred, as it is impossible to say that the 
 colon will be present in the loin. So uncertain is the position 
 of the intestine that in such a case a median incision will be 
 probably most satisfactory, more especially as the artificial anus 
 is intended to be kept open, only until another attempt can be 
 made to open the bowel in the ordinary position. 
 
 The mortality of the operation is not very great, whether 
 the lumbar or Littre’s be performed ; but as it is usually under- 
 taken for malignant disease, and when the patient’s strength is 
 spent, the mortality, as shown by statistics, is greater than the 
 severity of the operation ought to justify. The choice of the 
 operation will vary much with the surgeon ; there is not much 
 
THE OPERATION OF LUMBAR COLOTOMY. 191 
 
 to choose between the two, and the lumbar will usually he 
 preferred by those who are not accustomed to abdominal work, 
 the operation being rather more simple, especially when the 
 posterior surface of the colon is unprotected by peritoneum, and 
 this is usually the case. The disadvantages of this operation lie 
 in the anatomical relations of the colon, and also in the fact 
 that the wound 'is deeper, and that there is therefore more 
 danger of infiltration into the divided tissues with resulting 
 septic absorption. 
 
 The Operation of Lumbar Colotomy. 
 
 For the purpose of obtaining as much room as possible be- 
 tween the ribs and the ileum — a space which in exceptional 
 circumstances may measure little more than an inch — the 
 patient is to be placed on his right side and a firm pillow is put 
 underneath the loin. As in all other operations, the patient 
 must be well covered up, with a hot bottle to the feet, and as 
 little of the body as possible exposed. The skin is thoroughly 
 purified, and the incision is made either transversely or 
 obliquely. The guide to the position of the bowel is the edge 
 of the erector spinae, and the incision, when the left side is being 
 operated on, is to be commenced slightly behind this muscle, 
 midway between the crest of the ilium and the ribs, if the in- 
 cision is to be made transversely ; or nearer the ribs if it is to be 
 oblique, the amount of obliquity being determined by the con- 
 figuration of the patient. When the intestine is being opened 
 on the right side the incision begins in front and ends beyond 
 the erector spinse muscle. It is prolonged forwards and down- 
 wards for from two to four inches, the length depending on the 
 thickness of the abdominal wall. In cutting towards the bowel 
 only one surgical landmark need be borne in mind, and that is 
 the border of the erector spinse, the incision being continued on- 
 wards until the subperitoneal fat is reached. To do this easily 
 and in a direct line, forceps on each side of the wound must be 
 
192 
 
 THE INTESTINE. 
 
 used to prevent any deviation. When the suhperitoneal fat is 
 reached, the deeper layers of the wound are divided to the full 
 extent of the external incision if there he any difficulty in 
 finding the colon. When the colon is distended with faeces or 
 with gas there is no difficulty in recognising it. Should it be 
 empty and not easy to find, it may be distended from the 
 rectum with hydrogen gas or air blown in by a bellows, though 
 this is scarcely necessary. The mistake which is usually made 
 is in not keeping the straight line to the bowel with the forceps, 
 the tendency being to reach the peritoneum too far forward, 
 with the result that the abdominal cavity is likely to be entered. 
 When this accident happens, the opening should be closed at 
 once either by drawing it forwards with forceps and surround- 
 ing it wdth a circular ligature if small, or if large by an in- 
 terrupted suture, bringing peritoneal surfaces together. Before 
 this is done the finger should be passed into the cavity and the 
 exact position of the colon determined. If the bowel be not 
 distended, or if a mesocolon be present, the peritoneum may 
 have to be separated to allow of the opening into the gut being 
 made. Before the bowel is opened, it is drawn forward as far 
 as possible with the pedicle forceps, and gauze, soaked in the 
 carbolic and glycerine solution, is packed into the wound be- 
 tween the bowel and the raw surface to prevent any soiling of 
 the cut surface. The incision into the gut itself is made trans- 
 versely when the operation is performed for malignant disease, 
 and longitudinally when it is proposed to close the gut at some 
 future time. Should the colon be filled with hardened masses 
 of faeces, considerable difficulty may be found in getting rid of 
 them, and a great deal of ingenuity has often been required to 
 effect their removal. A bent teaspoon will often prove of service. 
 When the bowel has been emptied, the gauze is removed, and 
 sutures are passed through the ends of the external wound, but 
 are not to be tied until the gut has been secured. The opening- 
 in the gut is then stitched with interrupted silk stitches, each 
 passing through the superficial parts of the external wound and 
 
THE OPERATION OF LUMBAR COLO TOM Y. 193 
 
 the whole thickness of the bowel. The angle formed by the 
 drawing up of the colon directs the faeces towards the outside. 
 The dressing should consist of large antiseptic pads of some 
 absorbent material well sprinkled with iodoform, and for the 
 first day or two covered with a piece of jaconet to prevent the 
 discharge soaking directly through the dressing, which is kept 
 in position by a single broad bandage round the body. The 
 position of the patient after the operation is of little importance, 
 probably on the back is the best ; but the secret of giving 
 comfort lies in the frequent changing of the dressing, for other- 
 wise the skin becomes sodden and irritated. The stitches need 
 not be removed until they begin to cut out, and after the wound 
 is firmly healed the patient may use his ingenuity in devising 
 some means of temporarily closing the opening. A hollow 
 rubber pad distended with air and kept in position by a 
 flannel bandage is likely to do as well as any of the more com- 
 plicated appliances, but the rubber requires to be frequently 
 renewed. When trouble arises from the passage of faeces into 
 the bowel below the opening, the lower orifice may be partially 
 closed with sutures, the bowel being first invaginated as much 
 as possible, and at the time of the operation sutures should 
 always connect the skin and the angles where the bowel has 
 been divided, so as to draw the gut upwards and make the 
 angle very acute. The bowel below the opening must be 
 washed out daily with some warm non-irritating antiseptic 
 fluid. 
 
 When the operation has been performed for simple ulcera- 
 tion of the rectum, it is rather an advantage not to have much 
 of a spur when the bowel is fixed in the wound, and when the 
 opening has been made in a longitudinal direction it may close 
 itself without any operative interference. Should an operation 
 be required to close the opening in the bowel, the surrounding 
 adhesions are to be gradually and carefully broken down or 
 divided with scissors to allow of the colon sinking back towards 
 the abdominal cavity, and thus permit of the passage of the 
 13 
 
194 
 
 THE INTESTINE. 
 
 faeces in the direction of the rectum. If this simple plan fail 
 to effect the closure of the artificial opening, the divided edge of 
 the bowel will have to be refreshed and a few stitches put in, 
 the lumbar wound being then allowed to granulate over. 
 
 LiTTRfi’s Operation. 
 
 Littre’s operation can be performed on either side, though 
 the original operation was on the left. It commonly goes by 
 the name of inguinal colotomy, and this name describes the con- 
 dition very correctly, as it is not advisable to make the opening 
 in the middle line except perhaps when operating for imper- 
 forate anus. The exact site of the incision varies with different 
 operators, some prefer to make it parallel to Poupart’s ligament, 
 an inch or an inch and a half above, commencing a little to 
 the inside of the crest of the ilium, the length of the incision 
 being not less than two, and not more than three inches. Others 
 prefer to make a vertical incision through the left linea semi- 
 lunaris. It does not seem to be of very much importance whether 
 the oblique or the vertical incision is used. The peritoneum is 
 reached, drawn up with forceps, opened, and other forceps are 
 fixed on to it to prevent its separation during the future 
 manipulation. 
 
 Two fingers are passed into the cavity, the colon is drawn 
 up into the wound and examined for the longitudinal striation, 
 to be certain that a piece of small intestine has not been taken 
 hold of. • The colon is then drawn out from above, the lower end 
 being pushed in as this is done, until the mesenteric attachment 
 of the bowel is fiush with the centre of the wound. It is 
 advisable to do this to reduce the risk of future prolapse. Very 
 various methods of fixing the bowel in the wound are used. 
 The principle on which this is done will depend on whether it 
 is expected that the continuity of the bowel can be restored 
 later, or whether the artificial anus is to be permanent. 
 
 When there is no expectation that the opening will be 
 
LITTRE^S OPERATION. 
 
 95 
 
 closed, the object is to afford as free a passage as possible for 
 the intestinal contents to the outside, preventing at the same 
 time their passing into the lower part of the intestine. This is 
 to be managed by flexing the bo\vel as acutely as possible, thus 
 making what is technically known as a spur. The bowel, being 
 kept well forward, is to be opened if there be immediate hurry 
 for doing so, the incision being made in a longitudinal direction 
 for from one to two inches if the disease be not of a malignant 
 character. 
 
 When it is malignant the bowel is to be divided transversely 
 to the extent of nearly half its diameter, and this can be 
 enlarged later if the faeces tend to pass into the lower part of 
 the intestine. Before the bowel is opened, a small sponge 
 attached to forceps or a piece of silk is passed into the abdo- 
 minal cavity, and the wound and bowel are well surrounded by 
 gauze to prevent the possibility of infection of the peritoneum. 
 The contents are then emptied out, and the gut is closed above, 
 either by the Anger and thumb of the assistant, or with a clamp 
 or rubber band. 
 
 In the angle or V caused by the flexure of the bowel, and 
 near to the mesentery, several flne silk sutures are to be 
 introduced connecting the one side of the V to the other, to 
 increase the acuteness of the angle. Interrupted stitches are 
 then to be passed through the abdominal wall, taking a Arm 
 hold of the peritoneum, and then through the bowel, coming out 
 at the opening. By taking in a good part of the peritoneum 
 the bowel can be brought near the surface of the wound. At 
 each angle one or two stitches are passed through the wall on 
 one side, through the bowel, and then they transfix the wall on 
 the other side so as to keep the angles in close apposition to the 
 abdominal peritoneum; and assistance will often be given in 
 doing this if the peritoneum has not been opened to the full 
 extent of the wound. Should the incision have been made too 
 long it must be reduced in size as usual by silk stitches. 
 
 The dressing is the same as in the lumbar operation, and the 
 
196 
 
 THE INTESTINE. 
 
 after treatment differs in no detail from that of any other abdo- 
 minal operation. The stitches are quite enough, as a general 
 rule, to support the bowel ; but if there be any fear of their not 
 being sufficient, a modification of the operation, as described by 
 Maydl, may be performed. A hard rubber cylinder covered with 
 iodoform gauze, or any rigid bar about the size of a goose quill, 
 is passed through a hole made in the mesentery close to the 
 bowel, and the ends of the cylinder resting on the skin on both 
 sides of the wound prevent the bowel from slipping back into 
 the abdominal cavity. The two legs of the drawn out piece of 
 bowel are stitched together on both sides below the cylinder, 
 the sutures not passing through the whole thickness of the 
 intestinal wall. When the bowel is to be opened immediately 
 the edges of the opening are stitched to the skin. When a 
 delay of four or five days can be afforded, iodoform gauze is 
 packed round the gut and underneath the supporting bar; 
 adhesions soon form, and the gut can be incised before the end 
 of the week. When the case goes on well the bowel which has 
 originally been opened to the extent of half its circumference 
 may be completely divided in a few weeks, the bar serving as a 
 useful guide. When this is done, a few stitches will connect 
 the intestine and skin together. When it is desired to close the 
 opening in the bowel, the bar is withdrawn, the bowel is allowed 
 to sink downwards, and the opening may close of itself, or it 
 may be necessary to separate adhesions and close the intestinal 
 opening, after which the gut is passed back into the peritoneal 
 cavity. The operation lends itself to a great variety of minor 
 modifications, but so long as the intestine is so fixed in the 
 wound that there is no septic infection, and the faeces pass easily 
 to the outside, the exact procedure is not of any consequence. 
 
 Before deciding whether Littre’s or Amussat’s operation is 
 to be performed, the advantages and disadvantages of both must 
 be considered in reference to each particular case. In acute 
 obstruction, one can never say with certainty that by opening 
 the colon in either the right or left loin one will be above the 
 
LITTRE^S OPERATION. 
 
 197 
 
 seat of the obstruction, even when a chronic condition predis- 
 posing to acute obstruction is known to be present in the large 
 intestine. In all such cases Littre’s operation is the one to be 
 adopted, either primarily or after the obstruction has been 
 searched for through a median incision. The same operation is 
 to be performed for imperforate anus, with the modification in 
 this case that the median instead of the inguinal incision be 
 adopted. For putting the rectum and colon at rest either of the 
 operations may be chosen, but unless the patient be very stout 
 the lumbar colotomy is the more easy and the more safe. 
 
 The discomfort of the patient after any operation where an 
 artificial anus has been made is lessened often in a very marked 
 degree by the administration of charcoal in the form of lozenges. 
 This helps to keep the contents of the bowel firm, and at the 
 same time prevents disagreeable odours. 
 
 When treating of surgical diseases of the stomach, an 
 operation was described which might save the life of a patient 
 after rupture of a gastric ulcer. Somewhat similar ulcerations, 
 and ulcers due to other causes, occur in the intestine. These 
 consist of ulcerations of the duodenum resembling a gastric 
 ulcer, or in this situation they may follow after an external 
 burn. Ulceration may occur in the course of typhoid fever, 
 dysentery, tuberculosis, and syphilis. Ulceration may also 
 result from the irritation of a fsecal impaction, and the bowel 
 may give way after the reduction of a hernia. 
 
 In any of these cases ulceration may go on to rupture. 
 During the course of any of these foregoing conditions or 
 diseases, when sudden symptoms of collapse accompanied by 
 severe abdominal pain come on, it is probable that a rupture 
 has taken place, and if the general condition previous to the 
 time of rupture has been fairly good, the propriety of an explora- 
 tory abdominal operation may be considered. When it is 
 evident that the perforation is the “ last straw ’’ in the course of 
 the disease, any operation is entirely out of the question. 
 
 When operation has been determined on, the abdomen is to 
 
198 
 
 THE INTESTINE. 
 
 be opened in the middle line, and that part of the intestine is 
 first examined which is usually the seat of ulceration — viz. in 
 typhoid fever, the large intestine or lower part of the ileum ; in 
 dysentery, the large intestine ; in tubercular disease, about the 
 caecum ; in syphilis, about the sigmoid flexure and rectum. 
 
 Injury of the Intestine. 
 
 These result either from gunshot wounds, stabs, or injuries 
 such as a kick or fall ; and in all, success is likely to follow 
 early operation, while if it be delayed even a few hours, the 
 successful cases will be much less numerous. A gunshot wound 
 of the abdomen does not necessarily mean perforation of the 
 intestine. In judging whether the peritoneum has been injured 
 we have to take into consideration the direction from which the 
 bullet was fired. It may be difficult to get any definite informa- 
 tion concerning this, and we may have to draw our inference on 
 the subject from the appearance of the external wound. A bullet 
 striking the abdomen at right angles will give evidence that it 
 has done so by the equal appearance of injury or bruising round 
 the opening ; while if it has struck obliquely the bruising will 
 be irregular, and the opening will probably be not so clean cut. 
 As cases are on record where a bullet has passed round the 
 abdomen without injuring the peritoneum, there seems to be no 
 valid reason why a probe should not be passed gently into the 
 wound. In the hands of an educated surgeon the instrument 
 can surely do no harm, and it may give a positive indication 
 whether the peritoneum has been opened or not. The one 
 certain symptom of perforation of the intestine will be the 
 appearance of the contents at the external opening. This is 
 unfortunately seen only in rare cases. When the case is seen 
 early, the symptoms will be chiefly those of collapse due to the 
 shock, and possibly also to hasmorrhage. If not seen for some 
 hours, the shock will have passed away as a rule, and there will 
 be evidence of peritonitis, probably of a septic character. 
 
INJUR Y OF THE INTESTINE. 
 
 199 
 
 Treatment . — In every case where the peritoneum has been in- 
 jured by a bullet the abdomen should be opened without waiting 
 for symptoms, unless the shock be very profound and apparently 
 not due to haemorrhage. In such cases, almost more than in 
 any other, every care must be taken to keep the patient warm, 
 and the perforated rubber sheet must be employed, partly for 
 this purpose, and partly to keep him dry, as the peritoneal cavity 
 is certain to require washing out. The incision ought to be 
 made, as a general rule, in the middle line. From this position 
 all parts of the abdominal cavity can be reached, and an in- 
 vestigation of the exact injury more easily made. The incision 
 must be a free one, certainly not less than will easily admit the 
 whole hand. As soon as it has been made, the peritoneal bullet 
 opening must be examined in case there should be bleeding ; 
 and if there be much blood in the peritoneal cavity it must be 
 cleared out, and its origin searched for and secured. While this 
 is being done, an opening may be discovered in the intestine, 
 and if so it must not be allowed to pass out of sight, and it is to 
 be stitched up in the following way as soon as the bleeding has 
 been arrested. The edges are cut smooth if necessary. The 
 direction of the line of union should be in the transverse 
 diameter of the bowel, so as to prevent constriction. A 
 continuous suture is to be used as described in the operation 
 of gastrorraphy ; a few interrupted sutures, or another layer of 
 continuous ones, may be inserted to give support. If no other 
 openings have been seen while searching for haemorrhage the 
 intestine should at once be distended, according to Senn’s plan, 
 by the insufflation of hydrogen gas from the rectum. With the 
 coils in sight it will be easy to notice whether there is any leak, 
 although its exact position may not be discovered until the gas 
 has been ignited after the coil of intestine has been drawn 
 outside the wound. The flame can be extinguished by placing 
 a damp sponge on the opening. This rent is closed as before, 
 and the distension is continued until the whole of the intestine 
 has been examined, unless the condition of the patient be too 
 
200 
 
 THE INTESTINE. 
 
 bad to allow of this amount of manipulation. When the disten- 
 sion is found to interfere very much with the examination of the 
 upper part of the bowel, the insufflation from the rectum might 
 be stopped, a long tube passed through the sphincter ani to allow 
 the gas to escape, and the upper part of the gut distended by 
 the hydrogen which is passed in through the wound opening, 
 the assistant preventing the backward flow of the gas. The 
 abdomen is then thoroughly washed out with warm water 
 at a temperature about 100° F., and this may be done by 
 the assistant while the surgeon is closing the perforations. A 
 drainage tube, where there has been extravasation of the contents 
 of the bowels, must always be used. The median wound, and 
 the one made by the bullet, are closed in the usual way. 
 
 The great dangers are shock and septic peritonitis, and 
 stimulating enemata will be required as soon as the patient 
 is put back to bed. In cases where there is injury to the 
 mesentery, possibly sufficient to stop the blood supply to the 
 bowel, the fear of gangrene will make it desirable to make a 
 resection of the gut, the injured part of the mesentery being 
 removed in a V-shaped manner. The chance of recovery in a 
 case of this kind is very small, and wfflen the operation is a 
 prolonged one, several openings having to be closed, it might be 
 better to draw the part of the bowel whose mesentery has been 
 injured into the parietal wound, and to fix it there by passing 
 a quill covered with iodoform gauze under the bowel, wfflile 
 the rest of the wound is packed with gauze so as to shut off the 
 peritoneal cavity. If the bowel remained healthy the quill and 
 gauze could be removed at the end of a couple of days ; if it 
 sloughed, an artificial anus would be formed, and this could be 
 operated on at some future time. 
 
 Puncture Wounds of the Intestine. 
 
 The treatment of puncture wounds of the abdomen does not 
 vary from that of those inflicted by bullets, but in an injury 
 
RUPTURE OF THE INTESTINE. 
 
 201 
 
 from such a cause the intestine is less apt to be wounded, for, 
 being more or less non-resisting, it may be pushed aside by the 
 cutting instrument. It is more likely to be injured when the 
 gut is distended than when it is in a collapsed condition ; but 
 as it ought to be a recognised practice to open the abdomen in 
 all cases where there is a penetrating wound of the abdominal 
 wall, an opportunity will be given for examination, assisted by 
 distension by hydrogen gas. The injury inflicted by a knife, 
 pitchfork, etc., is likely to be a less severe one than when the 
 abdomen has been perforated by a bullet. The treatment is the 
 same, either suturing the opening or openings, resection, or the 
 formation of an artificial anus if the mesentery be much injured. 
 The after treatment is similar to that which has been recom- 
 mended in operations on the stomach and intestines ; most of 
 the nourishment, however, is to be given through the rectum for 
 the first few days. The enemata are to be diluted as largely as 
 possible, if thirst, which is likely to be a prominent symptom, is 
 more distressing than usual. 
 
 Eupture of the Intestine. 
 
 Eupture is of necessity a fatal accident if the opportunity be 
 not given to close the opening by sutures. This accident may 
 be caused either by direct or indirect violence, as a blow, a kick, 
 a fall, being run over, or coming forcibly against a bar, are 
 examples of the former ; a fall on the back of the latter. The 
 symptoms come on at once, there is collapse usually of a very 
 severe character ; as the patient comes out of the collapse, pain 
 sets in of such a severe nature that it is usually necessary to 
 give a large dose of morphia before any examination can be 
 made. There is nausea and vomiting, restlessness, retention of 
 urine, and other symptoms which commonly follow cases of 
 severe injury. The situation of a rupture caused by direct 
 violence is usually in that part of the small intestine which is 
 least movable, excepting only the duodenum, the most fixed 
 
202 
 
 THE INTESTINE. 
 
 part of all, because it, like the large intestine, is well protected. 
 Eupture due to indirect violence is usually found in the duo- 
 denum. The actual injury to the bowel is of the nature of a 
 contused or lacerated wound, and more or less evidence of this 
 will be seen surrounding the opening in the gut when the 
 abdomen has been opened. This bruised condition of the bowel 
 has to be borne in mind when we come to the treatment, and 
 a bruised and injured state of the mesentery must also be 
 expected. 
 
 Symptoms arising from a case of bruising of the abdominal 
 contents, especially if the injury be in the upper part of the 
 abdomen where so much of the sympathetic nervous system lies, 
 are very similar to those where an actual lesion of the bowel has 
 taken place. To distinguish between these two conditions, when 
 the case is seen before there is much distension, an attempt 
 should be made to make a diagnosis by distending the intestine 
 by hydrogen gas. If the gut be intact the intestine will distend 
 gradually from below, and will finally reach the stomach ; when 
 there has been a solution of continuity, the distension will be 
 more general, and the edge of the liver will be lost much more 
 early, as is described by Senn. There is one special source of 
 fallacy, and that is, that a rupture high up in the small intestine 
 would not allow of the appearance which is due to the passage 
 of the gas into the peritoneal cavity, for the abdomen would be 
 already well filled with the distended coils. 
 
 Treatment — When the diagnosis of rupture is made, treatment 
 should follow immediately ; the abdomen should be opened in the 
 middle line, when probably a mixture of blood and the contents 
 of the intestine will have to be removed either by sponging or 
 by washing out with warm water before any examination can be 
 made. The arrest of the hemorrhage must be the first thing to 
 be attended to. When this has been accomplished the nature 
 of the injury to the bowel will be investigated, but in any case 
 it is probable that the best hope of saving the life of the patient 
 will lie in the immediate formation of an artificial anus, the 
 
RUPTURE OF THE INTESTINE. 
 
 203 
 
 whole of the bruised part of the intestine being fixed in the 
 wound as in the manner described in Littre’s operation. If the 
 patient recover from the injury, the continuity of the intestinal 
 tract can be renewed later. This method seems to give a better 
 chance of success than resection. A simple stitching up of the 
 rent in the bowel is not likely to be often successful on account 
 of the bruising which is certain to be present, even although 
 there may not be much evidence of it at the time of operation. 
 So far, we have treated the condition as if the bowel had been 
 injured at one point only. Should, unfortunately, there be 
 several ruptures, it is almost certain that the patient will die. 
 In such a case it would probably be better to suture the openings 
 immediately, unless the bruising were very marked or the 
 mesentery much injured, as much of the edges of the gut being 
 turned in as can well be managed. Any specially badly injured 
 portion can be fixed in the wound. What seems best at the 
 moment must be done, but in any case the friends must be 
 warned that they may look for an almost certainly fatal result. 
 
 In every case of rupture the abdominal cavity is to be 
 thoroughly washed out, and a drainage tube introduced to drain 
 the cavity from the bottom. 
 
 An interesting example of the necessity of leaving nothing 
 to chance, of never giving up hope, and saying the injury is too 
 severe and nothing can be done, is illustrated by the history of 
 an accident which occurred about fifty years ago on a ship in 
 the arctic region. In this case, although the intestine was not 
 actually ruptured, the knowledge of abdominal surgery was so 
 slight, that comparatively the chances of recovery were as small 
 as if a rupture of the intestines had occurred at the present 
 time. Two whalers were blocked in the ice some distance apart, 
 a sailor fell from the rigging of one on to the deck, severely 
 rupturing the abdominal wall, through which there was a large 
 protrusion of the intestine. The “ doctor ” on board, a second- 
 year medical student, not knowing what to do, sent over for 
 assistance from the other ship. This ‘‘doctor” took the common- 
 
204 
 
 THE INTESTINE. 
 
 sense view that the prolapsed intestine should be washed, put 
 hack into the abdominal cavity, and the laceration in the 
 abdominal wall closed by stitches. During the night the ships 
 separated, and the doctor ” on the second ship heard nothing 
 more of the case until he reached home. As he landed on the 
 pier at Peterhead several sailors who were lounging about raised 
 a cheer, and one of them came forward and told him that he was 
 the patient whose belly he had sewn up ! 
 
CHAPTEE VIIL 
 
 THE APPENDIX. 
 
 An inflammation situated in the right iliac region has long been 
 known under the names of typhlitis and perityphlitis, the terms 
 representing either an inflammation in the caecum or in the 
 tissues round about it. But the names were used very in- 
 definitely, and it came to this that a typhlitis or perityphlitis 
 signified an attack of inflammation either with or without 
 perforation of the bowel somewhere in the right iliac region. 
 Classifications of various kinds have been made, founded more 
 on opinions than on exact pathological conditions; and, although 
 the pathology has now been very much cleared up, the tendency 
 is still to make classifications which will not bear the test of 
 bedside examination, and which tend to confuse rather than to 
 simplify the study of this diseased condition. 
 
 As the name implies, appendicitis means an inflammation of 
 the appendix, and the disease, which was known under the 
 names of typhlitis and perityphlitis, was in reality an inflam- 
 mation of the appendix, at least in the great majority of cases. 
 In the present state of our knowledge we are not prepared to say 
 positively that such a disease as a simple typhlitis or perityphlitis 
 can never exist without the appendix having been inflamed ; and 
 in one instance we have seen strong evidence that such might 
 be the case, though the history was not rendered complete by a 
 post mortem examination. This disease has become of the very 
 greatest importance in abdominal surgery. It seems that, as 
 
2o6 
 
 THE APPENDIX. 
 
 with every new thing, the pendulum has swung too far towards 
 operation, and that the time is coming, as it has already come 
 in the operation for the removal of the ovaries, that a definite 
 stand must be made against the indiscriminate removal of the 
 appendix vermiformis. One firm of instrument makers in New 
 York is reported to have made to order six dozen trusses for 
 ventral hernia, following the removal of the appendix, during 
 the first six months of 1893 ! Even if this meant carelessness 
 in the closure of the wound in every case, it surely indicates a 
 number of unnecessary operations ; and it is probable that many 
 of the patients would gladly have back their appendix if they 
 could get rid of the hernia. 
 
 Surgical Anatomy. 
 
 According to Quain, the position of the caecum and appendix 
 is as follows : “ The caecum is situated in the right iliac fossa, 
 immediately behind the anterior wall of the abdomen. It is 
 covered by the peritoneum in front, below, and at the sides ; but 
 behind, it is usually destitute of peritoneal covering, and is 
 attached by areolar tissue to the fascia covering the right iliacus 
 muscle. In this case the caecum is comparatively fixed, but in 
 other instances the peritoneum surrounds it almost entirely, and 
 forms a duplicature behind it, called meso-caecum. Coming off 
 from the inner and back part of the caecum, at its lower end, is 
 a narrow, round, and tapering portion of the intestine, named 
 the appendix caeci, or appendix vermiformis. The width of this 
 process is usually that of a large quill, or rather more, and its 
 length varies from three to six inches, these dimensions differing 
 much in different cases. Its general direction is upwards and 
 inwards behind the caecum, and after describing a few slight 
 turns it ends in a blunt point. It is retained in its position by 
 a small fold of peritoneum, which forms its mesentery. The 
 caecal appendix is hollow as far as its extremity, and its cavity 
 
SURGICAL ANATOMY. 
 
 207 
 
 communicates with that of the caecum by a small orifice, some- 
 times guarded by a valvular fold of mucous membrane.” 
 
 The appendix does not seem to be of any use in the economy 
 of man, and its removal does not give rise to any disturbing 
 symptoms. Its structure is the same as that of the large 
 intestine, and its mucous membrane contains glands which give 
 off a mucous secretion. In length it varies very considerably, it 
 may be almost entirely wanting, or it may measure as much as 
 eight or nine inches. The reduplication of the mucous membrane 
 situated in the caecum at the origin of the appendix is to be 
 specially noticed, as its presence or absence may have something 
 to do with preventing or causing attacks of inflammation. The 
 point where the appendix comes off from the caecum is recognised 
 as being situated at a spot midway between the umbilicus and 
 the anterior superior spine of the ileum ; but as the caecum is 
 capable of relaxation and distension this spot cannot be an 
 absolutely flxed one. 
 
 The position of the appendix in the body varies very 
 considerably, and the different positions which it takes up 
 are of importance when surgical interference is required, as 
 the situation of an abscess resulting from perforation of the 
 appendix will depend on the position of that tube. The 
 different positions in which it may be found are downwards, 
 inwards, upwards and to the outer border of the CcCCum, 
 upwards and to the inner border, upwards and very much 
 behind. It is therefore evident that the appendix may be 
 found in any relation to the csecurn, and it is necessary to 
 know this both when making a diagnosis and when performing 
 an operation. In other words, the appendix may be so situated 
 that a rupture may set up either general peritonitis or inflam- 
 mation of the cellular tissue behind the peritoneum. 
 
 In addition to what may be called the natural positions, the 
 appendix may be fixed by adhesions in almost any part of the 
 abdomen. The exact relation of the peritoneum to the appendix 
 requires further consideration. In the description quoted from 
 
2o8 
 
 THE APPENDIX. 
 
 Quain, it is mentioned that the appendix is provided with a 
 mesentery, and this undoubtedly appears to be the general rule, 
 the tube being therefore free in the abdominal cavity with the 
 exception of this connection. In a minority of cases it is certain 
 that the appendix is not entirely surrounded by peritoneum, 
 but is in direct connection for a part or the whole of its length 
 with the subperitoneal tissues. This explains how it is possible 
 for a rupture to take place directly either into the peritoneal 
 cavity or into the cellular tissue behind. 
 
 Causes of Appendicitis. 
 
 The causes of appendicitis consist in the result of the presence 
 of a foreign body, such as a cherry-stone, pin, fish-bone, or scybala, 
 in the canal ; or the same result may be brought about by a stenosis 
 due to an acute flexion, or a cicatricial contraction. Of these 
 the most common is the presence of scybala. Pointed foreign 
 bodies act as direct irritants, and cause injury on account of 
 their shape. A rounded foreign body found in the appendix, 
 such as a small faecal mass, probably acts in the following way : 
 having passed into the appendix it either completely blocks 
 the canal, or it sets up so much irritation and swelling of the 
 wall, that a block soon occurs. The vessels then become engorged, 
 mucous secretion is poured out freely, and there is tension in 
 that part of the appendix between the foreign body and the 
 outer end. Should the obstruction not be relieved, the congested 
 mucous membrane pressed on by the pent-up secretion becomes 
 inflamed, suppuration or perforation may result, or the whole of 
 the tube may become gangrenous, the later stages being assisted 
 by the near presence of intestinal microbes. Exactly the same 
 process occurs when the appendix is doubled on itself. In the 
 early stages, if the obstructing cause be removed, the tube 
 empties itself, and resolution takes place. The explanation 
 given by Talamon of the presence of scybala is, that they must 
 be formed in the caecum, and that they are never made by the 
 
PATHOLOGICAL CONDITIONS. 
 
 209 
 
 passage of fluid fseces into the appendix. Did the faeces pass 
 into the appendix in the fluid state they would take on the 
 shape of the appendix, for there would not be any room for the 
 round pellets to be formed. In the caecum a faecal mass becomes 
 broken up into small pieces, and these become rounded on each 
 other through the peristaltic action of the intestine. The 
 tendency to the formation of these faecal masses is encouraged 
 by the presence of chronic colitis, and this condition is accom- 
 panied by want of contractive power in the wall of the bowel. 
 According to Talamon, the causes predisposing to appendicitis 
 are excess of food, especially if the food be indigestible and 
 highly spiced, thus giving rise to a condition of the intestine 
 favourable to the formation of scybala, namely constipation ; 
 irritation, followed by constipation and atony ; previous diseases, 
 which affect the colon, or leave it in an injured condition, such 
 as typhoid fever and dysentery, as these certainly favour the 
 production of constipation, and are also apt to leave behind 
 ulceration or inflammation of the mucous membrane. 
 
 An ulcer near the orifice of the appendix may cicatrise in 
 such a way that the ingress of a small fecal mass is favoured 
 while its egress is rendered more difficult. An additional cause 
 of disease of the appendix is tuberculosis, ulceration due to this 
 disease being common in the neighbourhood of the appendix. 
 The disease is more frequent in persons under the age of forty, 
 the most common age being between ten and thirty, and it is 
 more often found in males than in females. It is comparatively 
 rare after forty. A chill following violent exercise seems to be 
 very frequently a predisposing cause. 
 
 Pathological Conditions. 
 
 To understand the symptoms of this disease, and to form a 
 certain amount of classification, it is necessary to explain exactly 
 what are the pathological conditions which may be set up in 
 the appendix itself, and also those which may follow the rupture 
 14 
 
210 
 
 THE APPENDIX. 
 
 of the tube if the disease he not cured before this stage has 
 been reached. 
 
 The pathological stages are : first, simple congestion of the 
 wall with tension due to the retention of the secretion. This 
 results in a simple inflammatory action, which may resolve 
 before any more serious stage has been reached, provided the 
 cause be removed. Second, suppuration may supervene if the 
 cause be not removed, or if the inflammatory action be very 
 acute and septic. Third, gangrene may follow the suppuration. 
 Fourth, the disease may spread beyond the appendix, and the 
 lesion so formed will consist either in inflammation in the 
 peritoneum, or of a suppuration in the cellular tissue. 
 
 These pathological conditions will now be considered seriatim. 
 When the condition has not passed beyond that of simple 
 inflammation, it may be expected that the disease will resolve, 
 if the foreign body which is blocking the canal passes backwards 
 into the colon or becomes broken up in situ. A free drain is 
 thus formed for the removal of the pent-up secretion, tension is 
 relieved, and the appendix returns to its normal condition. 
 This condition may become chronic when the cause is not 
 entirely removed, because a sufficient amount of obstruction 
 remains to prevent the appendix from returning to its natural 
 condition. It must be evident that a condition of this kind 
 may at any time be subject to an acute exacerbation, and 
 this may account for some of the cases known as relapsing 
 appendicitis. 
 
 In the second variety the contained fluid has become puru- 
 lent, and the walls of the appendix are suppurating ; this 
 condition may also resolve, if the tube be allowed to drain freely 
 into the caecum, but it will leave behind peritoneal adhesions, 
 and a more or less damaged condition of the tube itself. 
 
 When the obstruction and consequent strangulation is very 
 acute, gangrene may follow in a very short time, and it will 
 either show itself in the form of a complete destruction of the 
 whole appendix, or there may be simply one or more per- 
 
PATHOLOGICAL CONDITIONS. 
 
 21 I 
 
 forations. The opening is usually easily visible, but sometimes 
 it may be very minute. When the disease has spread beyond the 
 appendix, towards the peritoneal cavity, a localised peritonitis 
 will be the first result, except in those cases where the appen- 
 dicular inflammation has been so acute that there has hardly 
 been time for a localised peritonitis, or at least for this 
 peritonitis to form adhesions. The formation of adhesions is to 
 be looked upon as a safeguard, as their presence may limit, for 
 a time at least, the spread of the inflammatory action to the 
 general surface of the peritoneum. The position in which these 
 adhesions will form will depend on the situation of the 
 appendix. At the commencement of the formation of adhesions 
 the appendix need not have ruptured, and if the appendicular 
 inflammation resolve, the localised peritonitis will also probably 
 resolve, unless the patient be imprudent and so run the risk of 
 a chill too early ; in this case it is probable that the peritonitis 
 will be lit up afresh, while the appendix may remain un- 
 affected. 
 
 When rupture occurs after adhesions have formed, the local 
 peritoneal inflammation will be increased, and an abscess will 
 form within the . adhesions in the peritoneal cavity, and yet 
 shut off from it. This abscess may in turn rupture into the 
 intestine, bladder, or general cavity of the peritoneum, and this 
 accident will be followed by an attack of acute septic peri- 
 tonitis. 
 
 When describing the relations of the appendix, we drew 
 attention to the possibility of rupture occurring into the cellular 
 tissue behind the peritoneum. As the appendix is entirely 
 covered by peritoneum in the majority of cases, and as in those 
 in which it is practically sessile and lying in contact with the 
 subperitoneal tissue, the part uncovered by peritoneum is small, 
 it follows that rupture in this position will occur less frequently 
 than in the direction which we have been considering. An 
 abscess resulting from the rupture of the appendix into the 
 cellular tissue may attain to a large size, and its exact situation 
 
212 
 
 THE APPENDIX. 
 
 will depend upon the position of the tube itself. It may pass 
 deeply into the pelvis, or into the iliac fossa, or behind the 
 caecum into the back, forming a tumour in the lumbar region, 
 which may extend up to and perforate the diaphragm, causing 
 an empyema. Talamon says : “ A forward and inward deviation 
 of the appendix explains those cases where the pus collects 
 above, and to the inner side of the iliac fossa, in the neighbour- 
 hood of the umbilicus. Occasionally we may see an abscess 
 evacuated through the umbilicus itself. It seems probable that 
 those cases of encysted suppurative peritonitis, described in 
 children as of spontaneous origin, and terminating by resolution 
 after an evacuation of the pus through the umbilicus, are 
 nothing more than cases of appendicitis belonging to this third 
 class.” 
 
 Clinical G-roups. 
 
 Appendicitis in all its phases is to be looked upon as a 
 single disease, but, as the symptoms vary with the severity of 
 the inflammation, and also with the ulterior results of this 
 inflammation, we may for clinical purposes make the following 
 groups : — 
 
 First, cases of simple inflammation of the appendix, possibly 
 with suppuration in the walls, which may be cured by medicinal 
 treatment ; second, cases where the disease appears to be cured 
 for a short time, but where the apparent recovery is quickly 
 followed by a relapse, because the original cause has not been 
 removed ; and third, cases where perforation of the appendix 
 has taken place, with the conditions which follow this accident. 
 
 When an appendicitis of the first variety has been cured, it 
 does not follow that the patient will never have a similar attack. 
 When once a hard mass has passed into the oriflce,a second may at 
 some future time pass in. A case of this kind is not to be con- 
 founded with the second variety, the relapsing appendicitis. In 
 the one case there is so far an absolute cure, as when a stone 
 lias been removed from the bladder there is no reason why a 
 
SIMPLE INFLAMMATION. 
 
 213 
 
 second should form ; while in the other, the relapsing form, the 
 cause of the distress is not removed, it has simply quieted down, 
 and is analogous to the synovitis caused by a loose cartilage in 
 the knee-joint slipping out of position. 
 
 The relapsing or second type is caused by the retention of 
 mucus in the tube by a bend due to adhesions ; or by partial 
 cicatricial contraction as a result of ulceration ; or it seems 
 possible that a scybalous mass may remain in the appendix, 
 causing a partial block, which at times may become complete ; 
 or there may be a chronic catarrhal condition of the tube, and 
 as the canal is so narrow a slight extra swelling would dam 
 back the secretions, and cause a recurrence of the local and 
 general symptoms. 
 
 Inflammation the result of a perforation, the third division, 
 has been already discussed when considering the different 
 positions in which the appendix may be found. 
 
 Sympto]\is of Simple Inflammation of the Appendix. 
 
 The commencement may be very sudden, or it may be 
 ushered in by scarcely noticeable symptoms of derangement of 
 the digestive tract. It is met with usually under the age of 
 forty, more commonly in males who are in good health, who 
 are accustomed to live well, and who may have been troubled 
 at times with flatulence. They may have suffered from some 
 irritability of the intestines, especially of the lower bowel, this 
 being shown by the occasional passage of fseces mixed with mucus. 
 In every case the actual onset of a first attack is sudden. The 
 patient is seized with a pain of an acute character in the right 
 iliac region. Accompanying this there will be an attack of 
 colic, the pain being referred to the umbilicus, and there may 
 be vomiting, this latter symptom, however, being due to the 
 severity of the pain. The colic passes away, leaving a dull 
 aching pain in the original position in the iliac region, and at 
 this stage there is constipation due to the paresis following the 
 
214 
 
 THE APPENDIX, 
 
 acute attack of colic. The onset of the pain in the right iliac 
 region is of a character similar to that of renal or biliary colic, 
 and is to be differentiated from these by the position from which 
 it starts. This position, known as McBurney’s point, is situated 
 midway between the umbilicus and the anterior superior spine 
 of the ilium of the right side, and the direction in which the 
 pain passes is backwards and into the pelvis, or towards the 
 umbilicus. In biliary colic, there may be some history of liver 
 derangement, the situation of the pain is over the gall-bladder, 
 radiating through to the back and shoulder, and also towards the 
 umbilicus. In renal colic, the pain commences in the back, and 
 passes downwards towards the bladder, and there may be also 
 symptoms to direct one’s attention to the kidney. When a 
 patient is suffering from an attack of renal, biliary, or appen- 
 dicular colic, he has considerable difficulty in describing in what 
 direction the pain radiates, but he is likely to be able to fix the 
 point where it first started. 
 
 The general condition of the abdomen is not to be relied 
 on for the purpose of diagnosis, for, while at first it is usually 
 retracted, later it frequently becomes distended. In the iliac 
 region there will be a decided amount of resistance, due to the 
 spasm of the muscles protecting a tender spot. After the acute 
 attack of pain is over, and the case is progressing favourably, 
 there is little general disturbance ; there may or may not be some 
 slight rise in temperature, but the pulse shows more sign of dis- 
 turbance. The tongue is coated, the bowels are inclined to be con- 
 fined, and the patient feels out of sorts. At the end of a week or 
 ten days the patient will have recovered, if the cause of the disease 
 have disappeared quickly, and he soon returns to his normal 
 condition. 
 
 Symptoms of Eelapsing Appendicitis. 
 
 The symptoms of the relapsing form of appendicitis are 
 simply those which are seen in an ordinary acute attack, but, 
 instead of a cure resulting by medical means, a second attack or 
 
SYMPTOMS OF PERFORATING APPENDICITIS. 215 
 
 relapse takes place within a short time, usually in from one 
 week to two months — the patient now having been thoroughly 
 well in the meantime — and during each acute attack there is 
 nothing peculiar which will differentiate it from a first seizure 
 of this kind. In the interval, there is usually slight dull aching 
 pain in the right side, a tendency to colic and constipation, and 
 the patient is more or less out of sorts. On examination we 
 either find increased resistance, or the dilated appendix may be 
 felt as an elongated mass about the size of a finger. This 
 swelling, however, may not always be made out, as it may easily 
 be situated in such a position that it is too well protected to 
 be come on during the examination. 
 
 Symptoms of Perfoeating Appendicitis. 
 
 The cases of this disease must be divided into three clinical 
 types : first, where the onset is rapidly followed by an attack 
 of general abdominal pain, occurring within about forty -eight 
 hours, and due to a perforation communicating directly with the 
 general peritoneal cavity. Second, where the rupture occurs 
 after sufficient adhesions have been formed to prevent a general 
 infection of the peritoneum, and the attack may be cured at this 
 stage, or there may be a second acute exacerbation due to the 
 giving way of the adhesions, general peritonitis resulting. Third, 
 where the rupture has taken place outside the peritoneum, and 
 into the cellular tissue. 
 
 Symptoms of the Eapidly Perforating Type. 
 
 After the first attack of acute pain is over, the patient feels very 
 much better, except for the dull aching pain in the side ; then, 
 within three days from the commencement of the attack, there is 
 sudden relapse, caused by the passage of an active and almost cer- 
 tainly septic irritant from the appendix into the peritoneal cavity. 
 The disease has now passed beyond the appendix, and the symp- 
 toms will be those of acute septic peritonitis. The primary result of 
 
THE APPENDIX. 
 
 216 
 
 this irritation is an attack of violent colic, rapidly followed by a 
 steady pain all over the abdomen, worse perhaps in the right 
 side at the commencement ; and there soon comes to be a state 
 of absolute paresis of the intestine. At the very first this is 
 not accompanied by abdominal distension, though this symptom 
 appears later. The bowels do not move, and no flatus passes 
 down, unless the poison be quickly removed by a successful 
 surgical operation. The patient commences to vomit, wind 
 comes up, and there may be hiccough. Everything taken into 
 the stomach is rejected; the vomited matter is at first green, 
 gradually altering in appearance until it is almost black, and 
 the odour is heavy and disagreeable. At first there is consider- 
 able straining, later the stomach empties itself almost without 
 effort. Along with this stoppage of the functions of the intes- 
 tine, the kidneys cease to secrete urine in any quantity ; what 
 is passed is of a high colour ; no urates are deposited ; and the 
 power to empty the bladder may be lost. The skin is harsh and 
 dry, and the sweat glands will not act. There is great thirst, 
 the tongue is bright red or dark brown, and like a piece of dried- 
 up meat. The temperature is generally little over normal, 99'5° 
 or 100° E., and is rarely so high as 102°. The pulse becomes 
 steadily quicker, and as steadily more feeble and wanting in 
 volume. The appearance of the patient is very characteristic, 
 the drawing up of the legs, the restlessness of the arms, the want 
 of expression, all make up a picture that can never be forgotten. 
 Death occurs on the second, third, or fourth day from the time of 
 perforation ; very rarely the patient lasts into the fifth day from 
 the time when the rupture occurred. This is a shorter period 
 than some of the descriptions would lead one to believe ; but a 
 peritonitis due to rupture must be more or less septic ; and when 
 the patient has lived on into the second or third week it is 
 evident that the commencement of the condition was that of 
 rupture within adhesions, and that a second rupture must have 
 taken place through those adhesions, and into the general 
 peritoneal cavity at a later date. 
 
SYMPTOMS OF SECONDARY RUPTURE. 
 
 217 
 
 Symptoms of Rupture after Adhesions have formed. 
 
 When the rupture occurs at a later period, after the inflamma- 
 tion has spread from the appendix to the surrounding peritoneum, 
 setting up a peritonitis with the usual effusion of lymph, in this 
 way forming adhesions ; the result is that the poison does not 
 pass at once into the general peritoneal cavity, but is encysted 
 in a circumscribed part by the peritoneal adhesions, and the 
 pus may remain in this situation without an opening forming 
 into the general peritoneal cavity. The symptoms therefore 
 come on more slowly, and are not so acute. The onset of the 
 attack is the same as already described, the pain becomes fixed 
 in the right iliac region, there is a little general disturbance with 
 some rise in pulse and temperature, and there is usually constipa- 
 tion. The abdomen is not distended. At the end of about a 
 week there is a distinct exacerbation of all the symptoms, caused 
 by rupture having taken place. This is accompanied by a feel- 
 ing of chilliness, without necessarily an absolute rigor. 
 
 At this time the abscess forms, and its presence will be shown 
 by the increase in the pulse and temperature, the latter rising 
 late in the afternoon, and falling in the morning as much as 
 perhaps two degrees. After a few days the very acute symptoms 
 may pass off, or there may be a rupture of the adhesions, followed 
 by acute septic peritonitis. When the pus remains within its 
 adventitious membrane, local examination of the abdomen will 
 show an increased amount of resistance in the right side ; and a 
 swelling, the exact position of which will vary with the situation 
 of the appendix. It will at best be not very clearly defined, and 
 it may or may not be felt on rectal or vaginal examination. The 
 want of definition in the swelling is accounted for by the presence 
 of the inflammatory adhesions which have matted together the 
 coils of intestine, and which make up, with the abscess itself, 
 the swelling which is felt. When the abscess does not rupture 
 into the peritoneal cavity, its presence may cause death simply 
 by septic absorption ; or it may burrow in different directions, 
 
2I8 
 
 THE APPENDIX. 
 
 and give rise to a fatal result by opening into a large blood 
 vessel ; or it may open into the intestine or bladder ; or the pus 
 may discharge externally. When it opens in any of these 
 directions, except when into a blood vessel, a cure is likely to 
 result after a more or less prolonged discharge. Death may, 
 however, be due to exhaustion, or to the absorption of the putrid 
 discharges. 
 
 Symptoms of Eupture outside the Peritoneum. 
 
 When the rupture occurs directly into the cellular tissue, 
 the symptoms will be somewhat less marked. Before it occurs 
 there will not have been so much general disturbance as is the 
 case when many peritoneal adhesions have been forming ; but 
 in other respects there is not much difference, except in degree ; 
 the feeling of chill, the pain, the tenderness in the right side, 
 and the rise in temperature, will all be present. Later, in a case 
 where the pus has come near the surface, there will be some 
 oedema under the skin, and the whole of the cellular tissue of 
 the back, reaching as high as the diaphragm on that side, may 
 become the seat of an abscess. 
 
 Diagnosis . — Nothing can be more simple than the diagnosis 
 of a typical case of appendicitis. The suddenness of the onset, 
 the pain in the right iliac region, and the general abdominal and 
 constitutional symptoms as shown by some degree of fever, 
 especially when these all occur in a youth or a man under forty, 
 are, when taken together, so very distinctive, that a mistake 
 as to the nature of the disease would be somewhat difficult 
 to make. 
 
 When the patient is not seen until the attack is far advanced, 
 there may be then some difficulty, even in a typical case. The 
 symptoms resemble those of obstruction, and the suddenness of 
 the onset, and other early symptoms, may not have been parti- 
 cularly noticed by the patient or tlie friends. The more acute 
 the attack, the more easy is the diagnosis. It is necessary to 
 
DIAGNOSIS OF APPENDICITIS. 
 
 219 
 
 make a double diagnosis in this diseased condition of the 
 appendix ; it has first to he differentiated from an acute attack 
 of intestinal obstruction, and, after a diagnosis of appendicitis 
 has been made, we have to go a step farther, and to make up 
 our minds whether the case is one of simple inflammation with- 
 out perforation, and therefore curable without operation ; or one 
 where a perforation either has already taken place, or is likely 
 to do so, and is consequently a case where medicinal remedies 
 would be worse than useless. 
 
 In considering the differential diagnosis between appendicitis 
 and acute intestinal obstruction, we find, in regard to the 
 question of age, that appendicitis is most usually met with 
 between the ages of ten and thirty. In this respect it resembles 
 obstruction due to paresis; but differs somewhat from intus- 
 susception, which is more common under the age of ten ; and 
 differs in a greater degree from obstruction due to bands, 
 volvulus, and concretions, which are met with, as a rule, in 
 middle life. 
 
 In regard to the previous history, the early symptoms are 
 usually so slight in appendicitis, and also in cases of acute 
 obstruction due to every cause, that the onset of the attack is 
 practically sudden in all. 
 
 The pain varies in degree, but it is impossible to depend 
 on such a symptom, for no two people feel anything 
 alike. 
 
 The situation and character of the pain may certainly help 
 in the diagnosis ; in appendicitis, it commences in the right iliac 
 region, and remains in that position, although it may also be 
 spread over the whole of the abdomen ; in paresis the pain is 
 general, it is like a very bad colic, and soon passes entirely 
 away; in intussusception, the pain, which is also like colic, 
 gradually becomes worse, and may be more marked at one 
 particular spot, this area of severe pain being situated in any 
 part of the abdomen, but not infrequently on the left side ; when 
 the pain is caused by an obstruction due to a band it becomes 
 
220 
 
 THE APPENDIX. 
 
 general and steady, after being first of a colicky nature, and 
 localised at the umbilicus ; while in volvulus it is steady, with 
 periods of very acute exacerbation. 
 
 Some little help is given by the condition of the bowels, for 
 in paresis, and in obstruction caused by bands, volvulus, and con- 
 cretions, constipation is absolute, and no flatus passes downwards, 
 in this way contrasting markedly with the presence of an in- 
 tussusception, where the tendency is towards diarrhoea, with the 
 passage of blood and mucus. In appendicitis the condition of 
 the bowels is midway between those two conditions ; there is 
 usually some difficulty in getting them to move, but flatus passes, 
 and there is no absolute obstruction. When the appendix is 
 inflamed, vomiting may occur, at the commencement; but 
 this is due more to the acuteness of the pain than to any 
 obstruction, and is comparable to the vomiting which may be 
 seen during the passage of a calculus through the bile duct, or 
 through the ureter. It quickly passes off, and is seldom a 
 prominent symptom. It differs also from the vomiting in 
 paresis, for while this is also caused by the acuteness of the pain, 
 it returns as the abdomen distends, and quickly becomes a dis- 
 tressing symptom. This symptom also helps in differentiating 
 a case of intussusception, for here it does not appear in the early 
 stages; when there is a band it begins early, and steadily 
 becomes worse ; in volvulus and in concretions its presence 
 will depend on the position of the obstruction. 
 
 The amount of distension varies very much in different cases 
 of appendicitis, and also with the exact stage which the disease 
 lias reached. At first the abdomen may be retracted, but it is 
 not at all infrequent to find it distended ; in comparison with 
 this, distension comes on early in paresis, and there seems to be 
 no limit to its amount ; in intussusception, the abdomen is 
 retracted ; in volvulus, the abdomen distends early ; and when 
 there are bands it comes on more slowly. 
 
 A feeling of resistance may be felt in the right iliac region 
 during an acute attack of appendicitis ; and, when the extreme 
 
DIAGNOSIS OF APPENDICITIS. 
 
 2 2 1 
 
 tenderness has begun to pass away, a narrow tumour, the shape 
 of a finger, may be felt ; or, where there has been rupture of the 
 appendix, there may be an ill-defined swelling, apparently fill- 
 ing nearly the whole of the right side of the abdomen ; a tumour 
 is absent when there is paresis, bands, volvulus, or concretions ; 
 and is usually present when there is an intussusception or 
 faecal impaction. A localised tenderness in the right iliac 
 region is almost invariably met with in cases of appendicitis ; 
 it is entirely absent when there is paresis ; it will be found 
 when a piece of bowel has become invaginated, and often when 
 there is a volvulus and concretion, but the position will probably 
 be different ; it is absent in bands. 
 
 In regard to the general condition of the patient, the tempera- 
 ture almost always rises when the appendix is inflamed, while 
 in the other forms of acute obstruction it is very rare to find the 
 temperature above normal, and it may even be subnormal. 
 
 The early symptoms of typhoid fever may be mistaken for 
 appendicitis, or vice versa, but it usually does not take long to 
 clear up any doubt as to which of these diseases is present. The 
 most prominent signs which assist in differentiating the two 
 diseases are, the general condition of the patient, the severity of 
 the pain, and the variations of the temperature. In typhoid 
 fever there are more premonitory symptoms of depression ; head- 
 ache and pain in the back are not only present, but are usually 
 well marked, and there is little abdominal pain, although there 
 may be a certain amount in the right iliac region. In both of 
 these conditions it is not advisable to palpate often or forcibly, 
 for it gives little information, and may do the patient harm. 
 As regards the temperature in typhoid fever the afternoon ex- 
 acerbation and the fall in the early morning are fairly regular, 
 each day showing some increase on that of the day before for 
 at least ten days; while in appendicitis the variations in the 
 temperature do not follow any definite course. 
 
 Tubercular disease in the neighbourhood of the caecum may 
 be mistaken for appendicitis when the onset of the appendicular 
 
THE APPENDIX. 
 
 2 2 2 
 
 disease is not very acute, and when an abscess has slowly formed 
 either in the subperitoneal connective tissue, or in the peritoneum 
 when shut off by adhesions. In both there will be the even- 
 ing rise in temperature, the thin cachectic appearance, drenching 
 perspirations, intestinal disturbance, sometimes diarrhoea and 
 sometimes constipation ; and as the symptoms of the one disease 
 thus resemble the other in a very marked degree, the diagnosis 
 will have to depend to a large extent on the physical examina- 
 tion of the patient. 
 
 A perinephritic abscess resembles to a certain extent a case 
 of suppuration in the cellular tissue following posterior rupture 
 of the appendix ; but the abdominal symptoms will be absent 
 or slightly marked, and there is little, except the swelling, which 
 would lead one to make this mistake. 
 
 A psoas abscess will be differentiated by its being impossible 
 for the patient to bring the heel to the ground, or to straighten 
 the leg, when in bed, without arching the back. 
 
 Both in fsecal impaction and malignant disease of the 
 CcCCuni the condition is a chronic one, and the shape of the 
 tumour does not resemble that of a distended appendix; and 
 unless the irritation causes an acute attack in the appendix 
 itself or in the caecum — a typhlitis — the absence of the usual 
 symptoms will prevent a mistake. 
 
 Barely salpingitis might be mistaken for appendicitis, in 
 a long-standing case, or in the relapsing form ; but this error 
 ought never to occur to any one who is accustomed to treat 
 diseases of women, and who is thoroughly conversant with the 
 diagnosis of diseased conditions within the pelvis. As the 
 pain of an acute attack of pleurisy may be referred to the 
 abdomen on the same side, it is well to examine the back of 
 the chest, to prevent what would appear to be a very foolish 
 mistake. 
 
 It has been already said that the majority of cases of 
 inflammation of the appendix result in recovery without opera- 
 tive interference, and without the question of operation having 
 
DIAGNOSIS OF APPENDICITIS. 
 
 223 
 
 to be considered. In the doubtful cases, and in those where 
 operation becomes necessary, we have to determine when 
 medicinal treatment is going to fail, and what will be the proper 
 time to operate. The question of operation will depend in 
 great measure on the general condition of the patient ; and, 
 as long as this keeps fairly good, there is no necessity to inter- 
 fere, it being understood that an abscess is not present. Pus 
 must always be evacuated without waiting for the general health 
 to break down, and there ought not to be any exception to this 
 general principle. 
 
 When a diagnosis of appendicitis has been made, if the pulse 
 be fairly strong and not over one hundred beats per minute, opera- 
 tion need not be thought of. The condition must be carefully 
 watched ; and, should the general symptoms not tend to abate, 
 and the pulse quicken and become less strong, a point will be 
 reached where it will be evident that the disease will not be 
 cured by general treatment. We can hardly emphasise too 
 much the necessity of observing the pulse, not only its rate, but 
 the quality of its beat. The temperature is by comparison of 
 little importance, and so long as it does not rise much over 102°, 
 it may be left very nearly out of account. One cannot say, 
 when the heart is beating so many beats per minute, now is the 
 time to operate. A steady rise or fall from day to day, or some- 
 times from hour to hour, of a few beats per minute, is a much 
 better guide than the rate observed in one case and that in 
 another; and so long as the patient is fully holding his own 
 there is no necessity to open the abdomen. The cases where opera- 
 tion is called for are those where relapses occur so frequently 
 that the patient is becoming more or less of an invalid, and 
 where the general health is breaking down. Except in the very 
 severe attacks, unless the life of the patient is endangered at 
 the moment, one can hardly advise the operation after the first 
 relapse ; but when there have been several, it is very unlikely 
 that the disease will subside and the patient become well with- 
 out an operation, because changes will have taken place beyond 
 
224 
 
 THE APPENDIX. 
 
 the appendix, which will not be likely to subside, even if the 
 inflammation in the appendix itself be cured. 
 
 In addition to operating on the relapsing cases, operation is 
 required, without a minute’s unnecessary delay, in the very 
 acute cases where the appendix has ruptured into the peritoneal 
 cavity before adhesions have been formed ; and no other treat- 
 ment but an operation will relieve those cases where a rupture 
 has occurred, either after adhesions have been formed, or where 
 the opening is in connection with the subperitoneal cellular 
 tissue. Under both of these circumstances nothing can be 
 gained by delay ; nature may cure, but the odds are heavily 
 against her. 
 
 Treatment . — The treatment is either medical or surgical. The 
 medical cases are those where rupture does not take place ; and 
 the surgical, where the appendix has given way, and in addition, 
 all the relapsing cases where the general health is breaking down. 
 The patient must be kept thoroughly warm and quiet in bed ; 
 and the acute pain at the commencement is to be relieved by a 
 dose of morphia ; a quarter of a grain is to be injected ; and this 
 dose is to be repeated in twenty minutes, if the pain does not 
 commence to abate. The abdomen is to be covered either by 
 a light poultice, or by fomentations. We do not consider it 
 advisable to medicate the fomentations with opium, for it is 
 impossible to say how much will be absorbed through the skin, 
 and it is better to use the hypodermic method, and thereby know 
 exactly the quantity that has been given. At the commence- 
 ment, great relief may be obtained by the application of half-a- 
 dozen leeches to the right iliac region ; and occasionally an attack 
 may be cut short by this means if employed sufficiently early. 
 It is too late to use leeches when the inflammatory condition is 
 well established, nor should they be put on in too large numbers, 
 for it is not advisable to draw much blood at what may be the 
 beginning of a serious illness. As soon as the diagnosis is 
 made, and the very severe pain has abated, a dose of castor-oil 
 should be given, unless the bowels have been already freely 
 
TREATMENT OF APPENDICITIS. 
 
 225 
 
 opened. The effect of a brisk purgative in the early stage of 
 any acute inflammation is always beneficial, and there does not 
 seem to be any sufficient reason why we should not avail 
 ourselves of this remedy. After the bowels have been thoroughly 
 moved, they can be left alone for several days ; salts or mineral 
 waters should not be ordered, as they are apt to cause too much 
 irritation and peristaltic action. 
 
 Sweating should be encouraged, and good nursing is most 
 important. The food is to be light, the patient being kept on 
 gruel, milk and water, and clear soups, no solid food being given 
 until the evident symptoms of inflammation have passed away. 
 The return to solid food is to be made very carefully and 
 gradually, beginning with toast and milk, a palatable form of 
 bread and milk, then fish, chicken, etc. 
 
 After the acute pain is over, the patient should be kept 
 comfortable and at rest by the administration of small doses of 
 morphia ; one- twelfth or one-ninth of a grain is to be injected, 
 perhaps three or four times in the twenty-four hours; but as 
 seldom as possible, consistent with obtaining the object in view. 
 When the attack is passing off, and if there be any trace of 
 discomfort, tenderness, or a feeling of resistance in the right 
 side, an occasional blister may be put on, one inch square, at 
 McBurney’s point ; and as one heals another may be put on, 
 radiating from this situation ; or the whole side may be painted 
 every second night with Churchill’s tincture of iodine. The 
 relative proportions of the iodide of potassium, iodine, and 
 alcohol are one, five, and forty. 
 
 When the case has been cured, and it is time for the patient 
 to get out of bed, special attention must be given to avoid chills 
 and over exertion for two or three months. A broad flannel 
 bandage or cholera belt must be worn by the patient for at least 
 a year, but preferably for all his life. 
 
 Enough has been said to show that, in our opinion, surgical 
 treatment is to be undertaken as soon as the diagnosis of per- 
 foration has been made, or where the patient is suffering from 
 15 
 
226 
 
 THE APPENDIX. 
 
 the relapsing type of the disease ; and what remains to be 
 discussed is simply, how is the operation to he done,? We 
 shall divide the operative methods into two classes : the first, 
 where a positive diagnosis has been made; and the second, 
 where the diagnosis is doubtful. It is not necessary to mention 
 again all the precautions which must be taken to protect the 
 patient and to keep him warm. The most convenient line 
 of incision is one parallel to Poupart’s ligament, rather less 
 than one inch above it, commencing a little to the outside of the 
 deep epigastric artery, and continued outwards and upwards for 
 three or four inches. This line of incision is preferable to that 
 along the outer border of the rectus muscle, as the appendix is 
 more easily reached, and there is not so much fear of opening 
 into the abscess close to its inner border. The division of the 
 abdominal wall is not to be made exactly as has been previously 
 described. Instead of cutting directly towards the peritoneum, 
 the incision is made to slant away from the middle line of the 
 body, so that the abscess cavity may be opened, if possible, 
 outside the peritoneum. As the incision is deepened, careful 
 examination must be made with the finger to determine the 
 exact condition; and if it be found that the abscess cannot 
 be opened without dividing the peritoneum, this must be done 
 cautiously. When the tissues are much matted together it will 
 be impossible to distinguish the different structures, and the 
 plan will be to work towards the ileum on the chance of finding 
 the abscess. 
 
 If the case is to be a difiicult one, the incision may be 
 enlarged, if the operator finds that he can gain more freedom 
 by doing so. If the collection of pus be not come on as soon as 
 the peritoneum is opened, the finger is to be introduced into the 
 wound, and gently insinuated among the adhesions ; and if pus 
 be not reached, the colon will have to be followed until the 
 appendix is arrived at. The very greatest care must be 
 exercised in separating adhesions, very little force must be 
 used, especially towards the inner side, for fear of making an 
 
TREATMENT OF APPENDICITIS. 
 
 227 
 
 opening into the general peritoneal cavity. The appendix may 
 have to be enucleated out of a bed of adhesions, and if this be 
 difficult it is best done by separating it all round at its con- 
 nection with the caecum, ligaturing it at this point, dividing it, 
 and then dissecting it out, and in this way avoiding traction 
 on the colon. When the appendix has been divided, the pout- 
 ing mucous membrane is to be cut off, and the interior, beyond 
 the ligature, purified with a 1 in 500 solution of corrosive 
 sublimate. It is safer not to stitch over the end, but to leave it 
 open for fear of some small collection between the stitches and 
 the ligature. When pus is present, there is usually not much 
 difficulty in removing the appendix ; in some cases it may be 
 found to be gangrenous, and lying loose among the pus ; or it 
 may be easily seen still attached to the csecum, when the pus is 
 emptied out. After the evacuation of the abscess any concre- 
 tion or f?ecal mass must be looked for, and the finger passed 
 into the cavity examines to find if there be any secondary 
 collections or pouches. If none be felt, adhesions must not be 
 broken down in a search for them for fear of causing rupture. 
 One or more large rubber tubes are put in to drain the cavity, 
 and the wound is closed, at least as far as this seems safe. 
 The wound should not be left open, nor should the abscess 
 cavity be filled with gauze, as the tendency to ventral hernia 
 seems to be considerable. A large antiseptic dressing is put on, 
 and is to be changed within the first four hours. The wound 
 does not require to be washed out if the progress be satisfactory, 
 and the size of the drainage tubes is to be reduced at the end of 
 forty-eight hours if the patient be doing well. 
 
 When the case is not seen until late, and the abscess is 
 threatening to point, the incision must be made over the 
 swelling, and in as suitable a position as possible for future 
 drainage. 
 
 When the patient is not seen until there has been a rupture 
 into the peritoneum, either directly from the appendix, or 
 secondarily from the abscess cavity, the incision should be made 
 
228 
 
 THE APPENDIX. 
 
 in the middle line ; and if the rupture has been from the 
 appendix it can be removed, the abdominal cavity washed 
 out with warm water, and drained with the ordinary glass 
 tube. 
 
 When rupture has been secondary, a second incision is to be 
 made in the inguinal region, and the pus removed from both 
 the peritoneal and abscess cavities, and one drainage tube fixed 
 in the median incision, and a second in the inguinal. This 
 plan ensures the complete removal both of pus and irritating 
 fluid, and also permits of free washing out, if the progress of 
 the case should render that necessary. 
 
 When the diagnosis is not considered to be certain, a median 
 incision, for the purpose of exploration, is first to be made. If 
 the abdomen be not much distended, the incision need not be 
 longer than will admit two fingers, the right inguinal region 
 is explored, and if a swelling be found there, stitches are to 
 be introduced into the median wound, but not tied ; a sponge 
 is inserted so as to temporarily close the wound, and the rest 
 of the operation is conducted as if the exploratory had not been 
 made. Should a rupture take place through the adhesions, the 
 first wound can be utilised for washing out the peritoneal cavity. 
 Should this accident not occur, the abscess cavity is drained 
 through the inguinal incision, and the stitches in the median 
 incision are tied after the sponge has been removed, a tube 
 not being required to drain the general cavity of the peri- 
 toneum. 
 
 There is nothing special to say about the after treatment, 
 as it does not vary from that of any other abdominal operation, 
 though special care should be taken by strapping the wound to 
 make the scar as narrow as possible ; and this strapping of the 
 wound should be kept up for at least three months after the 
 operation, if the skin will bear it. 
 
 It has been suggested, before operating on a case of appen- 
 dicitis, to insert a fine aspirator needle to clear up the diagnosis. 
 It does not seem to be necessary to enter into any details of 
 
TREATMENT OF APPENDICITIS. 
 
 229 
 
 this procedure, for it is a practice which does not offer any 
 advantage to the patient, and which is very likely to increase 
 whatever mischief is present at the time it is made. It cannot 
 do good, and it is not to be employed under any circum- 
 stances. 
 
CHAPTER IX. 
 
 THE LIVEE. 
 
 Surgical Anatomy. 
 
 Although the liver is capable of a certain amount of mobility, 
 it may, for all practical purposes, be considered as one of the 
 abdominal organs whose position is definitely fixed. Eoughly 
 speaking, it may be said to be situated in the right side of the 
 body, filling the right hypochondrium, and extending across the 
 epigastrium into the left hypochondrium. From above down- 
 wards it reaches from the fourth interspace to the free border 
 of the ribs on the right side. It extends across the subcostal 
 angle, with the lower border in the position of a curved line 
 drawn from the '' ninth right to the eighth left costal cartilage, 
 and crosses the middle line about a hand’s breadth below the 
 xiphi-sternal articulation” (Quain), a triangular space in the 
 pit of the stomach being thus left unprotected by any bony 
 covering. This unprotected part of the liver lies in direct 
 contact with the abdominal wall. As the liver is not absolutely 
 fixed, a certain amount of movement is possible, and it is found 
 that the exact position is varied by the posture assumed, and 
 also by the action of the lungs and diaphragm. 
 
 Artificially also, the liver may be pushed out of its usual 
 position, as for example, by tight lacing, by the pressure of a 
 pleuritic effusion, etc. The upper border may be determined 
 by deep percussion ; the lower, either by percussion or by 
 palpation. 
 
SURGICAL ANATOMY, 
 
 231 
 
 The position of the gall-bladder is on the under surface of 
 the right lobe of the liver, with the fundus situated beneath 
 the ninth costal cartilage. The body lies over the hepatic 
 flexure of the colon, the first part of the duodenum, and the 
 neck is sometimes in contact with the pyloric end of the 
 stomach. It cannot be felt in health, but it is said that the 
 notch in the anterior border of the liver, formed by the shallow 
 depression in which it lies, can be made out on careful examina- 
 tion. The gall-bladder normally measures about four inches in 
 length, and one and a half in width. When abnormally dis- 
 tended, its position is in that of a line drawn from the edge of 
 the ninth costal cartilage to the umbilicus. 
 
 The gall-bladder ends in the cystic duct, which is fully one 
 inch in length, and is joined by the hepatic duct near the trans- 
 verse fissure of the liver. The common bile duct — ductus com- 
 munis choledochus — which is thereby formed is nearly three 
 inches in length. It descends in the gastro-hepatic omentum to 
 the right of the hepatic artery, and anterior to the portal vein. 
 Thereafter it passes posterior to the first part of the duodenum, 
 and continuing downwards it usually coalesces with the pan- 
 creatic duct, the two passing by a common opening through the 
 wall of the second part of the duodenum on its inner and 
 posterior aspect. 
 
 Practically the whole of the surgery connected with the 
 liver is conducted in or through that part which is uncovered 
 by the ribs and sternum. One would hardly expect the liver 
 to be an organ that would stand surgical interference well ; 
 and operations, other than the simple opening of an abscess, 
 have only been performed in the past few years. 
 
 Since the early days of ovariotomy it was known that the 
 liver might be injured even extensively without the injury being 
 of necessity fatal. Bleeding was found to stop comparatively 
 easily by pressure, or on the application of a styptic, and injury 
 during an operation did not seem to cause any special shock. 
 
232 
 
 THE LIVER. 
 
 Operations on the Liver. 
 
 The conditions for which operations are performed on the 
 liver itself are two, viz. abscess and hydatid disease. 
 
 Abscess of the Liver. 
 
 Hepatic abscess is rare in people who have lived in a 
 temperate climate, though it may result from a direct injury, or 
 in connection with operations on the rectum, or it may follow 
 diseases in the right iliac fossa, as in t3^phoid fever, or it may 
 occur in pysemia. A common cause is the suppuration of a 
 hydatid cyst, but here also we have climate as an important 
 factor. The most usual history, however, is that the patient has 
 lived in a hot climate, and has suffered either from malaria or 
 dysentery. 
 
 The pus is usually situated deeply in the substance of the 
 gland. It is not infrequently found that there are, in the early 
 stages at least, several abscesses, and as these increase in size 
 they usually coalesce. Most commonly the abscess is situated 
 towards the posterior surface of the liver and in the right lobe. 
 Abscesses here, as elsewhere, tend to point, and the direction in 
 which the pus is inclined to travel varies ; the most frequent 
 mode of exit is through the lung, this being much more usual than 
 into the pleural cavity, and it is a decidedly favourable way ; or 
 the abscess may open into the abdominal cavity, the pus passing 
 either into the peritoneum, or into the intestinal canal, the 
 latter being also a favourable direction ; the third and least 
 dangerous, though unfortunately the least common mode of exit, 
 is when the pus tends to come to the surface of the body, and to 
 evacuate itself through an opening in the skin. When this is 
 so fortunate as to happen, the skin opening is usually below the 
 ensiform cartilage. 
 
 Symptoms. — Locally, tenderness and pain in the region of 
 the liver, or in its neighbourhood, or in the right shoulder ; 
 
HEPATIC ABSCESS. 
 
 233 
 
 enlargement of the organ; fluctuation occasionally; pain on 
 turning, the back being the most easy position to lie on. 
 
 Generally, fever, rigors, emaciation, disturbance of the 
 stomach and bowels, harsh skin, sweating, sallow complexion, 
 and usually depression of spirits. Earely, jaundice with 
 anasarca and ascites. If these symptoms were always present, 
 or even present in any marked degree, the diagnosis would be 
 of the simplest ; but an abscess of the liver may be present 
 without one well-marked symptom to draw attention to the 
 organ. There may be only general debility, with an occasional 
 feeling of chilliness and some slight uneasiness in the right side. 
 
 Treatment . — The treatment of a hepatic abscess must be carried 
 out on the general principle that pus must be removed as soon as 
 possible. Various methods have been employed to do this ; the 
 aspirator is one of those which deserves special attention, for it 
 is not only a means of diagnosis, but its use has been followed 
 by complete recovery, though such a happy result can only be 
 expected in exceptional cases. In using the aspirator the only 
 thing to be specially remembered is, that as the liver moves 
 with respiration the cannula must be allowed to move also, or the 
 result is that the soft liver tissue may be torn. In all other 
 respects the same precautions must be taken when the liver is 
 punctured as are employed when the needle is used in any 
 other part of the body ; one caution only need be given, not to 
 exhaust the air too forcibly. The essentials, it may be repeated, 
 are cleanliness, a fine needle, emptying of the abscess cavity as 
 far as possible, and leaving the patient in such a position that 
 the puncture opening is at the highest level. Aspiration ought 
 to be looked upon rather as an aid to diagnosis than as a method 
 of treatment, but it can be had recourse to even in cases where 
 another plan of treatment is considered to be better, when for 
 some reason or another the patient is not able to have at the 
 time any more formidable operation. A second plan which has 
 been frequently carried out is that of puncturing with a trocar 
 and cannula, and then leaving the hollow instrument to act as a 
 
234 
 
 THE LIVER. 
 
 means of drainage. After a few days, when it may be reason- 
 ably expeicted that adhesions have formed, a rubber drainage 
 tube replaces the metal one. When this is done it is well to 
 pass the rubber tube through the cannula, or at least to preserve 
 the direction of the canal by passing a probe, over which the 
 cannula is first withdrawn and then the drainage tube is inserted. 
 Neither this method nor that of making an opening by means 
 of caustic potass or other similar substance is used as much as 
 formerly. The special objections to the caustic treatment are 
 that it is both slow and painful, and in addition the opening- 
 may not be made over or near the abscess. There is too much 
 working in the dark with both these plans, and there is no 
 sufficient advantage gained by doing so. 
 
 Incision, with drainage, is undoubtedly the most suitable, 
 the most convenient, and the most satisfactory method of treat- 
 ment. In the older books it will be observed that the fear of the 
 peritoneal cavity, a fear well justified in the days when the 
 necessity for surgical cleanliness was not understood, was 
 constantly before the eyes of the early operators. The great 
 desire was to avoid opening the peritoneal cavity, and this was 
 accomplished by causing the part of the liver which was to be 
 opened to adhere to the parietal peritoneum, and thus allowing 
 of a track being formed through which a passage for the exit of 
 the pus could be made without running the risk of opening into 
 the abdominal cavity. Hence the caustic plan already referred 
 to, hence also the plan of waiting as long as possible in the hope 
 of adhesions having formed, and hence also the double operation, 
 the first stage being directed to the formation of adhesions, and 
 the second to the evacuation of the pus. 
 
 When adhesions have been formed between the abdominal 
 wall and the liver, the matter may be evacuated by a simple 
 incision. One cannot be absolutely sure that adhesions have 
 formed, and the result might and probably would be very 
 serious if slight or even no adhesions at all were found. The 
 pus, possibly putrid, would escape into the peritoneal cavity. 
 
HEPATOTOMY. 
 
 235 
 
 It will therefore be better to consider direct incision simply as 
 a fortunate circumstance discovered while performing the opera- 
 tion of opening the abdomen and suturing the liver to the wall, 
 which will be shortly described. 
 
 The operation in two stages is likely to disappear with the 
 knowledge that it is not the injury, but the infection of the 
 peritoneum which is to be feared. It consists in making an 
 incision over that part of the liver where the abscess is supposed 
 to be situated, and in suturing the liver to the edges of the 
 wound. The softness of the liver substance renders the pro- 
 cedure not an easy one, and if the abscess be near the surface 
 it may be quite impossible to get a sufficiently firm grasp. 
 After a few days the abscess is opened, and a rubber drainage 
 tube is passed into the bottom of the cavity. The great 
 objection to opening the abscess is the delay which the method 
 of necessity entails. 
 
 Hepatotomy. 
 
 The operation of opening a liver abscess through the abdo- 
 minal cavity is called hepatotomy ; it consists in opening the 
 peritoneum, and in stitching the liver to the abdominal wall 
 after evacuation of the pus. The incision through the skin will 
 be made, if possible, in the longitudinal direction ; the length 
 will be somewhere between three and five inches, and will 
 depend on the thickness of the abdominal wall. No effort 
 should be made to work through an incision shorter than is 
 perfectly convenient, and it is thus better to make it too long 
 than too short. The experienced operator will naturally manage 
 with a shorter incision than one who is not accustomed to 
 perform abdominal operations. The exact position of the 
 incision will vary with the supposed position of the abscess. 
 When the liver is found to be adherent beneath the wound, the 
 incision can be extended at once into the liver, so as to open the 
 abscess, or the pus may be evacuated with the aspirator, though 
 the latter procedure presents no special advantage in the present 
 
236 
 
 THE LIVER. 
 
 circumstances. Should there be no adhesions beneath the 
 wound, but a little to one side, it may be possible, by making a 
 second incision through the abdominal wall, to open the abscess 
 without having to stitch the liver ; this is, however, not very 
 likely to occur. When there are no adhesions the best point 
 for making the opening into the liver is to be fixed on, and 
 sponges are to be packed around this part to prevent any escape 
 of pus into the peritoneal cavity. The abscess is then to be 
 emptied as completely as possible with a Wells’ tapping trocar 
 and cannula attached to the aspirator ; this instrument is used to 
 avoid a greater flow of pus than the sponges might be able to 
 soak up. When the pus has been completely drawn off, the 
 trocar opening is freely enlarged, the edges are kept apart by 
 the help of catch forceps, which must not grasp the soft liver 
 tissue too firmly, and the interior of the abscess cavity is care- 
 fully sponged out. Any rough handling will quickly set up 
 bleeding. Haemorrhage from the cut surface of the liver can 
 be arrested either with sponge pressure, assisted, if necessary, 
 by perchloride of iron, or by the introduction of silk or catgut 
 sutures ; and it must be remembered that when friable tissue is 
 sutured it is not advisable to use very fine material. 
 
 As there may be in any case one or more secondary abscesses, 
 any appearance of such must be carefully looked for, and if any 
 be found they are to be opened through the abscess cavity which 
 has been already emptied. The opening may be made either 
 with the trocar or with a pair of sinus forceps. Should the pus 
 be putrid it is advisable to wash out the abscess cavity with a 
 warm antiseptic lotion ; a saturated solution of boracic acid is 
 very suitable for this purpose. After the abscess cavity has 
 been thoroughly cleansed, the sponges are to be removed from 
 the abdomen ; and, if the directions have been properly carried 
 out, it will not be necessary to wash out or even to sponge the 
 peritoneal cavity. 
 
 The surface of the liver surrounding the opening and the 
 parietal peritoneum round the abdominal wound must now be 
 
HEPATOTOMY. 
 
 237 
 
 brought closely in contact, so as to make a direct track for the 
 escape of the discharge from the abscess cavity without there 
 being any risk of a leak occurring into the peritoneum. The 
 opening in the liver is to be first brought into contact with the 
 wound, that it may be seen to what part it can be fixed without 
 causing traction. If the abdominal wound has been made too 
 large, sutures are introduced in the ordinary way, and left untied 
 until the liver has been secured. This is done by passing a 
 stitch through the wall on one side, taking a firm hold of the 
 peritoneum, and then through the corresponding side of the 
 liver opening. In this way the parietal peritoneum and the 
 peritoneum covering the liver are brought together and the 
 stitches tied. Stitches must be introduced in this way all 
 round, and when a sufficient number are used, about three to 
 the inch, the two peritoneal surfaces are brought quite closely 
 together. 
 
 When the cut surfaces of the liver are bleeding freely the 
 stitches may be passed in a somewhat different manner. The 
 needle is introduced as before through the wall and into the 
 abscess cavity, it is then returned in the contrary direction, 
 passing from the abscess cavity half an inch to one side of the 
 point of entrance, through the liver and then through the 
 abdominal wall from within outwards. As soon as all of the 
 stitches have been introduced those which include the liver are 
 tied before the others which close the abdominal wall. One or 
 more large-sized rubber drainage tubes are put in, extending 
 from the bottom of the cavity to the skin edge, and they must 
 not be allowed to project for fear of pressure on the interior of 
 the abscess. A large absorbent dressing is put on, and should 
 be changed for the first time in a few hours, after that twice in 
 the day will probably be sufficient. 
 
 The abscess cavity should not be washed out unless the dis- 
 charge be putrid. 
 
 The position of the patient after the operation ought to be 
 that which will allow of as free drainage as possible. As the 
 
238 
 
 THE LIVER. 
 
 discharge lessens, the drainage tube is gradually shortened, but 
 one must not he in too great a hurry to lessen its calibre. In 
 some cases it may be necessary to open a liver abscess through 
 the space between two ribs, or after resection of one or more ribs. 
 Here the operation does not differ in any essential detail, except 
 that it will be necessary to shut off the cavity of the pleura, but 
 if this cannot be managed the pleural cavity must be thoroughly 
 drained. 
 
 Hydatid Disease of the Liver. 
 
 Hydatid cysts of the liver are situated either on the surface 
 or deeply embedded in the substance of the gland ; they may 
 be single or multiple, usually the former, and they occur most 
 frequently before middle life. 
 
 Symptoms . — These are at first slight or altogether absent, 
 and in the later stages they depend very much on the position 
 of the cyst. When situated on the upper surface it is natural 
 to expect that the lung will be pushed upwards ; when situated 
 so as to cause pressure on the vena cava there will be symptoms 
 due to venous obstruction ; or there may be jaundice. In 
 other words, the symptoms are caused by the size and position 
 of the cyst, the actual disease being painless, and not affecting 
 the constitution in any way unless there be suppuration. 
 
 On examination a rounded cyst may be felt projecting from 
 the liver, or there may be more or less uniform enlargement of 
 the whole organ, even when the disease is situated somewhat 
 superficially, but more especially when it is placed deeply. The 
 growth is comparatively slow, the disease having been known 
 to exist for many years. It has to be distinguished chiefly 
 from chronic pleurisy, from an ovarian tumour, and from 
 hydronephrosis. 
 
 There may be nothing to differentiate a chronic pleurisy with 
 slight effusion from a case of hydatid cyst on the upper surface 
 of the liver except examination of the fluid. The only symptom 
 which might lead to the suspicion of the presence of a growth 
 
HYjDATIjD disease. 
 
 239 
 
 connected with the liver would be pain in the region of the 
 right scapula, but even this we may have with pleurisy. The 
 fluid from a hydatid cyst is of a slightly milky colour, its 
 specific gravity varies from 1004 to 1013, it does not contain 
 albumen, and it holds in solution one-half per cent, of common 
 salt, the presence of this being shown by the appearance of a 
 white cloudy precipitate on the addition of a weak solution of 
 nitrate of silver. If the deposit be examined microscopically, 
 booklets may be found. The fluid of a chronic pleuritic effusion, 
 on the other hand, is of a more or less straw colour, its specific 
 gravity varies from 1005 to 1030, it is markedly albuminous, 
 and it does not contain any common salt. 
 
 At first one would think it almost impossible to mistake an 
 ovarian tumour for hydatid disease of the liver, but there is no 
 doubt that this has not infrequently been done. The abdomen 
 may be filled by a large fluctuating tumour, which has given 
 rise neither to pain nor to discomfort, which has not affected 
 the general health in any way, and which may give a dull sound 
 on percussion over the whole front of the abdomen. The history 
 may tell nothing, for a patient has been known to assert tha4 a 
 liver cyst was first noticed in the lower part of the abdomen. 
 The uterus will be freely movable in the case of a liver cyst, but 
 it is not infrequently as freely movable when an ovarian tumour 
 is present. When there is an ovarian tumour large enough to 
 be mistaken for a hydatid cyst of the liver there will be a 
 greater amount of emaciation of the chest and arms than of the 
 rest of the body, while a hydatid cyst will have caused either 
 no emaciation or a general thinning of the whole body. The 
 presence of the hydatid fremitus is of importance, while its 
 absence does not mean anything. Should the cyst be aspirated, 
 the chemical and microscopical examination of the fluid, com- 
 bined with the direction in which the cyst collapses, will settle 
 the question between these two diseases should the naked eye 
 appearance of the fluid still render it doubtful. 
 
 In a case of hydronephrosis there may be a history of a 
 
240 
 
 THE LIVER. 
 
 condition which gives rise to this disease, as, for example, a renal 
 calculus. There may also be a record of the temporary dis- 
 appearance of the tumour ; the colon may be felt on the tumour 
 either as a rounded cord or as a tympanitic track ; and the cyst 
 will bulge more into the loin, especially in comparison with the 
 opposite side. The fluid of a hydronephrosis is in appearance 
 not unlike that of a hydatid cyst, it sometimes contains albumen, 
 it is of low specific gravity, and it contains common salt but 
 in smaller quantity than in the hydatid fluid ; urea may or 
 may not be present. The microscope will probably settle the 
 diagnosis between the two. 
 
 Treatment . — A hydatid cyst may be cured naturally and 
 without any treatment by the absorption of the fluid, which 
 causes the death of the scolices and their subsequent fatty, 
 calcareous, or caseous degeneration and transformation. Eup- 
 ture may occur, and if the fluid be not quietly absorbed it is 
 dangerous, either primarily, as when it takes place into the 
 vena cava, and then it is of course fatal ; or secondarily, as 
 when the disease is scattered broadcast over the whole of the 
 pejitoneal cavity. It is not therefore advisable to allow the 
 disease to go on too long, and treatment must be of a surgical 
 nature. One of two plans must be adopted : the first is the 
 complete removal of the fluid with the aspirator, the usual 
 precautions being taken, and the second is by incision followed 
 by drainage. Other methods have been adopted, viz. simple 
 puncture, puncture with the withdrawal of a few ounces of 
 fluid, emptying and the injection of some fluid, such as iodine, 
 and electrolysis. Though cases have recovered after these four 
 plans of treatment, so fortunate a result is far from common ; 
 besides, they are accompanied by a decided amount of risk 
 to life, for in all fluid is allowed to remain in the sac, and is 
 likely to escape into the peritoneal cavity through the opening 
 which has been made. The advantage of the complete emptying 
 of the sac over these other methods is that the risk of escape 
 of fluid is prevented, while there is at the same time more 
 
CANCER OF THE LIVER. 
 
 241 
 
 hope of recovery. This plan of complete removal really 
 belongs more to diagnosis than to treatment, the best method 
 being undoubtedly incision and drainage. This operation is 
 performed in exactly the same way as the operation for liver 
 abscess, and here also one must be certain that no secondary 
 cysts are left unopened ; and the sac cannot be emptied too 
 carefully, as the result of allowing any escape of hydatid fluid 
 into the peritoneal cavity might be disastrous. 
 
 The opening into the sac has been sometimes closed imme- 
 diately, and stitching to the parietal wall dispensed with ; but 
 although such a procedure is neater and more elegant, it seems 
 to be running an increased and unnecessary risk. 
 
 Hydatid cysts in the liver not infrequently suppurate, and 
 when they do the symptoms resemble those of liver abscess, 
 except that they are frequently not so marked. The following 
 is an example of a case of hydatid cyst of the liver cured by 
 tapping : — A lady, thirty-six years of age, was seen by Dr. Keith 
 in 1876 ; she had lived in Australia for six years, and had 
 noticed a swelling in the pit of the stomach for five years. The 
 growth had been quite painless, and the patient sought advice 
 simply on account of the size and disfigurement. The swelling 
 was limited to the upper part of the abdomen, it was almost 
 central, and the dull liver note was continuous with it. The 
 history and situation pointed to hydatid disease of the liver, and 
 the tumour was emptied with the aspirator, a fine needle being 
 used. Six years afterwards the sac had not refilled. 
 
 Cancer of the Liver. 
 
 This is of importance, surgically, only in relation to diagnosis. 
 When the growth is multiple it is not likely that a mistake will 
 be made, unless it be confounded with syphilitic gummata. 
 When the growth is single, as it usually is when the disease is 
 of a secondary nature, a cancerous mass may be mistaken for 
 dilatation of the gall-bladder, or for a hydatid cyst. The 
 16 
 
242 
 
 THE LIVER. 
 
 diagnosis will be assisted by examination of the general con- 
 dition of the patient, there will be more or less emaciation, with 
 a somewhat quickened pulse, there will be a sallow appearance 
 of the skin, running not infrequently into jaundice, and there 
 may be some ascitic fluid. Before any operation for malignant 
 disease in connection with any part of the abdomen is under- 
 taken, it is advisable to examine the liver carefully. We have 
 heard of a rectum being excised for cancer, when at the fost 
 mortem examination masses were found in the liver which might 
 easily have been discovered before the operation. 
 
 The Gall-Bladder. 
 
 Gall-stones are more frequently found between the ages of 
 forty and sixty than at any other period of life, and they seem 
 to be more common in women. They are usually met with in 
 persons of a sedentary habit who live well. They may be 
 found in the gall-bladder, in the cystic, hepatic, or common 
 ducts, in the liver itself, in the intestine, and in almost any 
 other organ, having reached it by ulceration, as for example, they 
 have been found in the lungs and in the urinary bladder. 
 
 Nothing is known of the exact reason of their formation, 
 they consist in great part of cholesterine, which is precipitated in 
 certain abnormal conditions of the blood and bile, found most 
 frequently in those affected with a gouty or uric acid diathesis, 
 and they may be of all shapes and sizes. It is usual to find 
 that there are either a few large calculi or a number of small 
 ones, many hundreds being sometimes found. 
 
 The presence of gall-stones does not of necessity give rise 
 to symptoms, nor is it necessary to resort to sluj surgical treat- 
 ment simply because they are known to be present. Still, the 
 condition is not one which is absolutely free from danger ; the 
 presence of these stones may lead to injury of the wall of the 
 bladder ; inflammation followed by suppuration may be set up ; 
 or a stone may pass from the bladder and give rise to trouble 
 
THE GALL-BLADDER. 
 
 243 
 
 in the cystic or common ducts, or in its passage through the 
 intestine. Ulceration and destruction of the gall-bladder at 
 one point will allow even a large calculus to pass into other 
 organs. This ulceration usually occurs at the fundus of the 
 bladder, and, if there have been sufficient irritation to cause 
 adhesive inflammation, the calculus may pass through the ab- 
 dominal wall, or into the stomach or intestine, without doing 
 much harm. If, on the other hand, the gall-bladder open 
 directly into the peritoneal cavity, or if the ulcerative process 
 go on to the destruction of a large blood vessel, a fatal termina- 
 tion is the result ; but this will not happen without the occur- 
 rence of previous symptoms. 
 
 Symptoms . — The most common symptom is the occurrence of 
 biliary colic. The pain comes on suddenly and lasts for a few 
 minutes, seldom for longer than a few hours ; it comes in 
 paroxysms, and is situated to the right of the pit of the stomach, 
 radiating to the back and towards the right shoulder. Between 
 the paroxysms there is a feeling of weight and soreness in the pit 
 of the stomach and towards the right side. During a paroxysm 
 the pain is very severe, it is often accompanied by vomiting, and 
 it may even cause rigors or fainting. As soon as the attack is 
 over the soreness is gradually relieved. Sometimes there is 
 jaundice, either of a passing character, if the stone be hut tem- 
 porarily impacted, or permanent, if the hepatic or common duct 
 be occluded. Unless the attack be much prolonged there is little 
 effect produced on the general condition ; the pulse and tempera- 
 ture do not rise, and in this way it may be possible to differentiate 
 the passage of a calculus from any acute inflammatory condition. 
 
 During an attack it is often difficult to examine the liver 
 very carefully, but when this can be done the organ is usually 
 found to be enlarged, and there is tenderness over the gall- 
 bladder, which may or may not be distended. 
 
 Opinions differ as to whether an attack of biliary colic is 
 more likely to come on after meals or not, but it is undoubted 
 that active exercise not infrequently is the starting point of the 
 
244 
 
 THE LIVER. 
 
 passage of a stone. An attack of biliary colic seems sometimes 
 to start from a confinement. The condition runs in families, 
 especially in those of the gouty type. 
 
 Treatment . — The treatment during the passage of a stone con- 
 sists in the use of hot fomentations, in the administration of 
 morphia with belladonna often in large doses, and sometimes 
 the inhalation of ether or cholorform may be required. After 
 the acute attack of j)ain is over, it is well to give a dose of 
 mercury, followed next morning by a saline draught. 
 
 It is not necessary to advise operation as soon as the pain 
 caused by the passage of a biliary calculus is over, for there may 
 never be a second attack of colic, or, should there be one, it may 
 occur only after a long interval. The treatment to be adopted 
 consists in attending to the general health, and in attempting to 
 eliminate the gouty poison which is so often present. To assist 
 in the easy passage of a stone, and also to prevent their formation, 
 ten grains of the bicarbonate of soda in a bitter infusion taken 
 at bedtime every alternate month is advised. Olive oil in large 
 doses, beginning with one or two teaspoonfuls and increasing the 
 dose rapidly until a pint is taken in the day, is well worthy of a 
 trial, and seems to be of undoubted value in some cases. Some 
 of the oil can be taken in salad. 
 
 Manipulation of the bladder, a kind of massage, seems to 
 favour the passage of a stone at times, a simple examination 
 being sometimes sufficient to cause a stone to pass downwards. 
 
 Various mineral springs are useful in these cases ; at home 
 there are Harrogate and Leamington ; abroad, Marienbad, 
 Vichy, Kissingen, etc. 
 
 The operative treatment for calculi in the gall-bladder will 
 be considered along with that for distension of the organ. 
 
 Distension of the Gall-Bladder. 
 
 This is caused by some obstruction due to the wall (mural) ; 
 by an obstruction, or the presence of foreign bodies, in the 
 
DISTENSION OF THE GALL-BLADDER. 
 
 245 
 
 ducts or bladder (intramural) ; and by pressure from the 
 outside (extramural). 
 
 Catarrh may be given as an example of the first. 
 
 The presence of a calculus in the cystic or common ducts, or 
 of a number of calculi in the bladder itself, are examples of the 
 second. 
 
 Obstruction due to the third cause is seen in the pressure 
 caused by the presence of malignant disease. 
 
 Distension is most frequently due to the blocking of a duct 
 by a stone, however formed, and the symptoms will depend 
 upon the exact position of the impaction. This can easily be 
 explained. If the cystic duct be closed, there is no obstruction 
 to the direct passage of bile from the liver into the intestine, 
 and there is consequently no jaundice. The symptoms are 
 limited to the disturbance which results from the distension of 
 the gall-bladder, and to the inflammatory changes which may 
 take place either in its walls or in the fluid which it contains. 
 The walls may become adherent to other organs and may 
 ulcerate, or the fluid may become purulent. 
 
 When the obstruction is absolute, and is situated in the 
 common duct, it is evident that no bile can flow into the 
 intestine, and that there must soon be ever increasing jaundice. 
 The liver suffers, it becomes enlarged and tender, and, whether 
 the obstruction be in the cystic or common duct, the gall- 
 bladder is felt as a more or less oval, tender, fluctuating tumour. 
 This swelling when small is situated in a line drawn from the 
 natural position of the fundus of the gall-bladder to the 
 umbilicus, but when large the weight may alter this direction. 
 Parasites may, though rarely, take the place of a stone in causing 
 obstruction. 
 
 Pressure from the outside is practically always caused by 
 cancer, which is frequently situated in the head of the pancreas. 
 On this account it is necessary to make a correct diagnosis and 
 thus avoid an unnecessary operation. In the early stages this 
 is by no means easy, especially as calculi are sometimes 
 
246 
 
 THE LIVER. 
 
 associated with cancer ; later in the course of the disease, a 
 nodular growth may be felt in the region of the gall-bladder. 
 That viscus becomes more or less fixed and tender, and 
 generally there is rapid emaciation with a quickening pulse. 
 
 When the gall-bladder is extended simply by a large 
 collection of calculi, it is found to be hard and irregular, 
 fluctuation is absent, and the swelling is usually movable, and 
 painless on pressure. The size is also constant, or should it 
 vary, the difference will be very slight. 
 
 The contained fluid which has remained for a length of time 
 in the gall-bladder may become altered in character; it may 
 become clear, and the bladder then has a white glistening 
 appearance. 
 
 This was well seen during the course of an abdominal 
 operation some twelve years ago. The gall-bladder projected as 
 a long sausage-shaped tumour, having a peculiar pearly white 
 appearance. The distension had not given rise to any symptoms, 
 nor were there any when the patient was last seen a number of 
 years after the operation. 
 
 In other cases the fluid remains as a thick yellowish-green 
 liquid, or it may become changed into pus. When the fluid 
 suppurates, there are, in addition to a possible history of 
 calculi, very much the same symptoms as have been described 
 in abscess of the liver. When the gall-bladder is distended 
 its walls are usually thinned, though in some cases they become 
 much hypertrophied. 
 
 The following account of a case, either of an enormous 
 distension of the gall-bladder, or of a peculiar cyst of the liver, 
 is worth relating in detail : — In the summer of 1882 a young 
 woman of dark complexion, aged twenty, was admitted to the 
 Edinburgh Eoyal Infirmary. Eor two and a half years the 
 patient had noticed that her abdomen was getting large, and 
 she stated both before and after the operation that the swelling- 
 had commenced at the lower part of the abdomen. The girl 
 herself had not thought it necessary to see a doctor, and she did 
 
DISTENSION OF THE GALL-BLADDER, 
 
 247 
 
 so only at the suggestion of her mistress. She had always been 
 perfectly healthy, had never been jaundiced, and had never 
 required to take a dose of medicine in her life. Examination 
 showed that the abdomen was distended by a large unilocular 
 thin-walled cyst. Percussion gave a dull note over the whole 
 front of the abdomen, and vaginal examination simply gave the 
 information that the tumour did not enter the pelvis, but could 
 be felt at its upper part. The only thing against the diagnosis 
 of ovarian tumour was that there had not been any emaciation 
 of the chest. On opening the abdomen in the middle line, a 
 thin membrane, resembling a very much stretched-out omentum, 
 was found to be adherent over the whole front of the tumour. 
 This was slightly separated, and the cyst was tapped by an 
 ordinary large trocar. A bright yellowish-green fluid resembling 
 bile came away. As the cyst was emptied and drawn forward 
 it was seen to be wanting in pelvic attachments, and was then 
 traced up to the liver. A large part of the sac was removed, 
 and the remainder was stitched into the upper part of the 
 abdominal wound and drained, after it had been thoroughly 
 washed out with carbolic lotion. Twenty-four pints of bile 
 were removed from the cyst, the exact origin of which could not 
 be made out. On the eleventh day the discharge was purulent, 
 and by the forty-fifth the sinus had entirely closed. The patient 
 has remained perfectly well. 
 
 Diagnosis . — An enlarged gall-bladder may be mistaken for a 
 tumour of the right kidney, or for a floating kidney, and especi- 
 ally when there is a combination of these two conditions. Other 
 growths with which it may be confounded are, a solid outgrowth 
 from the liver, a cyst of the pancreas, or when very large it may 
 be mistaken for any cystic growth in the abdomen. 
 
 It is differeutiated from a growth of the kidney by its 
 position being closer to the abdominal wall, it does not extend 
 so far into the loins, the intestine is not found lying in front, 
 what mobility there is will be in a different direction, and the 
 examination of the urine may give some definite information. 
 
248 
 
 THE LIVER. 
 
 The symptoms will also assist in making a diagnosis. In com- 
 parison with a movable or floating kidney, we have to depend 
 on the shape and different range of mobility, including the 
 possibility of pushing the kidney back into its place in 
 the loin. 
 
 A solid localised growth of the liver due to the presence of 
 cancer or syphilis will be diagnosed by the shape and exact 
 position, by the absence of fluctuation, and by the general 
 symptoms to be found when such diseases are present. 
 
 For the differential diagnosis of mesenteric and pancreatic 
 cysts we have to rely on the history, on the exact position of 
 the swelling, and on the presence or absence of symptoms 
 pointing to the enlargement of the gall-bladder. 
 
 Treatment . — It has been previously said that a biliary 
 calculus does not of necessity require removal. 
 
 Should there be repeated attacks of biliary colic, the question 
 of removal of the stones arises, and the decision will have to lie 
 very much with the patient, for he or she must decide whether 
 they will undergo the operation or go on hoping that each 
 attack of pain will be the last, for these attacks do sometimes 
 cease. A simple distension of the gall-bladder where there are 
 no symptoms does not require operation, it may be safely left 
 alone as long as it does not give trouble. 
 
 When there is suppuration, or where there is jaundice, the case 
 is different ; with the former there are symptoms necessitating 
 operative interference; with the latter it is not safe to leave 
 things alone, as there is no doubt that great risk is incurred 
 when the patient has become saturated with the bile poison. 
 
 Though Marion Sims was not the first to operate on the 
 gall-bladder, the surgery of that viscus may be said to date from 
 his first operation in 1878. The usual operation — cholecystotomy 
 — consists in opening the bladder and stitching it to the ab- 
 dominal wall. A few surgeons prefer to remove the bladder 
 entirely ; this operation is called cholecystectomy. Names have 
 been given to two operations which may be described as further 
 
CHOLE C YSTO TO MY. 
 
 249 
 
 stages of the operation of cholecystotomy. They are chole- 
 lithotomy and cholelithotrity, and signify respectively the 
 removal and the crushing of calculi in the gall-bladder or in 
 the ducts. 
 
 Cholecystotomy and Cholecystectomy. 
 
 These operations are performed for the removal of one or 
 more stones in the bladder or in the duct, for distension of the 
 bladder from other causes, and also for injuries of the bladder. 
 
 Cholecystotomy. 
 
 Unless the abdomen be much distended by the tumour, a 
 vertical incision three or four inches in length is to be made 
 over the most prominent part of the swelling. 
 
 Should the growth be very large, the incision must be made 
 nearer the liver, to be able to reach the ducts if necessary. 
 After the peritoneum has been opened in the usual way, sponges 
 are to be packed round the gall-bladder, unless adhesion prevents 
 this being done. When operating for stones, where there is no 
 distension, much greater difficulty than might be expected may 
 be met with in finding the gall-bladder. If there be any fluid, the 
 next step is to withdraw it with the aspirator, a needle of fair 
 size being used. The needle must be inserted low down, for the 
 fixed point of the gall-bladder being above, the opening might 
 be drawn so far upwards as to be above the upper angle of the 
 wound when the cyst wall contracts. The cyst wall is sometimes 
 very thin and friable, and care must be taken not to hold the 
 aspirator needle too stiffly, as the wall might tear against it and 
 allow the fluid to escape. For the same reason the catch forceps 
 used to grasp the sac after it has been emptied must not have 
 too firm a catch ; those used for preventing the slipping of the 
 ovarian pedicle after cauterisation will be suitable for the 
 purpose. The sac is then drawn forward to the abdominal 
 
250 
 
 THE LIVER, 
 
 wound by the forceps, the aspirator needle is withdrawn, and 
 the opening is enlarged with scissors to allow of the easy entrance 
 of one finger. The interior of the sac is then thoroughly explored. 
 If stones be felt, the opening is still further enlarged, and they 
 are removed either with forceps or with a scoop or spoon, and 
 the sac is then thoroughly dried out. One must not be satisfied 
 with the removal of the stones from the bladder, the ducts must 
 be examined, and this is to be done very carefully, especially 
 when there is jaundice. Should a stone be found in the cystic 
 or common duct, the ingenuity and perseverance of the operator 
 may be taxed to the utmost. The manipulation required to 
 remove a calculus from one of the ducts must be conducted 
 most gently and carefully, for the walls are thin, and may be 
 easily injured or even torn. Sometimes the stone can be grasped 
 with forceps and withdrawn, or it may be reduced in size by 
 careful chipping with a needle, and the manipulation will be 
 greatly assisted by fixing the stone with two fingers of one hand 
 outside the duct, but inside the peritoneal cavity. It may be 
 possible to dilate the cystic duct and thus to remove a stone 
 from the common duct. It has also been said that a stone has 
 been crushed in situ by forceps or the fingers. Efforts have fre- 
 quently been made to push a stone onwards into the intestine, 
 but it is not likely that this could be done as easily as it could 
 be drawn backwards, for the stone has already passed through 
 the cystic end of the duct while it has been arrested by the 
 intestinal end which has not been dilated. 
 
 The sponges are now to be removed, and as the general 
 peritoneal cavity had been shut off by them, sponging is not 
 required. The gall-bladder is to be fixed to the wound without 
 tension if possible, and if the sac be very large, part of it may 
 be removed. If the parietal wound be large, stitches are 
 passed through the walls in the usual way to reduce its length, 
 and they are not to be tied until the stitches securing the gall- 
 bladder have been introduced. The method of suturing the 
 gall-bladder is as follows : The first stitch is passed through the 
 
CHOLECYSTOTOMY. 
 
 251 
 
 wound on one side, then through the lower part of the sac as it 
 lies in relation to the wound, and finally through the parietal wall 
 on the other side. The second one passes through the wall on 
 one side, enters the sac one-third of an inch above the first, again 
 as it lies in relation to the wound, and is returned through the sac 
 and parietal wall on the same side, having included one-third of an 
 inch of sac wall. The two ends of this stitch come out on the same 
 side of the wound one-third of an inch distant from each other. 
 Other stitches are introduced in the same way until the upper part 
 of the wound is reached, when one similar to the first is put in. 
 The other side of the sac is fixed to the wound in the same way, 
 ordinary silk sutures being used. This is the best plan, but 
 some prefer to use one or two continuous sutures, and find this 
 satisfactory. It is not advisable to make the opening too small, 
 and to be certain of efficient drainage an indiarubber tube is 
 put in. The dressing is changed as often as necessary, any 
 absorbent material, such as wood-wool wadding, being used. 
 The drainage tube can soon be dispensed with, as the stitching 
 prevents too rapid closure of the wound. If there be no 
 obstruction to the flow of bile into the intestine the abdominal 
 fistula will probably close in six or seven weeks ; but if there be 
 a block in the common duct the bile will naturally go on flowing 
 through the wound, and attempts to close it will certainly fail, 
 indeed nothing else could be expected. 
 
 An alternative plan to the formation of a fistula is to sew up 
 the wound in the gall-bladder, if the stones have been removed, 
 and if there have been no suppuration. It is undoubtedly much 
 more satisfactory to be able to close the abdominal wall completely, 
 but it is usually recognised that, as in the case of irremovable 
 cysts in the abdomen, it is safer to stitch a sac to the parietal 
 wall ; and also in the case of the gall-bladder experience has 
 shown that there is decidedly more risk incurred when a fistula 
 is not made. The special risk of stitching the opening is that it 
 is difficult, perhaps impossible, to say that no calculus is left in 
 the common duct. Should there be obstruction damming back 
 
252 
 
 THE LIVER. 
 
 the flow of bile it will pass into and distend the wounded 
 bladder, and thus at the very best no relief will be obtained. 
 The edges must be turned in, so as to bring peritoneal surfaces 
 together, and a fine continuous stitch is best for this purpose. 
 Sometimes the gall-bladder is more or less atrophied, and cannot 
 be brought in contact with the wall. In a condition such as 
 this the operation is likely to be performed for obstructive 
 jaundice, and the stones must be removed. The treatment of 
 the bladder itself will lie between its removal or the stitching 
 together of the edges of the opening. In cases such as these 
 removal of the bladder seems to be the better operation. There 
 is no particular advantage in leaving an atropliied bladder, and 
 its total removal does no harm, and is at the same time less 
 dangerous. 
 
 The operation of removal of the gall-bladder does not present 
 any special difficulty if it be not adherent. In rare cases, where 
 the gall-bladder has become atrophied, and where there is much 
 adhesion, it may be a matter of very considerable difficulty to 
 discover its exact position. 
 
 Cholecystectomy. 
 
 The operation is performed by separating the bladder from 
 the liver, beginning at the fundus. This is best done by 
 means of a sponge, the fundus of the gall-bladder is laid hold 
 of, and the connections are simply sponged off. When the 
 bladder has been entirely separated, and the cystic duct has been 
 reached, this last connection is ligatured with silk, and before 
 it is divided a pair of catch forceps is used to close the opening 
 on the bladder side. This is less trouble, and takes less time 
 than the common practice of dividing between two ligatures. 
 The open end of the duct is to be thoroughly cleansed with a 
 little wadding dipped in a 1-500 solution of corrosive sublimate. 
 During the separation lisemorrhage may be at first brisk ; it may 
 be checked with sponge pressure, or a few ligatures of fine cat- 
 
CHOLECYSTECTOMY. 
 
 253 
 
 gut may be required to arrest the larger vessels which may have 
 been injured. 
 
 When a fistula has been formed and bile continues to flow 
 from it, and when the stools show that no bile is passing into the 
 intestine, it is evident that there is an obstruction in the common 
 duct. To get rid of the annoyance of the constant outward flow 
 of bile, and at the same time to obtain the benefit of this secretion, 
 it has been suggested that an opening should be made between 
 the fistula and the intestine, the connection with the bowel 
 being made as high up as possible. The plan which Greig 
 Smith suggests is the following : — “(1) Abdominal section below 
 and up to the site of the fistula. (2) Suture of a convenient 
 portion of the intestine to the under aspect of the gall-bladder, 
 as near as possible to the fundus and over an area as large as 
 convenient. These sutures to pass through the serous and 
 muscular coats only, and to extend from the margin of the fistula 
 at least an inch downwards. (3) At the end of a week or so, 
 perforation of the apposed and adherent surfaces by a cutting 
 operation. This might readily be done through the abdominal 
 fistula, and would not require antesthesia. A small solid bougie 
 of rubber or decalcified bone is placed in the opening, and left 
 for a few days longer until it has become a fistula. (4) Blocking 
 of the parietal fistula as soon as the fistula between gall-bladder 
 and bowel has been established. If simple mechanical pressure 
 does not succeed, then a plastic operation might be performed. 
 Such an operation, though somewhat tedious, is not dangerous ; 
 the whole of the proceedings are carried out near the surface, 
 almost under the eye ; and it follows uj) and takes advantage of 
 perfectly natural processes of adhesive inflammation and fistula- 
 formation.” 
 
 In an operation of this rare nature one would have to be 
 guided very much by the exact condition of the parts. It seems 
 that it might be more easy to bring the intestine and the fistula 
 together by small perforated bone plates. The external opening 
 would have to be enlarged upwards so as to get the plate into 
 
254 
 
 THE LIVER. 
 
 the bladder ; immediately below the external opening the 
 abdominal wall would have to be divided and the intestine 
 caught up ; a bone plate would then be introduced into it, the 
 two joined together, and the opening connecting the bowel and 
 the liver would be at once established. No difficulty would 
 be experienced in passing a sound through the interstitial opening 
 and the original fistula would soon close, or the edges could be 
 pared and brought together. 
 
 Injuries of the Gall-Bladder. 
 
 Injury of the gall-bladder is a rare accident ; when it does 
 occur it is usually caused by a stab or blow inflicted when the 
 gall-bladder is distended. Eupture may also occur from ulceration. 
 Should bile appear through the wound, or through an opening 
 caused by suppuration, the diagnosis can be made with certainty. 
 Should no bile be seen, the diagnosis is simply a matter of con- 
 jecture, assisted by the position of the injury and by the general 
 condition of the patient. The simple extravasation of bile into 
 the peritoneal cavity does not appear to be of necessity a fatal 
 accident ; but should a suppurating gall-bladder rupture, the 
 result will be very different. 
 
CHAPTER X. 
 
 THE KIDNEY. 
 
 Surgical Anatomy. 
 
 The kidneys are situated one on either side of the vertebral 
 column, and measure about four inches in length, two inches 
 and a half in breadth, and one inch and a quarter in thickness. 
 The left is somewhat larger than the right, and also somewhat 
 narrower and longer. The weight of each gland varies from four 
 to four and a half ounces. 
 
 One cannot make a dogmatic statement regarding their 
 exact relations, as they are not absolutely fixed, and as they 
 vary both in size and in position, and are usually lower in 
 women than in men. They lie deeply in the epigastric and 
 hypochondriac regions, to which the left kidney is usually 
 confined, but the right extends nearly an inch lower than the 
 left, and so occupies a part of the umbilical and right lumbar 
 regions. The right kidney lies alongside the twelfth dorsal and 
 first three lumbar vertebrae, being pushed down by the liver ; 
 the left reaches as high as the upper border of the twelfth 
 dorsal, and barely so low as the third lumbar vertebra. From 
 the front, about one half of the right kidney is covered by the 
 chest wall, and proportionally more of the left. On deep 
 inspiration, both, but especially the right, are pushed down to 
 an appreciable extent, and in this way it is often possible to 
 feel with great distinctness fully one half of each gland. The 
 outer borders of the kidneys correspond with the outer border 
 
256 
 
 THE KIDNEY. 
 
 of the erector spinse muscles, and are situated about four inches 
 from the vertebral spines. 
 
 Both kidneys lie behind the peritoneum, the anterior surface, 
 which also looks outwards, being covered more or less by that 
 membrane. They are kept in position by their vessels and by 
 a bed of adipose tissue which surrounds them. The posterior 
 surfaces look inwards and backwards, and rest upon the 
 
 Fig. 17. — Diagram to show the Normal Blood Supply of the Kidneys. 
 
 (Hepburn.) 
 
 1, Abdominal aorta ; 2, phrenic arteries ; 3, coeliac axis ; 4, superior mesenteric 
 artery ; 5, middle suprarenal artery (left) ; 6, renal artery (left) ; 7, ovarian (or 
 spermatic) arteries ; 8, inferior mesenteric artery ; 9, inferior vena cava ; 10, 10', renal 
 veins (the left is cut); 11, hepatic veins; «, a', kidneys; b, b', suprarenal capsules; 
 c, c', ureters ; d, oesophageal opening in diaiihragm. 
 
 diaphragm, lumbar fasciae, and the psoas muscles. In front of 
 the right are the liver, the second part of the duodenum, and 
 the hepatic flexure of the colon ; the position of the latter being 
 of especial importance, as it is pushed forwards by enlargements 
 of the kidney. It is thus an aid in diagnosis, and its position 
 has also to be borne in mind while operating. In front of the 
 left are the stomach, spleen, pancreas, and the descending colon. 
 
SURGICAL ANATOMY. 
 
 257 
 
 The blood supply comes direct from the abdominal aorta. 
 Before entering the kidney the renal artery usually divides into 
 several branches, and there is not infrequently a second or 
 inferior renal artery coming off from the aorta farther down. 
 Eenal arteries may also arise from the common iliac, the inferior 
 mesenteric, or the middle sacral arteries. More rarely a renal 
 
 Fig. 18.— Schematic Diagram to show the nature of certain of the more frequent 
 FORMS OF Accessory Renal Arteries. (Hepburn.) 
 
 1, Abdominal aorta ; 2, phrenic arteries ; 3, coeliac axis ; 4, superior mesenteric 
 artery ; 5, ovarian (spermatic) arteries ; 6, inferior mesenteric artery ; 7, 7', common 
 iliac arteries ; 8, middle sacral artery ; 9, 9', middle suprarenal arteries ; 10, 10', superior 
 accessory renal arteries; 11, 11', renal arteries; 12, inferior accessory renal arteries; 
 
 13, accessory renal from 6 ; 14, accessory renal from 7' ; I, lumbar arteries. 
 
 artery has been seen arising from the internal iliac, and one case 
 is recorded in which both renal arteries sprang from a common 
 trunk on the front of the aorta. The right renal artery is longer 
 than the left, and passes behind the vena cava inferior. The left 
 vein is the longer, and passes in front of the aorta and posterior 
 to the third part of the duodenum. 
 
 Each kidney is entirely invested by a strong fibro-elastic 
 
 17 
 
258 
 
 THE KIDNEY. 
 
 capsule called the tunica albuginea, which is turned inwards at 
 the hilurn, and forms sheaths for the blood vessels entering the 
 organ. 
 
 The ureters are about fifteen inches in length. They are 
 situated behind and quite free from the renal blood vessels, 
 and pass obliquely downwards and inwards from the kidneys to 
 the bladder, lying posterior to the peritoneum throughout their 
 whole course. They have the appearance of whitish collapsed 
 tubes the size of a goose quill. Having crossed the common or 
 external iliac vessels — the right one behind the termination of 
 the ileum, the left one behind the sigmoid flexure of the colon — 
 they enter the true pelvis and pass downwards, forwards, and 
 inwards to reach the outer wall of the bladder, being then 
 situated two inches apart. They run for three quarters of an 
 inch obliquely through the walls of the bladder, and by the 
 time they have entered that viscus the slit-like openings are 
 within an inch and a half of each other, and a similar distance 
 behind the urethral orifice in the prostate. In the female they 
 pass on either side of the neck of the uterus, and about three 
 quarters of an inch from it before entering the bladder wall. 
 
 The position of the kidney may vary in three different ways : 
 one variation is acquired, one is congenital, and the third is 
 sometimes acquired, though usually congenital. These three 
 alterations in position are known as the movable kidney, the 
 floating kidney, and the displaced kidney. 
 
 Movable Kidney. 
 
 By a movable kidney is meant one where the organ has an 
 abnormal range of movement behind the peritoneum. This 
 condition is due to a more or less complete disappearance of 
 the fat surrounding the kidney, which is known as the tunica 
 adiposa, and also to some lengthening of the blood vessels. 
 The condition is seen in any wasting disease, and it is also 
 common in women who have borne children, partaking both of 
 
MOVABLE KIDNEY. 
 
 259 
 
 the softening and relaxation of the pelvic and subperitoneal 
 tissue generally. 
 
 The amount of movement varies, and may even he so great 
 as to allow of the kidney being felt on pelvic examination. 
 There is sometimes a history in these cases of some shake or 
 jar, which appears to have first started the kidney from its bed, 
 the symptoms being not uncommonly described as having com- 
 menced after a rough drive or a slip while coming downstairs. 
 A movable kidney is met with much more frequently in 
 women than in men, it is seen especially in women who have 
 borne children, and the right is more often movable than the 
 left. The cause of this is probably due to its relation to the 
 liver. 
 
 Floating Kidney. 
 
 A floating kidney is one where free movement of the organ 
 is possible on account of its anatomical relations. Instead of 
 lying behind the peritoneum it is surrounded by that structure, 
 and is attached by a mesentery or meso -nephron. This condition 
 must be a congenital one, and a greater and different range of 
 movement is permitted than in the case of a movable kidney. 
 
 Displaced Kidney. 
 
 A kidney may be found to be permanently fixed in an 
 abnormal situation, due either to some congenital or acquired 
 displacement. In its altered position the kidney will be found 
 lying either in front of the sacro-iliac synchondrosis, in the 
 iliac fossa, in front of the sacral promontory, or more rarely 
 entering the true pelvis. Except from a diagnostic point of 
 view these displacements are not of much importance surgically, 
 but if the condition were not known, or were forgotten, an un- 
 necessary exploratory incision might be made to clear up a 
 diagnosis. 
 
 The left kidney is more frequently displaced than the right. 
 
26 o 
 
 THE KIDNEY. 
 
 and, as the disease is found more often under such circum- 
 stances than when the kidney is in its normal position, it is at 
 least probable that displacement is conducive to some of the 
 altered conditions here met with. 
 
 Symptoms of Movable and Floating Kidney . — The symptoms 
 of movable and floating kidney resemble each other, except 
 that in the former case they can often he traced to some 
 distinct cause, while in the latter there is no history to 
 account for the displacement. In a slight case, there is 
 usually a feeling of discomfort, with perhaps some sensation of 
 weight and dragging in one side, this feeling being entirely or 
 almost entirely relieved on lying down during the night, and 
 beginning to return by the time the patient has got dressed in 
 the morning. Exercise or any jar or shake, as in driving over a 
 rough road, or in falling or slipping downstairs, increases the 
 discomfort. In an extreme case this feeling of discomfort 
 increases into actual pain, and may be accompanied by marked 
 gastric disturbance. Flatulence with colic and even sickness is 
 not uncommon, and there may also he sudden attacks of severe 
 pain resembling those of renal colic, which may be accompanied 
 by symptoms of ureemic poisoning due apparently to the 
 obstruction of the flow of the urine. This is caused either by a 
 bend or kink in the ureter, or it may be due to twisting of the 
 blood vessels. 
 
 The patient is usually aware of the presence of a movable 
 swelling in one side of the abdomen. The size and shape of 
 this will resemble that of the kidney, and it can be easily 
 pushed hack into the loin. The swelling is sometimes but by no 
 means always tender to the touch, and is seldom if ever actually 
 painful unless roughly handled. On comparing the two sides 
 of the body when the swelling is in its abnormal position, the 
 one side will feel more empty, and will become filled when the 
 kidney is replaced. 
 
 A lady thirty-six years of age, whose general health had not 
 been good for some time, and who had lost a considerable 
 
DISPLACEMENTS OF THE KIDNEY, 
 
 261 
 
 amount of flesh, complained of pain and discomfort with a 
 feeling of weight and dragging, amounting almost to a bearing 
 down. On making a vaginal examination the edge of a rounded 
 tumour was felt high up on the right side. On placing the 
 hand on the abdomen, it was evident that the swelling did not 
 have any pelvic attachment, and it could be pushed into the 
 natural position of the kidney. There was no doubt about the 
 diagnosis, and it was almost equally certain that the case was 
 one of movable and not of floating kidney. Women with these 
 movable organs are usually neurotic, but this is probably due to 
 the condition of health, which has led to the absorption of the 
 tunica adiposa. 
 
 Percussion does not give much information ; anteriorly it 
 does not give any; and although in the back the note will be 
 found more resonant on the side from which the kidney has 
 become moved, the diagnosis can be more satisfactorily made in 
 other ways. During menstruation the kidney becomes decidedly 
 more sensitive, and it is said that an increase in size can be 
 made out at these times. 
 
 The range of mobility varies in the movable and in the 
 floating kidney ; in the former the organ moves almost entirely 
 up and down ; while in the latter the mesentery allows not only 
 of this downward displacement, but the kidney has some lateral 
 mobility, and may even cross the middle line. A movable or 
 a floating kidney may be mistaken for a tense cyst of the 
 mesentery, for a tumour of the, omentum, for a distended gall- 
 bladder, or for a small ovarian tumour with a long pedicle. A 
 mass of faeces may also be mistaken for it, and a case of hydro- 
 salpinx has been diagnosed as a movable kidney. 
 
 Treatment of Movable and Floating Kidney . — The treatment 
 of a movable kidney is to be directed to the original cause of 
 the condition, viz. that which is accountable for the loss of 
 padding. The general health must be attended to, the patient 
 must rest, and avoid shaking and active exercise, and in some 
 cases relief may be obtained by an abdominal bandage ; a curved 
 
262 
 
 THE KIDNEY. 
 
 pad placed inside of an ordinary belt will often keep the kidney 
 in its place. An arrangement of this nature need not be worn 
 except when the patient is up and going about. The treatment 
 of a floating kidney must be entirely mechanical. 
 
 When the symptoms caused by a movable or floating kidney 
 are of such gravity that an operation is rendered advisable, what 
 is done is to endeavour to fix the kidney in its proper position 
 in the loin by an operation known by the name of nephrorraphy. 
 
 Nephrorraphy. 
 
 The steps of the operation are as follows. The incision is 
 made in the space between the ribs and the crest of the ilium. 
 In some there is plenty of room in this situation for carrying 
 out all the manipulation which is required. In others the 
 costal margin and the ileum may be so close together, that it is 
 advisable, when the patient is lying on the side, to place a small 
 firm pillow so as to raise the opposite side, and thus enlarge the 
 space through which the incision is to be made by causing a 
 lateral curvature of the spinal column. Before commencing the 
 incision, the last rib is to be found, and it must be remembered 
 that the twelfth rib may vary in length on the two sides. It is 
 of importance to be perfectly certain that the twelfth rib has 
 been found, because if a mistake were made and the eleventh 
 taken as the guide, the pleura, which is attached to this rib 
 might easily be opened, should it be found necessary to enlarge 
 the incision. 
 
 Commencing a little below the twelfth rib, and immediately 
 outside the mass of the erector spinee muscle, the incision is 
 carried for at least three inches downwards and forwards, 
 the exact line depending on the amount of space between the 
 ribs and the ileum of the patient. The incision is deepened 
 until the tunica adiposa is divided and the capsule of the kidney 
 has been reached, scissors being used for this purpose, and the 
 
NEPHRORRAPHY. 
 
 263 
 
 straight line being kept by the help of forceps, as described 
 in making the ordinary incision through the linea alba. As 
 soon as the capsule is reached or before the 
 incision is completed in its whole depth, if the 
 bleeding be profuse, all the blood vessels are 
 secured by catch forceps, and they are twisted 
 or tied at once to avoid inconvenience from 
 the presence of the forceps. When the incision 
 has been completed, the assistant, with his hand 
 on the abdomen, pushes the kidney, which 
 might and probably would be out of reach on 
 account of the position of the patient, back- 
 w^ards, upwards, and against the wound, and 
 he must continue this abdominal pressure 
 until the stitches have been introduced. For 
 suturing the kidney a short curved needle 
 with needle-holder is required. For this pur- 
 pose there is no better instrument than that Sims’s Needle-Holder. 
 of Marion Sims, though Hagedorn’s is also third size.) 
 
 convenient. If a long -handled curved needle be preferred, 
 those used by Mr. Annandale for cleft palate are the best. 
 
 The stitch is passed through the tissue of the wall near the 
 kidney on one side, through the fibrous capsule of the organ, 
 and through a corresponding extent of the wall on the other 
 side. When the abdominal wound has been closed this suture 
 is completely buried. 
 
 When a firm hold can be got on the capsule, and silk stitches 
 are used, it is better not to enclose the parenchyma of the kidney 
 in the suture, as this might be followed by atrophy of the 
 enclosed part of the organ ; if, however, the suture is of some 
 absorbable material it is of no moment whether the suture 
 passes through the kidney substance in addition to the capsule 
 or not. It is best to use a number of sutures, and after they 
 have been introduced, the fibrous capsule is to be thoroughly 
 scarified, as well as the tissues which will be in direct contact 
 
264 
 
 THE KIDNEY. 
 
 with the kidney. Bleeding must be carefully stopped before 
 the wound is closed, and should there he any difficulty in bring- 
 ing the whole of such a deep wound together, a buried layer of 
 catgut sutures may he introduced to close the deeper part of the 
 wound. It is better to do without drainage if possible, but a 
 tube should always be introduced if there has been any trouble- 
 some oozing. Various kinds of suture have been used to fix 
 the kidney, the best is probably well prepared catgut ; but silk, 
 silkworm gut, and kangaroo tendon have all been tried by 
 different operators. Catgut suturing of the capsule of the 
 kidney, combined with thorough scarification, seems to give the 
 best results, but other methods have been employed, and with 
 success. Some incise the capsule of the kidney and stitch it to 
 the surrounding parts ; others advise the introduction of large 
 drainage tubes to make irritation and consequent adhesions ; 
 and others again are content to stitch the tunica adiposa to the 
 deeper parts of the abdominal wound without interfering with 
 the kidney itself. This latter plan is not to be recommended, 
 and must never be done unless the tunica be first opened to 
 make sure that the kidney is not movable within it, as is 
 sometimes the case. To give the operation every chance of 
 success it is necessary to keep the patient in bed for at least three 
 weeks ; and even when this is done and every possible care is 
 taken, the result may not be entirely satisfactory. Should the 
 operation fail, the want of success will be due rather to some 
 fault or omission on the part of the surgeon than to anything 
 the patient can have done, provided that he has not got out of 
 bed before permission has been given. The operation does not 
 present any special difficulty, and, with the exception of the 
 needle-holder, no special instruments are required for its per- 
 formance. 
 
 It is not often that the symptoms caused by the presence of 
 a movable kidney are of sufficient severity to warrant us in 
 advising any operative measures being taken, but in some cases 
 the life of the patient may be rendered -absolutely miserable ; 
 
NE PH R ORRA PH Y. 
 
 265 
 
 and, when this is so, it is universally considered that the 
 operation of stitching the kidney into its proper place in the 
 loin is a proper course to recommend. The risk of such an 
 operation, when ordinary precautions are taken, is not greater 
 than when any incised wound is made of a similar length, and 
 the patient’s future health is not interfered with in any way. 
 This is not the case when a floating or movable kidney has been 
 removed, as has been sometimes done. It is impossible to 
 understand how such an operation can be justifled, unless the 
 symptoms are very distressing, and one or two attempts to fix 
 the kidney by suturing have failed. When it is remembered 
 that the removal of one kidney means that the other will have 
 to do double work, and that the chances of life are very much 
 reduced, one can hardly imagine that the removal of a healthy 
 kidney could ever be a justifiable operation. 
 
 When, in addition to the mobility, the kidney is itself the 
 seat of a surgical lesion it may be right to remove the organ, 
 but the operation is then performed not for the mechanical diffi- 
 culty, but for the disease. Should a movable kidney, on the other 
 hand, be found in a patient who is suffering from any non-surgical 
 disease of these organs, any operation is out of the question. 
 
 Diagnosis of Displaced Kidney . — A displaced kidney may, like 
 a movable or floating one, be mistaken for a mesenteric or 
 omental tumour; for a collection of fseces in, or malignant 
 disease of, the bowel ; for an ovarian tumour ; or for a dilated 
 Fallopian tube. 
 
 The diagnosis of this condition is made by finding that the 
 kidney is absent from its usual position, from the shape and 
 consistency of the swelling, from the fact that it does not 
 increase in size, and from the general history. 
 
 Malformations of the kidney are frequently met with along 
 with displacement. One kidney may be entirely absent, or 
 the two may be joined together either intimately or by a 
 fibrous band, thus forming what is well known as the horse- 
 shoe kidney. Surgically the absence of one kidney is of 
 
266 
 
 THE KIDNEY. 
 
 importance, as this will prevent all operative interference ; and, 
 where the two are joined together, no operation will be proper 
 unless the organs are found to be connected simply by a band. 
 In such a condition operation may be performed on one organ, 
 or one may be entirely removed after the division of the fibrous 
 connection, and the patient recover. 
 
 Eenal Calculi. 
 
 A common cause of kidney disease is the presence of calculi 
 either in the pelvis, in the calices, or in the substance of the 
 kidney itself. These stones occur most frequently in the young, 
 and in those over the age of forty. In the former the calculus 
 which is commonly found is one consisting of urate of ammonia, 
 and its formation seems to be principally due to errors of diet. 
 It is met with most frequently amongst the poorer classes, and 
 is more common in some localities than in others. When a 
 renal calculus is found in a patient over the age of forty, it will 
 probably be formed of oxalate of lime or of uric acid. Here 
 again errors of diet have much to do with their formation ; 
 people as they get up in years are apt to eat more, to take 
 richer food, and also less exercise, than they were formerly 
 accustomed to do. Calculi are frequently formed of different 
 materials arranged in concentric layers, and the nuclei may be 
 of various kinds ; as for example, a clot, a piece of fibrin, etc. 
 While calculi of urate of ammonia, uric acid, and oxalate of 
 lime are much the most common, a rarer stone composed of 
 cystine is occasionally met with. About this substance little is 
 known, except that the condition predisposing to it seems to be 
 usually a congenital one. 
 
 Soft phosphatic stones are not very often met with in the 
 kidney, their common situation is in the bladder, and they 
 usually collect round a nucleus which may consist of any 
 material. Various rare calculi have also been met with in the 
 kidney. 
 
RENAL CALCULI. 
 
 267 
 
 lienal calculi are found either in the pelvis of the kidney, 
 in one calyx, or in a combination of these two situations, the 
 branches of the stone passing from the pelvis into the calices, 
 thus resembling a mass of branching coral ; or the stone may 
 be found in the substance of the kidney ; or it may be arrested 
 in the ureter while passing from the kidney to the bladder. 
 
 Symptoms . — The symptoms vary with the position which the 
 stone has taken up in the kidney, and with its size and exact 
 nature ; as, for example, a calculus situated deeply in a calyx 
 may remain entirely quiescent, while a movable one in the 
 pelvis may cause suppression of urine and other symptoms. 
 
 A stone firmly fixed in any part of the kidney will cause 
 little or no pain, and will not give rise to any symptoms ; a 
 movable one, on the other hand, especially if small or rough, 
 will give rise to well marked and distressing symptoms. The 
 rough oxalate of lime or mulberry calculus, as one would expect, 
 is the stone which gives rise to most pain, that symptom being 
 least marked when one composed of uric acid is present. 
 
 The usual symptoms of the presence of a stone in the kidney 
 are pain of a dull aching character, which may be entirely 
 absent when the patient is at rest in bed, but begins to return 
 when he gets up, and is as bad as usual by the time he has 
 dressed. This pain is increased on movement, especially on 
 active exercise ; it is worse when driving, even in a well-built 
 carriage, and in a marked degree if the springs are bad and the 
 roads rough. The pain is situated in the loins and back, it 
 often passes downwards along the course of the ureter, and may 
 even cause symptoms resembling those of the presence of a stone 
 in the bladder ; it also passes into the testicle or ovary, and there 
 may be retraction of the testicle when the suffering is very 
 acute. The whole of the side, over the ileum down to the thigh 
 and leg, and extending even as far as the foot, may be painful. 
 The loin and side of the affected kidney are tender on pressure. 
 Attacks of haemorrhage from the kidney are a very common 
 symptom, especially after rough movement, and the blood which. 
 
268 
 
 THE KIDNEY. 
 
 is passed at these times is always found to be thoroughly mixed 
 with the urine. 
 
 Crystals or small fragments of stone may be found on 
 microscopic examination of the sediment of the urine, and this 
 examination may have to be repeated a number of times, for it 
 will not do to be satisfied with one or two inspections, unless a 
 positive result be obtained. The microscopic examination must 
 be carried out with the most scrupulous care. When the stone 
 has been setting up irritation in the kidney for a considerable time, 
 it is usual to find that more or less pus is present in the urine, 
 and this in its turn sets up an irritable condition of the bladder, 
 leading to some degree of cystitis, with frequent micturition. 
 
 These are the direct symptoms usually met with in a case of 
 renal calculus, but at times a patient may have been perfectly 
 well, and there may have been absolutely nothing to make him 
 think that there is anything the matter, either in the kidney or 
 anywhere else, until the presence of a swelling is discovered in 
 the loin. The tumour is the distended kidney, and is due to 
 the damming back of the urine by the blocking up of the pelvis 
 and calices with a stone which is usually branching and coral- 
 like. The indirect symptoms are entirely reflex, having no 
 direct connection with the urinary system ; they consist of 
 headache, and more especially of disorders of the digestive 
 apparatus, flatulence, nausea with retching and even vomiting. 
 A great difficulty in the diagnosis is, that while a stone may be 
 present without giving rise to symptoms, it is by no means un- 
 common to have all the symptoms of a stone, and these even well 
 marked, when a calculus is not to be found in the kidney or ureter. 
 
 Although a calculus may be formed in the kidney it need 
 not of necessity remain in that situation, and it happens not 
 infrequently that a small calculus passes through the urinary 
 passages and is discharged from the body without any very 
 serious symptoms. Natural means of cure may sometimes be 
 obtained by a visit to a suitable watering-place, and it is said 
 also by the persistent and entire use of distilled water. 
 
RENAL COLIC. 
 
 269 
 
 The mechanism by which a calculus is driven down the 
 ureter and into the bladder is probably twofold. In the first 
 place, it is forced onwards by the contraction of the muscular 
 fibres of the ureter, which is set up by the irritation due to the 
 presence of the stone, and to the distension which it causes. In 
 addition to the muscular contraction, the weight and pressure 
 of the urine will assist in the downward passage, and it is 
 probable that the urine may help to lubricate and protect the 
 lining surface of the ureter. The pressure caused by the urine 
 will likely be greatest when the muscular fibres of the ureter 
 are relaxed, either by simple exhaustion, or where the same 
 result has been brought about by the use of drugs. The 
 distension of the ureter and the spasmodic contraction of its 
 muscular fibres is the cause of very severe, often agonising pain, 
 and it is known as renal colic. 
 
 Any solid or semi-solid substance may give rise to an attack 
 of renal colic ; but it is likely to be most painful when a stone, 
 such as a rough mulberry calculus, is being driven through the 
 ureter. A plug of mucus, a clot, or a small hydatid are the 
 common causes of renal colic in addition to the attacks caused 
 by a stone. 
 
 Eenal Colic. 
 
 During an attack of renal colic, the pain is sometimes so 
 severe that the patient may be unable to localise its exact 
 position, but it will usually be described as commencing deeply 
 in the loin and passing downwards and inwards in the direction 
 of the bladder. 
 
 Colic due to the irritation caused by the distension of a 
 narrow canal is also seen in cases of hepatic colic, and often at 
 the commencement of an acute attack of appendicitis. Eenal 
 colic is differentiated from an attack due to appendicitis, or to 
 the passage of a biliary calculus, by the position of the pain, 
 and the direction in which it passes. It is situated deeply in 
 
270 
 
 THE KIDNEY. 
 
 the loin and is directed towards the bladder when the colic is 
 renal ; it commences at McBurney’s point and radiates down- 
 wards and inwards in cases of appendicitis ; and when it is due 
 to the passage of a biliary calculus it starts from the position of 
 the gall-bladder and passes backwards and towards the right 
 scapula. In addition there is likely to be some history or some 
 symptom pointing to the presence of one of these diseases. 
 
 A calculus may pass through the whole length of the ureter 
 within a few hours, or the suffering may be prolonged for 
 several days. When a rough stone is passing, the pain may be 
 so great that it may cause convulsions, and patients have been 
 known to commit suicide. 
 
 The amount of general disturbance will depend to a certain 
 extent on the temperament of the patient. In some there may 
 be a severe rigor, followed by complete collapse. During the 
 attack the testicle on the same side becomes retracted, the 
 bladder becomes irritable, the urine, tinged with blood, is 
 usually passed frequently, but in small quantities, and though 
 the other kidney is sometimes stimulated to secrete freely, at 
 other times its action may be entirely arrested. 
 
 It is evident that when a stone becomes arrested during its 
 passage down the ureter, no urine can pass from that kidney to 
 the bladder, but a certain amount will collect between the 
 kidney and the point of impaction. This may be followed by 
 symptoms of suppression, and it is not necessary that both 
 ureters be blocked to cause this condition. 
 
 When symptoms of suppression of urine come on as an attack 
 of renal colic is passing off, and more especially if there be a 
 history of calculi in the kidney, and no reason to suspect the 
 presence of any other disease, such as paroxysmal haematuria or 
 Bright’s disease, it will be found that delay means disaster, and 
 immediate surgical interference is called for as soon as medical 
 treatment fails to bring urine into the bladder. 
 
 Diagnosis . — The positive diagnosis of one or more calculi, 
 either in the pelvis, in the ureter, or in the kidney itself, is at 
 
RENAL CALCULI. 
 
 271 
 
 times extremely difficult. Even in a well marked and apparently 
 typical case of renal calculus no stone may be found, and there 
 is no symptom, nor combination of symptoms, which makes it 
 possible to say with absolute certainty that a stone is present, 
 short of feeling the calculus itself It has been said that in 
 thin subjects stones have been detected on abdominal palpation. 
 When a calculus is present in a kidney, it is usual to find 
 that the organ is enlarged, but too much stress must not be laid 
 on this sign, because one kidney may be found to be increased 
 in size, due to a compensatory hypertrophy of the healthy organ, 
 when the other kidney has been more or less destroyed. This 
 sign taken alone might lead to an erroneous conclusion that a 
 stone was present, when the enlarged kidney was really healthy, 
 and some other disease had caused the destruction of its fellow. 
 The sensation of the patient may also prove deceptive, as it is 
 not altogether uncommon for the pain and tenderness to be 
 located in the healthy organ. When making a diagnosis of 
 renal calculus, mistakes may occur by confounding it with 
 bladder neoplasms causing haemorrhage, and with malignant, 
 strumous, and tubercular disease of the kidney. In bladder 
 growths, the great amount of blood lost, its clotted condition, 
 and the fact that it is not intimately mixed with the urine, 
 will draw attention to the bladder, and an examination of its 
 interior with the cystoscope will, when care is used, discover 
 even a small tumour. Even in the female, where digital 
 examination is very easy, it is better to use the cystoscope than 
 to run the risk of over-stretching the urethra and destroying 
 control over the bladder. 
 
 In malignant disease of the kidney hsemorrhage is usually more 
 continuous, and it is only in the early stages that a mistake is 
 likely to occur. Careful microscopic examination will show 
 crystals, or embryonic cells of malignant disease. 
 
 It is in the strumous and tubercular kidneys, especially when 
 the disease is commencing, that a mistake is likely to be made. 
 At first there is little except the history and microscopic 
 
272 
 
 THE KIDNEY. 
 
 examinatiou of the urine to guide one ; the pain will be, as a 
 rule, more severe and sudden if a stone be present and the 
 haemorrhage is not likely to be so steady, and it comes on after 
 exertion. 
 
 When we come to the positive diagnosis of renal calculus, 
 and it has been already pointed out that a certain diagnosis 
 cannot be made until a stone is actually felt, the first procedure 
 we have to consider is that of needling, i.e. of inserting a needle 
 into the kidney from the loin for the purpose of detecting the 
 presence or absence of a stone. This is not done so often now 
 as it was a few years ago, for it has been found to be a very 
 uncertain guide, nor is the method entirely devoid of danger. 
 To strike a small or even a large stone at a depth of several 
 inches is by no means easy, and the needle may be inserted 
 many times before the stone is found, or it may not detect its 
 presence. The danger consists in the possibility of injuring a 
 large blood vessel ; or, after having unintentionally transfixed 
 the kidney, the colon or intestine may be injured. Besides, an 
 unfortunate result may follow. Numerous needle punctures in 
 the loose cellular tissue of the loin may be the starting point of 
 an attack of inflammation going on to the formation of a 
 perinephritic abscess. 
 
 Treatment . — The treatment of renal colic is entirely 
 palliative. The first indication is to relieve pain. Morphia 
 must be given hypodermically, and it is useless to begin 
 with less than a quarter of a grain. In twenty minutes this 
 dose may be repeated if the pain has not begun to show 
 signs of alleviation. Should it get at all less severe, a second 
 dose need not be given so soon, as morphia does not always 
 overcome a very severe pain immediately. The quantity and 
 the number of doses must be regulated entirely by the effect 
 produced. Along with the morphia the one-hundredth of a 
 grain of sulphate of atropia may be given with the view of 
 relieving the spasm of the ureter. The patient is to be kept 
 warm in bed, and he will naturally take up the position which 
 
NEPHRO-LITHOTOMY. 
 
 273 
 
 gives him most ease. That will be on the side with the legs 
 drawn up and the shoulders well forward. Fomentations or 
 light poultices are to be kept on over the abdomen and the loin, 
 and a hot bottle is to be applied to the feet. The skin must be 
 encouraged to perspire, and at times a hot air bath given while 
 the patient is in bed will prove of service. The pain may 
 sometimes be so severe that chloroform must be administered 
 until the patient can be got under the influence of the morphia. 
 
 Treatment of Renal Caleulus . — When a stone is actually in 
 the substance or pelvis of the kidney little or but temporary 
 relief can be given, except by surgical measures. Eest, avoid- 
 ance of rough movements, and fomentations are the only means 
 which will give relief, short of the administration of narcotics. A 
 stone may give rise to little more than discomfort, and under 
 such circumstances the simple opinion that a stone is present 
 in the kidney is not sufficient to justify an operation. Should 
 the symptoms be of sufficient gravity to prevent the patient 
 working or enjoying the ordinary pleasures of life, or if there 
 be any evidence of coming disease or destruction of the kidney 
 itself, removal of the calculus by a cutting operation is called 
 for. This operation is called nephro-lithotomy, and it may be 
 performed in two different ways : the one is by a single loin 
 incision, the other by a combination of this with an abdominal 
 incision through the peritoneum. 
 
 Nephro-Lithotomy. 
 
 The operation for the removal of a stone through the single 
 loin incision is the same as that for nephrorraphy, until the 
 kidney is reached. When the wall is vascular it is best to tie 
 the bleeding vessels as soon as the incision down to the kidney 
 has been completed. The length of the wound will vary from 
 three to five inches, and its exact direction, as in nephrorraphy, 
 will depend on the configuration of the patient. The kidney 
 may be pushed down to the wound by the assistant from the 
 18 
 
274 
 
 THE KIDNEY, 
 
 front, or better, by the one hand of the operator, while with the 
 fingers of the other hand introduced into the wound the whole 
 of the kidney is examined with the most minute care. Should 
 several localised hardnesses be detected, and there is a doubt as 
 to whether they are stones or not, a fine needle may be intro- 
 duced to settle the question ; if, however, there be only one such 
 hardness, the incision into the kidney is to be made at once. 
 The incision may be made either through the pelvis or through 
 the substance of the kidney, and in both of these situations 
 there is one drawback ; when it is made through the pelvis 
 there is a slight risk that the opening will not heal, and that 
 a urinary fistula will remain permanently ; when the kidney 
 itself is incised there may be troublesome haemorrhage. The 
 balance between these two plans is about even, and it is there- 
 fore best to have no fixed rule, but to be guided entirely by the 
 position of the stone, and thus be free to make the opening into 
 the kidney in whatever seems to be the most convenient 
 situation. If it should happen that no hardness can be 
 detected, there will always be the fear that a mistake has been 
 made, and that it is the other kidney which contains the stone. 
 In such circumstances it is difficult to know what is best to do, 
 for one would be naturally as loath to injure what may turn out 
 to be a perfectly healthy organ, as to make an incision on 
 chance in the other loin. If this operation has been preferred, 
 and no stone has been felt, the better plan will be to incise the 
 kidney, the simple incision and depletion often doing good. 
 When a stone has been detected, the incision which must be 
 made for its removal ought to be large enough to admit the finger. 
 As there is certain to be excessive hcemorrhage from a wound in 
 the kidney, the finger is to be at once passed into the opening 
 to act as a plug, and the exact size and shape of the stone will 
 then be determined. A fine scoop passed alongside the finger 
 will assist in the removal of the stone, or various varieties of 
 crocodile forceps will be found at times of service. Although 
 tliere may be great difficulty in removing a stone tightly 
 
NEPHRO-LITHOTOMY. 
 
 275 
 
 embedded in the substance of the kidney, every effort should be 
 made to remove it entire, and thus avoid the possibility of leav- 
 ing behind any fragments which might form the nucleus of a 
 new stone. Bleeding is sometimes very brisk from the renal 
 tissue, but fortunately it can be easily controlled either after 
 pressure has been kept up for some little time with the finger, 
 or if this be not sufficient a stitch of catgut may be inserted 
 through the lips of the wound in the kidney to draw them 
 together. A large-sized rubber drainage tube is put into the 
 wound, extending down to, but not into the kidney, and it must 
 be cut off flush with the skin to avoid pressure on the organ. 
 Silk stitches are introduced through the parietal wall as usual ; 
 a large antiseptic and absorbent dressing is put on, and this 
 must be changed frequently. Little time must be spent over 
 this changing of the dressing ; the old one must be taken off 
 and the new one put on immediately, so as to expose the back 
 to cold as little as possible, and there must be no roller bandage, 
 the dressing being kept in position by a broad flannel bandage. 
 At first all the urine from the injured kidney comes away 
 through the wound ; soon it begins to pass down the ureter, 
 and after a few days the opening into the kidney closes. As 
 soon as the urine ceases to pass through the wound, the drain- 
 age tube may be shortened, and it can be withdrawn entirely 
 after two or three days. 
 
 The after treatment of this and other operations on the 
 kidney does not vary from that followed after any other 
 abdominal operation, except that morphia should be avoided 
 as much as possible, and when it is required it must be 
 administered in specially small doses. Little or no stimulant 
 should be allowed. It is frequently recommended that neither 
 morphia nor any stimulant is to be given after renal operations, 
 but it is wrong to lay down a hard and fast rule of this kind ; 
 the general condition of the patient must always be the 
 guide. It may be that a greater risk is sometimes run by 
 withholding these remedies than by giving them. 
 
276 
 
 THE KIDNEY. 
 
 The alternative operation which may be performed for the 
 removal of a renal calculus consists in cutting down on the 
 kidney from the front, and extracting the stone through a 
 second incision in the loin. The incision for this operation, 
 and for all others on the kidney wdiere the peritoneal cavity 
 is opened, is to be made through the linea semilunaris on the 
 side of the affected kidney. This line is immediately outside 
 the rectus muscle, and will be found from three and a half to 
 four and a half inches from the linea alba when the abdomen is 
 not distended. The incision through the linea semilunaris must 
 be long enough to admit the hand, and from it the bleeding 
 is rather more free than when the middle line is incised. As 
 soon as the abdomen is opened, it is advisable to pass the hand 
 across the peritoneal cavity to examine the other kidney in 
 case there has been transference of the pain from one side 
 to the other. It is well to do this at once, and thus be sure 
 that the kidney does not present at least any gross lesion, for 
 it is apt to be forgotten later. When no evidence of disease 
 is found in the opposite kidney, the one cut dowm on is to 
 be examined by the hand inside the abdominal cavity, assisted 
 by the other hand helping to fix the kidney from the loin. It 
 is not sufficient to be satisfied with the discovery of one stone, 
 but the whole of the kidney must be carefully gone over. 
 There must be no exception to this rule. As soon as the 
 presence of a calculus, or even of a hardness at one spot, has 
 been felt, the patient is turned on to the side, the abdominal 
 wound being meanwhile protected by a sponge, and a short 
 incision is made down to the kidney from the loin. The left 
 hand is passed again into the peritoneal cavity, and, holding 
 the kidney, it acts as a guide in cutting down on the stone, and 
 assists in its extraction. When both kidneys have been 
 examined without finding any trace of disease, the ureters 
 must be traced through their whole course from the kidneys to 
 the bladder. Should a stone be found in either ureter the 
 treatment to be adopted will depend on its exact position. If 
 
NEPHRO-LITHOTOMY. 
 
 277 
 
 it be at the upper part of the ureter it may be reached by the 
 ordinary lumbar incision ; if lower down the incision must be 
 made as low as possible, opposite the spot where the stone is 
 situated, if that can be managed, and the calculus must be 
 extracted without opening the peritoneum. When it is situated 
 close to the bladder, and is of such a size that it seems to be 
 impossible that it can pass onwards, the best plan probably, 
 when the patient is a man, will be to open the bladder above 
 the pubes, and dilate the orifice of the ureter from the bladder, 
 assisted by the one hand in the abdominal cavity. This would 
 be a most difficult operation, and we are not aware that it has 
 ever been done, but it would be the best treatment under the 
 circumstances. If the patient be a woman the stone may be 
 removed by cutting down on it through the vagina, but this is 
 open to the objection that a urinary fistula would probably 
 remain. If the calculus cannot be reached from the back, and 
 is not close to the bladder, it must be left alone, or the kidney 
 must be removed. 
 
 Unless the stone be small and situated deeply in the sub- 
 stance of the kidney, it is improbable that it would not be 
 found by this bimanual method. Still it may be passed over, 
 and symptoms which justify an operation will also justify an 
 incision into the kidney, a procedure which does not seem to 
 be attended by any special risk, and wdiich may do good by 
 depleting the organ. It is also possible that some granulation 
 tissue, whether tubercular or not, may be removed without being 
 noticed. When a stone is not found either in the kidney or in 
 the ureter, the kidney, which is supposed to be the seat of the 
 disease, must be opened and thoroughly explored. There is 
 no condition which would justify this being done through the 
 peritoneal cavity, but it must always be managed through the 
 loin incision. The pelvis is opened sufficiently to admit the 
 finger, and between this finger and those of the other hand 
 inside the abdomen, the whole surface of the kidney is to be 
 thoroughly gone over, and if nothing abnormal be felt a fine 
 
278 
 
 THE KIDNEY. 
 
 sound is to be passed into each calyx. After this thorough 
 examination, and whether a calculus be discovered or not, the 
 abdominal wound is closed, and the loin one drained as in 
 lumbar nephrotomy. 
 
 To any one with even a slight experience of abdominal 
 surgery, nephrotomy by the double incision presents great 
 advantages. Mr. Thornton has done much to show the advisa- 
 bility of this method, and as time goes on surgeons are gradu- 
 ally becoming converted to his views on the subject. The 
 special advantage is its certainty ; by the help of the hand in 
 the abdomen the condition of the whole of one kidney, and of 
 one ureter, and of the greater part of the other ureter, can be 
 determined, in addition to what information is obtainable by 
 the lumbar incision alone. The certainty of finding the stone 
 is also greater, and when this is difficult the kidney is less 
 likely to be unnecessarily injured. 
 
 The advantage of the lumbar nephrotomy is that an incision 
 is not made into the peritoneal cavity, but this advantage is so 
 infinitesimal, when no septic material is introduced, that it is 
 really not worth considering when so much is to be gained by 
 making the incision into the abdominal cavity. 
 
 The extraction of a stone from its bed in the kidney, or in 
 the upper part of the ureter, is sometimes a matter of great 
 difficulty. It must be done with care, especially when it is 
 situated near the peritoneal surface, and is to be managed by 
 the finger, assisted by a small scoop or a pair of narrow forceps. 
 Lister’s sinus forceps, made longer than usual, will be found to 
 be a most convenient instrument for loosening a calculus from 
 its position, and ordinary dressing forceps with long shanks for 
 withdrawing it. It is hardly possible to insist too much on the 
 necessity of removing a stone without breaking it while it is 
 inside the kidney. 
 
 The treatment of a large branching stone, which has been 
 the cause of hydronephrosis or pyonephrosis, will be considered 
 in connection with the operation of removal of the kidney. 
 
ENLARGEMENTS OF THE KIDNEY. 
 
 279 
 
 Enlargements of the Kidney. 
 
 We now come to the consideration of enlargements or 
 tumours of the kidney. These may be divided for the practical 
 purposes of diagnosis into cystic and solid growths. 
 
 As an example of the first variety, we have a simple cyst 
 in the substance of the kidney ; a distension of the pelvis of 
 the kidney and calices, to a greater or less extent by fluid — 
 a hydronephrosis ; a similar distension, where the contents are 
 purulent — a pyonephrosis ; and lastly, a cystic condition of the 
 kidney from the presence of a hydatid tumour. 
 
 Solid tumours are either sarcomata or carcinomata, or they 
 may be merely part of a general disease, such as lymphadenoma 
 or syphilis. 
 
 Enlargements due to scrofula and tuberculosis hold a 
 somewhat middle position between cystic and solid growths. 
 In the early stages the enlargement is principally solid, in 
 the later stages the growth breaks down and becomes more 
 or less fluid. 
 
 In addition to the growths already mentioned several rare 
 tumours of the kidney may be met with. These consist of 
 simple adenoid growths, cavernous and fibrous tumours, and 
 they are, with the exception of the last, of small size, and 
 have seldom been known to give rise to symptoms. An 
 operation is occasionally necessary for simple adenoid growths, 
 and several large fibromata have been removed. 
 
 The diagnosis of a cystic tumour is not generally difficult, 
 and it is only in the exceptional cases, or where the tumour 
 is large, that the special characteristics are absent and mistakes 
 are apt to occur. Attention will be first drawn to the history 
 relating to the position in which the growth was first noticed, 
 and to the rate of growth. These tumours usually grow slowly, 
 and the symptoms are seldom distressing unless there be 
 suppuration or the growth be very large. The swelling passes 
 deeply into one or other loin, and is fixed in that position. 
 
28 o 
 
 THE KIDNEY, 
 
 One special diagnostic point is the position of the colon ; owing 
 to its anatomical relation to the kidney it is pushed forward 
 by an enlargement of the organ, and is always to be felt 
 running across the front of the growth from above downwards, 
 unless the tumour be of very great size. Its position is 
 determined either by percussion, when a line of clear note 
 will be discovered if the colon be distended, or it will be 
 felt as a softish rounded cord fully larger than a flattened- 
 out finger. When the tumour is of very large size, or if the 
 colon has become fixed by adhesions, this diagnostic sign may 
 be absent, because if the tumour has grown more to the 
 outside it may overlap the colon. There is a dull note on 
 percussion over the loin on the side from which the growth 
 has sprung, on the other side the note is usually tympanitic. 
 On examination from the vagina or rectum a tumour cannot 
 be felt unless it be of great size, and in the female the uterus 
 will be found to be in a normal condition in regard to position 
 and mobility. The position of the uterus must not be relied 
 on as being absolutely diagnostic, for it is not infrequently seen 
 that an ovarian tumour does not affect the position and mobility 
 of the uterus in the slightest degree, while a cystic enlargement 
 of the kidney may develop in such a way as to enter the pelvis 
 and displace the uterus to one side. 
 
 Solid tumours of the kidneys do not vary from cystic 
 growths in their general characteristics except in the solidity 
 of the mass. They seldom attain to such a large size, and as 
 the position in the loin is therefore more distinct, the differential 
 diagnosis between such a tumour of the kidney and other 
 abdominal enlargements is not very difficult. 
 
 Simple Cysts of the Kidney. 
 
 Simple cysts of the kidney are by no means common, and 
 when small they are not of any importance ; but attention may 
 be drawn to their presence either on account of their size, or 
 
SIMPLE CYSTS OF THE KIDNEY. 
 
 281 
 
 from the growth giving rise to disturbance in the kidney itself, 
 by blocking the ureter, or by destruction of the kidney tissue 
 from pressure. 
 
 They grow from some part of the substance of the kidney, 
 and are probably caused by obstruction and consequent dilata- 
 tion of the tubules. The increase in size of these cysts is 
 slow, and they tend to go on enlarging indefinitely. In this 
 way they differ from cases of distension of the kidney caused 
 by some obstruction in the ureter, although cases are on record 
 of a cyst of this nature becoming emptied by a communication 
 being formed either with the ureter through a calyx, or with 
 the pelvis of the kidney. Should this happen, examination of 
 the urine will show the presence of albumen, and may thus 
 enable one to differentiate a cyst of this nature from hydatid 
 disease or from hydronephrosis. Fluctuation is easily made out, 
 and should the fluid be drawn off with the aspirator it will be 
 found to be of a light colour, to contain albumen, sometimes 
 blood, and, especially when the growth has been very slow, 
 a large quantity of cholesterin. The fluid is not urine, and does 
 not contain urea. 
 
 Conglomerate cysts of one or both kidneys have been met 
 with, but it is extremely rare to find that only one kidney is 
 affected. The symptoms are those of an enlarging semi-solid 
 tumour, and it is unlikely that a diagnosis will be made. The 
 disease is of importance surgically by reason of the frequency 
 with which it is found to be bilateral. 
 
 Treatment . — As long as the growth is small, and not giving 
 rise to symptoms, such cysts are best left alone. When large, 
 aspiration is the most simple treatment. Should the fluid 
 reaccumulate quickly after several aspirations, a cure cannot 
 be expected by going on drawing off the fluid indefinitely, 
 and removal of the kidney will have to be considered if the 
 gravity of the symptoms calls for such an operation, and if 
 there is nothing in the general health of the patient which 
 would render this operation more than usually dangerous. The 
 
282 
 
 THE KIDNEY, 
 
 patient ought certainly to be allowed to choose between re- 
 peated aspirations and nephrectomy, for the removal of the 
 kidney is a dangerous operation, and entails a considerable 
 amount of risk. If comfort and good health can be obtained 
 by removing the fluid once every year or two, most patients 
 will prefer not to run the immediate danger from the operation, 
 l^lus the remote risks entailed by the removal of an otherwise 
 healthy organ. 
 
 Aspiration is to be conducted on proper principles ; the 
 needle must be fine, it must be inserted into the cyst at its 
 highest level, and intestine must be avoided. 
 
 Eemoval of fluid through the loin in this and in all other 
 kidney enlargements must never be done, for the opening is of 
 necessity at the lowest level, and thus favours an escape of 
 fluid into the perinephric cellular tissue. 
 
 Hydronephrosis. 
 
 Hydronephrosis is a distension of the kidney by fluid, 
 accompanied by a thinning and destruction of its substance. 
 Though this condition may be congenital, a peculiarity of it is 
 that there may be no symptoms in early life. The congenital 
 causes are various, they are due either to some want of develop- 
 ment, or to some malformation in or outside the kidney or 
 ureter. Both kidneys may be affected at the same time. 
 The ureter may be represented by a fibrous cord, or it may 
 pass from the kidney at too acute an angle, it may be twisted, 
 or it may be occluded by the pressure of a supernumerary 
 artery. 
 
 The acquired causes are also numerous, and consist in a 
 more or less complete block at some point of the urinary tract. 
 The most common reasons of this are enlargement of the pelvic 
 organs, the presence of new growths in the bladder or in 
 the neighbourhood of the ureter, and aggravated cases of 
 prolapse of the uterus. A calculus impacted in the ureter. 
 
HYDRONEPHROSIS. 
 
 283 
 
 or at its junction with the pelvis of the kidney, will also 
 cause this distension. More rarely the ureter may be occluded 
 by a stricture, and a bend on the ureter, due either to floating or 
 displaced kidney, may also cause a block. 
 
 Symptoms . — The chief symptom caused by a hydronephrotic 
 condition of the kidney is the presence of a fluctuating tumour, 
 arising apparently from one flank. In some cases there may 
 be a history of a disease wliich may induce this condition, as, 
 for example, cancer in the pelvis, the presence of a calculus, 
 etc. The increase in size is slow, and there is at times in some, 
 but by no means in all cases, a sudden flow of clear water from 
 the bladder, accompanied by the disappearance of the tumour. 
 On this symptom alone too much stress must not be laid, as the 
 same thing results wlien an ordinary parovarian cyst ruptures 
 into the cavity of the peritoneum, the disappearance of the cyst 
 being accompanied by the flow of a large quantity of clear urine, 
 due to its rapid absorption. 
 
 Examination of the urine passed at the time when the 
 tumour has disappeared will show absence of albumen, and 
 this with the presence or absence of some history will help to 
 differentiate a hydronephrosis from a simple cyst of the kidney. 
 If the fluid be removed by aspiration it will be found to be 
 almost colourless, often without any, or only with a faintly 
 urinous odour, of low specific gravity, and it does not contain 
 albumen. When the kidney tissue is entirely destroyed by the 
 distension, there will be an absence of urea ; but when the 
 destruction is not so far advanced the fluid will more nearly 
 resemble ordinary urine. The general health is not usually 
 affected when the tumour is small, but when both kidneys have 
 become hydronephrotic, and especially in the advanced stages, 
 general symptoms will be much more marked ; the skin will be 
 dry, there will be some abdominal disturbance, with at first 
 slight and then more marked attacks of ura3mic poisoning. 
 
 Treatment . — The treatment consists either in aspiration, 
 incision and drainage, or in the removal of the kidney. This 
 
284 
 
 THE KIDNEY. 
 
 operation of removal is called nephrectomy, a comparatively 
 simple one in cases of hydronephrosis, hut an extremely grave 
 operation when a large solid growth has to he taken away. 
 
 When the diagnosis is clear, and where there is no disease 
 of the other kidney, it is better to remove the cyst without 
 resorting to aspiration, for this palliative treatment is at hest 
 hut temporary, and the sac invariably refills. Drainage of the 
 sac is not to be recommended unless complete removal he found 
 impossible. When both kidneys are distended the case is 
 entirely different, because, as there is certain to he a consider- 
 able amount of destruction of the structure of the kidney, it 
 would he most unwise to lessen that amount by removing any 
 excreting tissue, and besides, the risk of operating on one kidney 
 when the other is not sound is very great. The only plan, in 
 such circumstances, is to relieve the discomfort and misery 
 caused by the distension, by the withdrawal of the fluid when 
 required from one or both of the tumours. 
 
 Nephrectomy for Cystic Enlargements. 
 
 The preparations which must be made for the removal of a 
 distended kidney, and the instruments which are required, do 
 not differ from those of an ordinary operation for the removal of 
 any cystic tumour from the abdomen. The same precautions to 
 keep the patient warm, and the same scrupulous care in cleaning 
 the skin, must be taken. The only difference will be that the 
 rubber sheet must he fixed so that the linea semilunaris is in 
 the centre of the aperture. 
 
 The patient is placed on the hack, and the incision is made 
 through the linea semilunaris on the affected side, wdiich will 
 he found farther from the middle line than when performing 
 the operation of nephrotomy. 
 
 The length of the incision will depend chiefly on the thick- 
 ness of the abdominal wall, and should he at least three 
 inches ; it can be subsequently enlarged if there he much 
 
NEPHRECTOMY FOR CYSTIC ENLARGEMENTS. 285 
 
 difficulty either with the enucleation or with the securing of 
 the vessels. 
 
 As soon as the peritoneum has been opened, the hand must 
 be passed in so as to localise the position of the colon should 
 there be any doubt as to its exact position. Immediately in 
 contact with the parietal peritoneum the posterior peritoneum 
 will be seen pushed up by the distension of the kidney, and 
 before the aspirating trocar is introduced, after sponges have 
 been packed in, this posterior layer must be divided outside the 
 colon, as the vessels supplying the gut are situated in the inner 
 layer. 
 
 In emptying any cyst where an escape of fluid might cause 
 trouble it is advisable to use the aspirator with Wells’ tapping 
 trocar. 
 
 When the fluid has been entirely emptied, the trocar is 
 withdrawn and the opening closed with forceps, and after this 
 has been done it may be well to examine the other kidney. The 
 sac has now to be enucleated out of the cellular tissue to which 
 it is attached, and this is easily done, unless there has been at 
 any time an attack of inflammation in this cellular tissue. The 
 secret of success in performing this enucleation is to keep close 
 to the cyst and not to get lost in the cellular tissue, and to carry 
 on the enucleation in the direction of the vessels. A watch must 
 be kept for the ureter, and when it is discovered it is to be 
 divided between forceps, care being taken not to allow any fluid 
 to escape ; the divided ends should be at once disinfected with 
 a strong solution of corrosive sublimate. 
 
 As the enucleation comes near to the end, care must be 
 taken to draw as little as possible on the sac for fear of injuring 
 in any way the renal vessels, which form a sort of pedicle. This 
 pedicle is to be transfixed as near to the sac as possible, either 
 with a round-pointed blunt needle, an aneurism needle, or with 
 Lister’s sinus forceps, being careful that the instrument does not 
 injure the renal artery or vein. Each half of this pedicle is tied, 
 and the double ends are tied again, and while this is being done 
 
286 
 
 THE KIDNEY, 
 
 no traction whatever must be made on the sac. Before the 
 pedicle is divided a pair of forceps should be fixed on to its 
 edge on the aortic side of the ligature, so as to command the 
 stump should there be haemorrhage. The sac must be cut away, 
 leaving a sufficient amount of tissue to prevent the ligature 
 slipping, and if there be no bleeding the forceps can be at once 
 removed. 
 
 Should there be any difficulty in enucleating the sac, assist- 
 ance may be given by passing the fingers or hand into the 
 interior to act as a guide to the exact position. 
 
 In a case of nephrectomy for hydronephrosis there is usually 
 little trouble from bleeding, as tlie sac does not require much 
 nourishment. If necessary, bleeding vessels must be tied with 
 catgut, and as soon as this is done the cavity outside the 
 peritoneum is sponged dry. A drainage tube is seldom neces- 
 sary ; should, however, one be required a counter opening is to be 
 made through the loin, and the wound in the posterior layer of 
 the peritoneum can be loosely closed by a catgut suture, the 
 ed^es beiii" turned in so that the two serous surfaces will 
 
 O O 
 
 adhere together. The end of the ureter is to be again dis- 
 infected, and after it has been closed by a ligature it is brought 
 out at the lower angle of the abdominal wound, where it is kept 
 in position by forceps or a pin. 
 
 There is nothing to say in particular about the introduction 
 of the stitches, of wliich fully as many as usual are required. 
 
 Although this is the usual condition which is met with at 
 the operation, there are some cases where it is utterly im- 
 possible to complete the enucleation on account of the extent 
 and enormous vascularity of the surrounding tissues. 
 
 There is nothing special in the after treatment, except that 
 one has to be careful in the administration of stimulants and of 
 morphia, and this is common to the after treatment of all opera- 
 tions on the kidney. It may be necessary to give one or both 
 of these, but their administration should be avoided whenever 
 it is possible ; and when the general condition of the patient 
 
NEPHRECTOMY FOR CYSTIC ENLARGEMENTS. 287 
 
 calls for either, the dose should be carefully regulated, and must 
 always be small. 
 
 The remaining kidney may be swollen and painful for 
 some days after the operation, and may at first secrete little 
 urine. When this is the case the congested state of the kidney 
 should be relieved by dry cupping over the loin. 
 
 The following is a very typical account of a case of hydro- 
 nephrosis. An unmarried lady, aged twenty-six, had about the 
 age of twenty first noticed the presence of a swelling in tlie 
 right side. There was no history of any kind of kidney trouble, 
 nor had the tumour ever decreased in size, and the diagnosis of 
 hydronephrosis was made simply on the slow growth and the 
 position of the swelling in the loin. The cyst was tapped from 
 the front, and four pints of clear watery fluid were removed. The 
 cyst filled slowly, and was tapped five times at intervals of about 
 two years. As the general health began to fail the removal of 
 the cyst was suggested, and as the patient was then anxious to 
 have it done the operation was performed in June 1884. The 
 enucleation of the sac was accomplished without any difficulty, 
 the ureter was pervious but not dilated, and strangely enough 
 did not appear to be occluded at any part of its course. It was 
 fixed into the wound. The entire kidney structure had been 
 destroyed, a simple non -vascular cyst alone representing it. 
 After the operation the left kidney swelled up to almost twice 
 its usual size, it had been evidently hypertrophied, and this was 
 accompanied by the secretion of a small quantity of urine, and 
 considerable general disturbance. The lady kept fairly well for 
 fully nine years. While on a visit to London her legs began 
 to swell, the urine was found to contain a small amount of 
 albumen, and the quantity passed was said to be very great. 
 The patient died of ursemia a few weeks later. This case con- 
 trasts well with another where the diagnosis of ovarian cyst had 
 been made, and where it was found impossible to remove the 
 whole of the sac. 
 
 A young lady, twenty-four years of age, was seen with a 
 
288 
 
 THE KIDNEY. 
 
 large flaccid cyst entirely filling the abdomen. A short time 
 before this examination the cyst, which had been noticed but 
 one year previously, had been tapped and twenty pints of fluid 
 removed. The fluid was reported to have been viscid and of a 
 yellow colour. A diagnosis of ovarian cyst had been made. 
 There was nothing in the history nor in the examination of the 
 half- filled cyst to make one come to any other conclusion, 
 especially as on pelvic examination the tumour was easily felt 
 displacing the uterus slightly to the left. 
 
 At the operation the sac was found to have no pelvic 
 attachment, but the cyst passed deeply into the loin, and the 
 enucleation extended from the pelvic brim to the diaphragm. 
 Eventually it was found that the cyst could not be entirely re- 
 moved. As much was cut away as possible, and what remained 
 was stitched to the wound, which of course had been made in 
 the middle line. During the afternoon and evening there were 
 two most alarming attacks of hsemorrhage from the cellular 
 tissue, and some enormous clots had to be removed from high up 
 under the diaphragm. For years there was a constant discharge 
 of clear fluid, averaging about one ounce in the twenty -four 
 hours. Some five years after the operation the fluid became 
 altered into pus, quickly diminished in amount, and the sinus 
 became completely closed. 
 
 In another case, which had to be treated in the same way, 
 suppuration did not occur for fully six years. 
 
 Pyonepheosis. 
 
 Pyonephrosis differs from hydronephrosis in this, that the 
 fluid contained in the kidney is not a simple collection of urin- 
 ous fluid, but consists of pus. The causes which give rise to this 
 condition may be divided into those which are local and those 
 which are more remote. The local causes are irritation of a 
 calculus, tubercular disease, direct injury, or a chill when the 
 kidney is in a liydronephrotic condition. 
 
P YONEPHROSIS. 
 
 289 
 
 The more remote causes are septic infection directly from 
 the bladder, or indirectly from the lymphatics when the disease 
 is outside the bladder. 
 
 Sym,ptoms . — The symptoms resemble those of a hydro- 
 nephrosis, but they are more acute. The general health is more 
 markedly affected, though in a chronic case it is remarkable 
 that a large tumour may not give rise to any symptoms 
 beyond the presence of the swelling or a slight feeling of 
 malaise. 
 
 The appearance of the patient, the feeling of chilliness, and 
 perhaps some rise in the temperature at night, will point to the 
 presence of pus, and will be diagnostic, especially when there has 
 been sudden decrease in the size of the tumour, accompanied by 
 the presence of pus in the urine. An example of a case where a 
 pyonephrosis did not give rise to symptoms was seen in the 
 summer of 1889. The patient was fifty-four years of age, and 
 had noticed the presence of a swelling in the right side for about 
 two years. There had never been any symptoms referable to 
 disease of the kidney, and in addition to the swelling the only 
 thing complained of was a feeling of general debility, with steady 
 deterioration in the general health. She was not particularly 
 chilly, and there was no rise in temperature. The diagnosis 
 was made of a tumour of the kidney, the exact nature of which 
 was not determined, and removal was advised and agreed to. At 
 the operation the tumour was found to consist of the kidney 
 irregularly dilated with pus. The upper part of the ureter, the 
 pelvis, and some of the remaining calices were entirely filled 
 by a coral-like stone, weighing over three ounces. 
 
 Treatment . — The treatment of this condition will vary with 
 the amount of the disease. In an advanced case where the 
 tumour is large, and where it is practically certain that the 
 structure of the kidney has been destroyed, the proper plan is 
 undoubtedly to perform nephrectomy. 
 
 When the disease has only partially destroyed the kidney, 
 two methods of treatment have to be considered : the one plan 
 19 
 
290 
 
 THE KIDNEY. 
 
 is to remove the entire organ, the other is to treat the case as an 
 ordinary abscess by free incision and drainage. 
 
 What has to be taken into consideration before fixing on 
 either of these lines of treatment is the amount of kidney 
 structure remaining, the time the abscess of the kidney will be 
 likely to take to heal, the general state of the health of the 
 patient, and the condition of the other kidney. The amount of 
 healthy tissue will be judged by the history of the case, the 
 length of time since any symptoms were noticed, and especially 
 by the size of the swelling. 
 
 In regard to the length of time that the discharge will be 
 likely to continue after incision and drainage, we must be guided 
 by the constitution of the patient and by his surroundings. 
 
 The patient may not be seen until the strength is so far spent 
 that the immediate risk of nephrectomy will be considered 
 greater than that of an incision, followed, if necessary, at some 
 later period by the removal of the organ. 
 
 The condition of the other kidney is of great importance in 
 this connection. If it be not healthy the less formidable opera- 
 tion must be tried first, as, so long as the suppurating kidney 
 has any excreting tissue, it takes off at least some of the work 
 to be done by the other damaged organ. 
 
 When incision and drainage are determined on, the opening 
 is to be made into the abscess through the ordinary lumbar in- 
 cision. The kidney is to be freely incised, its interior examined 
 with the most minute care so that a stone may not be left be- 
 hind, and care must be taken that pockets are not left, which 
 might prevent free drainage. The cavity is to be thoroughly 
 washed out with a warm saturated solution of boracic acid, and 
 one or more short wide drainage tubes, either of glass or of 
 rubber, are left in the wound. A large absorbent and antiseptic 
 dressing is put on, and will have to be changed within the first 
 few hours. 
 
 If the abscess has been thoroughly opened, and the drainage 
 is satisfactorily carried out, and if the patient be otherwise sound, 
 
HYDATID DISEASE. 
 
 291 
 
 he ought quickly to regain strength and weight. The abscess 
 cavity begins to shrink at once, and if the ureter he pervious, 
 and if there be no obstruction to the escape of urine down to the 
 bladder, the wound may close within a few weeks. 
 
 It need hardly be mentioned that where malignant disease 
 in the pelvis is the cause either of a hydronephrosis or pyo- 
 nephrosis, any operative interference beyond a simple aspiration 
 or incision is not to he thought of. 
 
 The operation for the removal of a suppurating kidney 
 resembles that for hydronephrosis ; special care must be taken 
 to prevent escape of pus into the peritoneal cavity or into the 
 cellular tissue. 
 
 Hydatid Disease of the Kidney. 
 
 The frequency of this diseased condition varies greatly in 
 different parts of the world, as is the case with hydatid disease 
 in other parts of the body. In this country it is somewhat rare, 
 and it appears to be more common in England than in Scotland. 
 Enlargements from this cause are found more frequently in the 
 left than in the right kidney. The disease is situated either 
 deeply in the substance of the organ, or superficially underneath 
 the capsule. In the former situation these growths seldom 
 reach to any great size, as the cysts easily make their way into 
 the pelvis of the kidney, and passing down the ureter, are dis- 
 charged through the urethra. 
 
 Symptoms . — These may be altogether wanting, and the 
 disease may be discovered as a swelling due to a painless 
 abdominal tumour, or may be seen on post mortem examination. 
 When the growth is so situated that there has been a rupture 
 into the pelvis of the kidney, the passage of daughter cysts and 
 shreds of membrane down the ureter give rise to renal colic. 
 Suppuration in the kidney may occur, and when this happens 
 the abscess may burst into the lung, intestine, peritoneal cavity, 
 or ureter ; even without suppuration there may be discharge of 
 the cyst in any of these directions. 
 
292 
 
 THE KIDNEY. 
 
 Diagnosis . — There may be simply a cystic tumour of the 
 kidney, which is sometimes smooth and regular, at other times 
 irregular, in outline. Fluctuation may be present, or it may be 
 masked by the tenseness of the cyst. The hydatid thrill, of 
 which so much has been made, is seldom to be felt ; in other 
 respects the swelling does not differ from any other kidney 
 tumour. Should the tumour be aspirated, microscopic examina- 
 tion ought to settle all doubt as to the nature of the growth, 
 except in rare cases of acephalous cysts, where no booklets are 
 present. Attention may be drawn to hydatid disease of the 
 kidney by attacks of renal colic, and one or repeated examina- 
 tions of the urine will show what it is that has been passing 
 down the ureter. In such a case no actual cyst may be found 
 on abdominal examination, but the kidney will be observed to 
 be more or less enlarged. 
 
 The necessity for great care in the examination of the urine, 
 or of fluid withdrawn from a cyst by aspiration for hydatid 
 booklets, is well emphasised by the following case. An old 
 woman, nearly sixty years of age, was admitted to the Eoyal 
 Edinburgh Infirmary on account of an abdominal swelling. The 
 fluid was aspirated, and booklets were supposed to have been 
 seen by the house physician, thus apparently rendering the 
 diagnosis certain. But for the presence of the booklets the 
 diagnosis would have been that of ovarian tumour ; and at the 
 operation two ovarian tumours were discovered, both having 
 opened up the broad ligaments. 
 
 Treatment . — This will depend on whether the cysts are pass- 
 ing away through the ureter or not. Where there is a distinct 
 abdominal cyst, giving rise to symptoms which call for interfer- 
 ence, the first thing to do is to aspirate, using a fine needle. 
 As has been already pointed out, the needle is to be introduced 
 at the highest point of the tumour, the patient lying on the 
 back ; and there must be no exception to this rule, though the 
 usual advice is given to puncture through the loin. The whole 
 of the fluid which is removed is allowed to settle for twelve 
 
TUBERCULAR DISEASE. 
 
 293 
 
 hours, and the deposit is to be examined by the microscope as 
 usual. Should the fluid reaccumulate and cause much suffering 
 a more formidable course will have to be recommended, and the 
 treatment will lie between incision and drainage through the 
 loin — lumbar nephrotomy — and removal of the entire growth, in- 
 cluding the kidney, from the front. Of these two methods the 
 choice ought always to be made of lumbar incision and drainage. 
 When the passage of the daughter cysts down the ureter gives 
 rise to much discomfort, and even though no tumour be present, 
 the kidney must be incised from the loin, and the contents 
 thoroughly cleared out and drained. 
 
 Solid Tumours of the Kidney. 
 
 Solid tumours are best divided into two great classes, simple 
 and malignant. The simple consist of the tubercular or strumous 
 kidney, and these become in their later stages more of the nature 
 of a cystic than a solid tumour. Other forms of solid growths 
 are the fibromata, with the degenerations into fibro-cysts, and 
 lipomata, but these growths are rare, and may almost be classed 
 as surgical curiosities. 
 
 The enlargements connected with lymphadenoid disease, and 
 also those due to syphilis, are of no surgical importance. 
 
 Tubercular or Strumous Disease of the Kidney. 
 
 Tubercular or strumous disease of the kidney may be con- 
 sidered together, but tuberculosis, due to a general condition, 
 does not come within the range of a surgical work. 
 
 Taking the two diseases as one, we find that it occurs more 
 commonly in children and adults, and is not seen so frequently 
 in later life. The disease may attack one kidney, and when 
 both are found to be affected it is probable that the disease has 
 spread from one to the other through the medium of the bladder. 
 There is no special reason why tubercle should attack the kidney, 
 
294 
 
 THE KIDNEY. 
 
 but it most likely obtains a footing in the organ when the 
 vitality is temporarily lowered owing to a chill, in a subject 
 with a predisposition to tubercular disease. 
 
 Symptoms . — These are at first extremely slight, scarcely more 
 than some little uneasiness in the region of the kidney. As the 
 disease progresses the uneasiness becomes worse until actual 
 pain is complained of, there is also tenderness in the affected 
 side, haemorrhage caused by the ulceration and breaking down 
 of the tissues, and with this there may be attacks of renal colic. 
 Examination of the urine shows that it contains pus and shreds 
 of renal tissue, and that it has lost its natural acidity. Usually 
 there is frequency of micturition ; after a time the bladder itself 
 becomes irritated, and this is accompanied by a greatly increased 
 desire to pass water and increase in the pain. Sometimes in- 
 stead of passing water too frequently there may be suppression. 
 In fact the whole train of symptoms in a very marked degree 
 resembles those due to the presence of a stone. There is a certain 
 amount of difference in the character of the bleedings ; in tuber- 
 cular disease the losses are irregular, and are not so apt to follow 
 exertion as is the case when a stone is present. As the disease 
 progresses the kidney enlarges, and after a time can be easily 
 felt between the two hands. In the early stages the patient 
 may not present any of the appearances commonly associated 
 with tubercular disease, and there may .be no afternoon rise in 
 temperature. Later, the patient becomes thin, the expression is 
 anxious, there is fever and sweating at night, but these symptoms 
 are also set up when a stone, accompanied by suppuration, is 
 present. 
 
 The only absolutely certain diagnosis of the disease is made 
 when the tubercle bacilli are discovered on microscopic 
 examination. These may not always be found, but the best 
 and most simple method of examining for them is similar to that 
 recommended when peritoneal fluids were described. A kidney 
 affected by this disease may become caseous, and give rise to no 
 further trouble. 
 
TUBERCULAR DISEASE. 
 
 295 
 
 Treatment . — General treatment here, as in tuberculosis else- 
 where, consists in improving the state of the general health, and 
 the local treatment will lie between nephrotomy and nephrectomy. 
 Puncture of a kidney which is supposed to be tubercular can 
 never be advisable, for it can never by any possible chance 
 result in recovery. Another reason why this should not be 
 done is, that unless the kidney be very much enlarged, it 
 would be impossible to aspirate it from the front, and the reasons 
 for vetoing this slight operation from the loin have been given 
 elsewhere. The aspiration of a strumous or tubercular kidoey 
 from the loin would result, unless a very fine needle were used, 
 in some leakage into the cellular tissue, and this would be 
 followed by an attack of inflammation, probably running on to 
 the formation of a perinephritic abscess. 
 
 It is almost impossible to give more than general directions 
 for differentiating those cases of this disease which require 
 incision and drainage from those which are best treated by re- 
 moval of the kidney. 
 
 The chief guide must be the length of time that the disease 
 has been in existence, as shown by the symptoms ; and by the 
 quantity of pus which is being passed. In the consideration of 
 all these features it must be understood that only one kidney is 
 affected. If the disease be recent, the symptoms slight, and 
 the quantity of pus passed in the urine not great, it is reasonable 
 to expect that as yet there has not been much destruction of 
 kidney tissue, and an attempt to preserve a fairly healthy organ 
 is worth trying. In such a case incision and drainage is the 
 proper treatment, but it is very necessary to exert great care in 
 coming to this conclusion, for if the operation do not result in 
 a cure, a sinus remains with resulting adhesions, which will 
 necessarily complicate any future attempt at removal. 
 
 When the case is one of old standing, and when there is 
 much suppuration, it is useless to expect that incision and 
 drainage will be followed by complete recovery ; for, even if the 
 suppuration ceased and the disease were arrested, the remains of 
 
296 
 
 THE KIDNEY. 
 
 the kidney would be of little use, and would always remain a 
 source of danger. 
 
 When the disease has advanced a step farther, and the renal 
 abscess has ruptured into the cellular tissue, it is best not to 
 attempt the removal of the kidney at once, but to reduce the 
 surrounding swelling and infiltration by drainage, and thus at 
 the same time allow of improvement in the general condition of 
 the patient. When there is an abscess both in the kidney and 
 in the cellular tissue surrounding it, a free incision is to be made 
 and the finger passed into the wound, so as to make sure that 
 the opening through the kidney is of sufficient size to allow of 
 free drainage from the bottom of the wound. At the same time 
 any band or septum which might prevent the free escape of the 
 pus is to be broken down. 
 
 Malignant Disease of the Kidnev. 
 
 Following the plan adopted in this work we have classed 
 cases of sarcoma and of carcinoma together under the head of 
 malignant disease. For all practical purposes this is quite 
 sufficient, and it may simply be stated that primary sarcoma 
 occurs more frequently in children and carcinoma in adults. 
 With secondary malignant disease we have nothing to do here. 
 In children the disease may be congenital, in others it seems 
 that it may be lit up by the irritation caused by the presence of 
 a stone, or it may be due to a blow or other injury, especially in 
 those who are predisposed to malignant disease by heredity. 
 
 In children there may be no symptoms at first, or even when 
 the tumour is of some size, and during the whole course of the 
 growth there may be nothing to draw one’s attention to the 
 existence of renal disease. It is not uncommon to find that the 
 symptoms are due to the pressure of the growth, and to the 
 wasting which occurs in the later stages. 
 
 In the adult also it is not infrequent that the presence of a 
 swelling in the abdomen first directs the attention of the patient 
 
MALIGNANT DISEASE. 
 
 297 
 
 to the disease. The symptoms are haemorrhage and pain, the 
 latter being the more common, and it radiates in the way that 
 the pain of malignant disease usually does. The tumour is 
 seldom tender to the touch, haemorrhage may be entirely absent, 
 and the general health is rarely affected until the disease is far 
 advanced and beyond the reach of surgical skill. In common 
 with other diseases of the kidney there may be more or less 
 irritability of the bladder ; and, in one case which came under 
 our notice, a vesico-vaginal fistula had actually been made, the 
 condition of the kidney having been entirely overlooked. 
 
 Examination of the urine occasionally discovers the presence 
 of malignant-looking cells, but frequently no such information 
 can be obtained. 
 
 Treatment . — In young children it is doubtful whether it is 
 ever right to operate ; indeed, such operations must be looked 
 on more as surgical possibilities than as operations of advantage 
 to the patient. The disease returns quickly if the primary result 
 be successful, and the little patient gains little or nothing by 
 the operation. 
 
 In the adult removal of the kidney, when the case is seen 
 early enough, is the proper course to pursue. 
 
 The operation is decidedly more difficult in the case of a 
 solid as compared with a cystic tumour, the difficulty arising 
 chiefly in securing the renal vessels. The incision is to be made 
 through the linea semilunaris, the length varying with the size 
 of the tumour, and being necessarily longer than in those cases 
 where the tumour can be reduced in size by tapping. The 
 peritoneum is raised up, as has always to be done for safety 
 when opening the abdomen, and here it is specially necessary, 
 as troublesome bleeding might result if the kidney tumour w^ere 
 injured. The hand is passed into the abdomen and the other 
 kidney is examined. This precaution must never be omitted. 
 A healthy, or what at least appears to be a healthy kidney, having 
 been discovered, the operation can be proceeded with. The 
 peritoneal cavity is first shut off with sponges as far as possible. 
 
298 
 
 THE KIDNEY. 
 
 The peritoneum covering the tumour is next to be opened ; this 
 is best done with scissors, as there is no advantage in tearing it, 
 for it is undesirable to cause any more bruising than is absolutely 
 necessary. This opening should be to the outside of the colon, 
 and the peritoneum on its inner side must not be interfered 
 with, because the vessels for the nutrition of the bowel are 
 situated in this layer of the mesocolon, and their destruction 
 would be followed by gangrene of the intestine. 
 
 When there has not been any inflammation the enucleation 
 of the tumour from the surrounding cellular tissue is not difficult, 
 so long as attention is paid to keeping close to the tumour. This 
 is easily done when the tissues are not matted together, but 
 when this is the case very special care must be taken not to lose 
 touch of the tumour itself. As a general rule it is best to 
 enucleate towards the main vessels at the aorta, forceps being 
 used to arrest bleeding during the separation. Having succeeded 
 in enucleating the tumour all round until the tissues near the 
 renal vessels have been reached, great care must be taken to 
 avoid injuring the aorta or the vena cava. The vein is more 
 liable to injury than the artery, especially if the tumour be on 
 the right side. The artificial pedicle which has been formed is 
 to be transfixed, and for this purpose an aneurism needle is the 
 best instrument. It is of the greatest importance that no traction 
 should be made on the tumour when the aneurism needle is 
 passed or the ligature tied, for it would be easy to include a 
 piece of the vena cava in the ligature. The point of transfixion 
 is to be as near the kidney as will allow of the complete removal 
 of the disease, and at the same time there must be room between 
 the ligature and the kidney to permit of there being a sufficient 
 length of the pedicle beyond the ligature to prevent slipping, and 
 also if possible to allow of a narrow-bladed pair of forceps being 
 fixed on to the pedicle close to the kidney to prevent the escape 
 of the blood from the tumour. 
 
 When the pedicle has been tied it is to be very carefully 
 divided close to the forceps by short cuts of the scissors. In 
 
PYELITIS. 
 
 299 
 
 this way one can be certain that the pedicle is securely tied 
 before it is completely divided. 
 
 During some stage of the enucleation the ureter will have 
 been reached ; it is to be divided between forceps and the divided 
 ends at once rendered aseptic. This may be done by rubbing in 
 a little perchloride of iron, or washing with a strong solution of 
 corrosive sublimate. Owing to the somewhat irregular distribu- 
 tion of the blood supply, one or more large arteries may be met 
 with during the separation of the tumour. All bleeding vessels 
 must be tied, the sponges are removed from the abdomen, and 
 the cavity of the peritoneum is to be sponged out only if there 
 have been any escape into it. The edges of the posterior layer 
 of the peritoneum are simply allowed to fall back, and the 
 question of drainage has to be considered. In an ordinary 
 simple case it is not necessary to leave in a drainage tube, but 
 should there be oozing going on, should there have been extensive 
 enucleation in a weak subject, or should there have been any 
 escape of pus or urine, it is advisable to drain. A short wide 
 glass or rubber drainage tube is to be passed into the cavity from 
 which the kidney has been removed, and is fixed in the wound 
 as in any abdominal operation. 
 
 Before the stitches are secured the ureter is to be tied and 
 fixed into the wound ; on the whole this seems to be safer than 
 allowing it to drop back into the abdomen. 
 
 Pyelitis. 
 
 Pyelitis consists of a suppuration in the pelvis of the kidney. 
 It differs from a hydronephrosis in this, that no appreciable 
 tumour is usually to be felt, and that the pus is always found 
 in the urine, causing as a rule irritability of the bladder. The 
 exact cause is the spread of some septic poisoning from the 
 bladder to a not altogether healthy pelvis of the kidney. 
 
300 
 
 THE KIDNEY. 
 
 Surgical Kidney or Pyelo-Nephritis. 
 
 This consists in inflammation followed by suppuration 
 through the whole substance, usually of both organs, and it 
 is not a condition which can be interfered with surgically. 
 
 Injuries of the Kidney. 
 
 Injuries may result either directly, as from a gunshot wound 
 or a stab, or more indirectly, as when a wheel has passed over 
 the body, or when the patient has fallen in such a way that the 
 abdomen is struck, or merely as a result of violent concussion. 
 
 A gunshot wound will be discovered after the abdomen has 
 been opened, if the principle be carried out that when there is 
 a bullet wound of the peritoneum the cavity must be opened. 
 If any but a slight injury be found the only treatment would 
 be to remove the kidney, but if the injury be slight, and it be 
 possible to stitch over the opening in the posterior layer of the 
 peritoneum, an opening for drainage may be made through the 
 loin. The peritoneum should be washed out and drained, as 
 there may have been an escape of urine. The injury which is 
 more likely to be met with is a laceration of the kidney 
 without the presence of an external wound. The laceration 
 may be in the kidney itself inside the capsule. In this case 
 the prominent symptom would be haemorrhage passing down the 
 ureter into the bladder, possibly renal colic, and some pain and 
 collapse if the quantity of blood lost were great. Along with 
 these there may be a distinct swelling in the position of the kidney. 
 
 Treatment . — The treatment consists in absolute rest, and in 
 the administration of morphia if required. An ice bag may be 
 placed on the side, and if there be retention the water will have 
 to be drawn off. This plan of treatment is much more likely 
 to save the life of the patient than any operative interference. 
 A patient between forty and fifty years of age, standing on a 
 chair on a table, fell and struck her side against the end of a 
 
INJURIES OF THE KIDNE V. 
 
 30 
 
 sofa. She became very much collapsed, and for some days 
 passed a large quantity of bright coloured blood mixed with the 
 water. The amount of blood gradually diminished, and by the 
 end of three weeks the water was quite free of it. The patient 
 was simply kept in bed with ice to the side, and no other treat- 
 ment was required. 
 
 A perinephritic haematocele sometimes results from an injury 
 to the side. There is a history of the injury followed by pain 
 and the appearance of a tumour, without any symptoms of 
 disturbance of the kidney. The condition is a rare one, and 
 may be very puzzling. 
 
 The treatment is similar to that of rupture. A gentleman 
 living in the country, about fifty years of age, was kicked in 
 the side by a horse. When he was seen some hours afterwards 
 he complained of very great pain in the side, and a swelling as 
 large as an adult head was felt reaching far into the loin, 
 bulging out the side, and altering the shape of the abdomen. 
 The patient was at first very much collapsed, but this was 
 passing off. The treatment consisted in keeping the patient 
 absolutely at rest in bed, and in administering sufficient 
 morphia to soothe the pain. Under this treatment the swell- 
 ing gradually decreased, and within four months had entirely 
 disappeared. 
 
 A second example of this rare condition is worth noting. 
 A young man twenty years of age had run up against a stake 
 while playing tennis. He was at first doubled up with the 
 pain, and when seen nearly three months after the injury was 
 entirely confined to bed. He was losing flesh, the pulse kept 
 at about a hundred, and the temperature was a little over 
 normal. A variety of opinions had been given as to what the 
 swelling might be, and an exploratory incision had been very 
 strongly urged. A favourable prognosis was given, and although 
 no special treatment was advised, the young man was so well 
 that he passed the medical examination for the army about a 
 year afterwards. 
 
CHAPTEE XL 
 
 THE SPLEEN. 
 
 Surgical Anatomy. 
 
 The spleen is situated high up in the abdomen, and lies deeply 
 in the left side of the costal zone. Eor the most part it occupies 
 the left hypochondriac region, with its long axis directed down- 
 wards and outwards, and its upper end considerably nearer the 
 mesial plane than its lower end. Its upper end crosses the mid- 
 Poupart line, and so encroaches on the epigastric region. The 
 outer surface which looks outwards and backwards is in contact 
 with the diaphragm, by which it is separated from the ninth, 
 tenth, and eleventh ribs, but the upper part of this surface is 
 also separated from the chest wall by the thin lower margin of 
 the left lung. The inner surface presents two well-marked con- 
 cave areas, separated from each other by a ridge which runs from 
 the upper to the lower end of the organ. The area posterior to 
 this ridge is in contact with the left kidney, while the area 
 anterior to the ridge is mostly in contact with the posterior 
 aspect of the cardiac end of the stomach ; but the tail of the 
 pancreas and the splenic flexure of the colon also leave their 
 imprint on this surface. In consequence, the lower end of the 
 organ is flattened and rests upon the phrenico-colic ligament, 
 which is a fold of peritoneum attaching the splenic flexure of 
 the colon to the diaphragm. The upper end of the spleen 
 usually abuts against the left suprarenal capsule. The posterior 
 border is rounded and smooth ; the anterior border presents 
 
INFLAMMATION AND SUPPURATION 
 
 303 
 
 several notches, and their presence assists greatly in the 
 diagnosis of enlarged conditions of the organ. Its dimensions 
 are subject to great variations, but it is usually about five inches 
 in length, three or four in breadth, and rather more than one 
 inch in thickness. 
 
 The gastro-splenic omentum, which may be considered as a 
 lateral prolongation of the small omentum, passes from the 
 stomach to the spleen at the hilum, which is situated on the 
 gastric impression. At this slit the blood vessels, which are 
 enclosed in the gastro-splenic omentum, pass into and out of the 
 spleen. The artery which supplies the spleen is the largest 
 branch of the cceliac axis. It is known as the splenic artery, 
 and passes along the upper border of the pancreas, being very 
 tortuous, and terminating at the hilum of the spleen in five or 
 six branches. The splenic vein assists in forming the portal vein. 
 The gastro-splenic omentum is surgically known as the pedicle 
 of the spleen. The lieno-renal ligament is a fold of peritoneum 
 which attaches the spleen to the anterior surface of the left 
 kidney. 
 
 The spleen is an organ which does not often require surgical 
 treatment. The operations which may be performed on it are 
 splenotomy, that is to say, simple incision ; and splenectomy, or 
 removal of the whole gland. 
 
 Inflammation and Suppuration. 
 
 An inflammation of the spleen is seldom seen in this country, 
 it is usually caused by malarial poisoning. The results of the 
 inflammation are, however, met with in the form of suppuration 
 in the organ. Such an abscess may open through the skin, or 
 the pus may pass into the left pleura, stomach, or transverse 
 colon ; or in some cases the abscess may burst into the peri- 
 toneal cavity, or into a part of it shut off by adhesions. 
 
 Symptoms . — The chief symptom of an acute attack of inflam- 
 mation of the spleen is pain in the left side, at first acute ; and 
 
304 
 
 THE SPLEEN. 
 
 as the organ enlarges, it becomes of a dragging character. There 
 is some fever, and when suppuration commences it is ushered in 
 by a feeling of chilliness. Sometimes an abscess may form in 
 the spleen without any marked symptoms to draw attention to 
 the condition of the gland. 
 
 Diagnosis . — The diagnosis of abscess of the spleen is made 
 by the history of the acute inflammatory attack, the feeling of 
 weight and discomfort, the sallow appearance, the presence of 
 a tumour appearing from under the costal margin on the left 
 side and especially when notches can be felt at the right side 
 of this swelling. 
 
 Treatment . — When it is proposed to open the abscess, the in- 
 cision should be made in the longitudinal direction over the 
 most prominent point, or somewhat above it, as the spleen will 
 be drawn upwards when the pus is removed, unless there be 
 adhesions. The length of the incision will be from two to three 
 inches. When the surface of the spleen is exposed, unless it be 
 adherent to the abdominal wall, as is often the case, the abscess 
 is to be aspirated after sponges have been packed round the site 
 of the opening ; and, as soft friable tissue is being dealt with, 
 the air in the bottle must not be exhausted too forcibly. Before 
 removing the cannula, an incision is made into the abscess cavity, 
 and when this has been done, the edges are to be stitched to the 
 abdominal wall in the same way as an abscess of the liver, the 
 sponges in the peritoneal cavity having been previously removed. 
 A large-sized rubber tube is left in to drain the cavity from the 
 bottom ; and should there be any bleeding from the cut surface 
 of the spleen, pressure or a chain of stitches may be used to 
 arrest it. Should it not be possible to fix the spleen to the 
 parietal wall the whole organ will have to be removed. 
 
 Cysts of the Spleen. 
 
 These cysts are very rare, and a diagnosis has seldom been 
 made before operation. They are very liable to be mistaken for 
 
BISFLA CEMENTS. 
 
 305 
 
 cysts of the kidney, and with the exception of the want of 
 evidence of kidney disease, there are no symptoms which will 
 draw attention to the spleen, unless the case be seen very early. 
 
 Hydatid disease of the spleen is also very difficult to 
 diagnose, and certainty can only be arrived at by finding 
 booklets in the fluid withdrawn. The position of the cyst, 
 and the direction in which the swelling disappears after 
 aspiration, might indicate the primary situation of the disease. 
 
 Treatment . — The treatment of cysts in this part of the body 
 consists in withdrawing the fluid with the aspirator through a 
 fine hollow needle inserted into the sac. If the sac refill, 
 incision and drainage must be carried out on the same lines 
 as in the case of an abscess ; but the risk of haemorrhage from 
 the pedicle is so great that it is advisable to avoid total expira- 
 tion if a cure can be otherwise obtained. 
 
 Displacements. 
 
 The spleen is one of those organs which may be very much 
 displaced, sometimes without any particular reason, sometimes 
 from the pressure of an effusion in the left pleura. When the 
 spleen is displaced, it may become adherent in its new position, 
 and this renders diagnosis difficult. In one case it was found 
 to be situated in the left iliac fossa, having been pushed into 
 this position by an enormous effusion in the left pleura. When 
 the spleen is much displaced, the pedicle may become twisted, 
 and peculiar stomach symptoms may be caused by the dragging 
 downwards of that organ, as it is connected to the spleen by the 
 gastro-splenic omentum. When the spleen has become fixed in 
 a new position, and has become enlarged, it is extremely unlikely 
 that a diagnosis will be made. If the displacement be giving 
 rise to much trouble, the only treatment is to remove the organ 
 if it cannot be pushed back into its natural position, and retained 
 there by a well-padded bandage. 
 
 20 
 
3o6 
 
 THE SPLEEN. 
 
 Solid Enlakgements. 
 
 These are usually due to leucocythaemia, to lymphadenoma, 
 to waxy disease, to congestion in ague, during typhoid fever, 
 and occasionally a simple hypertrophy with or without indura- 
 tion may be met with. The symptoms, which a solid enlargement 
 gives rise to, are simply due to the size, unless there be any 
 constitutional disease in addition. An enlargement due to 
 leucocythaemia ought to possess no interest for the surgeon, 
 except from the diagnostic point of view ; for the removal of 
 the spleen in this disease seems to have been practically always 
 fatal. It is well known that there is a great tendency to 
 haemorrhage after any operation performed on a leucocythaemic 
 patient, and it is unlikely that removal will improve the general 
 disease. 
 
 The spleen may enlarge until it fills the whole of the left 
 side of the abdomen, dipping down into the pelvis, and passing 
 across the middle line to a very large extent. On examining 
 the organ, one deep and several shallow notches will almost 
 invariably be found on the right hand border of the swelling. 
 The presence of these notches is only diagnostic when they 
 are very well marked, for a doubtful notch may be occasionally 
 met with in other growths. The lower part of the chest wall 
 on the left side is bulged considerably outwards and upwards 
 by the swelling, and the consistency of these enlargements is 
 extremely solid and firm. Percussion gives an absolutely dull 
 note where the tumour comes out underneath the costal margin 
 on the left side. On percussing downwards the note is found 
 to be less dull until the lower margin of the tumour is reached, 
 when an almost tympanitic note is obtained ; this is due to the 
 shape of the organ, being thicker above and gradually thinning 
 as it descends. Posteriorly a clear note may be obtained on 
 percussing the back in the position of a normal spleen. A 
 patient who was supposed to have an ovarian tumour was sent 
 into the Eoyal Infirmary, Edinburgh, but on examination she 
 
SOLID ENLARGEMENTS. 
 
 307 
 
 was found to have an enormously enlarged spleen due to 
 leucocythaemia. The enlargement was so great that the tumour 
 could be felt from the vagina; and the notches, of which there 
 were three, were situated almost in a line with the anterior 
 superior spine of the right ilium. The case proved a puzzling 
 one to a number of abdominal surgeons who happened to be 
 visiting Edinburgh, — none of them had ever seen a spleen of 
 such magnitude. Some two years after, the diagnosis was 
 confirmed by fost mortem examination. 
 
 The following case illustrates the difficulty which may be 
 met with in diagnosing the exact situation of a tumour in the 
 region of the spleen. A lady twenty-eight years of age had the 
 ovaries removed, and one of the broad ligaments fixed in the 
 wound by a clamp. This was in 1883, and after she had 
 undergone a great deal of treatment for pelvic disease. She 
 became perfectly well, but in 1887 she began to complain of 
 pain in the left side, and a small tumour was discovered below 
 the ribs. The kidney, which was pushed down, was felt to be 
 unconnected with it in any way by Dr. Keith, and independently 
 by Sir William Jenner. The tumour steadily increased in size, 
 and by the summer of 1888 it filled a large part of the left side 
 of the abdomen, reaching below the umbilicus, raising the chest 
 wall on that side considerably, having an ill-defined notch on 
 the right side, and the note on percussion resembled that 
 obtained in enlargements of the spleen. Sir James Paget and 
 the late Sir Andrew Clark both saw the patient and confirmed 
 the diagnosis of enlargement of the spleen. The general health 
 of the patient was good, but she could not walk any distance. 
 The experiment was made of passing the galvanic current 
 through the tumour, and at first it seemed as if this treatment 
 would prove very successful : the tumour diminished in size so 
 much that the lady’s maid had to take in her dresses five inches, 
 and there was marked improvement in walking. After a time 
 she went home, the tumour began to increase, electricity was 
 again tried, but without benefit. She returned to London 
 
3o8 
 
 THE SPLEEN. 
 
 some time afterwards, consulted another surgeon, who advised 
 immediate removal of the growth ; and it is interesting to note 
 that he thought the scar made by the clamp some years before 
 had been caused by a drainage tube ! The tumour turned out 
 to be a sarcomatous growth unconnected either with the spleen 
 or the kidney ! The patient had a long illness, recovered, and 
 was fairly well for a short time, but suffered very greatly 
 before her death some two years after the operation. 
 
 In every case of enlargement of the spleen it should be a 
 rule to examine the blood ; and, if an increase in the number of 
 white blood corpuscles be found, the case must be handed over 
 to the care of a physician. 
 
 Increase in the size of the spleen, due to simple hypertrophy, 
 is slow ; and, unless the enlargement be giving rise to a consider- 
 able amount of discomfort, there is no necessity to advise any 
 further treatment than the support and fixation which may be 
 obtained by a light abdominal belt. When the size is great, or 
 there are distressing symptoms, removal of the organ is the only 
 course to pursue ; but this is an operation which ought not to 
 be undertaken lightly, as the risk is considerable. 
 
 Splenectomy. 
 
 The preparations are similar to those of any abdominal 
 operation. The incision has been usually made in the middle 
 line, and when the organ is much enlarged and the abdominal 
 wall is stretched, an opening made in this position will be as con- 
 venient as any. When the size of the spleen has not caused much 
 distension, the incision should be made through the left linea 
 semilunaris. If no adhesions be found when the peritoneum 
 is opened, the tumour is to be pressed out, a start being given 
 by passing the hand into the abdomen, and drawing up the 
 growth from behind. The lower part must be brought out 
 first, and as soon as it becomes engaged in the wound, the 
 
SPLENECTOMY. 
 
 309 
 
 complete extrusion of the tumour is effected by depressing the 
 abdominal walls over it. It is better to get it outside in this 
 way than to draw much on the organ itself as with a corkscrew, 
 because the greatest care must be taken to avoid dragging on 
 the pedicle. When adhesions are present, they must be treated 
 as in any other situation, and the tumour itself must not be 
 injured. The treatment of the gastro-splenic omentum or 
 pedicle requires to be carried out with particular care, as there 
 is great tendency to haemorrhage after the operation has been 
 completed. It has to be tied very much as a pedicle elsewhere, 
 but it is often difficult to reach it without dragging on the 
 vessels ; the best plan is to transfix with an aneurism needle 
 passed from behind forwards, each half is then tied separately, 
 and the double ends of each tied together. After this has been 
 done the pedicle is divided, leaving a sufficient amount of tissue 
 beyond the ligature to prevent slipping. When there is any 
 doubt, it is well to fix a pair of forceps on to the pedicle before 
 the spleen is removed ; and after division to tie the open mouths 
 of the vessels separately. If it be difficult to ligature the 
 pedicle in this way, it may be more easily accomplished by 
 clamping the pedicle close to the spleen with a pair of large 
 locking forceps ; and then, after the spleen has been removed, 
 the tissues below the forceps can be transfixed and tied. The 
 only objection to this plan is the difficulty in having the pedicle 
 completely relaxed, because the blades of the forceps keep it 
 stretched out to a certain extent. Each case will have to be 
 treated according to the exact condition of the pedicle, more 
 care being taken than usual on account of the great risk of 
 haemorrhage in this situation. What has to be attended to 
 chiefly is to avoid drawing on the tumour, because traction 
 alone may cause alarming symptoms, and when a pedicle is 
 stretched a ligature cannot be tied so tightly. The suspensory 
 ligament having been ligatured and divided, the tumour can be 
 completely removed. Sponging may or may not be required ; 
 it is not likely that a drainage tube need be left in, and except 
 
310 
 
 THE SPLEEN. 
 
 for the fear of haemorrhage, which may occur during the first few 
 hours, there is nothing peculiar about the after treatment. 
 
 Malignant Disease. 
 
 In malignant disease it is doubtful whether a diagnosis 
 could be made. The symptoms are very much the same as 
 those of simple enlargement, but the patient will probably show 
 general signs of malignant disease. If the diagnosis has been 
 made before the disease has spread, or numerous adhesions have 
 formed, the growth should be removed. The disease is more 
 liable to be found when an exploratory incision has been made 
 on account of a tumour on the left side, which is either growing 
 rapidly, or is markedly interfering with the general health. 
 
 Wounds. 
 
 A wound of the spleen may be found when an exploratory 
 incision has been made, on account of a penetrating wound of 
 the abdomen. Serious wounds of the organ may not give rise 
 to much haemorrhage if the substance which has caused the 
 wound be not withdrawn. Instances have been known, where 
 the removal of a body, such as a piece of rib, has been followed 
 by fatal haemorrhage. 
 
 If the injury to the spleen be serious, the best course to 
 pursue is to remove the whole organ ; should it consist of a 
 slight wound of the surface, it may be sufficient to stop the 
 bleeding either by pressure or by the introduction of a few 
 sutures. In any case, a diagnosis will not be made with 
 certainty until the actual condition is discovered. Fortunately 
 no special instruments or appliances are required, as the re- 
 moval of the organ must be determined on immediately if the 
 injury be severe. 
 
 Operations of all kinds on the spleen have been extremely 
 rare, and it is probable, in the large majority of cases, that a 
 
MALIGNANT DISEASE. 
 
 31 
 
 diagnosis is not made beforehand. The general mortality has 
 been so great that an operation which may have to end in the 
 removal of the spleen is one which requires very grave con- 
 sideration; but, where the symptoms are very distressing, or 
 the life of the patient is endangered, it may become absolutely 
 necessary to interfere surgically. 
 
312 
 
 THE PANCREAS. 
 
 THE PANCEEAS. 
 
 Surgical Anatomy. 
 
 The pancreas rests upon the posterior wall of the abdomen 
 behind the stomach, and is placed in front of the first and 
 second lumbar vertebrm. This organ projects into the abdominal 
 cavity, but is situated entirely behind the peritoneum. It 
 consists of a head, a body, and a tail. The head forms its right 
 extremity and lies within the horse-shoe curve of the duodenum 
 resting upon the crura of the diaphragm, the inferior vena cava, 
 the aorta, the superior mesenteric vessels, and the commencement 
 of the portal vein ; while in front it is covered by the posterior 
 wall of the small sac of the peritoneum, and is in close proximity 
 to the pyloric portion of the stomach. The central part or body 
 lies behind the posterior wall of the small sac of the peritoneum 
 and rests on the anterior surface of the left kidney, the left 
 suprarenal capsule, and the splenic vein. The tail extends as 
 far as the inner surface of the spleen. The transverse mesocolon 
 is attached to the front of the body of the pancreas along the 
 line which separates its anterior from its inferior surface. The 
 coeliac axis is seen immediately above the pancreas, and the 
 common bile duct passes behind its head on its way to open 
 into the duodenum. It receives its blood supply from the 
 superior and inferior pancreatico-duodenal arteries, and also 
 from the pancreaticse parvae and pancreatica magna branches 
 of the splenic artery. 
 
 The pancreatic duct begins near the tail of the organ, and 
 passes from left to right, gradually increasing in size. It receives 
 numerous tributaries during its course, especially a large one 
 from the lower part of the head, and opens into the duodenum 
 in conjunction with the common bile duct, by piercing the inner 
 and posterior aspect of its descending or second part. 
 
 To expose the pancreas, throw upwards towards the ribs the 
 
CYSTIC ENLARGEMENTS. 
 
 313 
 
 great omentum with the stomach and transverse colon ; then 
 cut through the inferior layer of the transverse mesocolon ; and 
 afterwards divest the surface of the pancreas from the peritoneum, 
 which constitutes the upward prolongation of the superior layer 
 of the transverse mesocolon. 
 
 The surgical treatment of the pancreas is practically limited 
 to the treatment of cysts, though various directions have been 
 given in cases of cancer, abscess, etc., but in those conditions the 
 directions may be looked upon rather as of theoretical than of 
 practical importance. 
 
 Cystic Enlargements. 
 
 Cysts of the pancreas are fortunately very rare, for the 
 diagnosis is by no means easy. Some grow rapidly, others with 
 extreme slowness ; digestion may be interfered with, and this 
 may be shown in the character of the stools ; but on the other 
 hand, these cysts may give rise to no symptoms. 
 
 The position of a cyst in the early stages will depend on 
 what part of the organ it has grown from ; as it enlarges it may 
 become completely central, and when of considerable size may 
 be mistaken for an ovarian tumour, a hydronephrosis, hydatids, 
 or a circumscribed collection of peritoneal fluid. 
 
 Treatment . — This consists in incision and drainage. When 
 the fluid is removed by aspiration it quickly refills, and an 
 attempt to remove the cyst is usually accompanied by great 
 danger. 
 
 The operation of incision and drainage is performed in the 
 following way : — An incision two or three inches in length is 
 made over the tumour in the middle line. When there are no 
 adhesions in front, the omentum is seen as soon as the peri- 
 toneum is divided, and is cut through with scissors, all bleeding 
 points being tied. The trocar, preferably attached to an aspira- 
 tor, as the fluid may be thick, is thrust into the sac ; as soon as 
 the fluid is emptied, the sac wall is drawn through the outside 
 
314 
 
 THE PANCREAS. 
 
 wound and connected to it by stitches, as much of the sac being 
 removed as can be done without causing tension. Should firm 
 adhesions exist in front, the incision is made down to the sac, 
 and the contents removed by the aspirator. The opening is 
 made of sufficient size to admit a large drainage tube, and the 
 adhesions take the place of stitches. It is better not to attempt 
 to remove any of the cyst wall in the adherent cases. A large 
 sized drainage tube is to be used in every case, and a second, if 
 necessary, should there be pouching. At first there may be very 
 free discharge, which will be apt to cause digestion of the skin, if 
 the cyst have been caused by a blocking of the pancreatic duct. 
 In such a case some greasy substance must be applied around the 
 wound. As the discharge lessens and the cyst closes up, the 
 drainage tube, which may have been reduced in calibre, is to be 
 gradually shortened. The fistula may or may not remain 
 permanently. 
 
SECTION II 
 
 THE SUEGERY OF THE ABDOMEN PECULIAR TO 
 
 WOMEN. 
 
CHAPTER 1. 
 
 TUMOURS OF THE OVARY. 
 
 SuEGiCAL Anatomy. 
 
 The ovary varies in size with age, and during its active life 
 in relation to a menstrual period. The average weight is from 
 sixty to a hundred grains, the length one and one-third inch, 
 and the greatest diameter three quarters of an inch. At or 
 about the time of a menstrual period it is much swollen, and 
 the corpus luteum which is formed has been sometimes mis- 
 taken for an ovarian haematoma or blood cyst. 
 
 The ovary is situated at the upper and back part of the 
 broad ligament, and is covered by its posterior layer, except 
 
 Fallopian tube. 
 
 Parovarium. 
 
 Round ligament 
 of uterus. 
 
 Utero-vesical 
 pouch. 
 
 Cellular tissue between 
 the broad ligament. 
 
 Fig. 20.— Diagrammatic Antero - Posterior Vertical Section of the Broad Ligament, 
 showing the normal relation of the organs enclosed within the peritoneal folds (Hepburn). 
 
 along the line of the hilum. At the same time it should be 
 noted that the cells characteristic of peritoneum are replaced by 
 the columnar (germinal) epithelium. 
 
 Blood vessels and nerves pass into it at the hilum from 
 
3i8 
 
 TUMOURS OF THE OVARY. 
 
 between the layers of the broad ligament. There is therefore a 
 direct communication between the hilum of the ovary and the 
 pelvic cellular tissue. In the annexed illustration (Fig. 20) is 
 represented, very diagrammatically, the relation of the ovary to 
 
 Cellular tissue between 
 the broad ligament. 
 
 Pediculated 
 ovarian tumour. 
 
 Recto-vaginal 
 pouch. ' 
 
 Fallopian tube. 
 
 Parovarium. 
 
 Round ligament 
 of uterus. 
 
 Utero-vesical 
 
 pouch. 
 
 Fig. 21.— Diagrammatic Antero-Posterior Vertical Section of the Broad Ligament, 
 representing a pediculated ovarian tumour with a long pedicle. Continuous line indi- 
 cates peritoneum, the dotted lines columnar epithelium of ovary. (Hepburn.) 
 
 the broad ligament and pelvic cellular tissue. The pedicle of an 
 ovarian tumour consists of that part of the broad ligament to which 
 the hilum is attached, along with the cellular tissue, blood vessels, 
 and nerves. It will be easy to understand how, if the part of the 
 
 Cellular tissue between 
 the broad ligament. 
 
 Fig. 22.— Diagrammatic Antero-Posterior Vertical Section of the Broad Ligament, 
 representing a sessile ovarian tumour. The peritoneum is shown by a continuous line, 
 the columnar epithelium of the ovary by a dotted one. (Hepburn.) 
 
 ovary farthest away from the broad ligament become enlarged, 
 the pedicle is formed, and how it may be even several inches in 
 length. On the other hand, should the ovary enlarge where it 
 is in connection with the cellular tissue of the broad ligament it 
 is evident that instead of drawing part of the broad ligament 
 
S7GJVS AND SYMPTOMS. 
 
 319 
 
 upwards and into a pedicle, it may push its way between the 
 folds of the broad ligament itself, and thus become sessile, there 
 being no pedicle, the anterior and posterior layers of the broad 
 ligament being stretched more or less over the tumour. 
 
 When the diagnosis of this latter condition comes to be 
 considered, it will be understood how a tumour, distending one 
 broad ligament, will displace the uterus ; and it will also be 
 easily seen that the operation will be a more formidable one 
 than when there is an ordinary pedicle. 
 
 These tumours may be divided into single cystic growths, 
 tumours composed chiefly of several cysts, tumours made up 
 principally of a mass of small cysts, semi-solid tumours, solid 
 fibroid tumours, dermoid tumours, and malignant tumours. 
 They are unlimited in size, and with the exception of the 
 dermoids, usually grow rapidly. In describing the symptoms 
 and diagnosis of tumours varying so much in consistence and 
 in size, it is impossible to describe in words all the variations 
 which may be met with, and it will be found in practice that a 
 diagnosis is made principally from the sensations conveyed to 
 the fingers. This can only be arrived at by experience. 
 
 Signs and Symptoms . — An ovarian tumour is per se a painless 
 growth. At any stage of its history it may give rise to pressure 
 symptoms, and it may also cause attacks of inflammation in the 
 abdomen. The rapidity with which these tumours increase in 
 size varies greatly ; as a rule they are seldom discovered until 
 they are large enough to affect the size of the abdomen. They 
 are not commonly seen in the early stages when they are limited 
 to the pelvis, and little is therefore known of their rate of 
 increase while of small size. 
 
 After the tumour has grown up to the anterior abdominal 
 wall, the increase in size may be very rapid, a few days some- 
 times showing a marked difference. Usually the growth is not 
 so rapid, but a month in the life history of an ovarian tumour 
 shows a marked increase. On an average it may be said that 
 the life of a patient is worth two years, perhaps three, after an 
 
320 
 
 TUMOURS OF THE OVARY. 
 
 ovarian tumour has become abdominal, and during the half of 
 this time the patient lives in misery. In exceptional cases 
 an ovarian tumour may grow very slowly, and the patient may 
 live many years in comfort without any surgical interference 
 being absolutely necessary. Until an ovarian tumour is of such 
 a size that it has filled the entire abdomen and is raising the 
 ribs, it may not affect the general health in any way. When it 
 begins to press upwards on the diaphragm the patient suffers 
 from the size, and the health becomes affected. The whole 
 body becomes thin, and the countenance of the patient is drawn 
 and anxious ; the pulse quickens, and the respirations become 
 shallow and laboured. This latter symptom is not a very 
 marked one unless the tumour be enormous. 
 
 The position of the tumour, when it is of small size, not 
 extending much above the umbilicus, is almost invariably to 
 one or other side of the middle line, but as it grows and fills the 
 abdomen, it becomes central. 
 
 The umbilicus, except in the early stages, is flattened out, 
 and enlarged veins in the abdominal wall used to be frequently 
 seen when the tumours were allowed to grow to a large size. 
 
 There is one symptom which is almost more to be relied on 
 than any other — it is the emaciation of the chest and arms in 
 comparison with the lower part of the body. In the small 
 tumours and in those of no great size, not perhaps more than 
 10 lbs. or 20 lbs. .in weight, the upper part of the body 
 is thin, the abdomen is distended, and the size of the legs 
 is little or not at all reduced. With the very large tumours 
 this symptom is lost, as the legs as well as the upper part of the 
 body emaciate. 
 
 The first thing to make out is the relation of the growth to 
 the uterus. The tumour may not be felt by the examining 
 finger, and the uterus may be found freely movable. With the 
 finger on the cervix, lateral and upward pressure must be made 
 with the other hand on the abdominal swelling to determine 
 whether the growth is free from the uterus or not. Downward 
 
S/GJVS AND SYMPTOMS. 
 
 32 
 
 pressure of an ovarian tumour does not give any information, 
 because, no matter what the connection, it must affect the 
 position of the uterus if it be pressed against it. When the 
 tumour is felt in the pelvis, it may be situated either in front, 
 or behind, or to one side of the uterus, or it may be found to 
 have retroverted the uterus, or the tumour may have filled the 
 whole of the pelvis and pushed or drawn the uterus into the 
 abdominal cavity. 
 
 When a tumour is fixed in the pelvis it gives rise mechani- 
 cally to irritability of the bladder or sometimes to retention, 
 and it may also partially obstruct the flow of urine from the 
 kidneys. An ovarian tumour may cause additional pressure 
 symptoms, there may be dropsical effusion into the lower limbs 
 and sometimes into the cellular tissue of the abdominal wall, 
 though this latter condition is due more frequently to some 
 complication, which will be referred to later. 
 
 In the very large majority of ovarian tumours fluctuation 
 will be made out at some part. This may be difficult to make 
 out when the cyst is tense, especially if the walls be thick, and 
 of course this sign will not be present when the growth is 
 absolutely solid. 
 
 When the tumour is large enough to touch the abdominal 
 wall, the percussion note is almost invariably dull from the 
 upper part of the tumour down to the pubes, but a coil of 
 intestine may run across the front of the growth. 
 
 Auscultation simply gives negative information. 
 
 It is never safe to rely on any one symptom alone, all must 
 be taken into consideration. The one upon which most stress 
 should be laid is the thinning of the chest and arms in compari- 
 son with the legs, and this is usually seen even in small tumours. 
 A well-marked example of the importance of this symptom is 
 given in the following history. A young lady twenty-nine years 
 of age was seen in the beginning of 1890. Two years before, 
 attention had been drawn to the presence of an abdominal tumour 
 by an attack of pain, and at that time the growth extended to three 
 21 
 
TUMOURS OF THE OVARY. 
 
 322 
 
 indies above the pubes. The patient was ana3mic, she was not 
 emaciated, the tumour swelled up markedly before every period, 
 and the quantity of blood lost was greatly increased. A sound 
 passed five inches apparently into the centre of the mass, which 
 was very little larger than it was said to have been two years 
 before. The diagnosis was doubtful, it lay between a uterine 
 and an ovarian tumour. As a positive opinion could not be 
 given the patient was sent home, as the treatment — by electricity 
 or by operation — depended on the diagnosis. She returned in 
 two months, the tumour had not increased in size, the monthly 
 swelling was more marked, the menorrhagia was more excessive, 
 but there was decided emaciation of the chest, and chiefly on 
 this symptom the tumour was diagnosed to be an ovarian 
 growth. It turned out to be a dermoid tumour. 
 
 Diagnosis . — The diagnosis of an ovarian tumour may be 
 difficult, for the growth may consist of one fluctuating cyst, or 
 of a tumour composed of several fluctuating cavities, or there 
 may be so many small cysts that the growth is semi-solid, or it 
 may be completely solid. It may be smooth and regular in 
 outline, or it may present all kinds of irregularities on its surface. 
 It may be of any size, from that of a billiard ball to beyond 
 100 lbs. in weight. It may grow with great rapidity, or 
 it may appear to be completely stationary in this respect. Its 
 position varies, sometimes it is more or less to one side of the 
 middle line, sometimes completely central, or a small tumour 
 may be fixed in the position of the kidney and with no apparent 
 pelvic connection. On making a pelvic examination nothing 
 abnormal may be felt ; or the uterus may be partially fixed by 
 a tumour out of reach ; or a fluctuating or solid block of tumour 
 may be felt behind, in front of, or on either side of the uterus. 
 In a difficult case a diagnosis seems to be arrived at, not so 
 much by any one sign pointing to ovarian tumour as by the 
 whole chain of symptoms indicating ovarian disease more than 
 anything else. 
 
 The effect produced by the presence of an ovarian tumour 
 
DIFFERENTIAL DIAGNOSIS. 
 
 323 
 
 on the menstrual functions is not of any assistance in coming 
 to a diagnosis ; there is usually no change, but there may be 
 menorrhagia, and amenorrhcea is not uncommon when the 
 tumour is of some size. 
 
 Differential Diagnosis . — The various enlargements of the 
 abdomen will be taken up in detail, and will be examined with 
 the purpose of giving as far as possible a differential diagnosis 
 between such growths and an ovarian tumour. 
 
 First in order will naturally come enlargements of the 
 uterus, as these are by far the most common even if pregnancy 
 be excluded. The normal enlargement of the uterus will be 
 taken first, for mistakes are common, and to overlook a pregnancy 
 or mistake it for something else is a failure not easily forgiven 
 by a patient. The history may mislead either intentionally or 
 otherwise ; if the former, it will be with the idea of putting off 
 the evil day of confession as long as possible, or with the hope 
 by misleading the doctor something may be done unawares for 
 her benefit ; if the latter, it will probably be in the case of 
 a woman well up in years, who has had a family, and does not 
 suspect that another is to be added to her flock. An unmarried 
 lady thirty-six years of age, whose thigh had been amputated in 
 childhood, complained of amenorrhcea ; an abdominal tumour was 
 found, and, although the question of pregnancy was thoroughly 
 debated, the conclusion come to by three medical men was that 
 the tumour was ovarian. An abdominal surgeon was written to 
 and asked to come and remove the growth ; he suggested that as 
 there was not any particular hurry it would be better to wait and 
 examine the patient again. This was done and the foetal heart 
 was discovered. 
 
 The mother of a large family, forty- seven years of years, and 
 whose youngest child was eight, had not been very well for 
 some time, when an abdominal swelling was noticed. The lady 
 could hardly be brought to believe that she was pregnant until 
 she could not mistake the movements of the child. 
 
 A mill-worker, nineteen years of age, was brought into the 
 
324 
 
 TUMOURS OF THE OVARY. 
 
 Edinburgh Royal Infirmary by her doctor in July 1885. About 
 the beginning of the year she had run the risk of becoming a 
 mother, and the size of the swelling was that of a seven months’ 
 pregnancy. The cervix was soft and moved with the tumour, 
 the outline was not well defined, and it was impossible to give a 
 positive diagnosis. Time alone cleared up the matter, and a 
 multilocular ovarian tumour was eventually removed. As the 
 tumour was slightly ruptured, the tension had been taken off ; 
 and this along with a small amount of free fluid and the tense 
 abdominal wall led to the difficulty in diagnosis. 
 
 When the foetal heart is heard the diagnosis is certain ; 
 when for some reason it cannot be made out the most distinctive 
 sign is a peculiar feeling of want of definition presented by the 
 tumour. There seems to be no distinct outline, the swelling 
 having almost the feeling of blending with the surrounding 
 structures, and in the interior of this swelling irregular firm 
 masses are felt. If one is so fortunate as to examine when the 
 uterus contracts or relaxes, the diagnosis is nearly certain. The 
 cervix may not be soft, it may not be affected by the movement 
 of the tumour, the foetal head may not be within reach, or if it is 
 there may not be ballottement. This sign of ballottement may 
 be well marked where there is a firm tumour surrounded by 
 ascitic fluid. There are various other symptoms which, though 
 by no means diagnostic when taken alone, yet go to weigh the 
 balance more in favour of one condition than the other. We 
 have for example sickness, a common symptom in pregnancy, 
 more especially in its early stages, while it is not common in 
 ovarian disease, and then only when the tumour is large enough 
 to cause pressure. The expression is different, and thinning of 
 the upper part of the body does not usually occur in pregnancy, 
 the reverse being rather the case. Movements or supposed 
 movements of the foetus, enlargement of the mammae, blue 
 appearance of the vagina, are more indicative of pregnancy than 
 of the presence of an ovarian tumour. The presence or absence 
 of the menses is not to be relied upon. 
 
DIFFERENTIAL DIAGNOSIS. 
 
 325 
 
 A fibroid tumour of the uterus differs from an ovarian one 
 in that it is usually more central. It is hard, often very hard, 
 and there is no fluctuation, there is no emaciation of the chest 
 and arms, the face is florid unless the patient be blanched by 
 excessive haemorrhage, the cervix is often altered in shape and 
 position, and can be moved by alterations in the position of the 
 tumour, and the sound may be passed many inches into the 
 mass. Menstruation is often excessive, and is rarely absent, 
 as is comparatively commonly seen in large ovarian tumours ; 
 the growth is comparatively slow, and the umbilicus is drawn in. 
 
 The fibro-cystic tumour of the uterus is much more difficult 
 to differentiate, it resembles an ovarian tumour in almost every 
 detail, but it is fortunately not often met with. It is frequently 
 of rapid growth, fluctuation may be very distinct, the cervix may 
 not seem to move with the tumour, there may be emaciation of 
 the chest, there may be and usually is no change in men- 
 struation, the sound may pass for a normal distance, and the 
 umbilicus is usually flattened out. For the diagnosis of these 
 tumours experience seems to be the only guide, and with the 
 greatest care mistakes will every now and then occur. 
 
 A broad ligament or parovarian cyst is of slow growth, it is 
 not tense like the usual ovarian cyst, it is a single cyst, and is 
 as a rule cured by tapping. It contains a fluid like clear water, 
 the specific gravity of which varies from 1003-1006. There is 
 no deposit in the fluid, and few, if any, cells are found on 
 microscopic examination. 
 
 Ascites, unless in very large amount, cannot be easily mis- 
 taken for an ovarian tumour ; percussion gives a clear note in 
 front, and a dull one in both flanks, and this is not likely to be 
 the case with an ovarian tumour. If the position of the patient 
 be changed, so will be the sound elicited by percussion. The 
 history ought also to put one on one’s guard. In very great 
 enlargements, when the quantity of fluid is so great that the 
 intestine cannot reach near enough to the wall to give a clear 
 note on percussion, the chief point of diagnosis will be afforded 
 
326 
 
 TUMOURS OF THE OVARY. 
 
 by the difference in respiration. In ascites the difficulty in 
 breathing is very marked, and this is much more so than when 
 there is a large ovarian tumour. 
 
 Encysted dropsy of the peritoneum, like fibro-cystic tumours 
 of the uterus, is not common ; the history will probably reveal a 
 previous attack of inflammation, the fluid increases slowly, the 
 sac wall appears to be thin, intestine is found close to the fluid 
 in every direction, and percussion along the pelvic brim often 
 shows that the swelling does not possess any pelvic connection, 
 a clear note being obtained completely across the lower part of 
 the abdomen. The same clear note above the pubes and across 
 the abdomen may occasionally be noted in ovarian growths. 
 A patient fifty years of age presented herself at the Eo}^! 
 Edinburgh Infirmary complaining of an abdominal enlargement. 
 On examination a collection of fluid was found having all the 
 characteristics of an encysted dropsy. There was no pelvic 
 connection to be made out, and a tympanitic note stretched 
 across the abdomen a couple of inches in depth. The case was 
 not an urgent one. When the patient returned, the band of 
 clear sound had disappeared, and it was then evident that the 
 swelling was an ovarian tumour, as it turned out to be. 
 
 Intestine adherent in front of an ovarian tumour might also 
 confuse the diagnosis ; but in any such cases we have seen, the 
 symptoms of ovarian tumour could not be mistaken. 
 
 A cystic tumour of the kidney may be mistaken for an 
 ovarian tumour. The chief points of difference when the cyst is 
 not large enough to entirely fill the abdomen are the position of 
 the cyst in the loin, the want of pelvic attachments, a clear note 
 on percussion across the lower part of the abdomen below the 
 cyst, and the presence of the ascending or descending colon 
 running across the front of the tumour. INIistakes are more 
 likely to occur when the cyst is very large, and when no definite 
 history can be obtained of the origin of the swelling. The cyst 
 may be felt in the pelvis, and there may be an absence of clear 
 sound across the lower part of the abdomen; but the position of 
 
DIFFERENTIAL DIAGNOSIS. 
 
 327 
 
 the colon, and the less amount of emaciation of the upper part 
 of the body as compared with the lower limbs of the patient, 
 will be the most reliable diagnostic signs in such large tumours. 
 
 Cysts of the mesentery, of the pancreas, and retro-peritoneal 
 growths, have been occasionally mistaken for tumours of the 
 ovary, and when they are large such a mistake is very easily 
 made. When the growth is small, the position will usually 
 exclude the possibility of ovarian disease, and such need not be 
 considered at present. Large cysts of the mesentery usually 
 grow slowly, and when they are situated in or behind the 
 mesentery near the brim of the pelvis, and have pushed the 
 intestines completely to the sides, it is probable that the 
 diagnosis of ovarian tumour will be made. It is difficult to see 
 how’ this mistake can be avoided, unless it be by the difference 
 in the effect produced on the general nutrition of the patient. 
 Large cysts of the pancreas may also be difficult to diagnose 
 unless they be aspirated ; as the fluid is withdrawn some 
 indication will be gained as to which part of the body the 
 tumour has sprung from, and when there is also a history of 
 swelling having begun at the upper part of the abdomen a 
 correct diagnosis may be arrived at. Solid retro-peritoneal 
 growths, especially if malignant, may resemble a cancerous 
 ovarian tumour very closely, and in such cases there is no 
 manifest point of difference, as the general nutrition becomes 
 affected by the maligant disease whether the tumour be retro- 
 peritoneal or ovarian. 
 
 An enormous cyst of the liver or gall-bladder may resemble 
 an ovarian cyst so closely that the diagnosis can be made only 
 by reference to the original position of the tumour, and to the 
 want of emaciation of the chest. In smaller growths, the 
 evident want of any connection with the pelvis shows that the 
 tumour cannot be an ovarian one. A solid enlargement of the 
 liver, especially when accompanied with ascites, has been 
 diagnosed to be an ovarian tumour. The shape and position 
 of the tumour ought to be sufficiently diagnostic ; and when 
 
328 
 
 TUMOURS OR THE OVARY. 
 
 ascitic fluid is present the symptoms will be those already 
 described, combined with the presence of a hard solid tumour 
 in the right side and continuous with the liver dulness. 
 
 A hypertrophied condition of the spleen may be so great 
 that the tumour fills the larger part of the abdomen and extends 
 into the pelvis. The diagnostic signs consist in the raising of 
 the ribs on the left side ; in the position of the growth being 
 more in the left than in the right ; in the presence of notches 
 along the right side ; and in the percussion note being 
 absolutely dull where the tumour appears from beneath the 
 ribs, and becoming less dull as the right and lower borders are 
 approached. 
 
 A condition of the abdomen known by the name of phantom 
 tumour may resemble a cyst of the ovary in a very marked 
 degree. This peculiar condition is seen usually in young women, 
 or in women about the menopause; it is a distension due to 
 some abnormal nervous state, especially affecting the intestines 
 and the diaphragm, and the appearance of the abdomen may 
 resemble one distended by a unilocular or multilocular ovarian 
 tumour. The diagnosis is simple, because a clear note is elicited 
 on percussion all over the abdomen. It has sometimes happened 
 that in spite of this diagnostic point a patient has been prepared 
 for operation, and a correct diagnosis has not been made until 
 the anaesthetic has been administered. As soon as the patient 
 becomes unconscious the distension disappears, but it returns 
 when the effects of the anjnsthetic have passed away. 
 
 Diagnosis of Adhesions . — Although it is not possible to be 
 always absolutely correct as to the amount of adhesion present, 
 yet an attempt should be made to determine before operation the 
 exact connections of an ovarian tumour. In the first place, the 
 history is a great guide ; when there has never been any attack 
 of pain in the abdomen, either since the tumour was first noticed, 
 or for some time previously, the assumption is that the tumour 
 will not have formed any adventitious connections. Should the 
 patient have been confined to bed for some days, or more especially 
 
DIAGNOSIS OF ADHESIONS. 
 
 329 
 
 for some weeks, on account of abdominal pain, the assumption 
 is equally strong that there will be adhesions, and the longer 
 the inflammatory attack has lasted, and the more severe it has 
 been, the more firm are these adhesions likely to be. The 
 strongest and most difficult adhesions of all to deal with are 
 those met with when there has been a tumour in the pelvis 
 during pregnancy. When there is a history pointing to the 
 presence of adhesions, difficulty with the bowels will make one 
 suspect that they have become attached to the tumour. When 
 the tumour is free in front and the patient takes a long breath, 
 the tumour can be seen or felt to move independently of the 
 parietal wall. Careful percussion also at the upper part as 
 the patient inspires deeply may show that intestine moves down 
 between the wall and the tumour. The peristaltic movement in 
 a piece of bowel adherent in front can be seen, and the gut 
 itself can be felt either as a rounded band or as a tympanitic coil. 
 Should there be a little ascitic fluid it may clearly show the 
 presence of partial parietal adhesions, by the possibility of its 
 being pushed in front of some parts of the tumour, and not in 
 front of others. Sometimes, however, there may be the most 
 intimate adhesion to the intestine without a history of any 
 inflammatory attack whatsoever. A young married woman was 
 sent into the Edinburgh Infirmary in June 1885. Eor about 
 six months previously a painless abdominal swelling had been 
 noticed. There had never been any history of abdominal pain, 
 nor had the patient been confined to bed on account of any 
 trouble in that region or in the pelvis. Examination of the 
 abdomen showed that the tumour was composed of a single cyst, 
 which was freely movable in front. The cyst could be felt on 
 vaginal examination high up in the pelvis, and the uterus was 
 ((uite movable. On opening the abdomen the cyst was seen to 
 move freely on respiration, it was emptied with the trocar, but 
 on drawing the flaccid sac forwards, it was seen that intestine 
 was apparently incorporated with the wall of the tumour on 
 both sides and above. This intestine was so intimately incor- 
 
330 
 
 TUMOURS OF THE OVARY. 
 
 porated with the tumour that it was not considered advisable 
 to make any attempt at removal ; the sac was therefore stitched 
 to the abdominal wall, and within seven weeks a sinus two 
 inches in length alone remained. This sinus closed within a 
 twelvemonth. 
 
 When an ovarian tumour has grown between the layers of 
 the broad ligament, the condition resembles very much that of 
 adhesion ; and the surface of the tumour has to be separated 
 from the inner surface of the expanded broad ligament, almost 
 as if it were a newly formed adhesion. In such cases the 
 uterus is invariably drawn out of position, and is not infrequently 
 entirely raised up into the abdomen, the cervix being felt above 
 the pubes on one or other side. The uterus, when it can be 
 reached, is not freely movable, and movement of the tumour 
 affects it at once. When the tumour is small it pushes the 
 uterus to the opposite side, and as it enlarges takes the womb 
 up with it into the abdomen, and the uterus will then be felt on 
 one or other side above Poupart’s ligament. Should the tumour 
 have burrowed very deeply into the pelvic tissues, and pushed 
 its way behind the uterus, and into the opposite broad ligament, 
 the position of the uterus, instead of being lateral, will be almost 
 central. 
 
 A cystic tumour, especially in young unmarried women, wdll 
 not infrequently cause a retroversion, and apparent fixation of 
 the uterus in this abnormal position ; there are no adhesions, 
 but the organ is simply pushed over by the tight abdominal 
 walls. 
 
 The advantages to be derived from attempting to make a 
 diagnosis of the exact condition, and the difficulties to be met 
 with, will often save trouble at the time of operation, for one will 
 then be prepared for difficulties in certain cases, and time will not 
 be lost in considering what is the best thing to do. In addition 
 to this, habits of precision are gained, and one becomes able 
 to give a more correct prognosis than would otherwise be 
 possible. 
 
ROTATION OF OVARIAN TUMOURS. 
 
 331 
 
 Dermoid Tumours. 
 
 A dermoid ovarian tumour is one in which fatty matter, 
 hair, skin, bone, are one or all found. Such tumours are of 
 slow growth, and do not usually attain to any great size ; one of 
 28 lbs. being the largest we have met with. They are often 
 somewhat tender to the touch, and their presence may be 
 suspected when the tumour is very hard. A positive diagnosis 
 can be made when a piece of hone is felt. Their importance is 
 due principally to the contents, and when entirely filled with 
 hair their extraction, except through a long incision, is difficult. 
 They are more liable to inflame than ordinary ovarian cysts, and 
 adhesions are consequently found in a larger proportion of the 
 cases. They are not very common, occurring once in about ten 
 or fifteen cases. 
 
 Eotation of an Ovarian Tumour. 
 
 Sometimes an ovarian tumour rotates and causes a twisting 
 of the pedicle. 'No satisfactory reason has been given for this 
 accident, and when slight it does not give rise to any symptoms. 
 When the twisting is sufficient to cause strangulation, the effect 
 both on the patient and on the tumour is well marked. There 
 is a sudden attack of severe pain in the abdomen, accompanied 
 by general symptoms of prostration, and in some cases by a rise- 
 in the temperature and in the pulse rate. When this acute 
 attack is over, the tumour often ceases to grow, or increases 
 extremely slowly. When the attack is very acute, showing 
 probably that the twisting has been sudden, and that the veins 
 in the pedicle have become closed partly or entirely, there may 
 be profuse haemorrhage into the tumour, and the growth will be 
 then found to have become suddenly enlarged. At times the 
 pedicle becomes entirely twisted off, and the tumour is kept 
 alive by the blood supply brought in through adhesions ; these 
 are not necessarily very extensive, and are commonly to the 
 
332 
 
 TUMOURS OF THE OVARY. 
 
 omentum. The tumour itself becomes altered in appearance, it 
 loses its white shiny colour, becoming dull and of a brownish hue. 
 The lining surface shows no trace of blood vessels, and has 
 sometimes almost a gangrenous appearance. This appearance of 
 gangrene will be more marked if the tumour be removed when 
 the acute symptoms are present, but, though tumours are 
 sometimes reported as being gangrenous, there do not seem to 
 be any cases on record where the tumour did actually become 
 gangrenous as the result of twisting of the pedicle, though it 
 may become so from simple inflammatory action. An acute 
 attack of this nature may be followed by inflammation, and this 
 may run on to suppuration. 
 
 The lessened amount of the blood supply explains the slow 
 growth of those tumours, and a certain number do not fill up 
 after a tapping. 
 
 In March 1883, an ovarian tumour was removed from a young 
 woman twenty-four years of age, who gave the following history. 
 Five years before she first noticed that her abdomen was 
 enlarging, and soon afterwards she was confined to bed for two 
 weeks with severe pain, accompanied by slight fever. After 
 this illness the tumour grew very slowly, and there had been 
 several similar, but not such severe attacks of pain in the 
 abdomen. The tumour was fairly movable, but adhesion on the 
 right side was diagnosed. At the operation the omentum was 
 found to be adherent, and there was not any pedicle. The sac 
 and contents weighed 8J lbs., and on examination the twisted-up 
 remains of the pedicle were seen. The inner lining of the cyst 
 was of a dark grey colour, and showed no signs of vascularity. 
 
 In October 1888, a lady thirty-two years of age was seen in 
 consultation with her usual medical attendant, who had been 
 called in on account of a severe attack of abdominal pain without 
 fever, but accompanied by collapse and symptoms of hsemorrhage. 
 Some time before, he had diagnosed the presence of an ovarian 
 tumour. The acute attack passed off, and when she was seen the 
 diagnosis was confirmed, the attack of pain having been evidently 
 
RUPTURE. 
 
 333 
 
 due to a twisting of the pedicle. Ovariotomy was advised, but 
 the patient and her husband insisted on having a preliminary 
 aspiration. This was done, and forty-eight ounces of bloody 
 fluid were removed. A flaccid cyst could then be distinctly 
 felt. The cyst has not refilled, and the patient has been 
 perfectly well since the fluid was removed. 
 
 Euptuee. 
 
 An ovarian tumour may rupture either from gradual thinning 
 of the wall at one spot due to pressure from within, or to injury 
 from without, or there may not be any apparent cause. 
 
 This accident is most common in papillomatous tumours, 
 and the leakage may be either slow or sudden. A blow on the 
 abdomen may cause rupture, or it may result from a rough 
 examination. The amount of general disturbance which may 
 follow a rupture will depend chiefly on the kind of fluid effused, 
 and the rapidity with which it flows into the peritoneal cavity. 
 When the fluid is non-irritating there will not be any disturb- 
 ance, indeed the patient may not know when the rupture 
 occurred. If the fluid be not of this simple character, there 
 will be a more or less severe attack of general peritonitis. 
 
 The opening, instead of leading into the peritoneal cavity, 
 may be into the bowel, vagina, or bladder, but a rupture in any 
 of these directions only occurs when there are adhesions. This 
 is more apt to happen in dermoid tumours, perhaps because 
 they are adherent in a large proportion of cases. 
 
 A patient twenty-six years of age was admitted into the 
 Edinburgh Infirmary in 1886, on account of an abdominal 
 enlargement, which had been noticed for seven months. There 
 was no history of pain or discomfort at any time. The ex- 
 amination showed that there was a quantity of free fluid in the 
 peritoneal cavity, the presence of which could only be accounted 
 for by the rupture of an ovarian tumour. An opening the size 
 of a sixpence was found in the sac wall. 
 
334 
 
 TUMOURS OF THE OVARY. 
 
 A thin delicate woman of twenty-four was admitted into the 
 Edinburgh Infirmary in 1884. A cystic enlargement of the 
 ovary had been discovered nearly two years before. On ex- 
 amination the tumour was found to extend half way up to the 
 umbilicus, and was completely covered by adherent intestine. 
 In the pelvis the cervix was felt to be much swollen, and all 
 of the pelvic contents were firmly matted together. The 
 history pointed clearly to a rupture having occurred into the 
 bowel. As the tumour was not causing any trouble, the patient 
 was advised to wait for a time in the expectation that removal 
 would be more easy when the growth had increased in size, and 
 that the general health might improve in the meantime. Some 
 time afterwards the cyst ruptured into the vagina, and when 
 the patient was next seen an opening was discovered in front of 
 the cervix. As the discharge had become intensely offensive, 
 the opening was dilated, and a large drainage tube was left in, 
 after the interior of the cyst had been thoroughly washed out. 
 This was followed by a great improvement in the general health, 
 and the discharge became much lessened in quantity after a 
 great number of long black hairs had been thrown off. . 
 
 Suppuration. 
 
 Suppuration in an ovarian tumour is an accident which may 
 follow a badly performed tapping, a simple chill, or a twisting 
 of the pedicle. The inflammation in the cyst is not unlikely to 
 spread to the general peritoneum, and the result of this is that 
 ovarian cysts in this condition are almost invariably adherent. 
 These adventitious connections are often universal and of great 
 firmness. 
 
 The diagnosis is to be made by the history of the patient. 
 After being well up to a certain time there is a sudden failure 
 in health, following on one of the above-mentioned causes. A 
 definite starting point may not always be discovered; the 
 patient complains of rigors, or at least of a feeling of chill. 
 
SUPPURATION— MALIGNANT TUMOURS. 335 
 
 usually in the back ; the pulse becomes quickened, the temper- 
 ature may be subnormal, or perhaps raised half a degree or so, 
 and there may not be any rise in the afternoon or at night; 
 there is sweating, and the skin has a sodden appearance, with a 
 peculiar acrid smell. The appearance of the patient is also 
 very distinctive of suppuration. 
 
 A patient twenty-four years of age was operated on in June 
 1887 for a suppurating ovarian tumour. Since her third baby 
 was born sixteen months before, the abdomen had not been quite 
 flat. Her fourth child was brought into the world one year 
 after the third. In the previous four months the abdomen was 
 tapped twice, the fluid being described as of a yellow colour. 
 The patient looked ill, and said she felt chilly, the pulse was 
 130, temperature 99°, the skin was sodden, and she sweated 
 profusely. On examining the abdomen a partially filled cyst 
 was felt, and the abdominal wall was hard and solid. The 
 diagnosis was made of a universally adherent suppurating cyst. 
 Best in bed for a month brought the pulse down to 90, the 
 temperature during that time varying from 97*8° to 99*2''. On 
 making the incision the peritoneum was seen to be hard, 
 cartilaginous, and fully one- third of an inch in thickness, and it 
 was so incorporated with the cyst wall that an attempt was not 
 made to effect its separation. The pus and lymph were removed, 
 the sac washed out, dried and sponged over with chloride of 
 zinc (forty grains to the ounce), a rubber tube was put in reach- 
 ing to the pelvis, and a second over a foot long in the direction 
 of the ribs. The patient went home in six weeks with a narrow 
 sinus three inches in length, and had another baby within 
 fifteen months. 
 
 Malignant Tumours. 
 
 For practical purposes malignant disease of the ovary may 
 be divided into cases where there is and where there is not 
 any cystic enlargement. 
 
 When the disease is found in the interior of an unruptured 
 
336 
 
 TUMOURS OF THE OVARY. 
 
 cyst after ovariotomy has been performed, permanent recovery 
 may result, but in a great majority of cases there will be at 
 some future time a return of the disease in the abdominal 
 cavity. 
 
 When the disease consists of a solid enlargement of one or 
 both ovaries it is usually accompanied by ascitic fluid, and the 
 treatment of this condition, and also of that when a cystic 
 tumour with malignant contents has ruptured, has been con- 
 sidered when dealing with the examination of peritoneal fluids. 
 A malignant tumour of the ovary more frequently opens up the 
 broad ligament than a simple one. 
 
 Some of the rapidly -growing, thin -walled tumours with 
 viscid jelly-like contents, are closely allied to malignant growths. 
 
 Prognosis . — A patient with an ovarian tumour can only look 
 forward to a few years, usually to but a few months, of unutter- 
 able misery, unless the disease can be removed. What then 
 are the chances of recovery we can offer when we tell a woman 
 that she has one of these tumours ? Naturally she will wish to 
 know. The prognosis to be given now compared with that of 
 twenty -five years ago is very different. Then, the patients 
 applied late for operation, after they had often gone through 
 several attacks of peritonitis, and only when the general health 
 was much deteriorated. At that time no one with the exception 
 of Dr. Keith could offer a mortality of under 20 per cent. 
 Now, this is quite changed, and any woman who is fairly strong 
 and healthy need not run a greater risk than at the outside 
 5 per cent. Before giving a prognosis it is necessary to have 
 a good general idea of the condition inside the abdomen ; the 
 presence or absence of adhesions, in what part of the abdomen 
 they are, their probable consistency, and the condition of the 
 tumour, suppurating or otherwise. If we know that the tumour 
 is not adherent, we can then give the comforting assurance that 
 the risk of the operation is practically nothing, and that all that 
 has to be feared is the accidental risk present in all operations 
 of one, or at the outside two, per cent. If the tumour be badly 
 
MALIGNANT TUMOURS. 
 
 337 
 
 adherent, or if the broad ligament be extensively opened up, we 
 must allow for some risk in the operation itself — say 5 per 
 cent. The amount of risk entailed by the presence of adhesions 
 varies chiefly with their extent and position. Pelvic adhesions 
 do not add much to the danger of the operation ; but when the 
 adhesions are in the upper part of the abdomen or to the 
 mesentery, especially when the tumour is very large so that 
 their extent is great, there is a certain amount of risk from 
 shock, due to injury or irritation of the sympathetic nervous 
 filaments, which must be taken into consideration. 
 
 The prognosis will differ also in another class of cases, viz. 
 that of the delicate women ; some of whom, when the heart is 
 weak or where there is fatty degeneration, bear operations 
 extremely badly, and the removal of a perfectly simple non- 
 adherent tumour may result in death within forty or fifty hours 
 from shock. 
 
 A lady forty- two years of age was operated on in May 1885 
 for ovarian disease. A simple non-adherent tumour was 
 removed, and when the patient was put back to bed the pulse 
 was 120, soft and weak. Flatus passed, the abdomen was 
 perfectly flat; but in spite of the favourable progress at the 
 seat of the injury the pulse steadily increased, while the heart’s 
 action became weak, and the patient died before the end of the 
 second day. At the 'post mortem examination nothing was 
 found to account for death except the presence of a heart which 
 had undergone a considerable amount of fatty degeneration. 
 
 When there is the combination of a delicate woman or of 
 one with the general health thoroughly broken down by suffer- 
 ing and a badly adherent tumour, it is reasonable to suppose 
 that there will be a greater risk than if one of these factors 
 alone were present. 
 
 The prognosis in the case of suppurating ovarian tumours is 
 very favourable. 
 
 The operation of ovariotomy is now so successful that 
 several surgeons have had more than fifty cases of recovery 
 22 
 
338 
 
 TUMOURS OF THE OVARY. 
 
 without a death intervening. Dr. Keith was the first to have 
 one of these series, having eighty consecutive recoveries more 
 than ten years ago. A much larger list has been published, but 
 other than cases of ovarian tumour were included in this series. 
 
 When the patient asks when should the operation be 
 performed, the answer must be the sooner the better, for the 
 longer the tumour remains in the abdomen the more likelihood 
 there is that the operation will be complicated, and at any 
 moment an attack of peritonitis may begin. The patient must 
 not wait until the health is broken down. 
 
 During the course of an acute disease operation is out of the 
 question, and in the far advanced cases of phthisis and of 
 malignant disease the patient must be content with palliative 
 measures. 
 
 Ovarian Tumours with Pregnancy. 
 
 When an ovarian tumour is discovered during the course of 
 a pregnancy, the treatment to be adopted will depend on the 
 stage at which the pregnancy has advanced, and on the presence 
 or absence of pelvic adhesions. The operation does not of 
 necessity cause abortion when one ovary has been removed, and 
 it is even possible to go on to full time after the removal of both. 
 In the early months, removal of the tumour ought always to be 
 advised without any hesitation, unless there be much adhesion 
 in the pelvis, and consequently in all probability to the uterus. 
 Adventitious connections to the pregnant uterus are certain to 
 be exceptionally vascular, and this condition would not only 
 have to be combated, but a considerable risk of injuring the 
 softened uterus would be incurred. Under the circumstance 
 of pelvic adhesion, if the tumour be growing slowly, it will be 
 possible to carry the patient on to full time either by doing 
 nothing, or by one or more aspirations if the tumour be 
 composed of one or several large cysts. When the tumour is of 
 such a nature that its bulk cannot be reduced by aspiration, it 
 is probable that its growth will not be rapid, and it can therefore 
 
TUMOURS WITH PREGNANCY, 
 
 339 
 
 be left alone. In the exceptional circumstance of a solid 
 tumour growing rapidly, the growth must be removed ; or if it 
 appear to be certain that much separation of adhesions in the 
 pelvis will have to be done, the preferable course will probably 
 be to induce abortion and operate six weeks or two months 
 afterwards. When a small ovarian tumour is found to be fixed 
 in the pelvis, where it must inevitably cause obstruction to the 
 birth of the child, it ought to be removed immediately, for if it 
 be left alone there will be in the first place great difficulty 
 during the labour, and if the mother survive the birth, the 
 pressure which has been exerted by the passage of the child on 
 the growth will result in the formation of most intimate 
 adhesions, which will complicate in a marked degree the future 
 removal of the tumour. In the later months of pregnancy an 
 ovarian tumour ought to be left alone until after the birth of the 
 child, and it would only be advisable to remove it in the 
 presence of exceptional circumstances. Unless there be any 
 special reason for operating before the birth, nothing is to be 
 gained by doing so, and a very considerable risk is run of 
 bringing on premature labour. In a recent number of the 
 British Medhcal Journal two cases were reported, one in this 
 country and one abroad, where ovariotomy was performed 
 apparently without any special reason at the seventh and eighth 
 months of pregnancy, and in both of these cases premature 
 labour was the result. 
 
 In 1885, a woman was operated on in the Eoyal Infirmary, 
 Edinburgh, for ovarian disease. The patient knew that she was 
 about three months pregnant, and sought advice on account of 
 the unnatural size of the abdomen. A cystic tumour was 
 found, nearly the size of an adult head, freely movable, and as 
 there was no history leading one to expect the presence of 
 adhesions, the tumour was removed. The patient made an 
 uninterrupted recovery, and a year after the birth of the child 
 it was found that the scar had not stretched in the very slightest 
 degree. 
 
340 
 
 TUMOURS OF THE OVARY. 
 
 To sum up shortly what is to be done with an ovarian 
 tumour when the patient is pregnant, it may be said that before 
 the fourth month, when adhesions are not suspected, the tumour 
 ought to be removed ; if there be adhesions it is best to 
 temporise, aspirating the fluid if necessary, unless the growth be 
 adherent in the pelvis. When so adherent it will be best to 
 empty the uterus. After the fourth month no more serious 
 operation than removal of the fluid ought to be resorted to. 
 
CHAPTER IL 
 
 OVARIOTOMY. 
 
 Historical. 
 
 The removal of a tumour of the ovary has been called by the 
 name of ovariotomy. As the history of the operation in its early 
 days is also the history of abdominal surgery, it is interesting 
 and instructive to look back to the early operators and their 
 methods, and to trace the various changes which have taken place 
 in the treatment of these growths. In the comparatively short 
 space of eighty years methods have been tried, have been found 
 wanting, and, in some cases, have again come into practice, either 
 to be again discarded, or to be adopted with perhaps some 
 modification, which renders them useful or convenient. 
 
 To Ephraim -McDowell of Danville (Ky.) undoubtedly be- 
 longs the credit of having first deliberately performed the opera- 
 tion of ovariotomy in 1809, and of thus being the illustrious 
 founder of the whole practice of abdominal surgery ; a practice 
 which now embraces operations on every organ in the abdomen. 
 It is also almost as certain that he was the first to remove an 
 ovarian tumour from a living woman. The honour, however, has 
 been claimed both for Houstoun of Scotland and for LAummonier 
 of France. From the description given of Houstoun’s case it 
 appears that he made a free opening into an ovarian tumour 
 filled with colloid material, the cyst wall was adherent to the 
 peritoneum in front, and the thick gelatinous contents were 
 drawn out by the help of a fir branch. The cyst was drained 
 
342 
 
 OVARIOTOMY. 
 
 by placing lint in the wound to keep it open, and the result 
 was that recovery took place then, as it may do now. For 
 example, in the year 1885, a lady seventy-five years of age was 
 seen with a large abdominal tumour; a diagnosis of a single 
 ovarian cyst adherent in front and partly covered by intestines 
 was made. As the lady was old and feeble, it was advised that 
 the cyst should be drained, unless the adhesions were found to 
 be less firm than was expected. In addition to their being very 
 firm they were exceedingly vascular, so the contents which were 
 gelatinous were emptied, a couple of drainage tubes were put 
 into the sac and the wound was left freely open. Within six 
 weeks the sac, which had contained over twenty pints of fluid, 
 had contracted down to a sinus flve or six inches in length, and 
 without the occurrence of suppuration. 
 
 L’Aummonier’s case in 1776 appears to have been one of a 
 collection of pus in a Fallopian tube. The ovary was removed 
 without any apparent reason, and the tube or abscess cavity was 
 opened and drained. This patient also recovered. There is 
 nothing doubtful about M'DowelFs operations. While a student 
 in Edinburgh, M‘Dowell undoubtedly obtained the idea of the 
 possibility of removing an ovarian tumour from Dr. John Bell, 
 and after his third operation he sent the account of his cases 
 to his former teacher. Dr. Bell was, however, ill in Eome, 
 and the description of the operations seems to have been 
 retained by Lizars, who was at that time doing Dr. Bell’s work. 
 
 It is not necessary to mention all the names connected with 
 ovariotomy in its early days, and reference will be made only to 
 those who threw special light on the operation. 
 
 Dr. McDowell made a long incision, not in the middle line 
 but along the outer border of the rectus muscle. In his first 
 case he had to reduce the size of the tumour before he could bring 
 it outside, and one is inclined to wonder why he continued to 
 make unnecessarily long incisions. The pedicle was tied with 
 cord, the ends were left long and were brought outside through 
 the wound. This was a correct practice to adopt at the time. 
 
HISTORICAL. 
 
 343 
 
 for it was supposed that the distal part of the pedicle must 
 slough, and that an open path must therefore be left for its exit. 
 Sometimes the pedicle sloughed and sometimes it did not, and 
 looking back it is easy to see how this happened. We now 
 know that the distal portion need not die, but in the old days a 
 septic or dirty piece of cord was used to constrict this piece of 
 tissue. The part beyond the ligature had its vitality lowered, 
 and, if the septic poison in the ligature were strong, this injured 
 part naturally succumbed and had to be thrown off. If, on the 
 other hand, the natural vitality of the tissues was great, or if the 
 ligature was cleaner than usual, the tissue did not die, and the 
 ligatures were drawn away with difficulty. As M'Dowell used 
 these septic ligatures, his practice of leaving them long was 
 perfectly correct with the knowledge he then possessed. 
 
 Twelve years after M'Dowell’s first operation. Dr. Nathan 
 Smith removed an ovarian tumour composed of a thin-walled 
 single cyst. He had not heard of any previous operation, and it 
 is interesting to see how different his methods were as he had no 
 traditions to follow. He made an incision three inches in length 
 through the middle line, and instead of tying the pedicle en 
 masse, he ligatured two vessels in it with a strip cut from a kid 
 glove. The abdomen was then completely closed. The patient 
 recovered. Here there was already an improvement ; the incision 
 had been made shorter, and the pedicle had been allowed to 
 drop back into the abdomen. It may be considered doubtful 
 whether this was at the time good practice ; but the attempt 
 was made to use an animal substance for the ligature, with the 
 idea doubtless that it would not cause suppuration. 
 
 The third American surgeon who was successful in removing 
 an ovarian tumour was Dr. Alban Smith of Danville. Again 
 there were new departures, for, though he followed Dr. M‘Dowell 
 in so far as to use the long ligatures, he carefully included the peri- 
 toneum in his sutures, and administered on the night after the 
 operation a dose of senna, which caused the bowels to act next 
 day. 
 
344 
 
 O VARIOTOMY. 
 
 Fifteen years after the first operation of ovariotomy, Lizars of 
 Edinburgh was induced, doubtless by the perusal of the account 
 of the three first cases sent to John Bell, to operate on a case of 
 supposed ovarian disease. An incision was made from the 
 sternum to the pubes, and every spectator put his hand into the 
 abdomen to satisfy himself that a tumour was not present. The 
 patient recovered ! At his second operation, Mr. Lizars met 
 with a case of double ovarian disease ; he removed one of the 
 tumours, but failed to take aw’ay the other. This patient also 
 recovered and lived for a number of years. 
 
 In 1837, Mr. Jeafferson of Eramlingham successfully removed 
 a single cyst. He was acquainted with the details of Dr. Nathan 
 Smith’s case, and following his example did not use the long 
 ligatures, but allowed the pedicle to drop back. The incision 
 also was short, being described as one inch in length. 
 
 A pupil of Lizars, Dr. Charles Clay of Manchester, operated 
 in 1842, and had three successful cases out of his first four 
 operations. He used the long ligatures. 
 
 Dr. Washington Atlee and Dr. Peaslee were amongst the 
 early operators ; the former began in 1844, the latter in 1850, 
 and both these surgeons assisted greatly in establishing the 
 operation in America. 
 
 In 1853, Baker Brown began to operate. Not being satisfied 
 with the results obtained by the use of the long Ligatures, and 
 being unable to understand why it was that cases did badly 
 when the pedicle was ligatured and allowed to drop back into 
 the abdomen, he came to the conclusion that the fault lay with 
 the ligature itself, and that it must be got rid of. He therefore 
 closed the blood vessels in the pedicle by means of the actual 
 cautery. This was a great step in advance, because it allowed 
 of the intra-peritoneal treatment of the pedicle, and at the same 
 time did not leave a septic ligature in tlie abdominal cavity. 
 This plan of treatment is undoubtedly the most perfect method, 
 but it has not been generally adopted, simply because we do 
 not now use the septic or dirty ligature of forty years ago. 
 
HISTORICAL, 
 
 345 
 
 In 1858, Spencer Wells performed his first operation in 
 London, and it was a success. The long ligatures were used. 
 In his third case, however, he fixed the pedicle outside the 
 abdomen by means of a clamp, as it was evident that if suppura- 
 tion were to take place, it would be better that it should do so 
 outside rather than inside the peritoneal cavity. Here also 
 there was a great advance over the usual practice, and one 
 reason why the clamp failed to get such good results thirty 
 years ago as can be obtained now, is that knowledge was want- 
 ing to teach the necessity of preventing the tissues about the 
 clamp from becoming putrid or septic. There are minor objec- 
 tions to its use, but the great fault was not so much in the 
 instrument itself as in the way it was used, for, if sufficient care 
 be taken to dry the tissues and mummify them so that they do 
 not give rise to septic discharge, the mortality will not be much, 
 if any greater than when the intra-peritoneal method is used. 
 The length of his incision was regulated according to circum- 
 stances, a large solid tumour requiring a long incision, a small 
 thin-walled cyst a short one. It is an unfortunate sign of the 
 times that some are nowadays inclined to minimise the work 
 done by Wells in the early days, when they themselves were 
 children. This should not be, for a great work was done ; 
 he assisted very largely in convincing a sceptical medical 
 profession that the operation of ovariotomy was not only a 
 justifiable one, but also a work of necessity, and this operation 
 is now so successful that it is difficult to understand how there 
 ever could have been any doubt as to the propriety of the 
 procedure. 
 
 To Koeberlee, who commenced to operate in 1862, we owe 
 the catch forceps, and the idea of draining the abdominal cavity 
 by means of a glass drainage tube. 
 
 In 1862, Dr. Thomas Keith performed the second successful 
 ovariotomy in Scotland, the first having been done a few days 
 before by Mr. Baker Brown in Aberdeen. After his first case 
 he advocated the thorough cleansing of the peritoneum, and 
 
346 
 
 OVARIOTOMY. 
 
 after a visit to Koeberlee he devised the method of draining 
 from the bottom of the pelvis. 
 
 It is impossible at the present day to realise what the 
 operation was thirty years ago ; very little was known about it, 
 and when operative measures were denounced on all hands, it is 
 not to be wondered that patients did not apply for relief until 
 they could go on no longer. 
 
 The one great and prominent idea seems to have been “ do 
 not injure the peritoneum, anything but that.” 
 
 Gradually the plan of ligaturing the pedicle has come into 
 use, and with it the intra- peritoneal method, which is un- 
 doubtedly the correct way ; and now, as the outcome of Lister s 
 teaching, we leave silk ligatures in the abdominal cavity with 
 impunity, always provided that these ligatures have been 
 rendered clean, either by boiling or by soaking in an antiseptic 
 solution. The difficulty was to get a ligature which would not 
 do harm, and for a number of years Dr. Keith used fine, soft 
 iron wire with the best results. Indeed by the help of the 
 cautery, the soft iron wire ligature, and drainage, he had reduced 
 his mortality to less than 4 jper cent., and this was more than 
 fifteen years ago, — an amount of success which was not even 
 approached by any one at that time. 
 
 With improved practice and better results, it was impossible 
 to allow patients to go on so long as before without advising 
 operation, and the first to practise this was Baker Brown. The 
 propriety of advising patients to wait as long as they could is 
 easy to understand when operation meant a mortality of 30 or 
 40 per cent. It is quite a different thing when the mortality 
 is less than 5 per cent. One reason for this diminished mor- 
 tality is that the operations are now in the great majority 
 of cases more simple than they used to be. Dr. Peaslee shows 
 this very well in his book written in 1872, when he says 
 tumours of “40 or 50 lbs. are so common as scarcely to deserve 
 mention.” Even so late as 1882, five consecutive operations 
 were performed in the Edinburgh Eoyal Infirmary, where 
 
HISTORICAL. 
 
 347 
 
 the average weight was 44 lbs., though one tumour weighed 
 only 8 lbs. 
 
 At the present day it is a great mistake to wait until the 
 general health begins to break down, but at the same time it is 
 not right to be in too great a hurry even with an ordinary case. 
 The rule should be to perform the operation as soon as possible, 
 but it is not right to tell the patient that it is a matter of life or 
 death to have it done within a day or two. It is often not 
 convenient for a woman to have a serious operation performed at 
 a day’s notice, and a delay of some weeks will as a general rule 
 do no harm. At the same time it must not be forgotten that 
 danger may arise from delay, and that therefore unnecessary 
 putting off must not be allowed. 
 
 What has brought abdominal surgery within the range of 
 many with a fair prospect of success is the teaching of Lister or 
 the outcome of that teaching. Before his time every operator 
 was more or less septic. Dr. Keith was indeed as careful of 
 cleanliness then as now, with the result that his mortality was 
 much less than that of any other operator ; but to be rigidly 
 clean was not a good surgical “ cry,” and it was necessary to be 
 aseptic. Kot ten years ago, this was once brought very forcibly 
 to mind by hearing a gentleman who was going to assist at an 
 abdominal operation say, when asked to wash his hands, ‘‘ I did 
 it this morning.” He was quite willing to wash them in 
 carbolic lotion however ! 
 
 To recapitulate the great advances, we have in order of 
 time, first, the short instead of the sternum to pubes incision ; 
 second, the clamp rather than the long ligatures ; third, the 
 toilet of the peritoneum ; fourth, drainage ; fifth, the cautery 
 and intra-peritoneal method rather than the clamp and extra- 
 peritoneal method ; sixth, early operation ; and seventh. Lister- 
 ism and its outcome of perfect cleanliness. 
 
348 
 
 OVARIOTOMY. 
 
 Treatment of Ovarian Tumours. 
 
 The withdrawal of the fluid from an ovarian tumour used 
 to be a common mode of practice, and in some of the out of the 
 way country districts is still much resorted to. Not twelve 
 years ago, a patient who was admitted into the Edinburgh Eoyal 
 Infirmary with an ovarian tumour gave as her reason for coming 
 early that a neighbour had been tapped until she died, and that 
 she herself wished to try something else ! 
 
 Aspiration of an ovarian tumour without a distinct object 
 in view is to be condemned. It may, however, be used under 
 the following conditions : — 
 
 When the general health has become broken down on 
 account of the great size of the tumour, temporary relief may be 
 given by removing the fluid, and this will allow of some 
 improvement in the general health before the operation of 
 ovariotomy is performed. This relief is obtained either by 
 taking off pressure from the chest or from the kidneys, and 
 at the same time anasarca of the lower limbs and abdominal 
 wall will be reduced. 
 
 For the same purpose a smaller cyst might have to be 
 emptied if the fluid had become purulent, the major operation 
 being performed in about ten days, when the patient had 
 improved as much as she would be likely to do. 
 
 In the course of some acute disease such as bronchitis great 
 benefit may be obtained by aspiration, and the patient may thus 
 be tided over such a complication. 
 
 In the later months of pregnancy the reduction in size of an 
 ovarian cyst will allow the patient to go on to full time with 
 comfort. 
 
 It may happen that a patient is unable to undergo the 
 operation of ovariotomy for private reasons, and aspiration may 
 allow her to carry on until her affairs are settled, and she could 
 have the operation performed. 
 
 Ascitic fluid surrounding a tumour, when there is any 
 
TREATMENT OF O FA RIAN TUMOURS. 
 
 349 
 
 suspicion of malignant disease, must be removed for microscopic 
 examination, or a cyst may be aspirated to clear up a doubtful 
 diagnosis. 
 
 It may again be repeated that a cyst must never be emptied 
 except with the aspirator, and that ascitic fluid is always to be 
 removed by tapping. For diagnostic purposes a syringeful of 
 fluid is sometimes withdrawn from a cyst. A more dangerous 
 practice has never been adopted, for it simply means that a great 
 risk of rupture is incurred while very little information is 
 obtained, as a large quantity of fluid is required to get the 
 deposit necessary for a satisfactory microscopic examination. 
 Whenever a needle is put into a cyst all the fluid must be 
 withdrawn, and, as thick fluid may be met with, a powerful 
 aspirator is necessary. It is impossible to make a diagnosis 
 of an ovarian tumour from the examination of the fluid alone ; 
 it can only assist, and it is a practice that need seldom be re- 
 sorted to. 
 
 The following cases are typical examples of the advantages 
 of aspiration under certain circumstances : — 
 
 In 1880, a patient thirty- three years of age was admitted 
 into the Edinburgh Eoyal Infirmary with an enormously 
 distended abdomen. The patient stated that four months before 
 she had been quite flat, and the rapid accumulation of the fluid 
 probably accounted for her very weak condition. The pulse 
 was small, weak, and was beating 125 to the minute. She had 
 rapidly fallen away chiefly in the upper part of the body, but 
 also in the lower limbs ; and, as the examination of the abdomen 
 made one suspect the presence of extensive parietal adhesions, 
 it was thought that her chances of recovery would be increased 
 by a preliminary aspiration. This was accordingly done, 62 lbs. 
 by weight of fluid being removed. Next day the pulse had 
 fallen to 100, and when the tumour was removed ten days 
 afterwards it was under 90. The amount of adhesion was fully 
 more than was expected, but the patient recovered without a 
 bad symptom. 
 
350 
 
 OVARIOTOMY, 
 
 In 1889, a young lady twenty years of age was sent from the 
 country with a large suppurating ovarian cyst. The condition 
 of the patient was extremely bad, she was terribly emaciated, 
 became faint on making any little exertion, and the pulse the 
 day after the journey was 140. Sixteen pints of putrid pus 
 were removed from the cyst with enormous benefit ; the pulse 
 fell rapidly, the temperature became normal, sweating stopped, 
 and nine days afterwards, when the operation was performed, the 
 patient was in fairly good condition. It was fortunate that the 
 general health had been improved, for the tumour was intimately 
 adherent, in front to the parietes, above and behind to intestine, 
 and below in the pelvis. It is at least probable that recovery 
 would not have resulted if the preliminary aspiration had not 
 been performed. 
 
 In 1885, a patient forty-two years of age was seen late one 
 night with an enormously distended abdomen. The legs were 
 fully twice their natural size, and the abdominal wall was greatly 
 thickened by oedema, the face was puffy, and the patient could 
 not lie down in bed. For about a week she said she had been 
 passing very little water, and in fourteen hours only three and 
 a half ounces were obtained. On boiling and adding nitric acid 
 albumen deposited to nearly two-thirds. The fluid was drawn 
 off from the abdomen by a trocar four inches in length inserted 
 some way above the umbilicus, and it had to be pushed in its 
 whole length before the peritoneum was reached. Nearly 70 lbs. 
 of fluid were removed, revealing a flaccid ovarian tumour, and as 
 the abdomen began to fill up rapidly as the cedematous swelling 
 of the legs and wall went down, ovariotomy was performed at 
 the end of a week. The urine was then free from albumen. 
 The patient made a good recovery. 
 
 After the removal of fluid for any of those causes, the exact 
 day for the major operation will depend on the condition of the 
 patient. It can seldom be postponed beyond a fortnight, and it 
 should be performed whenever the patient has improved as much 
 as it is expected she will do. If this time be allowed to pass 
 
TREATMENT OF OVARIAN TUMOURS. 
 
 35 
 
 it will be found that even two or three days’ delay will make a 
 considerable difference in the strength of the patient. 
 
 It is not often that one meets with a patient who absolutely 
 declines to have the operation of ovariotomy performed simply 
 because her business prevents her lying up for the necessary 
 three or four weeks, but in 1890 such a patient was met with. 
 AVhen first seen two years before, the tumour extended half way 
 up to the umbilicus, and a diagnosis had been made by two 
 hospital physicians of fibroid enlargement of the uterus. The 
 patient was told that the tumour was not uterine but ovarian, 
 but as it was small, and giving rise to no trouble, an operation 
 was not insisted on. Twice within the following year the patient 
 was examined, little difference being found in the size of the 
 grow’th, and the general health remained good. In the next six 
 months the tumour had increased so much that it filled the 
 whole abdomen, and raised the ribs on both sides ; the patient 
 now presented the typical appearance caused by an ovarian 
 tumour, she having become much emaciated in the upper part 
 of the body. She positively declined to submit to ovariotomy 
 because she was too busy, and aspiration had to be resorted to. 
 A few months afterwards the tumour was removed. 
 
 The slight operation of removing fluid from an ovarian cyst 
 by aspiration is absolutely safe when properly carried out. The 
 essential precautions to be adopted are, — a clean instrument of 
 small calibre, a clean skin, complete emptying of the fluid, 
 puncture opening at the highest level, and absolute rest in bed 
 for three or four days. The usual mistakes which are made 
 are, — too large an instrument is used, the fluid is not completely 
 emptied, the puncture opening is not made at the highest level, 
 and absolute rest in bed is not insisted on. In addition, the 
 patient is not protected from catching cold when the large 
 quantity of warm fluid is being removed. 
 
 The operation of ovariotomy having been decided on, the 
 patient is got ready in the way already described, by the adminis- 
 tration of a dose of castor-oil, and light food the day before. 
 
352 
 
 OVARIOTOMY, 
 
 This amount of preparation is amply sufficient for the great 
 majority of cases/ Should there be any intercurrent disease, 
 such as an attack of acute bronchitis, or any of the conditions 
 
 Fig. 23. — Nelaton’s Forceps. 
 (One-third size.) 
 
 Fig. 24.— Cyst Forceps. 
 (One-third size.) 
 
 already mentioned, it must be attended to before the operation ; 
 but these can hardly be included under the ordinary prepara- 
 tions of a patient. Three or four weeks’ preparation by laxatives, 
 tonics, feeding up, vapour baths, etc., is quite unnecessary ; it is 
 
INSm UMENTS REQ UIRED. 
 
 353 
 
 likely to alarm the patient and make her think that something 
 dreadful is going to happen. 
 
 A few special instruments are required for the operation. 
 Trocar and tube. Much ingenuity has been spent in attempt- 
 ing to improve on the old simple trocar. Various additions, 
 23 
 
354 
 
 OVARIOTOMY. 
 
 such as teeth for grasping the cyst, have been made, but it is 
 more than doubtful if any of them are improvements. 
 
 An aspirator with a small trocar. The instrument known 
 as Wells’ tapping trocar is to be taken when pus is expected. 
 When the aspirator is used there is less risk of rupture of the 
 
 Fig. 2T. — Cautery Clamp. (One-third size.) 
 
 sac and escape of fluid, and the pus is conducted away from all 
 fear of contaminating instruments or sponges. 
 
 It should be remembered that there is usually no great 
 advantage in any special make of forceps or other instrument, 
 and the one will be best as a rule which the operator has become 
 accustomed to use. Every one should be as simple as possible. 
 
 Nelaton’s forceps. 
 
 Cyst forceps are lighter and perhaps more convenient than 
 Nekton’s. 
 
 Cautery clamp. 
 
 Cauteries, three are sufficient. 
 
 Forceps which prevent slipping of the pedicle after the 
 cautery has been used. 
 
 Thermocautery. 
 
THE INCISION. 
 
 355 
 
 The Incision. 
 
 The incision is to be made through the linea alba, not by 
 the anatomist, but by the surgeon. A page or two might be 
 written about the anatomical structure of the abdominal wall, 
 but it is not necessary to spend five or ten minutes making a 
 dissection, the object is to cut into the peritoneal cavity in as 
 many seconds. It is futile to attempt to count the layers of the 
 abdominal wall, as has been gravely suggested. If five minutes 
 be taken to open the cavity, four and a half have been wasted 
 on the least important part of the operation. It is sometimes 
 recommended that the length of the incision should be at first 
 two inches or so, and should be enlarged if necessary ; but when 
 a proper and full diagnosis has been made, the necessary length 
 of the incision is made at once. When the tumour is cystic, 
 and is not composed of any semi-solid material, a cut of two or 
 three inches is quite long enough ; when the growth is semi- 
 solid a longer incision is necessary. The length of incision 
 which is first made is simply a matter of diagnosis. It is well 
 to know, that although the peritoneum is usually a thin soft 
 membrane, it may be sometimes half an inch or more in thick- 
 ness ; and, instead of being soft, may be as hard as cartilage. 
 When the tumour will not come out through a comparatively 
 short incision, and the opening has to be prolonged beyond the 
 umbilicus, there is no reason why that part should be avoided, 
 and the scar is firmer there than at any other part of the wound, 
 but it must be accurately brought together with a number of 
 stitches. The incision should stop at least one inch above the 
 pubes, as this helps to prevent the bladder being injured. 
 
 The advantage of a very short incision is, that there is so 
 little exposure of the peritoneal contents that the operation 
 becomes almost a subcutaneous one. In regard to the question 
 of a subsequent ventral hernia, it is at least open to doubt 
 whether a very short incision is an advantage. Certainly one 
 sees more of these herniie now with short incisions than in the 
 
356 
 
 OVARIOTOMY. 
 
 wounds of ten or fifteen years ago, but this may be accounted 
 for by want of care in stitching, and by the fact that many who 
 have had no surgical training frequently perform abdominal 
 operations. The intra-abdominal pressure acts at one weakened 
 spot instead of being spread over a longer one, and this is prob- 
 ably a disadvantage. Whether the short incision conduces to 
 the formation of a hernia or not, it does not alter the surgical 
 principle that a free external incision is advisable ; and manipu- 
 lation should never be hampered, nor a tumour dragged through 
 a wound with violence for the sake of an inch or two of cut 
 abdominal wall. 
 
 When the peritoneum has been exposed it must always be 
 opened at the upper angle of the wound. 
 
 Extraction of the Tumour. 
 
 The tumour having been exposed, it will be seen, if not 
 adherent in front, to move freely with respiration ; it is not 
 necessary at this stage to pass the hand into the abdomen, 
 indeed the more it is kept out of the peritoneal cavity the better. 
 The trocar, to which is attached a rubber tube long enough to 
 reach to a bath below the table, is plunged straight into the 
 tumour at the most prominent point. This prevents oozing 
 alongside of the trocar, as the tension on the cyst wall is at once 
 relieved, and as the opening is at the highest level fluid cannot 
 escape into the peritoneal cavity. The assistant takes charge 
 of the trocar, and also of the tumour as it comes out, and this 
 leaves the two hands of the operator free. As the fluid flows 
 away, the cyst is caught above and below the trocar on the 
 assistant’s side by a pair of cyst forceps, and these are handed 
 over to him. The object of this is to draw the tumour out of 
 the abdomen and to prevent fluid leaking into the peritoneal 
 cavity, as it might do if the tumour on the side of the operator 
 were caught hold of, for the trocar opening would then be pushed 
 round into the abdomen. As the tumour empties it is slowly 
 
THE PEDICLE. 
 
 357 
 
 drawn forwards, and as it comes out the operator inserts a sponge 
 into the abdomen to shut off the contents from the outside. 
 The assistant supports the sac and prevents dragging on the 
 pedicle, the treatment of which has now to be determined. 
 
 The Pedicle. 
 
 It is universally agreed that in all but very exceptional cases 
 the pedicle must not be fixed outside the abdomen. At one 
 time, with the knowledge of the day, the clamp was a useful 
 instrument. It prevented the loss of blood by constricting the 
 pedicle, it was fixed across the lower part of the wound and 
 came away in from ten to fourteen days, leaving a small healing 
 ulcer. Dr. Keith’s mortality with his first fifty clamp cases was 
 under 15 per cent., showing that it was not this method of treat- 
 ment which was the cause of the heavy mortality of twenty-five 
 years ago. This method of treating the pedicle is nowadays 
 only required when there is a prolapse of the uterus in addition 
 to the ovarian tumour ; and both the disease and the displace- 
 ment can be cured by the one operation, when the uterus is fixed 
 to the abdominal wall by clamping the pedicle. 
 
 The closure of the blood vessels in the pedicle, when it is to 
 be treated intra-peritoneally, is accomplished either by the 
 ligature or by the cautery. Of these two methods the ligature 
 has gained much greater popularity than the cautery. The 
 reason is not far to seek, for the cautery not only requires a 
 little more care and delicacy of manipulation than the ligature, but 
 also some of that rare quality — faith — though strangely enough 
 the pedicle never bleeds after the cautery, while a number of 
 deaths have resulted from this cause after the use of the ligatures. 
 
 . Ligature of the Pedicle. 
 
 When it is determined to tie the pedicle, a piece of chemi- 
 cally clean silk three feet in length is grasped in the middle by 
 
358 
 
 OVARIOTOMY. 
 
 the pair of sinus forceps. A spot near the centre of the pedicle 
 where there are no blood vessels is selected, and the point of the 
 forceps holding the silk is pushed through ; the loop of silk is 
 drawn out, divided, and the forceps withdrawn. Instead of the 
 forceps, a Peaslee’s or a round-pointed needle may be used. 
 Each half of the pedicle is in turn constricted by one half of the 
 divided ligature, and the loops are not allowed to interlock. 
 Each half is tied as tightly as possible, a double twist being 
 made on the first knot to prevent slipping, and the two double 
 ends are tied tightly together, thus constricting the pedicle very 
 securely. A second way of tying is to transfix, some preferring 
 to do it with a needle rather than with the forceps, tie each half 
 having interlocked the silks, and then surround the whole 
 pedicle with a single ligature. The disadvantages of this way 
 are that the knot of tlie first loop is drawm on when the second 
 is tied, and the supplementary single ligature is useless as it lies 
 in the groove already formed, and would not prevent haemorrhage 
 from a splitting downwards of the pedicle. Interlocking does 
 not prevent this accident, which, however, is only likely to occur 
 when the transfixing or tying has been roughly or carelessly 
 performed. A third method is by the well-known Staffordshire 
 knot ; the silk can be arranged either by putting the loop round 
 the pedicle, and carrying the free ends back to the loop by 
 transfixing wdth Lister’s forceps, one end passing above and one 
 below it ; or by taking the centre of the ligature through the 
 pedicle, bringing the loop over the top, and passing one free end 
 above while the other is below. The ends are then tied. The 
 only disadvantage is, that the silk has to be rather thicker than 
 when the other methods are employed, as the knot is tied over 
 what is practically a rigid bar. 
 
 The tumour is then cut away, fully half an inch of pedicle 
 being left beyond the ligatures. 
 
THE CAUTERY. 
 
 359 
 
 The Cautery. 
 
 When the cautery is preferred to the ligature, the pedicle is 
 enclosed in the cautery clamp, and the old instrument of Baker 
 Brown is better than any of the more complicated ones. The 
 blades of the clamp are tightly screwed together, and as the 
 pedicle is allowed to take its natural shape, it does not become 
 bunched together as is the case when the ligature is used. The 
 tumour may be cut away, leaving half an inch or so beyond the 
 clamp, or the separation may be effected by the cautery. 
 
 Towels which have been rendered aseptic are tucked in 
 under the clamp to prevent burning of the skin, and the 
 remainder of the pedicle is burnt off with one of the heavy 
 cautery irons heated to a white heat, leaving a line or so of 
 tissue beyond the clamp. The chief aim is to heat the clamp, 
 and it is for this reason that large cauteries are required ; an 
 instrument like the Paquelin cautery gives out much too small 
 a quantity of heat to do this quickly. The clamp should be so 
 hot that the fingers can barely touch it ; and if the pedicle 
 be thick and fleshy a second heavy iron may be required to 
 thoroughly heat it. It will be then found that the clamp can 
 be screwed up a little tighter, and this must be done, as what is 
 wanted is the result of the combination of heat and pressure. 
 The charred portion of the pedicle is smoothed over with the 
 sharper and lighter cautery. The clamp is to be quickly cooled 
 with a wet sponge, a towel removed, and a pair of pedicle forceps 
 fixed gently on to each side below the clamp to prevent it slip- 
 ping, until it is certain that the blocking of the vessels is perfect. 
 The clamp is unscrewed and the blades separated ; this must be 
 done carefully and gently, as the pedicle sometimes sticks to the 
 blades of the clamp, and rough manipulation might easily cause 
 bleeding. With ordinary care this need never happen. As the 
 forceps prevent the pedicle slipping out of sight, that part which 
 had been enclosed in the clamp will be seen to be almost trans- 
 lucent, like a thin piece of horn. Should the pressure or the 
 
36 o 
 
 OVARIOTOMY. 
 
 heat have been insufficient, one or more blood vessels will be 
 seen making their way through the cauterised part. This may 
 occasionally happen at first, but after a little practice it need 
 never occur. The part where such a vessel appears can be 
 easily ligatured. 
 
 As soon as it is seen that no blood vessels pass into the 
 compressed part, the pedicle is allowed to drop back into the 
 pelvis, and this can be done with a feeling of absolute safety. 
 The great advantage lies in this, that should there be bleeding 
 from the pedicle it occurs immediately, and not after the abdomen 
 has been closed. 
 
 When much sponging is required, the pedicle is temporarily 
 secured in the grasp of one or two large catch forceps, and the 
 tumour is cut off and got out of the way ; then, after the spong- 
 ing is finished, the cautery can be applied to the pedicle, as 
 it is not advisable to run the risk of ruffling it with much 
 sponging. 
 
 The only advantage the ligature possesses over the cautery 
 is in the question of time. A pedicle can be ligatured in about 
 a minute ; the cautery takes from two to three minutes. The 
 ligatures have, how^ever, several disadvantages ; the knot may 
 slip from imperfect tying ; or one loop may slip over the end of 
 the pedicle when the distal portion has been cut off too short, 
 thus causing a want of proper proportion between the size of the 
 silk loop and the amount of tissue beyond. The pedicle may 
 also split downwards from the puncture opening, possibly from 
 pressure of the knot of silk at that spot. 
 
 The following are examples of how hiemorrhage may occur 
 after the pedicle has been tied. The first case was operated on 
 by Dr. Keith, and is the only one where such an accident has 
 happened either in his or in our practice. The patient thirty- 
 one years of age was operated on in 1886. Two small ovarian 
 tumours were removed, and in both the pedicle was thick and 
 short. The cautery was applied to the one, the ligature to the 
 other. After the ligature was applied, the end of an artery, the 
 
THE CAUTERY, 
 
 361 
 
 size of a large radial, was noticed projecting from the cut 
 surface ; about half an inch on the other side of the ligature 
 the peritoneum had been slightly injured when drawing up the 
 short pedicle, and there was a very slight oozing at this point. 
 Eive hours after the operation the patient was very well, but 
 four hours later the nurse noticed that she became suddenly 
 very white, and she was dead before assistance could be 
 obtained. An examination was made, it was found that 
 a large haematocele had formed in the right broad ligament, 
 and that the tension had drawn the artery previously men- 
 tioned through the ligatures. The hsemorrhage came from 
 that vessel and discharged into the peritoneal cavity through 
 the injured part of the broad ligament. The ligatures were 
 apparently perfectly firm. No bleeding had occurred from the 
 pedicle which had been cauterised. 
 
 A non-adherent ovarian tumour was removed from a patient 
 twenty-seven years of age, the pedicle was tied with the 
 Staffordshire knot. Within half an hour of the patient being 
 put back to bed the abdomen had to be reopened, as there were 
 evident signs of haemorrhage, and one half of the ligature was 
 found to have slipped over the pedicle. In spite of the 
 infusion of saline solution the patient never rallied, and died 
 the next day. 
 
 In another simple case, where the pedicle was also tied with 
 the Staffordshire knot, a split in the pedicle below the ligature 
 was discovered when the abdomen was reopened an hour after 
 the patient had been put back to bed. It had apparently 
 been caused by the pressure of the knot. This patient also 
 never rallied. 
 
 There is always the possibility that some septic infection 
 may be taken into the abdominal cavity on the silk, and the 
 following are examples. An operator was seen to pick up a 
 needle threaded with a piece of silk so long that it trailed on the 
 floor before it entered the abdominal cavity; and on another 
 occasion, when the specially prepared silk ran short, a further 
 
362 
 
 OVARIOTOMY. 
 
 supply was taken directly from a pocket-case, and was not 
 purified in any way. Both of these patients died of septicaemia. 
 Cases such as these are, undoubtedly, extreme examples of how 
 septicaemia may be caused, and how necessary it is that the 
 most minute attention be paid to every detail. 
 
 Examination of the Second Ovaey. 
 
 After the pedicle has been disposed of, the other ovary must 
 be felt ; should it be enlarged it must be drawn up into view 
 and visually examined. If the enlargement be due to the 
 presence of a corpus luteum, sometimes called a blood cyst, the 
 organ must be dropped back ; but if there be a doubt as to 
 whether it be diseased or not it is better not to remove it, if 
 the patient be young. If undoubtedly diseased the whole 
 gland should be removed, and there is no objection to using the 
 cautery for this second pedicle. 
 
 A long pair of forceps holding a sponge is passed to the 
 bottom of the pelvis to ensure that the peritoneum is dry, and 
 that no haemorrhage is going on. The omentum is then drawn 
 down over the intestines, and a sponge is placed between it and 
 the wound to catch any blood from the needle punctures. The 
 sponges are counted by the assistant, while the surgeon is 
 putting in the stitches ; if the number be correct the sponge 
 beneath the wound is removed, the stitches are tied, the 
 dressing put on, and the patient is lifted back to bed. This 
 describes an ordinary ovariotomy of the simplest kind ; it will 
 have lasted something under twenty minutes, and the risk 
 incurred by a woman with a fairly good constitution will have 
 been very little. Still the operation is not devoid of all 
 danger. Simple operations such as this are not the rule, 
 and we must now turn to the various difficulties and com- 
 plications which may be encountered at any time or in any 
 
 case. 
 
ADHESIONS. 
 
 363 
 
 Adhesions. 
 
 The first difficulty is met with when a tumour is adherent 
 to the parietal peritoneum beneath the wound. When it is 
 known that there is no bowel in front of the tumour, and this 
 can always be made out during the examination, we can safely 
 make the incision as usual through the probable thickness of 
 the wall, and then go on cutting until the peritoneum is 
 recognised. With parietal adhesions the distinctive appearance 
 of the peritoneum, and also of the cyst, may be entirely absent ; 
 the peritoneum may be thickened and of a dull colour ; and the 
 tumour may not be whitish blue and shining, but dull and of a 
 dirty or dusky red colour. If the point of division between the 
 tumour and the peritoneum cannot be made out, it is better to 
 open at once into the cyst than to run the risk of separating 
 the wall before the peritoneum has been reached. 
 
 When the cyst has been opened the point of separation can 
 be easily found. After a little experience there is not much 
 difficulty in knowing when the peritoneum has been divided, 
 unless the adhesions be specially close and firm, and the cyst 
 wall specially thin. When the peritoneum has been divided 
 without opening the cyst, and the tumour is not very large, say, 
 less than 10 lbs. or 15 lbs. in weight, the adhesions are to 
 be separated until there is a space exposed into which the 
 trocar can be thrust. This is done, the fluid is evacuated, 
 and after the trocar is withdrawn, the cyst opening is closed 
 with a pair of forceps. The separation is to be continued with 
 the fingers or a sponge. Towards the upper part the omentum 
 will probably be come upon, adhering more or less to the 
 tumour by its edge or by its flat surface. It is to be stripped 
 off, and forceps are put on to any bleeding point. It is then 
 got out of the way by pushing it on one side, or by turning it 
 up over the upper surface of the wound, and enclosing it in a 
 warm towel. Should there be much bleeding, an attempt may 
 be made to reach the pedicle, if the broad ligament be not 
 
364 
 
 OVARIOTOMY, 
 
 opened up. The parietal adhesions are separated towards the 
 pelvis, and if one get beyond them, as is often the case, the 
 circulation through the pedicle may be stopped by compression 
 with one or two large pairs of catch forceps ; another pair is 
 put on close to the tumour, and the pedicle divided between 
 them. By this plan the haemorrhage from the tumour is 
 lessened, and the adhesions may be often got at more con- 
 veniently by turning out the lower part of the tumour first. 
 Eecent adhesions, though often more vascular, are much more 
 easily separated than those of old standing. 
 
 When the tumour is large, with a fairly strong cyst wall, 
 and when the whole front of the anterior surface is adherent 
 to the parietes, time may be saved by separating with the 
 fingers a sufficient space to allow the hand to get in. This is 
 done before the cyst is emptied. The hand and arm are swept 
 over the whole of the anterior surface of the tumour, separating 
 all the parietal adhesions with great rapidity. The hand must 
 be kept flat on the tumour, must not be allowed to wander off 
 into surrounding tissues, and must be able to distinguish bowel 
 or other abdominal contents. 
 
 When the intestine is attached to the tumour, the con- 
 nection can often be separated with a sponge, care being taken 
 to divide the adhesions close to the tumour and not close to the 
 bowel. Any bleeding points on the bowel must be tied at once 
 with fine catgut. Should there not be room to do this, or 
 should the peritoneal covering be torn, the pressure of a sponge 
 wrung out of hot water may arrest the haemorrhage, or the part 
 may be touched with perchloride of iron in glycerine. This, 
 combined with pressure, is always efficacious. Should the 
 intestinal adhesions be both close and firm, it may be necessary, 
 in very exceptional cases, to leave a piece of the cyst wall 
 attached to the bowel. In such a case the outside layer alone 
 is to be left, the secreting surface must be removed. 
 
 Should an opening be made into the bowel, the separation 
 of the tumour must be stopped, and the rent sewn up at once. 
 
ADHESIONS. 
 
 365 
 
 Adhesions to the mesentery must be separated with the 
 very greatest care and gentleness so as to injure the membrane 
 as little as possible. The importance of this is evident, seeing 
 that the blood vessels and nerves of the bowel pass through the 
 mesentery, and that if the injury be very extensive it may even 
 be necessary to resect the part of the intestine deprived of its 
 blood and nerve supply. 
 
 The very greatest care must be taken in separating the 
 liver and gall-bladder. Fortunately adhesions in these situa- 
 tions are not very common, for bleeding when the liver is 
 injured is apt to be profuse. Pressure, with or without per- 
 chloride of iron, will be required to arrest it. 
 
 Should the gall-bladder be injured, it must either be 
 removed entirely or a biliary fistula be formed. This is prefer- 
 able to attempting to stitch up the tear. 
 
 Adhesions to the diaphragm and to the stomach are seldom 
 met with ; when to the former they may be troublesome, as 
 interference with the diaphragm may cause stoppage in the 
 respiration. 
 
 Adhesions to the spleen are apt, like those to the liver, to 
 give rise to troublesome haemorrhage during their separation. 
 They also are rare. 
 
 Adhesions in the loins over the kidneys often give rise 
 to much bleeding ; the vessels are difficult to tie, and 
 pressure, perchloride of iron, or the thermocautery may be 
 required. 
 
 Destruction of kidney-substance during the separation of 
 adhesions would cause extravasation of urine. It is doubtful if 
 this has ever occurred, but division or ligature of one or even 
 both ureters has happened. If this accident be discovered the 
 ligature is cut ; or if the ureter have been divided it may be 
 possible to stitch the ends together. If the injury cannot be 
 repaired, the renal end of the ureter must be brought outside 
 the abdomen in the loin, or, if the patient be not too weak, the 
 kidney ought to be removed at once. This latter plan is the 
 
366 
 
 OVARIOTOMY. 
 
 better practice, as a renal fistula entails untold misery and 
 renders a subsequent operation necessary. 
 
 When a cord is come on during any abdominal operation, 
 which may possibly be a ureter, one can determine whether it 
 be the ureter or not by making pressure on it with the finger 
 and thumb. If it be the ureter, within a very short time, 
 perhaps a minute, the renal end will be found to have become 
 slightly dilated. 
 
 Vascular pelvic adhesions are often difficult to ligature, 
 especially when low down on the rectum ; and it is much less 
 trouble to ligature everything than to trust to . the pressure of 
 the forceps being sufficient. The laryngoscopic mirror is of 
 immense service when looking for any source of bleeding in the 
 pelvis. The intestines are drawn out of the way by one hand, 
 and the light from the window is thrown down by the mirror. 
 In this way the whole of the pelvis can be examined with 
 ease. 
 
 Vesical and uterine adhesions are often very firm ; they 
 have to be separated with special care to avoid opening into the 
 bladder. The uterine are very vascular. Should the bladder 
 be opened, the rent must be sewn up at once with a continuous 
 silk suture, and of course the peritoneal cavity must be washed 
 out and drained. 
 
 After an adherent tumour is got out of the abdomen, sponges 
 are packed in, in all directions, and the tying of the adhesions 
 is begun. Occasionally large vessels in the peritoneum have to 
 be tied, though, as a rule, the haemorrhage from this part ceases 
 spontaneously, or by the pressure of a sponge wrung out of hot 
 water. Bleeding from the omentum must be stopped by tying 
 the vessels, or, if the bleeding points be numerous, large pieces 
 of the omentum may be ligatured with catgut or fine silk, and 
 the distal portion cut offi The less the mesentery is interfered 
 with the better ; bleeding points are to be tied, and as little 
 tissue as possible included in the ligatures. 
 
LESSENING THE SIZE OE THE TUMOUR. 367 
 
 Lessening the Size of the Tumour. 
 
 It is not always possible to reduce the size of an ovarian 
 tumour by emptying cysts with the trocar alone. When there 
 are several cysts and little semi-solid matter the trocar can be 
 pushed from one cyst to another without withdrawing it from 
 the original opening in the tumour. The hand must be used to 
 reduce the size of the tumour when it is semi- solid in order to 
 get it out through a comparatively small incision. Whenever 
 it is possible the tension of the tumour is lessened by emptying 
 even one small cyst, as this will allow the tumour wall to be 
 grasped by Nelaton’s forceps. The assistant, drawing on this 
 pair of forceps, pulls the tumour forwards, and, if possible, over 
 the edge of the wound, the trocar is then withdrawn and the 
 opening enlarged with scissors. The hand, and if necessary the 
 arm, is passed into the tumour to break down its interior in all 
 directions; when the inside of the tumour is friable this is 
 easily done ; when more solid, much force may be required, or 
 it may be necessary to divide the septa by cutting from the 
 inside. During the breaking down it is essential that the 
 assistant gives his entire attention to keeping the tumour open- 
 ing well forwards to prevent anything entering the abdomen. 
 When the tumour is so solid that the forceps cannot take hold 
 of it, the mass is pushed well into the w^ound, and an opening 
 is made to admit the hand. As soon as possible the cyst forceps 
 are fixed on to the wall. 
 
 When the cyst wall is very friable the forceps are apt to 
 tear out, and the assistant must be careful not to draw much on 
 the tumour, being satisfied if he can prevent anything passing 
 back into the abdomen. 
 
 Tu:\iours Enclosed in the Broad Ligament. 
 
 Tumours wdiich have grown between the layers of the broad 
 ligament often present special difficulties. So much is this so 
 
368 
 
 OVARIOTOMY. 
 
 that unfinished operations appear usually to belong to this 
 class. The reason of this seems to be, not that the cases 
 present insuperable or sometimes even great difficulties, but that 
 their exact relations are not properly understood. A reference 
 to the diagrams on p. 318 will show how simple it is for an 
 ordinary ovarian tumour to grow downwards between the layers 
 of the ligament. When the tumour grows at first completely 
 between the layers, without projecting upwards into the peri- 
 toneal cavity, it continues to grow in what is the direction of 
 least resistance, viz. downwards, until it is brought to a stand 
 by the bony pelvis ; then the direction of least resistance is 
 changed, and the tumour grows upwards, carrying with it on 
 its upper surface the peritoneum, and pushing the uterus up- 
 wards and to the other side. In very rare cases, after reaching 
 the pelvic walls, the tumour, instead of growing upwards, passes 
 across in the pelvic cellular tissue behind the uterus, and rais- 
 ing up the peritoneum in the pouch of Douglas, passes into the 
 other broad ligament. In this way the tumour, being below 
 tlie peritoneum, raises the whole of the pelvic floor and con- 
 tents into the abdomen as it grows upwards. In a case such 
 as this the tumour may be entirely outside the peritoneum. 
 When the tumour from its commencement grows both down- 
 wards into the pelvis and upwards into the abdomen, part of it, 
 i.e. the lower part, will be between the layers of the broad 
 ligament, and the upper portion will be in the peritoneal cavity 
 uncovered by the peritoneal folds of the broad ligament. 
 
 It is impossible to say what is the proportion of cases where 
 ovarian tumours grow between the layers of the broad ligament, 
 for it is evident that the condition is often not clearly under- 
 stood. In our experience the tumours grow either wholly in- 
 side the folds of the broad ligament or partly in about one case 
 out of ten. 
 
 It will now be understood how the diagnosis of this con- 
 dition is made. The uterus must be displaced to the opposite 
 side from the tumour and is drawn up into the abdomen, as it 
 
TUMOURS IN THE BROAD LIGAMENT 369 
 
 comes to be practically part of the tumour itself. It may be 
 almost central when both ligaments are opened up. 
 
 The operation in these cases varies very much from the 
 usual one. Suppose half of the tumour, which for convenience 
 in description may be considered to be a single cyst, be covered 
 by the distended folds of the broad ligament, and that there are 
 no adventitious adhesions on the part of the tumour uncovered 
 by these folds of peritoneum, it is evident that the stretched and 
 enlarged broad ligament must be separated off the tumour. After 
 the cyst has been emptied it will be found tliat it cannot be drawn 
 through the incision, and on investigation it will be seen that 
 there is no pedicle, but that the base of the cyst is very large. 
 If the hand be inserted into the interior of the sac it will pass 
 deeply into the pelvis below the apparent base of the tumour 
 as seen from the peritoneal cavity. An artificial pedicle has to 
 be formed by stripping off the peritoneum which surrounds the 
 lower part of the tumour. The separation is begun at the edge, 
 where the peritoneum ends on the sac wall, and it is to be con- 
 tinued in the direction of the uterus. Special attention must 
 be paid to the bladder ; it is better not to begin the operation 
 with it empty ; and as the enucleation gets deep down into the 
 pelvis a careful watch must be kept for the ureters. During 
 the enucleation keep close to the tumour wall and do not be 
 tempted to wander off into the cellular tissue, or before long a 
 ureter or a big iliac vessel may be wounded. It is not always 
 easy to keep to the tumour, more especially if there have been 
 any inflammatory attacks in the j)elvic cellular tissue. To 
 assist in doing this it is sometimes useful, when the pelvic part 
 of the tumour is cystic, to enlarge the trocar opening so that the 
 assistant can pass his hand into the interior of the cyst, and thus 
 allow the operator to know exactly where the tumour ends and 
 the cellular tissues begin. As the tumour sometimes dips very 
 deeply into the pelvis, the enucleation may liave to be continued 
 down between the vagina and rectum, almost to the perinoeuni. 
 During the enucleation, forceps are put on to every separated 
 24 
 
370 
 
 OVARIOTOMY. 
 
 piece of adhesion which seems likely to bleed, the large size of 
 forceps being used when we come to the separation near the 
 uterus. As oozing is usually free, sponges must be packed into 
 the cavity from which the tumour has been enucleated, while 
 the adhesions nearer the surface are secured with fine silk or 
 catgut. When the forceps are fixed deeply in the pelvis the 
 vessel enclosed should be tied without trying to see if the 
 pressure has stopped the bleeding, for once lost bleeding vessels 
 may be found again only with much difficulty and loss of time. 
 It is wonderful to observe into what a small space the enor- 
 mously enlarged broad ligament contracts. It may be left 
 open, or may be stitched loosely together, the former being 
 usually the better plan. If it be considered advisable to 
 drain, the end of the tube should not rest in the opened-up 
 broad ligament, but in its ordinary position at the lowest 
 point of the peritoneal cavity, care being taken that there is 
 no fold of peritoneum to make a pocket, and so prevent 
 effusion from the injured cellular tissue from reaching the 
 drainage tube. 
 
 An operation was witnessed where a drainage tube was 
 placed in Douglas’s pouch. The patient died of septicaemia, 
 and on fost mortem examination a pool of red serum was found 
 in a pocket in each broad ligament, as there was no communica- 
 tion between them and the end of the drainage tube. 
 
 When the tumour is entirely behind the peritoneum, the 
 method of enucleation is the same, except that at the com- 
 mencement an opening has to be made through the posterior 
 peritoneal lining of the abdomen. 
 
 A lady forty-four years of age was operated on, in February 
 1890 , for an ovarian tumour, which filled the abdomen and 
 reached up to the ribs. The tumour, composed of one large 
 cyst, fluctuated freely, except above the pubes and Poupart’s 
 ligament on the left side. Here there was a solid mass, which 
 was evidently the enlarged uterus. The tumour filled the 
 pelvis, the vagina was drawn up in a funnel-shaped manner 
 
TUMOURS IN THE BROAD LIGAMENT 371 
 
 towards the left, and the cervix could not be reached. The 
 diagnosis was of an ovarian cyst without adhesions, but with 
 extensive opening up of the right broad ligament. A free 
 incision exposed an enlarged uterus ; feeling sure of the 
 diagnosis the incision was enlarged almost to the umbilicus, 
 and the ovarian cyst was exposed beyond the fundus uteri. It 
 was emptied by the trocar, drawn forwards, and fully half of 
 the cyst was found to be covered by the expanded layers of the 
 broad ligament. The enucleation was commenced in the usual 
 way, beginning at the point farthest from the uterus and work- 
 ing towards it. When the separation had become very deep in 
 the pelvis, the assistant kept his hand in the interior of the sac 
 as a guide until the separation was completed. Some twenty 
 or thirty pairs of forceps were fixed on to the divided tissue, 
 the small pieces were tied with catgut and the larger with silk. 
 Bleeding was free from the posterior surface of the uterus, from 
 off the whole extent of which the cyst had been divided ; 
 several vessels were tied, but as the oozing was general, the 
 capsule, i.e. the separated broad ligament, was stitched across 
 the back of the organ to make pressure, which it effectually did. 
 
 A drainage tube was left in for sixty hours, and less than 
 two ounces of bloody fluid were withdrawn. The patient 
 slept almost continuously for the first three days, and went 
 home within three weeks. 
 
 A patient aged forty-six was operated on in ISTovember 1886 
 for an ovarian tumour. The growth had been first discovered 
 three years before, and during that time the patient had never 
 been confined to bed with pain. 
 
 The tumour, softish and multilocular, extended up to the ribs, 
 and was free in front. The uterus was felt to be raised up 
 almost centrally on the tumour entirely out of the pelvis, but it 
 was situated somewhat to the left. The cervix was drawn up to 
 the left, and could barely be reached at the level of the pelvic 
 brim. The whole of the pelvis was filled with a mass of tumour, 
 which was slightly movable with the respiration. 
 
372 
 
 OVARIOTOMY. 
 
 A semi-solid ovarian tumour, with one, probably both broad 
 ligaments opened up, was diagnosed. On opening the peritoneum 
 the right Fallopian tube was seen immediately beneath the 
 wound, and the broad ligament was found to be stretched over 
 the entire surface of the tumour. The incision was enlarged up 
 to the umbilicus, and the trocar was pushed into the tumour 
 through the peritoneal covering, but only a little bloody fluid 
 came away. The tumour was pushed forwards, the trocar open- 
 ing through the posterior layer of the peritoneum was enlarged, 
 and the enucleation was commenced. Fortunately the connec- 
 tions of the tumour were not very firm, and the enucleation got 
 on fast. Forceps were put on anything likely to bleed, and at 
 the last a couple of large pairs secured the uterine connection of 
 the tumour. Sponges were packed into the gap made in the 
 pelvic cellular tissue, vessels were tied with fine silk or catgut, 
 the sponges were removed, and the other bleeding points were 
 tied. Sponge pressure was used to stop a very free oozing. A 
 drainage tube was put in, with the end in the cellular tissue, as 
 that was the lowest part of the pelvis, the pouch of Douglas 
 having been destroyed. The tumour weighed 17 lbs., the opera- 
 tion lasted fifty-five minutes, and though a careful watch was 
 kept for the ureters neither came into view. On examining the 
 tumour it was found that it had not been uncovered by the 
 expanded layers of the broad ligament at any point. 
 
 The drainage tube was removed on the fourth day, seven 
 ounces having been withdrawn. Progress was most satisfactory 
 until the second week, when there was a slight attack of pelvic 
 cellulitis, and the convalescence was in consequence prolonged 
 to six weeks. 
 
 When a patient is put back to bed with a pulse of 140 or 
 more, and when the heart shows no tendency to quiet down 
 within twenty-four hours, the patient almost invariably dies, 
 apparently from prolonged shock. The following is a typical 
 example of such a case : — In December 1884 a patient twenty- 
 seven years of age was admitted into the Edinburgh Eoyal 
 
TUMOURS IN THE BROAD LIGAMENT 373 
 
 Infirmary. She had known of the presence of an abdominal 
 swelling for about a year, and the case had been diagnosed as a 
 very favourable one for operation. The patient was unable to 
 lie in bed on account of severe abdominal pain, unaccompanied 
 by any sign of peritonitis. The abdomen was distended by a 
 tense cyst, and on vaginal examination the cervix was felt to be 
 pushed downwards, the body being lost in the cyst. The urine 
 was passed frequently, its specific gravity was 1012. 
 
 The operation was performed on the 17th of December. 
 The incision was made from the umbilicus downwards, and on 
 opening the peritoneum the tumour was found to be covered by 
 a thickened broad ligament. The cyst was emptied, and the 
 tumour drawn as far forward as it would come. It was then 
 found that the right broad ligament was stretched over the 
 whole of the tumour, and that the uterus which was enlarged 
 was intimately connected to the left side of the cyst. The 
 bladder was closely incorporated with the enlarged uterus in 
 front. The broad ligament was separated, and after a large 
 number of forceps had been used to arrest the hsemorrhage, 
 which was very profuse, the cyst was removed. Nine spouting 
 arteries were ligatured on the posterior surface of the uterus, 
 and a large number of bleeding points were secured in the 
 capsule and in the pelvic cellular tissue. Dr. Keith tried to 
 draw the uterus upwards so as to remove it, but was prevented 
 from doing this by the remarkably close connection of the 
 bladder. The abdomen was then thoroughly sponged, and a 
 clamp was put on the separated uterine stump, because the 
 uterus fell back into the pelvis in such a way that drainage 
 could not have been efficiently carried out. The operation lasted 
 rather more than an hour, and the tumour weighed 12 J lbs. 
 The patient was put to bed shortly after one o’clock. The pulse 
 was then 140. 
 
 5.30 P.M. — Did not wake up till after three o’clock. At four 
 ten ounces of clear water were drawn off by the catheter. P. 140. 
 
 Shortly after this she began to complain of a very bad 
 
374 
 
 OVARIOTOMY. 
 
 stomach-ache, one-sixth of a grain of morphia was given, and in 
 a few minutes she fell asleep. Urine ten ounces. 
 
 9 P.M. — Has been very quiet. Fully three ounces of bloody 
 fluid from the tube and in the sponges. Expression good. 
 Twenty-one ounces of urine. One-sixth of a grain of morphia. 
 Fifteen minims of tincture of digitalis by the rectum. T. 100’6°, 
 P. 178. 
 
 18th, 6 A.M. — A quiet night. Digitalis repeated. T. 100*4°, 
 P. 176. 
 
 10 A.M. — Hot much more than an ounce from the tube. 
 Urine passed frequently in small quantities, and contains a 
 considerable amount of mucus with a little albumen. Stomach 
 flat, no sickness, a third dose of digitalis. T. 100*4°, P. 160. 
 
 1 P.M. — Feels tired, but is dozing. T. 101*4°, P. 168. 
 
 5.30 P.M. — Has been sleeping soundly. Nutrient enemata 
 have been given all day, now quinine is to be added. T. 101*4°, 
 P. 168. 
 
 9.30 P.M. — Flatus is passing very freely. Expression 
 natural. No sickness. One ounce from the drainage tube. T. 
 101°, P. 168. 
 
 19th. — Had a fair night, flatus passing freely. One ounce 
 of clear serum from the drainage tube. P. 160. 
 
 At 11 A.M. the pulse had come down to 156, and the tem- 
 perature was 101*6°. During the day the patient was able to 
 retain food, flatus passed freely, and the pulse varied from 158 
 to 168. On the morning of the 20th the patient was in much 
 the same condition, and was looking perfectly natural. She had 
 not become thin, the pulse was weak at 160. As the day went 
 on the pulse became more feeble, and about four o’clock she 
 died. One hundred and fifty ounces of urine were passed in the 
 seventy-five hours she lived after the operation. 
 
 A case when the patient recovered where the symptoms were 
 very similar to those seen in the foregoing instance may also be 
 given : — The patient was thirty years of age, and the operation 
 was performed on the 15th January 1890, a non-adherent 
 
PARTIAL REMOVAL OF TUMOURS. 
 
 375 
 
 ovarian tumour being removed along with the second ovary. 
 The operation lasted less than twenty minutes. On being put 
 back to bed about three o’clock the pulse was 145. 
 
 9 P.M. — Eestless. Nutrient enemata with brandy were 
 
 commenced. One-sixth of a grain of morphia. T. 99*2°, P. 156. 
 
 16th. — Inclined to be restless and talkative all night. One- 
 hundredth of a grain of strychnia and minims of tincture of 
 strophanthus were injected. T. 99*8°, P. 156. 
 
 9. P.M. — Much the same. The strychnia and strophanthus 
 have been injected every four hours. Flatus is passing freely, 
 and there has been no vomiting. The pulse is still 156. 
 
 l7th. — No change all day. Is taking food well, there has 
 been no trouble with the urine. T. 98*8°, P. 154. 
 
 18th. — There was no improvement till the evening, when the 
 pulse fell to 145. The strychnia was stopped as the neck was 
 getting a little stiff, and five minims of strophanthus were given 
 by the mouth every four hours instead of hypodermically, as the 
 large number of injections which had been given had made the 
 arms very tender and painful. 
 
 19th. — The pulse was down to 135, but it did not fall below 
 100 for eight days. At that time the strophanthus was stopped. 
 During the whole progress of the case, the danger was evidently 
 limited entirely to the condition of the heart, the abdomen 
 having given rise to no trouble. 
 
 Partial Kemoval. 
 
 It sometimes happens that it is impossible to remove the 
 whole or a part of an ovarian tumour. With increased personal 
 experience such cases naturally become more rare. As a general 
 rule it is advisable to go on and finish the removal if possible ; 
 still there are cases where the patient’s chance of recovery 
 will be better if the operation be not completed. It is always 
 hard to stop an operation before it is satisfactorily completed, 
 but if this have to be done it is better to make up one’s mind 
 
376 
 
 OVARIOTOMY. 
 
 to do it soon. As the patient recovers much more quickly after 
 complete removal, the extirpation of a cyst must not be given up 
 lightly, determination will carry one through a good deal. When 
 the tumour, instead of being cystic, is more or less solid, the 
 operation if once begun must be finished at all risks. 
 
 The conditions which make it necessary to perform a partial 
 removal are close or very extensive intestinal adhesions, intimate 
 adhesion of the tumour to the aorta, and an occasional enuclea- 
 tion case in the pelvis, w^here the connections of the cellular 
 tissue are very firm and dense. In this latter case it is sometimes 
 possible to complete the operation by removing the uterus along 
 with the tumour. 
 
 A lady forty-two years of age was operated on for an 
 ovarian tumour in 1886. The broad ligaments were known to 
 be opened up, and at the operation two ovarian tumours were 
 found, each having opened up its broad ligament. The enuclea- 
 tion was extremely difficult, and a small piece of the cyst was left 
 adherent to the rectum. On account of the difficulty of enuclea- 
 ting the cyst it was found that the safest plan was to remove 
 the uterus, which was high up and almost central. A clamp 
 was put on round the neck and below the base of the cysts. 
 When the clamp began to loosen at the end of a week faeces 
 commenced to pass alongside the stump, but this did not incon- 
 venience the patient much, and by keeping the wound clean the 
 opening had healed up twenty-eight days after the operation. 
 The mass which was removed consisted of the ovarian cysts of 
 the greater part of the uterus, and of two dilated Fallopian 
 tubes. 
 
 A surgeon with a fair amount of experience will be unable 
 to complete a case perhaps once or twice in one hundred opera- 
 tions. Such cases must always be looked upon as unsatisfactory, 
 and partly in the light of failures. 
 
 When the cyst is adherent to the parietes, and it is 
 determined to make no attempt to remove the tumour, the 
 operation is a simple one, — the incision is made directly into 
 
PARTIAL REMOVAL OF TUMOURS. 
 
 377 
 
 the cyst, the contents evacuated, and the cavity thoroughly dried. 
 One or more glass or rubber drainage tubes are jjut into the sac, 
 and plenty of iodoform and absorbent cotton are used as the 
 dressing. 
 
 This is practically treating the case like an abscess cavity ; 
 it is only likely to be necessary when the cyst is suppurating, or 
 when the patient is weak, and the adhesions are known to be 
 extensive. If the tumour be not adherent in front, or if part 
 have been separated, the operation is rather more complicated, 
 especially if the sac wall be very thin. Silk stitches are first put 
 in to lessen the size of the parietal wound if necessary ; then 
 one or two are passed through the whole thickness of the wall on 
 one side, taking in a larger amount of peritoneum than usual, 
 then through the sac, and the abdominal wall on the other side. 
 This is done both at the upper and lower angles of the tumour. 
 A stitch is passed through the parietal and cyst walls not more 
 than one-third of an inch from the angle stitch, it then returns 
 through the cyst and parietal wall on the same side one-third 
 of an inch farther away from the angle. Stitches passed in a 
 similar way fix the rest of the cyst to the abdominal wall, 
 and when they are tied they bring the sac close to the 
 peritoneum. 
 
 The cyst is cut off, leaving half an inch or so above the 
 stitches, and this part of the sac wall is thoroughly dried with 
 the solution of perchloride of iron in glycerine. In this way the 
 sac remains open, and is in much the same condition as if it had 
 been adherent beneath the wound. Should there have been 
 much separation of adhesions in the peritoneal cavity, it may be 
 necessary to leave a drainage tube there, as well as in the sac 
 itself. 
 
 There is usually wonderfully little discharge, and there may 
 or may not be suppuration. When suppuration occurs there is 
 some rise in temperature, beginning from the third to the fifth 
 day, and in this case the sac ought to be washed out at least 
 twice a day with boracic lotion or other antiseptic which cannot 
 
378 
 
 OVARIOTOMY, 
 
 do harm. A sinus seldom remains for longer than two or three 
 
 O 
 
 months, though in some cases it becomes permanent. 
 
 The tumours which lend themselves to this method of treat- 
 ment are either unilocular, or those where several cysts can be 
 broken down into one. 
 
 Fibroid Tumours of the Ovary. 
 
 Ovariotomy for fibroid tumours of the ovary does not differ 
 in any particular from the foregoing descriptions, except that, 
 as the tumours are solid, a longer incision will be necessary. 
 Fortunately they are not only rare, but seldom reach to any great 
 size. The largest of the three which we have seen did not 
 weigh more than 10 lbs. Their practical importance is not 
 great ; they consist of pure fibrous tissue, but this is only made 
 out on microscopic examination after the operation. 
 
 Cysts of the Broad Ligament. 
 
 There seems to be a certain amount of confusion about cysts 
 of the broad ligament. They may arise from the parovarium, 
 or in the broad ligament itself. Their symptoms are very much 
 those of a unilocular ovarian tumour, except that they do not give 
 rise to the general effects of such tumours. They grow slowly, 
 five or even ten years often elapsing before any treatment is 
 called for. They are seldom tense, the abdomen is less promi- 
 nent than in an ovarian tumour, fluctuation is well marked, and 
 the cyst \vall feels thin. Frequently they are felt on pelvic 
 examination, as they are not uncommonly wuthout a pedicle, but 
 are sessile on the broad ligament, and may have opened up its 
 layers very extensively. When this latter conditon is present, 
 the uterus will be displaced upwards and to one or other side. 
 They do not cause pain, and do not tend to become adherent. 
 There is little or no thinning of the chest and arms. The slow 
 growth, the want of general symptoms, the thinness of the sac 
 
TUMOURS CONNECTED WITH LIGAMENT 379 
 
 walls, and the llaccidity of the sac itself, are the most important 
 symptoms. 
 
 The treatment is either by aspiration or by removal. Now 
 that abdominal surgery has made such great advances, the 
 operation of ovariotomy for a simple cyst is so devoid of danger, 
 that removal has come to be the common way of treatment, and 
 little or no attention is paid to the diagnosis as between ovarian 
 and broad ligament cysts. 
 
 Broad ligament cysts not infrequently rupture; when this 
 happens there are seldom if ever any symptoms beyond the 
 passage of large quantities of clear urine. This is the simplest 
 method of cure. The nearest approach to it is by aspiration. 
 This simple and safe operation cures the great majority of cases ; 
 the women in whom it is most certain that the sac will not 
 refill are the young ones. In middle-aged and old women a 
 repetition of the aspiration may be required. Should the fluid 
 collect quickly, the best plan is to remove the tumour. Aspira- 
 tion should always be tried first, it confines the woman to bed 
 for a day or two, it is free from all risk, and no weak point is 
 left in the abdominal wall. The fluid in all the flaccid cysts, so 
 far as our experience goes, is as clear as spring- water. Should 
 the fluid be found to be of a different appearance, one need not 
 expect that the tumour will not refill, and it is probable that a 
 mistake in diagnosis has been made. 
 
 The operation of removal is often extremely simple, and even 
 should the broad ligament be opened up, the enucleation is very 
 much more easy than in the case of ovarian tumours which have 
 opened up the broad ligament. In other respects the operation 
 and after treatment do not differ from that of an ordinary 
 ovariotomy. 
 
 Tumouks connected with the Broad Ligament. 
 
 A soft oedematous tumour of the broad ligament is very 
 rarely met with. As such a tumour will in all probability be 
 
38 o 
 
 O VARIOTOMY. 
 
 indistinguishable from a solid or semi-solid ovarian, nothing 
 need be said as regards diagnosis. The pedicle may be long, and 
 in such a case the operation is of the most simple description. 
 
 A patient fifty- two years of age was sent to the Edinburgh 
 Eoyal Infirmary in the end of 1886. She had noticed that the 
 abdomen was enlarging for about three years, and latterly she 
 had been getting thin about the chest and arms. On examina- 
 tion, what appeared to be a semi-solid tumour was found 
 entirely filling the abdomen, the largest cyst was on the left side, 
 and the tumour was free in front. The diagnosis was made of a 
 multilocular ovarian tumour. A free incision was made from 
 the umbilicus to within an inch of the pubes, and on opening 
 the peritoneum the tumour looked like an oedematous fibroid. 
 It was turned out of the abdomen, and was found to he 
 attached to the broad ligament by a long narrow pedicle con- 
 sisting almost entirely of blood vessels. The left ovary, small 
 and atrophied, was situated midway on this pedicle. The 
 right ovary was also atrophied. The tumour was a remarkably 
 soft oedematous fibro-cyst growing from the broad ligament. It 
 weighed 14|- lbs. 
 
CHAPTER III. 
 
 DISEASES OF THE OVARIES AND FALLOPIAN 
 TUBES. 
 
 The operation of removal of the ovaries and Fallopian 
 tubes is usually known by the name of removal of the uterine 
 appendages, though they are appendages only in the surgical 
 sense. It is an operation of recent date. Blundell, however, in 
 the year 1823, suggested that the operation, or at least removal of 
 the ovaries, was a right and proper one for cases of dysmenor- 
 rhoea and menorrhagia. Fifty years elapsed before his advice 
 was put into practice. There has been much controversy as to 
 whom the credit of the operation belongs, and if we leave Blundell 
 out of account it will rest between Battey, Hegar, and Tait. The 
 operation was greatly extended by the last named, and his 
 teaching has undoubtedly resulted in the performance of many 
 unnecessary operations. Although there is still a difference of 
 opinion in regard to the frequency with which it ought to be 
 performed, yet there ought not to be the slightest doubt about 
 the advisability and even the necessity of this operation in 
 suitable cases. 
 
 As the operation is not always necessary to save life, but is 
 only to alleviate suffering, and to allow a woman to lead a useful 
 instead of an invalid life, it is only fair that she should be 
 made clearly to understand the exact nature of the operation. 
 It is not sufficient, nor is it right, to say simply that two little 
 glands must be removed ; the patient must be told that the result 
 of the operation will be to bring about the “ change of life.” At 
 
382 DISEASES OF O VARIES AND FALLOPIAN TUBES. 
 
 the same time she may be told, when an operation is necessary, 
 that the disease has rendered the ovaries unfit to perform their 
 duties, and that it is almost impossible that she can bear children. 
 
 The conditions for which the removal of the ovaries and 
 Fallopian tubes is to be performed may be divided into two 
 classes, — the one where there is actual disease in the ovaries 
 and tubes ; and the other where they may be healthy, but are 
 removed to bring about a change, either in some other organ, or 
 in the general condition of the patient. 
 
 The first class may be divided into cases where there is 
 suppuration, and into those where suppuration is not present. 
 The disease may be in the ovaries, in the tubes, or in both, and 
 there will be also in a certain number of cases a varicose 
 condition of the veins in the broad ligament. 
 
 The ovaries may be inflamed — ovaritis, — cirrhotic, suppurat- 
 ing, or misplaced. The Fallopian tubes may be inflamed — 
 salpingitis, — may be distended with simple fluid — hydrosalpinx, 
 — with blood — hseniatosalpinx, — with pus — pyosalpinx, — or 
 with a foetus — extra-uterine pregnancy. 
 
 Healthy ovaries may be removed to make an artificial change 
 of life, and thus arrest the growth and cure the symptoms of a 
 fibroid tumour of the uterus ; for the same purpose they may 
 require to be removed in cases of infantile uterus ; and in some 
 cases of mania and epilepsy good success has been obtained by 
 their excision. 
 
 The operation is not justifiable in cases of uterine dys- 
 menorrhoea, nor when the patient is simply neurotic and when 
 no actual disease can be found in the pelvis. 
 
 There is no difficulty in advising operation when there is 
 suppuration, either in the ovary or tube. If the condition be 
 one of chronic inflammation only, and under this may be in- 
 cluded distension of the tubes by simple fluid, it is often a 
 difficult question to decide when the disease can only be cured 
 by operation ; and great help may be obtained from the patient’s 
 friends as to the amount of suffering, her own statements being 
 
CA C/S£S. 
 
 383 
 
 received with caution. The operation for the removal of the 
 appendages for uterine fibroid will be taken up in its proper 
 place, in connection with the treatment of these tumours. 
 
 Cases of infantile uterus are very rare, but in some the re- 
 moval of the ovaries may be necessary. 
 
 In mania and epilepsy much care must be given to the con- 
 sideration of the case before operation is advised, and it must 
 only be done in the early stages of these diseases. 
 
 What has been long known as pelvic peritonitis or pelvic 
 cellulitis is now generally recognised as not being, as a rule, a 
 primary disease in itself, but a result of some altered state of 
 the uterine appendages. 
 
 There is a considerable amount of difference of opinion as to 
 what is the cause of disease of the uterine appendages. This 
 may be accounted for by the fact that the causes are numerous, 
 and that it is often impossible to prove a direct relation between 
 the cause and the effect. For convenience we may consider the ap- 
 pendages as one, and not the ovaries and the tubes as separate. 
 
 The whole generative tract may be looked on as one 
 continuous tube, commencing at the vulva and ending at the 
 ovaries ; the vagina, uterus, and Fallopian tubes being included 
 in the canal. An irritation, whether specific or not, at one part 
 of this tube, may spread throughout its whole length, and will 
 give evidence of its presence at its weakest part. 
 
 Causes . — Inflammatory disease of the uterine appendages 
 can usually be traced to an abortion ; to the birth of a child ; 
 to a simple chill during menstruation ; to a gonorrhoeal infection 
 at any part of the generative tract ; to the passage of a sound 
 when the vagina has not been purified, and especially if the 
 instrument be so roughly used that a small abrasion of the 
 uterine lining surface is made, thus forming a perfect nidus, 
 possibly at the very mouth of one Fallopian tube, for any vaginal 
 bacteria to propagate. 
 
 Laceration of the cervix uteri, while secondary to delivery, 
 is a cause of some frequency. 
 
384 DISEASES OF O VARIES AND FALLOPIAN TUBES 
 
 As an example of tlie disease following an abortion, the 
 following case may be given. A lady thirty-two years of age 
 aborted at the end of the third month. For ten days afterwards 
 the progress was not very satisfactory, the temperature was 
 a little over 100°, and the pulse was slightly quickened. For 
 the next fortnight she was apparently quite well, but was kept 
 in bed as a precautionary measure. At the end of that time, 
 that is, nearly four weeks after tlie abortion, a slight attack of 
 fever was noticed every afternoon, and in a few days the rise in 
 temperature became steady. Examination showed the presence 
 of a swelling on each side of the uterus. These increased rapidly, 
 and the patient was advised to have them removed, but she 
 would not consent, and at the fost mortem held eight weeks 
 after the abortion both tubes were found to contain about half 
 an ounce of pus. There was no history of gonorrhoea. 
 
 An example of the disease following the birth of a child 
 is that of a woman twenty-eight years of age, who was delivered 
 after being two days in labour. She was unable to get out of bed 
 for three months. Since that time she was able to do very 
 little, and on three occasions had been in bed for over a month 
 at a time with an attack of so-called pelvic peritonitis. The 
 patient was practically useless, and a mass could be easily felt 
 on each side of the uterus. The ovaries and tubes were removed 
 in 1885, twenty- seven months after the birth of the child. 
 Within six months the patient was able to say that she felt 
 as well as she had ever done in her life, and she has been in 
 constant employment from that time. 
 
 The following is the history of a case, due to a chill caught 
 while menstruating, treated by an American surgeon. A lady 
 thirty-seven years of age, who was in perfect health and without 
 any history of disease of the uterine appendages, got up one even- 
 ing in her night-dress while menstruating to shut a window. It 
 was winter-time, and the thermometer showed about 10° of frost. 
 By the time she got back to bed her feet were cold, and there 
 was no hot bottle in the bed. An hour afterwards she had a 
 
CAUSES. 
 
 385 
 
 shivering fit ; when she was seen two hours later the tempera- 
 ture was 105° and the pulse 135. On vaginal examination the 
 pelvis had the plaster-of-Paris feeling, and the lower part of the 
 abdomen was tender. The patient lived for three months with a 
 temperature never below 101‘5°. Five days before death the ab- 
 domen was opened, the ovaries and tubes were found to be much 
 enlarged and matted together, but no pus was found anywhere. 
 
 As an example of gonorrhoeal infection, a lady twenty-five 
 years of age had contracted gonorrhoea from her husband three 
 years before, and had suffered from that time from general 
 malaise and occasional attacks of pelvic peritonitis. On 
 examination the right tube was found to be distended, the 
 uterus was enlarged and retroverted, and the temperature 
 when she was first seen was 103°, with the pulse at 120. 
 Immediate operation was strongly advised, but was not con- 
 sented to for eight days. By that time the temperature had risen 
 to 106°, and the pulse to 140. The patient and her friends 
 then gave their consent. The right tube, containing two ounces 
 of stinking pus, and with walls fully half an inch in thick- 
 ness, was removed. The left tube presented a perfectly normal 
 appearance. The patient only survived twenty-two hours. 
 
 It would be very difficult to prove that the passage of a 
 sound is actually the starting point of this diseased condition, but 
 it is undoubtedly the case that the symptoms may be aggravated 
 after this has been unskilfully done. A patient twenty-six 
 years of age had sought relief at two teaching institutions 
 on account of general debility and pain in the back and sides, 
 from which she had suffered more or less for six years. 
 Although no complaint was made, it was very evident that 
 the symptoms had been much aggravated by the treatment 
 she had received, and on guarded inquiry it was found that 
 a sound had been frequently passed by the students. At 
 the operation in June 1886, both ovaries were found to be 
 enlarged, the tubes were dilated, and the walls were thickened. 
 
 As an example of disease resulting from laceration of the 
 25 
 
386 DISEASES OF O VARIES AND FALLOPIAN TUBES. 
 
 cervix, a patient twenty-nine years of age was seen in July 1880. 
 She had suffered, since the birth of her eldest child six 
 years before, from constant burning pain in the lower part 
 of the abdomen and back, very much aggravated at the time 
 of the period. The patient was emaciated, and her medical 
 attendant reported that she had been a big stout woman. 
 On examination the tubes could be felt with the greatest ease 
 on account of the thin lax condition of the abdominal wall; 
 they were hard, and felt as thick as the finger ; the ovaries 
 were tender, but otherwise appeared to be normal. The cervix 
 was large, hardened, and deeply lacerated. The condition of the 
 tubes and ovaries was confirmed by Dr. Howard of Baltimore 
 and Dr. Maury of Memphis, and they advised that the tear in 
 the cervix should be sewn up after some preliminary treatment ; 
 but they both thought it probable that the tubes would have 
 eventually to be removed. Their advice was followed. Three 
 weeks after the operation the pain had almost disappeared, and 
 the patient was beginning to gain weight. The left tube could 
 not be made out, and the right felt soft, and about half the 
 thickness it had been before the operation. Four months 
 afterwards, the doctor reported that the patient was perfectly 
 well, and had gained so much in weight that her waist had 
 increased five inches. 
 
 Accompanying and perhaps acting also as a cause of disease 
 of the appendages must be included a varicose condition of 
 the veins in the broad ligament. 
 
 A lady thirty-seven years of age, seen in 1893, was suffering 
 from constant pain in both groins, in the thighs and back, with a 
 feeling of weight in the pelvis and inability to stand. Treatment 
 by injections of hot water and astringent applications to the 
 vagina had been frequently used, always with benefit, but the 
 "ood effects never lasted for more than a month or two, and the 
 patient was very anxious to be made quite well. On examina- 
 tion both ovaries were felt to be somewhat enlarged, the right 
 was prolapsed, and the tubes were hard and slightly dilated ; in 
 
SYMPTOMS. 
 
 387 
 
 addition there was the feeling similar to what had been noticed 
 in cases where varicose conditions of the veins in the broad 
 ligament had been seen at other operations. At the operation 
 two large bunches of veins were found in the broad ligament 
 which formed the pedicle. They were removed along with the 
 somewhat enlarged tubes and ovaries. The feeling of weight 
 and the pelvic pains were relieved, and the patient is steadily 
 gaining in every way. 
 
 Symptoms . — Where there has not been suppuration the 
 symptoms are varied indeed, and may be divided into local and 
 general. The local symptoms are pain in one or both groins, in 
 the back, in the front over the pubes, down one or both thighs, 
 in the hips, in the groins on raising the arms above the head, 
 and a sensation of weight and general discomfort in the pelvis. 
 These pains may be acute, or of a dull aching character ; they 
 may be constant, and are usually worst about the menstrual 
 period, sometimes between the periods, and at times they may 
 be almost or quite absent in the middle of the month. In 
 certain cases there is pain or a feeling of obstruction when the 
 bowels move. In addition there are usually recurrent attacks 
 of more or less severity of pelvic peritonitis, when all the 
 symptoms are aggravated, and the patient is confined to bed 
 with usually some rise in temperature. As regards the amount 
 of menstrual flow there may he no alteration, or there may be 
 either an increased or a diminished quantity. 
 
 The following is a typical history of this condition : — A young 
 woman thirty years of age was delivered of her only child three 
 years before operation. After the birth she made a bad recovery, 
 and did not feel well when she got up. Since then she could do 
 little work, and a day’s washing would send her to bed for two 
 or three days. On several occasions she had been confined to 
 bed for a few weeks at a time with increase of symptoms and 
 fever. She suffered from constant pain in both groins, bearing 
 down, and pain in the back ; all worse before and during 
 menstruation. There was some increase in menstruation. Life 
 
388 DISEASES OF O VARIES AND FALLOPIAN TUBES. 
 
 was said to be not worth living on account of the general misery. 
 Examination during one of the acute attacks revealed nothing 
 except a very well marked plaster-of-Paris feeling in the pelvis. 
 Before the operation the uterus was large, fairly movable, and 
 enlarged ovaries and tubes were easily made out. 
 
 The constitutional symptoms consist in a breaking up of the 
 general health. After a longer or shorter time, depending on 
 the original constitution of the patient, she begins to lose flesh, 
 becomes poorly nourished, takes her food badly, suffers from 
 constipation, is unable for much fatigue, cannot walk or stand, 
 has frequent headaches, is anaemic, irritable, and sooner or later 
 loses control of her nervous system and becomes hysterical. 
 There may be also pain in the breasts. 
 
 A lady thirty- three years of age, the mother of three children, 
 and who had never been robust, had gradually failed in health since 
 the birth of her first child. After the third she became a semi- 
 in valid, she suffered chiefly from pain in both groins and down 
 the thighs, from dyspepsia, constipation, headache, and loss of 
 strength. She became terribly thin. All these symptoms, and 
 especially the dyspepsia, were much aggravated during the 
 menstrual periods. At those times she was unable to retain 
 anything on the stomach, and latterly rectal feeding had to be 
 resorted to. During the last period before the operation, this 
 had to be continued for eight days, absolutely no food being 
 taken by the mouth for that time. Treatment of all kinds had 
 been thoroughly tried and had failed. The uterus was large and 
 heavy, the ovaries were tender to the touch, but were not larger 
 than natural, and they appeared to be adherent. The debility 
 had increased so much that it was evident that the patient 
 would die if something were not done. The operation was 
 therefore performed in June 1888. The ovaries were rather 
 smaller than natural, hard and adherent ; the tubes appeared to 
 be normal. Progress in every way was extremely slow, and at 
 the end of one year little strength seemed to have been gained. 
 The pain was, however, very much less, the sickness had stopped. 
 
SYMPTOMS. 
 
 389 
 
 but the headaches were still frequent. She got on better in the 
 second year, but it was two and a half years before she was able 
 to go to a dinner party or to the theatre. 
 
 The symptoms caused by the presence of pus in an ovary 
 or tube may sometimes be extremely slight ; indeed, cases have 
 been known where there were no symptoms except the abdominal 
 swelling. When present they are usually those already described 
 in the case of simple inflammation, and in addition shivering or 
 a feeling of chilliness, sweating, and a certain amount of fever. 
 The disease becomes at times acute, and the attack is ushered in 
 with a rigor. 
 
 An example of this condition without symptoms is the 
 following ; — A married lady thirty-two years of age came for ad- 
 vice on account of increase in size of the abdomen, though there 
 had never been any pain or discomfort. A peculiarly irregular 
 tumour was found extending up to the umbilicus, fluctuation 
 was indistinct, and on vaginal examination the tumour could 
 barely be reached, the uterus was movable. The disease was 
 diagnosed as an ovarian tumour, but turned out to be the 
 Fallopian tubes enormously distended with pus ; the smaller 
 held one pint, the larger about half as much again. 
 
 An example of an acute attack may be given ; — A patient 
 thirty-eight years of age was seen in consultation in 1890. Since 
 the birth of her last child nearly three years before she had suffered 
 from pain in the groins and thighs, and a swelling in each broad 
 ligament had been discovered, which was supposed to contain 
 pus. The patient had refused to have the swellings removed, 
 and the reason for the consultation was a sudden rise in pulse 
 and temperature following a rigor. Two large sausage-shaped 
 masses were felt, and operation was strongly advised, but the 
 patient declined to have anything done, and she collapsed and 
 died about a week afterwards. A rupture was found at the 
 'post mortem examination. 
 
 Diagnosis . — The physical diagnosis is often difiicult on 
 account of the exquisite tenderness either in the whole pelvis or 
 
390 DISEASES OF OVARIES AND FALLOPIAN TUBES. 
 
 at one or other part of it. The first thing to be noticed is that 
 the mobility of the uterus is lessened, and that it cannot be 
 moved as freely as usual without causing pain. The broad 
 ligaments convey a feeling of contraction and of resistance to the 
 finger. The hand placed on one or other side of the middle line 
 of the abdomen is to be pressed deeply backwards in the direction 
 of the pelvic brim, while the finger in the lateral fornix is directed 
 far back in the pelvis, meeting as nearly as can be the outside 
 hand. The two hands being now brought forv/ard, everything 
 which had been in front of them can be examined. Should a 
 tender swelling be discovered, information must be obtained by 
 feeling round the part, and not by continuing the pressure on the 
 tender spot. 
 
 It is impossible to tell in words the feeling conveyed to the 
 fingers by diseased uterine appendages. There may be a slightly 
 enlarged and tender ovary, with perhaps in front of it a cord 
 very much the size of a cedar- wood pencil — the Fallopian tube ; 
 or the uterus and pelvic contents may seem to be inextricably 
 matted together ; or there may be an intermediate condition, 
 where an enlarged rounded ovary or a sausage-shaped swelling 
 is felt behind the uterus. 
 
 Treatment . — When disease is found on examination, the 
 treatment will greatly depend on whether the presence of pus is 
 suspected or not. If there be pus, general surgical principles 
 must be applied and the poison got rid of by operation. When 
 there is not pus, a less severe mode of treatment must be first 
 tried, unless the tubes be evidently greatly distended. Eest, 
 complete rest, either alone or in combination with other treat- 
 ment, is essential, and by complete rest is meant not lying down 
 on a couch for part of the day, but absolute confinement to bed. 
 In no other way is it possible to keep a patient quiet, and in bed 
 she can also be kept warm. At this stage a “ hot pack ” should 
 be given every day ; a couple of sheets are folded up into broad 
 roller bandages, one is wrung out of hot water and wound round 
 the pelvis, going as high as the navel and w’ell down on to the 
 
TREATMENT. 
 
 391 
 
 thighs. The second sheet is used dry to cover the first. The 
 sheets are kept on for an hour, and after they are taken off 
 perspiration is encouraged by a hot bottle at each side, as well 
 as one at the feet, which should never be allowed to be out of 
 the bed. This packing is to be continued for a week or ten days. 
 
 Hot water is to be injected twice a day for fifteen minutes at 
 a time. After this, the lower part of the abdomen is to be 
 painted as often as the skin will bear it with Churchiirs tincture 
 of iodine. The top of the vagina is painted three times a week 
 with the same preparation of iodine, and this can only properly 
 be done through a Sims’ speculum. Pads of wool saturated with 
 glycerine are also placed against the swelling after the iodine 
 has been used. If the case improve, the patient at the end of 
 six weeks is allowed to get up for an hour, and then for longer 
 according to the progress made. The general health must be 
 attended to, and often an hour’s massage in the day will improve 
 the general nutrition, and help the patient to sleep. Should 
 there not be any improvement at the end of six weeks it is not 
 advisable to continue the local treatment. On the other hand, 
 if there be any improvement, even though it be slight, the treat- 
 ment must be continued. 
 
 Patients with inflammatory disease of the uterine appendages 
 seldom come for treatment in the early stages, and have often 
 seen numbers of doctors, changing from one to another as they 
 are disappointed with their slow progress. It must be strongly 
 impressed on every one that under the best of circumstances 
 progress will be slow, and that it may be several months before 
 any great improvement is felt. 
 
 As an example of the progress made by those cases, the 
 following history may be given: — A young married lady twenty- 
 four years of age, whose only child was four, was brought over to 
 London in October 1892, in an invalid carriage from the South of 
 France. The illness dated from a chill caught while menstruating 
 eighteen months before. She suffered chiefly from pain in the 
 back and general debility until the beginning of August 1892, 
 
392 DISEASES OF O VARIES AND FAIIOPIAN TUBES. 
 
 when she was seized with a very acute attack of pelvic peritonitis. 
 Examination at that time showed that the uterus extended half 
 way up to the umbilicus, and that the whole of the pelvic 
 contents were matted together, one enlarged ovary being felt 
 immediately behind the cervix. She was treated by a well- 
 known French gynaecologist, who was afraid that the ovaries 
 would eventually have to be removed. When she arrived in 
 London in the beginning of October, she was found to be 
 emaciated, and to be suffering constantly from pelvic pains, and 
 from a severe back-ache. On examination the uterus was found 
 to be enlarged, the left ovary was prolapsed, tender, and swollen ; 
 both Fallopian tubes felt as thick as the forefinger, and the 
 right ovary appeared to be enclosed in a mass of adhesions. On 
 comparing the condition with the written account which the 
 patient had received in France, it was evident that there had 
 been a marked improvement in the local condition, although the 
 patient did not feel much better. The treatment consisted in 
 hot water injections for twenty minutes three times a day, in 
 absolute rest in bed, in general massage for one hour every day, 
 and in the administration of suitable tonics. This treatment 
 was continued for eight weeks with marked benefit. Shortly 
 afterwards the patient became pregnant, and was delivered of a 
 healthy child in November 1893. 
 
 Another method of treatment consists in rest combined with 
 Dr. Apostoli’s treatment. As electricity for such conditions is 
 in an early stage of development, it is impossible to say if cases 
 can be permanently cured by its means. Some are cured at 
 least for a time, but our experience is not sufficiently old to 
 allow us to say that there will not be a return of the disease. 
 The method will be described when the treatment of uterine 
 fibroids is taken up. The passage of a constant current of 
 electricity appears to be able to give positive information 
 whether the uterine appendages are diseased or not. If they 
 be diseased, patients cannot bear a large dose — 10, 20, or 30 
 milliamperes will be about the maximum. 
 
TREATMENT. 
 
 393 
 
 The wife of a doctor, twenty-eight years of age, who had been 
 married four years, had suffered from dysmenorrhoea for about six 
 years, the starting point being a chill got while riding one wet day. 
 She was first examined about the beginning of 1890 on account of 
 constant pain in the back, dysmenorrhoea, and general debility. 
 As there was no improvement she saw the late Dr. Matthews 
 Duncan, who diagnosed inflammation behind the uterus, either 
 in the tube or ovary, and advised rest, and perchloride of mercury 
 with chloride of calcium. There was still no improvement, and 
 the husband took her to see Mr. Tait. His diagnosis was 
 occlusion of the left Fallopian tube, which was distended with 
 fluid ; probable occlusion also of the right tube, as there had not 
 been any family. Hopeless sterility. He said two courses were 
 open, either to go on suffering with the prospect of cure at the 
 change of life, or to have the appendages removed. ISTothing 
 else, he added, would do good ; and if the pains were not so 
 severe as to make her desire the operation, she must not undergo 
 any treatment, for nothing could give her any relief 
 
 On examination a few days afterwards, Mr. Tait’s diagnosis 
 was confirmed ; and in addition there was a well-marked retro- 
 version. The tube seemed to be about an inch in diameter at 
 its widest part, and stretched across the whole of the left fornix, 
 behind the uterus, and into the right side of the pelvis. The lady 
 could not make up her mind to the operation, and it was there- 
 fore suggested that she should try experimentally Dr. Apostoli’s 
 treatment, being assured that it would at least do no harm. 
 
 The first ten applications averaged less than 40 milliampm^es; 
 the next eight, fully 70 ; and then seven punctures were made of 
 30 milliampk’es. At the first period there was rather more 
 pain, but after that was over improvement, both general and 
 local, was marked. At that time there was a swelling the size 
 of a large marble. The patient went home, and was to come 
 back if necessary. 
 
 In the following year twenty applications were made, though 
 the patient was better in every respect. 
 
394 DISEASES OF O VARIES AND FALLOPIAN TUBES. 
 
 In February 1892, the husband wrote : “ I am thankful to 
 say that she is immensely better, thanks to your treatment ; the 
 periods are now practically painless.” 
 
 An example where this treatment was tried and failed was 
 seen in a lady twenty-seven years of age, who suffered from severe 
 intermenstrual pain. On examination the uterus was felt to be 
 fixed, and to the left and low down there was a very tender 
 swelling, which was diagnosed to be an enlarged ovary. Thirteen 
 electrical applications were made without any benefit. Operation 
 was therefore performed in May 1891, when the ovaries were 
 enucleated with great difficulty from between the folds of the 
 broad ligaments at the very bottom of the pelvis. 
 
 Improvement after this form of treatment may not be very 
 marked for some months. 
 
 No operative treatment is to be countenanced in cases of 
 simple neurosis. The symptoms may greatly resemble those 
 caused by disease of the ovaries or tubes, but the local signs 
 will be entirely absent. 
 
 When the diseased condition of the appendages appears to be 
 caused by the irritation of a lacerated cervix. Emmet’s operation 
 must be performed. This may be safely done, provided that the 
 uterus be not drawn down. Should the uterus be much dragged 
 on during the operation, it is likely that an attack of pelvic 
 peritonitis will be lighted up. 
 
 The Operation of EExMoval of the Ovaries and Tubes. 
 
 The appendages are usually removed through a short incision, 
 not that there is any very special advantage in such an incision, 
 other than that there is so little exposure of the intestines that 
 the operation is practically subcutaneous. The two fingers of 
 the left hand, with which the operation is usually performed, 
 quickly become educated to recognise the different structures 
 to be met with. If the surgeon be in doubt, he should never 
 hesitate to enlarge the incision, push the intestines out of the 
 
REMOVAL OF THE OVARIES AND TUBES. 395 
 
 pelvis, and keep them away with sponges, while light is thrown 
 into the pelvis either from the reflector or an electric lamp. 
 During difficult operation cases, touch is a better guide than 
 sight, for it is impossible in such cases to trace the tube from 
 the uterus as has been recommended. Indeed, this cannot some- 
 times be done even when the parts have been removed. The 
 elevation of the pelvis, so as to allow the intestines to slip into 
 the abdomen, as recommended by Trendelenburg, is therefore 
 not considered advisable. The incision is to be made in the 
 middle line in the way described on page 45, care being taken 
 not to bring it too near to the pubes. When the peritoneal 
 cavity has been opened, the two fingers of the left hand are 
 passed in, and, keeping close to the peritoneum, are insinuated 
 behind the pubes, over the bladder to the fundus uteri, then 
 running along one broad ligament for an inch or two, they get 
 hold of the tube from behind, and as it is drawn up the ovary 
 follows. The ovary and tube are drawn well up into the wound, 
 and the pedicle which is thus artificially made is transfixed and 
 tied in the usual way. The assistant, who holds up the ovary, 
 makes no tension while the ligatures are being tied. The point 
 transfixed is to be made as close to the uterus and as far away 
 from the ovary as possible. The ends of the silk ligatures must 
 be at once cut short to prevent traction. The ovary and tube 
 are then removed, the pedicle being divided with short snips of 
 the scissors, and the cut surface is carefully examined as the 
 separation is made. The appendages on the other side are 
 removed in the same way. For a simple case such as this the 
 cautery acts extremely well, and is a great improvement on the 
 ligature, as it prevents a foreign body being left in tissues which 
 are likely to be in a state of irritation or inflammation. 
 
 Such is the operation in the rare non-adherent cases. It is 
 a more difficult matter when there is much adhesion, either in 
 the pelvis or to the intestine. It may be impossible to reach 
 the uterus in the way described without having to break through 
 a layer of adhesion, but it is always advisable to make out the 
 
396 DISEASES OE O VAEIES AND EALLOFIAN TUBES. 
 
 exact position of that organ before commencing any separation 
 in the pelvis. Occasionally when the uterus is retroverted and 
 firmly fixed in that position, help may be obtained by an 
 assistant raising the pelvic floor from the vagina. After the 
 uterus has been reached, the fingers are passed to one or other 
 side behind the broad ligament, and the separation is begun. It 
 is often difficult to commence the enucleation, and much force 
 may be required. If the ovary or tube be distended with fluid, 
 the sac is emptied with the aspirator after sponges have been 
 first packed in to catch any drops of fluid which may escape. 
 After the sac is emptied the cannula is withdrawn and the open- 
 ing closed with forceps ; it can then be drawn up high enough to 
 be seen, and the separation is continued as in an ordinary case 
 of pelvic enucleation, the finger being kept in the interior of the 
 sac if necessary. When thick walled the separation is more 
 easy when the sac is distended. The separation is continued 
 towards the uterus. As soon as the appendages are loosened 
 and turned up, sponge pressure is used to check bleeding. The 
 pedicle is ligatured as usual, or if possible the cautery is applied. 
 If the appendages on both sides have been removed without 
 rupture and there is little bleeding, a drainage tube is not 
 necessary. Should the tube or ovary on either side rupture, in 
 a case where there has not been room to surround the part with 
 sponges large enough to take up all the fluid, the pelvis must be 
 sponged out at once and the rent closed with forceps. When 
 the appendages on one side are diseased, those on the other 
 must also be removed, if they do not appear to be absolutely 
 normal. 
 
 When the presence of pus is suspected, great care must be 
 taken to avoid rupture, and unless the w^alls are very thick it is 
 better to aspirate than to run that risk. Should this accident 
 occur, the pus is to be at once removed, and warm water is to be 
 poured into the pelvis and sponged up ; this is to be done several 
 times, and it is better than flushing the general cavity of the 
 abdomen. Such a case must be drained. 
 
CHAPTEK IV. 
 
 FIBEOID TUMOUES OF THE UTEEUS. 
 
 The removal of a fibroid tumour of the uterus or uterine 
 myoma was the natural outcome of the operation of ovariotomy, 
 and strangely enough, it appears also to have been first inten- 
 tionally performed by an American surgeon. Dr. Kimball of 
 Lowell, Mass., in 1855. It is only within the last fifteen 
 years that the operation has become a common one ; before 
 that time it was performed occasionally, sometimes in mistake 
 for an ovarian tumour, and sometimes after a correct diagnosis 
 had been made. The operation for the removal of the uterus 
 with a fibroid tumour is called hysterectomy, though this 
 name is also used to signify the removal of the uterus for any 
 cause. It can never be compared with ovariotomy, for in the 
 former the disease itself seldom shortens life, though it may, 
 and often does, give rise to much illness and misery ; while in 
 the latter a painful death is the natural end if the tumour be 
 not removed. The operation of hysterectomy is a dangerous 
 one, and it is therefore necessary that there should be no doubt 
 that the symptoms which the tumour gives rise to are sufiScient 
 to make the patient’s life wretched and miserable. 
 
 The life of a fibroid tumour is limited, it rarely commences 
 before puberty, and seldom grows after the menopause. The 
 age of the patient ought therefore to influence us greatly in the 
 treatment to be advised. The most common year for the 
 menopause under ordinary circumstances is perhaps the forty- 
 
398 FIBROID TUMOURS OF THE UTERUS. 
 
 sixth year. It is later in a woman with a fibroid which does 
 not bleed, usually from the forty-sixth to the forty-ninth year. 
 When there is menorrhagia the change of life is usually from the 
 fiftieth to the fifty-fourth year. Occasionally it may even be 
 later. The most active period in the life of one of these tumours 
 is when the menopause is approaching, — “ evils, most of all show 
 evil at their departure.” The important part which the age 
 plays in influencing us in advising treatment or not lies in this, 
 that a woman at fifty is in a very different position from one at 
 thirty, and what may not be justifiable in the first may be 
 perfectly right in the second. For example, a hysterectomy 
 was performed on a patient forty-nine years of age for a large 
 tumour, the patient justifying the proceeding to a friend by 
 saying that as she was in perfect health she would probably 
 recover. She wanted a neat waist ! Had she been thirty, there 
 would have been no doubt as to the necessity for performing 
 the operation. 
 
 Clinically there are three varieties of tumour, the hard 
 fibroid, the soft oedematous tumour, and the fibro-cystic growth. 
 The first is by far the most common. It occurs either in the 
 wall of the uterus itself, intramural ; or as a pediculated out- 
 growth, sub-peritoneal ; or as a tumour projecting more or less 
 into the uterine cavity, submucous ; but this last variety ought 
 seldom to come within the range of abdominal surgery. 
 
 A pediculated outgrowth seldom gives rise to symptoms 
 justifying its removal; and though these operations are some- 
 times included in the statistics of hysterectomy they ought not 
 to come under this heading. 
 
 The soft oedematous tumours, when there are no cysts, but 
 simply a general honeycomb structure, do not always cease to 
 grow after the change of life, and an operation may in such a 
 case be the right thing, even in a woman well up in years. 
 
 Symptoms . — The symptoms caused by an ordinary hard 
 uterine myoma are very varied. The growth is slow, and a 
 patient will frequently know that she has had a swelling for 
 
SYMPTOMS OF FIBROID TUMOURS. 
 
 399 
 
 five or ten years before she first seeks advice. The rate of 
 increase is steady, though sometimes these tumours may increase 
 in size with great rapidity ; and at other times they may 
 diminish, or cases have even been known of their entire dis- 
 appearance before the menopause has been reached. These 
 tumours are very common, and in many cases they do not give 
 rise to any symptoms, and even when of considerable size 
 may be discovered accidentally. When they give trouble, 
 the most common symptom for which treatment is required 
 is menorrhagia, occurring at any time. This may vary from 
 a slight hsemorrhage to a flooding of most alarming character. 
 The best way to find out the quantity of blood lost is to inquire 
 how many napkins are required during the period, and how 
 many were required before the patient began to lose too much. 
 This naturally gives only the relative amount of ha3morrhage. 
 In health, a fair average may be taken at from five to eight 
 diapers, and a woman who has used about this number while 
 well may require one hundred or more ; a case has been met 
 with where over three hundred were used. The flow may 
 come in sudden gushes, and this is the most distressing way, 
 or the periods may go on to two or three weeks, leaving but one 
 week clear. 
 
 A second common symptom is pain or discomfort, this may 
 be in the tumour itself, or in distant parts, and is caused by its 
 pressure. A mass of tumour in the pelvis may cause obstruction 
 to the passage of faeces, or pain on defaecation ; or the function 
 of the bladder may be interfered witli, there being frequency in 
 passing water, or difficulty or total retention. There may 
 possibly be pressure on one or both ureters. With enormous 
 tumours there may be difficulty in getting about, and also 
 distress in breathing. (Edema of the lower limbs is sometimes 
 seen, but is not so common as with ovarian tumours. Usually 
 a woman with one of these tumours gets stout all over, especially 
 about the chest, and the face is florid unless the loss of blood be 
 
 excessive. 
 
400 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 Local Examination. 
 
 On examination of the abdomen the tumour is usually found 
 to be central, even when quite small, and in this it differs from 
 an ovarian growth. It is hard, solid, and does not fluctuate at 
 any part ; it may be quite smooth and regular in outline, or it 
 may be covered more or less with irregular nodules. The 
 umbilicus is drawn in. 
 
 On vaginal examination the condition will depend very 
 much on the exact relation of the tumour to the uterus. 
 Should the growth be situated in or growing from the fundus, 
 the cervix and the part of the uterus felt from the vagina may 
 appear to be perfectly normal. On moving the abdominal part 
 of the tumour while the finger rests on the cervix a distinct 
 connection between the two will be made out — pressure upwards 
 perhaps drawing the cervix quite out of reach ; lateral pressure 
 from the abdomen will also markedly affect the cervix ; down- 
 ward pressure of course gives no information. It is customary 
 to pass a sound for the purpose of diagnosis. This is of doubtful 
 value, as it may lead to many fallacies. In some cases the 
 uterine cavity is not enlarged, while in others where there is 
 a long cavity, the sound may stop at some obstruction and 
 make it appear as if the length were normal. Undoubtedly, 
 when it can be passed to a great depth, it is probable that the 
 case is one of fibroid tumour ; but even here we may be mistaken 
 by having passed it into an elongated uterus drawn up on an 
 ovarian tumour. Should the instrument be used, the short 
 sound of Matthews Duncan is much to be preferred to the long 
 heavy one of Simpson. 
 
 If the tumour, instead of growing from the fundus, is situated 
 more or less in the uterine wall, the pelvic examination may 
 reveal many varied conditions. The cervix may be natural, it 
 may be too large, or it may have entirely disappeared, an oval 
 or slit-like os alone representing it. It may be lying against 
 the perimeum or it may be drawn entirely out of reach of the 
 
LOCAL EXAMLNATLON. 
 
 401 
 
 examining finger, and may even be felt on abdominal palpation. 
 It may be central, or to one or other side, and the pelvis may 
 be, and often is, full of tumour. Movement of the tumour from 
 the abdomen will determine whether the cervix and pelvic part 
 of the growth move together ; the fact of the cervix not being 
 affected when the tumour is moved is against the diagnosis of 
 fibroid. 
 
 It is easy to understand how the broad ligament may be 
 opened up by a fibroid tumour ; it must happen more or less in 
 every case, unless the growth spring entirely from the fundus 
 uteri, and the explanation is exactly the same as in the case of 
 an intra-ligamentous ovarian tumour. 
 
 The upper edges of the opened-up and raised broad ligaments 
 can sometimes be felt from the abdomen ; if the ovaries can be 
 felt that is a guide to the condition ; when the cervix is pulled 
 well up to one side, and if it be shortened by being drawn into 
 the tumour, and still more if it has entirely disappeared, one 
 will expect that much enucleation will be required. 
 
 The soft oedematous fibroids occur more frequently in young 
 women, they grow* more rapidly than the hard variety, are much 
 less common, and may be accompanied by a watery flow, which 
 either discharges itself by the vagina or passes into the peritoneal 
 cavity. When there is this discharge the only treatment is to 
 remove the growth. In other respects they do not differ from 
 the hard tumours as regards their treatment. 
 
 Fibro- cystic tumours of the uterus are not infrequently 
 mistaken for ovarian tumours, and many of the early operations 
 of hysterectomy were begun with the intention of removing such 
 a tumour. The growth is comparatively rapid, there may be 
 emaciation of the upper part of the body, the umbilicus is 
 flattened out, there is frequently no menorrhagia, fluctuation 
 may be very distinct, and when there is nothing to be felt in the 
 pelvis the diagnosis is very difficult. These tumours may be 
 divided into two varieties, the one where there is a general 
 honeycomb condition with perhaps one or more large spaces ; 
 
 26 
 
402 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 and the other where there is one cavity with thick walls. On 
 aspirating the first of these, the fluid conies away not in a con- 
 tinuous stream, but in jerks : in colour it is a pale yellow, and 
 it coagulates spontaneously even without the admixture of any 
 blood. In the other variety the fluid removed may be of a dark 
 brown colour, may not coagulate, and under the microscope it 
 shows evidence of broken-down cells and debris. The fluid in 
 the first case reaccumulates rapidly; in the second, where the 
 condition may be described as one of degeneration, a second 
 aspiration may not be required for a number of years. 
 
 A lady fifty-eight years of age was seen in consultation in 
 1887, in regard to the question of Apostoli’s treatment. She had 
 known of the presence of a tumour for years. The abdomen was 
 much distended, and fluctuation could be made out on deep 
 pressure. The fluid was drawn off by aspiration, the trocar 
 passed through at least two inches of tumour substance, and over 
 twelve imperial pints of dark brown fluid were removed. The 
 sac did not fill up for over four years, when it was again 
 aspirated. 
 
 Treatment — The treatment will depend on the gravity of the 
 symptoms, on the size of the tumour, and on the age of the 
 patient. When one of these tumours is discovered in a woman 
 well up in years, the near approach of the menopause, which 
 unfortunately comes late, is looked forward to as an almost 
 certain end to her trouble ; but relief does not come immediately. 
 Indeed, the pain and discomfort are at first augmented, for the . 
 tumour continues to fill up with blood, and misses the relief 
 afforded by the monthly losses. This stage of increased dis- 
 comfort may continue from six months to two years after the 
 last appearance of menstruation. Such patients do not require 
 any active treatment unless there be symptoms of extreme 
 gravity. 
 
 It is little comfort for a patient of thirty or thirty-five years 
 of age, especially when there are troublesome symptoms, to be 
 told that in fifteen or twenty years she will be quite well ; 
 
TREATMENT. 
 
 403 
 
 and treatment which would be absolutely unjustifiable at 
 the age of fifty may be absolutely necessary at the age of 
 thirty. 
 
 While judging of the severity of the symptoms, the age must 
 always be borne in mind. Treatment is most commonly required 
 to lessen haemorrhage, to ease pain, or sometimes simply on 
 account of the size of the growth. 
 
 There is considerable choice in the treatment ; it varies from 
 rest at the menstrual periods, diet, medicines, medicinal springs, 
 Apostoli’s treatment by galvanism, to curetting, removal of the 
 ovaries, and hysterectomy. 
 
 The treatment by rest and diet consists in the patient 
 remaining in bed during the whole of the period, and in the food 
 being light and moderate in quantity. No port wine is to be 
 taken, no burgundy, no beef, no mutton, and in fact all stimu- 
 lating food must be avoided. Fish, chicken, game, milk, milk 
 puddings, fruit and vegetables, may be taken, and if a stimulant 
 be absolutely required, brandy or whisky and water. A patient 
 with a bleeding fibroid must not be fed up, she should rather 
 live below par. Feed a patient on animal food, and she will 
 bleed worse than she has ever bled before. Medicines will be 
 combined with the rest and diet ; of these the chief is ergot, but 
 it must be freshly prepared. Drachm doses of the fluid extract 
 given three times a day, commencing three days before the 
 period is expected, and continued until the worst of the flow is 
 over, will sometimes carry people on for a time. Small doses are 
 not very efficacious. In very rare cases a tumour has been known 
 to disappear under its use. The following case where this 
 occurred is reported in the late Dr. Matthews Duncan’s Clinical 
 Lectures: “The treatment of this case was not to produce 
 absorption ; it may be hoped for in an old woman. The treat- 
 ment adopted was a course of ergot. In many cases this drug 
 is of no avail, but in this case it had results so immediate as to 
 cause astonishment. I must remind you that the tumour was 
 so soft as to give the idea of fluid ; this is exactly the kind which 
 
404 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 is known to be most benefited by ergot. We injected three 
 grains of ergotine underneath the skin ; this was repeated 
 several times at intervals of a day ; but it had at length to be 
 discontinued because it produced very serious diffuse inflamma- 
 tion of the cellular tissue, narrowly and fortunately without a 
 suppurative termination. This effect we found to be peculiar to 
 the patient, for the same injection caused no inflammation in 
 several other women, the same syringe and solution being 
 employed. In place of it a fluid drachm of the fluid extract of 
 ergot was given daily by the mouth. The result of the treatment 
 has, as far as I know, never been surpassed as regards rapidity 
 of diminution of the tumour. The dulness which extended one 
 inch above the umbilicus was in forty-eight hours reduced so as 
 to extend only to the level of three inches below it. Such a 
 remarkable and rare result could only have been produced in a 
 soft tumour. 
 
 “ This improvement was accompanied by arrest of bleeding. 
 After being in the hospital two months she went out, having 
 lost the puffy anaemic appearance, and having acquired a healthy 
 aspect. (Years afterwards she was heard of, and fully main- 
 tained all the improvement.) ” 
 
 Hydrastis Canadensis is at times a useful remedy for check- 
 ing haemorrhage, and Hamainelis Virginica is occasionally of 
 service. Of other drugs, digitalis given in suitable cases is the 
 only one wdiich appears to be of much use. The general health, 
 must be taken care of, and iron tonics must be given in modera- 
 tion. CEdematous tumours and fibro-cysts can be reduced by 
 free purgation, and the reduction in size sometimes lasts for a 
 considerable time. 
 
 It is doubtful if medicinal springs such as Kreuznach and 
 Woodhall Spa are of much use in the treatment of these tumours. 
 The change and the different mode of life undoubtedly make a 
 patient feel better for a time, but the waters have probably little 
 to do with the improvement. 
 
 Treatment hy Electricity . — The treatment of fibroid tumours of 
 
TREATMENT BY ELECTRICITY. 
 
 405 
 
 the uterus by electricity is a very old method ; it has been tried 
 over and over again, but always in an ignorant and happy-go- 
 lucky mariner, until Dr. Apostoli of Paris put the treatment on 
 a definite and scientific basis. Dr. Apostoli had received much 
 information on this subject from Dr. Tripier ; still, the treatment 
 was very imperfect until Apostoli worked it out. The great aim 
 of this treatiuent by electricity is to stop the growth of a fibroid 
 tumour, and at the same time to cure any symptoms the tumour 
 may be giving rise to. There is also a certain amount of reduc- 
 tion in the size of the growths ; and in the case of small tumours, 
 they may even disappear entirely, leaving the patient in a 
 perfectly healthy and natural condition. This can be done 
 without any risk to life and without the assistance of any other 
 treatment ; the patient need not rest, she can take what food she 
 pleases, and can take iron with impunity. Operations, when no 
 special difficulties are expected, are now so safe that the question 
 of safety alone would not be sufficient to make one advise elec- 
 tricity rather than an easy operation ; but, putting out of account 
 the palliative operation of curetting, an operation means a serious 
 mutilation. In a woman of forty or forty-five this mutilation is 
 of little importance, but in a young woman it may influence in 
 a very marked way the rest of her life. 
 
 The apparatus for the proper carrying out of Dr. Apostoli’s 
 treatment is not very complicated, and a knowledge of electricity 
 beyond the very rudiments, though advisable, is not essential. 
 A battery is required which will be of sufficient strength to 
 pass a current of two or three hundred milliamperes through a 
 patient. In the choice of a battery two points have to be borne 
 in mind : the amount of force which can be got out of the 
 battery, called the electro-motive force ; and the amount of 
 resistance which this electro-motive force has to overcome in 
 the cells themselves — the internal resistance ; and in the wires, 
 patient, etc., outside the battery — the external resistance. This 
 brings us to the only electrical law we have to pay heed to, viz. 
 Ohm’s Law. The law is, “ the current equals the electro-motive 
 
4o6 fibroid tumours OF THE UTERUS. 
 
 force divided by the sum of the resistances.” This described 
 symbolically is 
 
 Current (C) = 
 
 Electro-motive force (E.M.F.) 
 Internal and external resistance (K 4- R') 
 
 The unit of current is called an ampere ; in medicine and 
 surgery this unit is divided into thousandths, and they are called 
 milliamperes. The unit of electro-motive force is called a volt, 
 and the unit of resistance an ohm. In the selection of a battery 
 we will require to know what is the electro-motive force of the 
 cells composing it, the resistance to the passage of a current of 
 electricity in the cells themselves, and also the resistance to be 
 overcome outside the battery, i.e. the amount of work to be done. 
 For home work thirty or forty large (quart) Leclanche cells 
 make a battery which gives sufficient electro-motive force, and 
 which at the same time gives the least possible amount of 
 trouble, and requires least attention. The electro-motive force 
 of a Leclanche cell may be roughly taken at 1'5 volts, and the 
 internal resistance of the quart size of cell at *5 ohm. If thirty 
 such cells be joined together in series, i.e. the carbon of one to 
 the zinc of another and so on, until there is at one end a free 
 carbon, the positive pole, and at the other a free zinc, the 
 negative pole, the electro-motive force of the whole will be 45 
 
 volts, and the internal resistance 15 ohms ; thus ^ ^ 
 
 ampm^es or 3000 milliamperes. This would be the amount of 
 current obtainable from such a battery, if there were no external 
 resistance to be overcome. This external resistance is in the 
 wires, instruments, and chiefly in the patient herself. When 
 Dr. Apostoli’s directions are carried out, the total sum of external 
 resistance will probably never exceed 150 ohms. We shall thus 
 
 have = 150 ^ milliamperes. This amount of 
 
 current will be of this strength only when the cells are freshly 
 charged and in perfect working order. At the end of six months 
 of daily use the cells will have to be cleaned and recliarged with 
 the sal ammoniac solution, as the battery will have lost some- 
 
TREATMENT BY ELECTRICITY. 
 
 407 
 
 what in strength ; or a more simple plan is to add some 
 additional solution to each cell, and so increase the power of the 
 battery. By doing this a battery of large Leclanche cells may 
 he used every day for a year without requiring to be recharged. 
 The battery, once it is in working order, requires attention only 
 in two matters ; the watery solution of sal ammoniac evaporates 
 and has to be added to occasionally, and after a time the zinc 
 elements are destroyed and have to he renewed. With these 
 attentions a Leclanche battery will last for at least seven years 
 without the porous pots containing the carbon and binoxide of 
 manganese having to be renewed. The battery is to be kept in 
 a cool place, and a couple of well -insulated wires are to be 
 brought into the consulting-room, one from the positive, and the 
 other from the negative end of the battery. 
 
 One essential part of the apparatus for use with a battery 
 arranged in this way is a rheostat. This instrument is for the 
 purpose of gradually increasing and as gradually diminishing 
 the current ; its principle consists in the introduction into the 
 circuit of such an amount of resistance that the electro-motive 
 force of the battery cannot overcome it. This resistance is 
 gradually taken out, and as the amount is reduced the electrical 
 current begins to flow. The strength of the current is lessened 
 by reversing the action, and again putting in the resistance. 
 By this means all jerk or jar is avoided. In the batteries 
 usually sold the arrangement is somewhat different ; two wires 
 are taken from each cell to a disc, and when the current is in- 
 creased it is done by means of a handle which is passed on from 
 one of those discs to another. When the handle is at No. 1, one 
 cell is included in the circuit, when at No. 2, two and so on. 
 The disadvantages of this arrangement are, that when there are 
 so many wires, some may easily get broken; and that some 
 patients feel a shock or jar when each cell is added to the 
 circuit. Various forms of rheostats are used, the best one we 
 have tried is the graphite instrument of Dr. Lewandowski of 
 Vienna. 
 
4o8 
 
 FIBROID TUMOURS OF THE UTERUS, 
 
 For scientific purposes a galvanometer is required to measure 
 the strength of the current. Without this instrument it is 
 impossible to tell what dose of electricity a patient is taking ; 
 and, although the sensation of the patient is the guide we must 
 always go by in regulating the dose, still it is satisfactory to 
 know the strength of current so as to be able to compare one 
 day with another and one patient with another. Several instru- 
 ments are made for this purpose, and any one which registers 
 correctly will do. For convenience a current changer or com- 
 mutator is to be added to the list of apparatus. 
 
 A useful portable battery will be found to be one composed 
 of modified Marie Davey cells. They are made with a collector 
 attached to them, and the current can be increased by using it, 
 or if it be desired to use the rheostat the full strength is used, 
 and the rheostat regulates the dose. 
 
 So much for the apparatus. We now come to the method 
 of application. The electrical current has to be passed through 
 the tumour, and as the body resistance lies chiefly in the skin, 
 it is necessary to reduce that resistance, as otherwise the skin 
 would be destroyed. This is to be done by spreading the 
 current over a large surface, so that little electricity enters at 
 any one spot. The best material for making this external or 
 skin electrode is modelling clay; a pad is made of this, nine 
 inches by seven and three quarters of an inch in thickness. 
 The clay is kept together by a piece of muslin, and a sheet of 
 block tin with an insulated wire attached is laid on the surface. 
 The advantages of the clay pad are, that it can be applied closely 
 to the skin, and it is a good conductor of electricity ; the 
 disadvantages are, that it is cold and heavy. It is also said to 
 be dirty, but should any adhere to the clothes it can be easily 
 brushed off. In spite of these disadvantages the clay pad is 
 better than any other. With its use, and when it is of proper 
 size, all burning of the skin is avoided. Apostoli’s internal 
 electrode consists of a platinum sound which is inserted into a 
 hollow handle, and can be projected to any length. The vaginal 
 
TREATMENT BY ELECTRICITY. 
 
 409 
 
 portion of the sound is protected by a sheath of celluloid, and 
 by this means any length of platinum can be exposed in the 
 uterus. To those who are ac- 
 customed to use a short sound, 
 the same principle can be 
 carried out by having several 
 of the shape of Matthews Dun- 
 can’s ordinary uterine instru- 
 ment, made with platinum 
 points, the stem being covered 
 with vulcanite. 
 
 In the treatment of a bleed- 
 ing fibroid it is best, when the 
 patient can bear a fair dose, 
 say 130 milliampMes, and when 
 the cavity is not enormous, to 
 have the platinum long enough 
 to extend from the internal os 
 to the fundus. During the 
 application the sound is passed 
 slowly, and with as much pres- 
 sure as the patient can bear, 
 over the whole of the uterine 
 mucous membrane. In this 
 way the soft fungous surface of 
 the membrane is destroyed. 
 
 When the dose is small or the 
 cavity very large, we must con- 
 tent ourselves with going over 
 only a part at one time. It 
 may happen that a sound cannot 
 be introduced into the uterus ^ 
 if in such a case there be a part of the tumour within 
 reach of the finger, a shallow puncture is made through 
 the vagina into the growth. 
 
 Fig. 29. 
 Apostoli’s Sound. 
 (One-third size.) 
 
 Fig. 30. 
 
 Keith’s Sound. 
 (One-half size.) 
 
 These punctures should always 
 
410 
 
 FIBROID TUMOURS OF THE UTERUS 
 
 be made behind the cervix and at a spot where no pulsa- 
 tion is felt. The depth must never exceed half an inch, 
 and may be even less. Before passing a sound or making a 
 puncture, the vagina must be thoroughly purified by being 
 syringed out with a strong solution of perchloride of mercury. 
 This is a precaution which must under no circumstances whatso- 
 ever be omitted. Should this not be done, the operator has only 
 himself to blame, if any trouble result. After the application 
 is over, the vagina must be again syringed out ; and when a 
 puncture has been made a pad of antiseptic gauze must be 
 placed against the spot. In all the haemorrhagic cases, and in 
 the majority of others, the positive pole is to be used inside 
 the uterus. The negative must always be employed with 
 caution, especially in delicate women. It reduces the size of a 
 tumour more quickly than the positive, and is generally used 
 when punctures are made, or when the tumour is giving rise 
 to pressure symptoms. 
 
 There must always be a certain amount of local action, and 
 this is of use in the bleeding cases, as the chemical cauterisation 
 destroys the bleeding surface. The chief action appears to be a 
 more general one, it consists in a lessening of the circulation of 
 the tumour, and is accompanied by a partial starvation and 
 consequent atrophy of the growth. Each application lasts for 
 five minutes, and there does not appear to be much, if any, 
 advantage in allowing the current to fiow for a longer time. 
 The sittings may be repeated every second day. 
 
 It is not necessary for the applications to be made while the 
 patient is in bed ; unless she be very weak she can come to the 
 surgeon’s house. After the application she may wish to rest 
 for half an hour or so, but many prefer to go home at once. 
 On the day of the application she must keep quiet, no dinner 
 party or theatre. The day after she can do much as usual, but 
 the more delicate people rest the more quickly they improve. 
 It is not uncommon for a patient to say, ‘‘ I cannot come next 
 day, as I am going out to dinner.” 
 
TREATMENT BY ELECTRICITY. 
 
 411 
 
 When the patient is very weak it is better to carry out the 
 treatment in her own home and in her own bed. 
 
 The first effect is often a depressing one ; for five or six 
 applications the patient may feel disturbed, after that, and if 
 too many applications are not made, the treatment has a tonic 
 effect, some patients feeling as if they had had a glass of 
 champagne. The number of applications will vary with the 
 strength of current the patient has been able to bear, and also 
 with the age of the tumour ; the older the growth, the slower 
 the progress. As a general rule it will be found that thirty 
 applications will be required. Should the patient be able to 
 bear but a small dose, 40 milliamperes or less, we may feel 
 certain that the growth is not a uterine fibroid, or that there is 
 some co-existing disease in the pelvis, probably of an inflam- 
 matory nature. The great advantage of the treatment by 
 electricity is the avoidance of all mutilation and the absence of 
 risk to life. Mutilation is placed first, because, as will be seen 
 when the consideration of the operative treatment of these 
 tumours is reached, the risk to life following one of the two 
 major operations is very little. ISTo young woman will willingly 
 allow her ovaries to be sacrificed, if she be made really to 
 understand what the operation means, and if the hope of a cure 
 can be held out to her without this mutilation. It is not 
 sufficient to say that the ovaries will have to be removed, 
 without explaining that their removal means the stoppage of 
 menstruation, and the impossibility of bearing children. The 
 disease under consideration is not a disease of the ovaries. It 
 is one thing to remove ovaries diseased in themselves, and quite 
 another to remove healthy glands for the purpose of curing 
 disease elsewhere. 
 
 A lesser advantage is, that the patient does not require to be 
 confined to bed, even for a single day, during the treatment. A 
 nurse is not required, and the bedroom need not be turned into 
 a sick-room. The patient has no anxiety, the friends are not 
 alarmed, and the whole excitement and general disturbance 
 
412 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 entailed by an operation is avoided. The chief disadvantage is, 
 that except in the case of small tumours the growths do not 
 entirely disappear. Small tumours, and by small are meant those 
 which do not rise much out of the pelvis as a rule, are completely 
 dissipated ; and when this result is obtained nothing could be 
 more satisfactory, the patient being restored to health a sound 
 and whole woman. 
 
 In a larger growth the symptoms disappear, the tumour is 
 reduced in size, and its future increase arrested. A second 
 disadvantage is that the treatment will usually extend over 
 three months. This is perhaps not a very great drawback 
 when the patient does not live at a distance, an hour’s journey 
 being of no particular moment; but when she has to leave 
 home for three months the question of time becomes of 
 considerable importance. 
 
 A third disadvantage, and perhaps the most important of all, 
 lies in the fact that with our present knowledge it is not possible 
 to say when the patient is cured; all that can be done is to 
 make an average number of applications and warn the patient 
 that a second course of treatment may be necessary, though this 
 is seldom required. Sometimes six months even may elapse 
 after the treatment is over before the patient can say she is 
 quite well. 
 
 When large tumours of 20 lbs. and upwards are treated 
 it is best to give half of the applications at one time, and 
 the remainder six or twelve months afterwards. In such cases 
 it may be even necessary to repeat the treatment at intervals, in 
 order to carry the patient on till the menopause. In these large 
 tumours this treatment is recommended only if the patient be 
 near the menopause, or if operation be impossible or is declined. 
 
 When a patient is so far spent that time is of importance, it 
 is advisable to make the applications every second day whether 
 bleeding is going on or not. 
 
 The menopause seems to come sooner, after this treatment 
 has been gone through, than would naturally be expected. 
 
TREATMENT BY ELECTRICITY, 
 
 413 
 
 One or two precautions which have been learned by experi- 
 ence may be given. The treatment ought not to be a painful 
 one, and should much suffering be caused it is certain that Dr. 
 Apostoli’s directions are not being carried out. The directions 
 to be given to the patient are, that the strength of the dose must 
 not be great enough to cause internal pain, and that if she 
 suffers it is her own fault for not at once mentioning it. The 
 reason why internal pain must not be allowed is that such 
 treatment is not free from danger, and even if it should not do 
 harm, the difference in the strength of the current which gives 
 comparative comfort and that which causes actual pain is so 
 small, that the slight good cannot balance the five minutes’ 
 suffering. 
 
 An application should not be made on any day when the 
 patient is feeling out of sorts, especially if she be in the slightest 
 degree feverish. The following are examples of how this treat- 
 ment is carried out : — 
 
 A patient forty-five years of age was sent to Edinburgh from 
 Inverness by her doctor for operation in the month of June 
 1887. She was probably the first patient treated by Apostoli’s 
 method in Great Britain. The lady and her husband were 
 willing to do anything to avoid the risk and anxiety of an 
 operation, even to be experimented upon so far at least as to be 
 the first case. The history was that she had never been 
 pregnant, and up to the age of forty had enjoyed good health ; 
 the periods were regular and were not in excess. Between the 
 ages of forty and forty-one there was a change. The time the 
 flow lasted began to be prolonged, and the quantity of blood lost 
 steadily increased. Keeping pace with this the general health 
 began to suffer ; she became breathless and anaemic ; the periods 
 continued for about two weeks, and returned sometimes after an 
 interval of one week, sometimes after an interval of two weeks, but 
 she was never dry for longer than two. She had to remain in bed 
 for at least one, and sometimes for two weeks at a time, or, in 
 other words, from three to six months in the year. While lying 
 
414 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 • in bed she was afraid to do anything for herself, as even the 
 simple raising of the arms above the head caused a sudden rush 
 of blood from the womb. After the period she was unable to 
 walk upstairs without assistance. When the bleedings began 
 to be severe she took ergot in large quantities with marked 
 benefit for a time. Latterly, however, it had ceased to be of 
 service, except that she thought that the bleeding would have 
 been worse had the drug not been taken. About the beginning 
 of the year the tumour was first noticed. 
 
 The patient was very anaemic and breathless, and on examina- 
 tion the tumour was found to extend to fully three inches 
 above the pubes. The cervix was situated far back, and there 
 was some difficulty in passing a sound to a depth of three and 
 three quarter inches. It was evident that this was a case for 
 the use of the positive pole in the uterine cavity. 
 
 The treatment was begun in June 1887, and, fortified by 
 what we had seen at Dr. Apostoli’s clinic in Paris, the patient 
 was allowed to walk home to her apartments, a distance 
 of perhaps three hundred yards. Next day she was found 
 to be none the worse, and a slight bloody discharge had 
 stopped. 
 
 The period came on at the end of the month and was much 
 as usual. The second did not appear until twenty-six days after 
 the first had stopped, the longest interval for more than three 
 years, and the quantity was much lessened. The patient went 
 liome nine weeks after the commencement of the treatment, 
 after twenty-one applications, averaging less than 100 milli- 
 amperes, each application having lasted for from five to ten 
 minutes. The following letters show the after results : — 
 
 “17th November 1887. — I beg to inform you that Mrs. E. 
 has passed through another of her periods, which was longer in 
 duration than the two former ones, although accompanied by 
 less hsemorrhage. It commenced on Sunday the 5th, and was 
 scarcely noticeable for three or four days, after that it was more 
 perceptible until the loth, when it vanished. The last two days 
 
TREATMENT BY ELECTRICITY. 
 
 415 
 
 there was very little. She did not go to bed through the day, 
 and feels quite strong now.” 
 
 “ 22nd December 1887. — I am glad to say that your treat- 
 ment has made her like another person.” 
 
 “27th January 1888. — I am happy to inform you that Mrs. 
 E. has just passed through another of her monthly periods very 
 easily, something similar to what used to be previous to her 
 tumour affliction. She had not to go to bed through the day, 
 and now feels quite strong.” 
 
 “ 27th August 1888. — Mrs E. desires me to acknowledge the 
 receipt of your kind note of inquiry, dated 24th inst., and to 
 thank you very much for your remembrance of her case, and to 
 say that her February period was light ; March, April, May, 
 June, and July, scarcely any bleeding ; but during her August 
 one a good deal, which was not to be wondered at, seeing there 
 was next to nothing the five previous months.” 
 
 “ 7th September. — Mrs E. had arranged to have her photo- 
 graph taken on Saturday last, the 1st inst., but her September 
 period coming on prevented her. She wished to have a card 
 freshly taken to show you how well she is looking ; but this turn 
 has made a very great change on her — she is now white and 
 weak. 
 
 “The first day there was not much bleeding; the second 
 there was more ; on the third, fourth, and first half of the fifth 
 there was much — very much; but less and less every day 
 since.” 
 
 “24th October. — Since I last wrote you about Mrs E., her 
 October period has come and gone. She was not nearly so bad 
 this time, although there were five and a half weeks between 
 the October and September ones. Mrs. E. desires me to enclose 
 her photograph, which, I think, will testify to her being in 
 pretty good health.” 
 
 “21st January 1889. — Since I last wrote you on the 24th 
 October, Mrs. E. has only had one slight — very slight — period, 
 and that on the I7th November ; thus nine weeks have passed 
 
4i6 fibroid tumours OF THE UTERUS. 
 
 without any indication of another. She is in good health and 
 spirits.” 
 
 It is interesting to note that there is no mention of the con- 
 dition of the tumour. The tumour itself was evidently considered 
 of no importance as long as it did not give rise to symptoms. A 
 thoroughly sensible view of the case. 
 
 In the summer of 1893, the patient called to show herself; 
 she said that she had menstruated fairly regularly for five years 
 after the treatment, and had kept well the whole of that time. 
 She ceased altogether at fifty, and had no trouble at that time. 
 
 A second example is the following, a patient forty-four years 
 of age, treated in 1887. The history had indeed been a sad one. 
 She said that she had been to every doctor in Edinburgh, and 
 that no one had been able to do her any good. She had been 
 ailing for fourteen years, or according to her husband for twenty- 
 one, but had been very ill for seven years after catching cold. 
 At that time she was in the early months of pregnancy and had 
 aborted. Since then her business had apparently consisted in 
 trying to get well. She had been an in-patient in the Infirmary 
 under the care of Professor Simpson and the late Dr. Angus 
 MacDonald ; and had been in 1885 in the Special Ward for the 
 treatment of ovarian diseases. All of the usual remedies had 
 been tried over and over again, and her recuperative power 
 appeared to be so slight that operation could not be advised, 
 more especially as it seemed probable that it would be difficult, 
 or perhaps impossible, to remove the ovaries. After three months’ 
 experience in the use of Dr. Apostoli’s method, and being con- 
 fident that the general tonic effects of the treatment would more 
 than counterbalance any disturbance the passage of a sound 
 mmht cause, the woman was sent for, and came for treatment 
 on the first day she was able to be out of bed, three weeks after 
 she got the message. 
 
 The patient was a thin, dark, sallow woman. On examination 
 of the abdomen an irregular tumour was felt lying against the 
 abdominal wall, and extending to three inches above the pubes. 
 
TREATMENT BY ELECTRICITY. 
 
 417 
 
 In the pelvis the cervix was found to be situated far back, and 
 a part of the growth pressed on the bladder. The sound passed 
 to a depth of four and a quarter inches. The patient stated that 
 she had been in constant pain for the last seven years, and for 
 fifteen years there had been a steadily increasing quantity of 
 blood lost at the periods. Before and for the first few days of 
 the menstrual flow the pain was very much aggravated, and 
 prevented her from sleeping. Menstruation now lasts for four- 
 teen days, and recurs after an interval of one week ; formerly, 
 its duration was seven days with a twenty-one days’ interval. 
 This was a very satisfactory case for the treatment, as there 
 appeared to be a very general consensus of opinion that any 
 operation would be attended by great danger to life. 
 
 21st September — 40 milliampbres for 5 minutes. 
 
 23rd „ 50 „ 5 
 
 Says that she feels stronger already. 
 
 3rd October — 40 milliamperes for 5 minutes. 
 
 The period came on ten days ago; the loss of blood was 
 greater than usual, and the patient feels very ill. 
 
 5th October — 40 milliampm’es for 5 minutes. 
 The bleeding stopped after the last application. 
 
 12th October — 40 milliamperes for 5 minutes. 
 
 14th 
 
 
 70 
 
 17th 
 
 
 70 
 
 24th 
 
 
 80 
 
 A second period since the treatment was begun is over. 
 It lasted seven days, was not very severe, and there was an 
 interval of two weeks instead of the usual seven days. 
 
 28th October — 120 milliamperes for 5 minutes. 
 
 There htis been some bleeding for two days. 
 
 27 
 
FIBROID TUMOURS OF THE UTERUS. 
 
 418 
 
 31st October — 120 milliamperes for 5 minutes. 
 
 4th November — 120 „ 5 ,, 
 
 Feels better and stronger, and looks more cheerful. 
 
 18th November — 100 milliamperes for 5 minutes. 
 
 Has been flowing for five days. Feels much better, is 
 stronger, and can walk better, and has little pain. 
 
 25th November — 135 milliamperes for 5 minutes. 
 
 28th „ 155 „ 5 
 
 5th December — 135 „ 5 „ 
 
 There has been rather more pain. 
 
 9th December — 100 milliamperes for 5 minutes. - 
 
 The pain is relieved ; there has been some haemorrhage for 
 three days. 
 
 12th December — 100 milliamperes for 5 minutes. 
 
 6th January 1888 — 160 „ 5 „ 
 
 Feels well although there has been as great a loss of blood 
 as she has ever had. The general health is undoubtedly much 
 improved. 
 
 8th January — 160 milliamperes for 5 minutes. 
 
 23rd „ 145 „ 5 „ 
 
 30th „ 110 „ 5 „ 
 
 Flow six days. Does not feel strong. 
 
 3rd February — 130 milliamperes for 5 minutes. 
 
 Is feeling better again. The weakness complained of at 
 last visit was probably due to some little stomach derangement. 
 
 10th February — 135 milliamperes for 5 minutes. 
 
 13th „ 140 „ 5 „ 
 
 27th „ 275 „ 5 „ 
 
 The period on this occasion lasted nine days ; there was 
 much less flow and much less pain. 
 
TREATMENT BY ELECTRICITY. 
 
 419 
 
 29th February — 220 milliamperes for 5 minutes. 
 
 2nd March — 250 „ 5 „ 
 
 5th „ 230 „ 5 
 
 The patient says that she feels quite well to-day, and has 
 not done so for ten years. 
 
 9th March — 245 milliamperes for 5 minutes. 
 
 19th „ 270 „ 5 „ 
 
 There has been less loss during the menstrual period, which 
 is just passed, than there has been for a long time. There was, 
 however, more of the old pain for the first two days. 
 
 21st March — 220 milliamperes for 5 minutes. 
 
 23rd „ 225 
 
 26th „ 200 
 
 28th „ 210 
 
 30th „ 235 
 
 31st „ 210 
 
 2nd April— 210 
 
 The internal electrode was, in every one of the thirty-seven 
 applications, attached to the positive pole of the battery. 
 
 The patient was afraid that the improvement might not be 
 permanent, but the following extract from a letter, dated 5th 
 February 1889, shows that her alarm was groundless : — “ My 
 period now comes once a month and lasts a week. I have pain 
 a day or two before, and rather worse the first day of the period, 
 but nothing to what it was before the electricity. My general 
 health had been bad since the pain began. I have not felt 
 so well for twelve years. After the treatment was stopped I 
 gradually grew stronger, and have never been laid up a day 
 since you left Edinburgh. I am able to walk without pain or 
 discomfort of any kind, and can’t feel grateful enough to you for 
 all your kindness.” 
 
 In the beginning of 1891, the patient was examined and a 
 uterus of normal size, with a two and a half inch cavity, was 
 
420 
 
 FIBROID TUMOURS OF THE UTERUS 
 
 found. The patient was perfectly well, and menstruating 
 regularly. 
 
 A patient twenty -four years of age gave the following 
 history : — The periods began at fourteen and had been always 
 copious. By degrees the intervals became shorter and the 
 quantity greater. For four years menstruation came every 
 three weeks, and the last went on for twenty-one days without 
 any interval. She was thin, though there was no pain, and she 
 could walk fairly well. In a wnrd, her only complaint was the 
 long continuance of the period and its uncertainty as to quantity 
 ■ — the least excitement increasing the flow. She could not go 
 out with a light dress to a theatre or concert, or out to dinner 
 or any evening amusement, or play tennis in summer. She was 
 debarred from the pleasures of young people, and on the very 
 few occasions she ventured out in a light dress it was almost 
 always soaked through before she got home again. Eemedies 
 had been tried without making any change in this condition. 
 
 The uterus was large and somewhat fixed. The cervix was 
 very large, and the os admitted the point of the finger. The 
 probe passed with difficulty three and a. half inches, and would 
 probably have gone farther if the uterus had not been so fixed. 
 There was no growth inside the cavity. The treatment lasted 
 six weeks, and twenty applications were made. Instead of at 
 most three days’ respite, the first interval was three weeks — the 
 longest for four years. The period lasted four days, and was 
 quite moderate; and as the next was also normal, no farther 
 treatment was advised. The uterus was then soft and movable, 
 the cervix was no longer open, the os was small and closed, and 
 the cervix half the size. The uterine cavity was scarcely above 
 two and a half inches in length. Six months afterwards the 
 patient was married, and has since had at least one child. 
 
 There is a somewhat unreasonable objection to Dr. Apostoli’s 
 treatment, and two examples of this may be given : — A lady 
 sufi’ering from menorrhagia was very strongly urged to submit 
 to the removal of the ovaries, and, after she had been cured by 
 
CURETTING. 
 
 421 
 
 electricity, and before any signs of the menopause, she was asked 
 by the same gentleman whether she had been cured l)y time or 
 by Dr. Keith ! In the other case, a surgeon attached to one of 
 the large hospitals said to a lady whom he had known six years 
 before when she was in bad health due to symptoms caused by 
 a fibroid tumour, that she was looking very well, and he asked 
 what had done her good. Although he must have known that 
 the lady had been kept in her bed for two years without benefit, 
 and was so ill that hysterectomy had been consented to, yet he 
 said it was “ rubbish ” when she told him that Apostoli’s treat- 
 ment had cured her. He said that rest had done it ! She had 
 not rested either during or after the electrical treatment. 
 
 In this connection may be mentioned the remarks made by 
 a medical student speaking in glowing terms of a lecturer who 
 had dismissed the electrical treatment in a few words as being 
 absolutely useless : — “ I saw a hysterectomy performed on a 
 patient forty-five years of age where there were almost no symp- 
 toms. How any one could have made a diagnosis with so little 
 to go on I cannot imagine.” This tumour, causing scarcely a 
 symptom, was about the size of a breakfast cup, yet hysterectomy 
 was performed. 
 
 Curetting. 
 
 When a patient with a bleeding fibroid has nearly reached 
 the menopause, and when the uterine cavity is not very irregular, 
 nor longer than perhaps five inches, scraping away the soft 
 unhealthy bleeding surface, or curetting, may be sufficient to 
 tide the patient over the menopause with comfort. This slight 
 operation may have to be repeated several times, but it is useless 
 in young women, or when the menopause is likely to be delayed 
 for a number of years. The operation is of the simplest, ether 
 is administered, the patient is placed on the side, and a Sims’ 
 speculum is introduced ; the vagina is thoroughly washed out 
 with a solution of perchloride of mercury ; the cervix is rapidly 
 dilated, Goodell’s dilator being better than Hegar’s ; and the 
 
422 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 whole lining surface of the uterus is gone carefully over with a 
 blunt curette, — Martin’s will be found a useful instrument. An 
 attempt to examine the interior of the uterus with the finger 
 should be made. This is sometimes not easy, and at other times 
 it is impossible. The cavity is next thoroughly washed out with 
 a hot antiseptic solution introduced at a low pressure, and as 
 much iodoform gauze as the uterus will hold is packed tightly 
 in. The advantage of using the gauze is that any fungosities 
 missed by the curette will be destroyed by pressure. The gauze 
 is to be taken out in twenty-four or forty-eight hours. The 
 patient remains in bed for a week or ten days, and can then go 
 about as usual. 
 
 Eemoval of the Ovaries. 
 
 The consideration of the removal of the uterine appendages 
 for the cure of a uterine fibroid opens up the question of what 
 is the cause of menstruation. Until lately the influence of the 
 ovaries was supposed to be the only cause. Later it was 
 suggested that the Fallopian tubes might have something to 
 do with the phenomenon, but this theory appears very properly 
 to have been given up. A third suggestion has been made by 
 Dr. Johnstone of Cincinnati, that the cause is situated in a nerve 
 fjanglion which is to be found at each side of the uterus. To 
 say that the nervous system has something to do with the 
 monthly flow is little more than a truism, but at present we do 
 not know of any part of the nervous system, the removal of 
 which will stop menstruation, although it is practically certain 
 that there is a nerve centre in the spinal cord. 
 
 The following history excludes the idea that the origin of 
 menstruation lies in these ganglia on each side of the uterus, 
 for it will be seen that the case is one on which the theory was 
 principally built up, and the removal of the ganglia did not stop 
 the monthly discharges : — 
 
 In March 1890, Dr. Keith was asked to see a young lady, 
 who was then residing in Bournemouth, and who sent the 
 
REMOVAL OF THE OVARIES. 
 
 423 
 
 following history of her case : — “ My illness first began ten years 
 ago. I had a swelling every month in my right side. I went 
 to Scotland, and walked a great deal, and swam every day in the 
 sea. Suddenly a bad pain came on in the back of my leg, just 
 opposite to where I had the swelling in front. My monthly 
 time would never come on, except I put mustard poultices on 
 the back of my leg. I had this pain for more than two years. 
 The doctors thought it was sciatica. I had electricity and two 
 steam baths a day. When I was in my bath my pain was 
 better. I was three months at the Turkish baths, the pain 
 returned directly I stopped having them. A pessary with a 
 stem was introduced, and I was told that I need not take any care 
 of myself, that I might even ride ; a fortnight afterwards I went 
 to the North of Scotland ; inflammation set in ; the pain, instead 
 of only being at the back of my leg, began also to come into the 
 front. I became sick, and had to send for a doctor, and he said 
 that the pessary had fallen out, I was obliged to have leeches 
 on. I managed to get to Edinburgh, where Dr. Angus Mac- 
 Donald attended me, and on examining me he said that my 
 inside was like a boggy mass. He painted me with iodine, and 
 I had also iodine injections, and was burnt at the back of my 
 leg. At last I had an operation; Dr. MacDonald took away 
 my left ovary, hut, although he hunted for an hour, and told me 
 I had been very roughly handled in the search, he could not 
 find the right ovary. The next month, my monthly period 
 came on again, and the pain in the hack of my leg was as 
 bad as ever. At last Dr. MacDonald told me that he had 
 just seen Mr. Lawson Tait, and he was of the opinion that 
 they might have another try to find the missing ovary ; 
 but before the operation could be attempted. Dr. Angus Mac- 
 Donald died. I then went to Mr. Tait. He operated again 
 and took away the uterus, as he said there was an incipient 
 tumour in it. At first we did not know that he had not found 
 the ovary, but in reply to a direct question, he admitted it, and 
 said it must be virtually destroyed, and would not affect me in 
 
424 FIBROID TUMOURS OF THE UTERUS. 
 
 any way. A month afterwards my monthly period came again, 
 however, and I could never raise my right leg without bringing 
 on a great deal of pain in my right side. I went to Mr. Tait, 
 but he said that I was all right, and must amuse myself as much 
 as possible. I went to the Kiviera, and was a little better there, 
 if I kept very warm and did not walk. Subsequently we went 
 for a year to India, and the improvement was much more 
 marked, though still I could not walk or raise my right leg 
 without pain. For a month I even attempted riding and playing 
 tennis, but had to give these up, as at my monthly times they 
 brought on strong irritation, although all the doctors had told me 
 I might take any exercise I liked. If I kept quiet, I never 
 suffered at all from my monthly periods while I was in India. 
 Suddenly we were obliged to return to England, and since then 
 I have scarcely been out of bed. I have usually a severe attack 
 of three weeks’ duration nearly every month, and besides the 
 ovary the stump of the uterus now gives me constant pain. I 
 was five months in bed last winter and expect to be so again. 
 During the summer the pain is not quite so bad. It is now 
 four years last March since my last operation, and my monthly 
 times still continue, but in England a very small quantity comes 
 from me, and that is as thick as glue.” In a letter from the 
 sister about the patient coming to town she said, ‘Mt is 
 her monthly period at present, so she could not travel for 
 another ten days.” The continuation of the history is taken 
 from Mr. Tail’s book on Diseases of Women and Abdominal 
 Surgery : — 
 
 “ When the ovary of one side (or of both) has not been 
 developed, the uterus being normal, a curious condition is met 
 with, which I have not yet seen described, but which I have 
 often seen in operating. From the uterine cornua the tubes 
 depart in a normal condition of size, direction, and relation to 
 other structures. But before they have gone far the folds of the 
 broad ligament separate, it gets lowered and flattened, and it 
 finally gets lost in the walls of the pelvis. The tube (or tubes) 
 
REMOVAL OF THE OVARIES. 
 
 425 
 
 is lost in the ordinary widening of the broad ligament, and no 
 ovary (or ovaries) is to be found. 
 
 ‘‘ In the great bulk of such cases it is reasonable to suppose 
 that no trouble exists save sterility in such as have married. 
 But in some cases the sufferings are so great as to call for 
 surgical interference, and a typical case of this kind was placed 
 under my care, as almost the last act of his life, by my lamented 
 friend, the late Dr. Angus MacDonald of Edinburgh. The 
 details of this case possess such extreme interest that I must 
 give them in full. 
 
 “ I communicated with her, and had a long letter from the 
 patient’s mother, giving a lamentable account of her sufferings. 
 The patient was entirely unable to walk, could not even be 
 driven in a carriage without intense pain, and when I saw her 
 every feature of her face confirmed a belief in the reality of her 
 sufferings. These had without doubt been increased by the 
 incomplete operation in the previous September. I visited the 
 patient at Clifton on the 14th of March 1886, and arrived at 
 once at the conclusion that nothing short of the removal of the 
 body of the uterus would be of any avail. I found that the 
 patient’s symptoms had been added to by a fresh complication 
 of menorrhagia, that since the operation in September the amount 
 of monthly loss had been increased, and with it her sufferings 
 had been intensified. On examination it was quite evident that 
 the fundus of the uterus was very large, and was pulled down 
 to the left side. I reopened the abdomen and found the condi- 
 tion as Dr. Angus MacDonald had told me. A puckered spot 
 on the left broad ligament, from which he had removed the 
 uterine appendages, was perfectly apparent, and no trace of 
 ligature could be discovered. On the right side the tube could 
 be felt on the cornu of the uterus, going into the broad ligament, 
 and then the broad ligament opened out and was flattened down- 
 wards, and was lost in the wall of the pelvis. No trace of any 
 ovary could be discovered on that side at all. I pulled the 
 uterus well out of the wound, dissected out from the incomplete 
 
426 FIBROID TUMOURS OF THE UTERUS. 
 
 broad ligament the Fallopian tube as far as it could be felt, 
 and then separated the body of the uterus from its secondary 
 textures. I passed a ligature through it, well down towards the 
 cervix, and tied it by the Staffordshire knot, and then cut away 
 at least two- thirds of the organ. The patient made an easy 
 recovery. In the wall of the uterus I found a small myoma, 
 not much bigger than a filbert nut. The growth of this after 
 the first operation is remarkable, and no doubt its presence 
 explained the increased suffering and the increased menorrhagia. 
 The Fallopian tube on the right side was found on the cornu of 
 the uterus, perfectly normal in appearance and structure ; then, 
 as I have already said, it became lost in the cellular tissue of 
 the broad ligament. 
 
 “ The subsequent convalescence of the patient was extremely 
 slow, for at the end of the year, after several months’ residence 
 in the Eiviera, she had made much less progress than I had 
 anticipated. She was able to walk (which she had not done for 
 many months before the operation), but not for more than ten 
 minutes at a time. She suffered intensely from cold, her 
 mother said her circulation was extremely bad, and that she 
 literally was never warm. She got an idea that she would like 
 to go to India, where she had a brother, and with this proposal 
 I quite agreed. Up to this time there was still an appearance 
 of menstruation, but irregularly, more scanty, and relatively 
 devoid of pain. She has now excellent health, and is able to 
 play lawn-tennis. Menstruation has entirely ceased, and she is 
 quite free from pain.” 
 
 The following is an extract from Dr. Arthur Johnstone’s 
 
 O 
 
 paper as reported in Mr. Tait’s book, and it shows very clearly 
 that the removal of these plexus did not in this case at least 
 stop the menstruation ; — 
 
 “ This led me to study more closely the sympathetic plexus 
 of the broad ligament, and I found that, besides quite a large 
 amount of filaments, which accompany the Fallopian tube and 
 the uterine branch of the spermatic artery, there is one 
 
REMOVAL OF THE OVARIES. 
 
 427 
 
 particularly large trunk wtiich comes up at a very acute angle 
 to the body from deep down in the base of the broad ligament, 
 and enters the uterine cornu just underneath the angle of the 
 Fallopian tube. This nerve lies so close to the body that, if the 
 operator is not extremely careful to extirpate the whole of the 
 Fallopian tube, he is very apt to miss it. This I believe is the 
 track through which the endometrium receives its physiological 
 orders, and that section of this nerve does for the endometrium 
 exactly what the section of the chorda tympani does for the 
 submaxillary gland. 
 
 “ I saw, in connection with Mr. Tait, another striking case in 
 support of this idea. The attempt at an artificial menopause 
 had been made by an Edinburgh surgeon, but the patient came 
 with the report that only one tube and ovary could be removed. 
 
 “ At the second operation no trace could be found of anything 
 that looked like a tube or ovary on the right side. As she had 
 been made desperate by her sufferings, she urged on Mr. Tait 
 the necessity of relief at any risk, and he accordingly removed 
 the uterus at the internal os. I took the specimen, and after 
 carefully freezing it, and examining every section from the 
 margin of the endometrium to the peritoneal periphery, the only 
 attempt at a Fallopian tube I could find was a slightly exaggerated 
 development of the uterine follicles in the right cornu. Although 
 she had one or two slight attempts at menstruation, she 
 subsequently quieted down, and got permanent relief from her 
 old trouble. 
 
 “ The first operation had completely isolated the endometrium 
 from its nerve supply on the left side, but, in spite of the fact 
 that the tube and ovary on the right side had never been 
 developed, still the nerve plexus kept up its control of the 
 endometrium until completely severed by the second operation. 
 Thus I think that we will be safe in saying that it is not the 
 removal of the ovary, or the removal of the tube itself, that 
 brings on the change of life, but that it is the neurotomy which 
 the ablation of these organs necessitates which completely 
 
42 8 FIBROID TUMOURS OF THE UTERUS. 
 
 isolates the endometrium, and leaves it like the lower limb 
 after the section of the great sciatic.” 
 
 The lady was seen on 22nd April 1890. She was emaciated 
 to an extreme degree, the pulse was rapid, she looked forty or 
 forty-five instead of twenty-nine years, and looked as if she were 
 in constant pain. In every way she was worse since the operation 
 on the uterus, and whenever she got the slightest chill the pain 
 in that organ was terrible, and was accompanied by persistent 
 vomiting. On going carefully into the history, there could not be 
 a doubt about the presence of the right ovary ; the statements 
 were so exact that there liad never been any pain in the region of 
 the uterus until after Mr. Tait’s operation, and the fact of the 
 continuance of menstruation made this certain. On examination 
 the uterus was found to be somewhat fixed and drawn to the 
 left, the uterine cavity measured slightly over two inches, and 
 the ovary could not be felt. It was to be expected that after 
 Drs. MacDonald and Tait had both failed to find the ovary, it 
 would be discovered in some abnormal position, and from the 
 patient’s description it was concluded that it was probably lying 
 in the sciatic notch. On writing to Sir William Turner, he 
 told us that the account of an ovary being found in this 
 situation was to be obtained in Camper’s Demonstrations, and 
 here we found it described. 
 
 A few days after coming to town the lady had one of her 
 “ chills,” accompanied by vomiting and excruciating agony 
 in the position of the uterus. She became so much reduced 
 that an operation hardly seemed possible. After waiting 
 seven weeks to allow of a slight recovery the operation was 
 performed. Expecting a difficult operation, a three inch 
 incision was made, the fingers were passed at once into the 
 sciatic notch and over the whole side of the pelvis ; there did 
 not appear to be a particle of fat anywhere, but the ovary was 
 not found. The uterus to which the omentum was adherent 
 was drawn over towards the left side. Not finding the ovary 
 below its natural position, it was felt for higher up and was 
 
REMOVAL OF THE OVARIES. 
 
 429 
 
 immediately discovered. It was enlarged, non- adherent, and 
 was removed along with an inch of the outer end of the 
 Fallopian tube. Its weight was found to be 295 grains. The 
 operation lasted twelve minutes, and it was fortunate that it was 
 so simple, as the patient would probably have died on the table 
 had it been much longer. Menstruation has never recurred, the 
 original ovarian pain is gone, but the uterine pain, which first 
 appeared after Mr. Tait’s operation, is still at times troublesome, 
 and has prevented the patient regaining her strength. 
 
 The ovarian theory of menstruation plus a centre in the 
 spinal cord somewhere is still the best. Patients have 
 undoubtedly menstruated regularly after the removal of both 
 ovaries, but the fact that both these glands have apparently 
 been removed is not a guarantee that no ovarian tissue has been 
 left. 
 
 The practical outcome — and it is this that is of importance to 
 the patient — is, that the ovaries and as much of the broad ligament 
 as possible, including the Fallopian tubes, are to be removed. 
 There is no harm done by taking away too much, the fault is 
 in removing too little. 
 
 The necessity of removing the whole of the Fallopian tubes is 
 well seen in the following case : — In the beginning of 1893 a lady 
 thirty-three years of age was operated on, who gave the following 
 history. Three years before, the left tube and ovary had been 
 removed for persistent pain in the left side by an accomplished 
 abdominal surgeon. Improvement did not follow the operation, 
 and when seen the pain was situated not only on the left side 
 but also in the right. Examination revealed an ovary enlarged 
 to fully four times its natural size on the right side, and on the 
 left projecting from the side of the uterus an exquisitely tender 
 nodule the size of the tip of the forefinger could be felt. When 
 the second operation was performed this nodule was found to be 
 the closed end of the Fallopian tube, which when removed was 
 found to contain a few drops of sero-purulent fluid. 
 
 The operation of the removal of the ovaries for the purpose 
 
430 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 of bringing about an artificial menopause, and in this way 
 curing the symptoms caused by the presence of a uterine fibroid, 
 was first performed by Dr. Trenholme of Montreal. The field 
 for this operation is limited by the size of the tumour, by its 
 exact nature, and by the position of the ovaries in relation to 
 the tumour. AVhen the uterine growth extends much above the 
 umbilicus, the effect of the removal of the ovaries does not 
 appear to be beneficial. Soft oedematous tumours, and those 
 also where there is ascitic fluid or when there is a profuse 
 leucorrhoea, cannot be cured by this operation with certainty. 
 In a certain number of cases, the ovaries are placed so close to 
 the tumour or even may be so incorporated with the capsule, 
 that it is not possible to remove them without injury to the 
 uterine growth. 
 
 The ultimate result of the complete removal of the ovaries 
 in small tumours is extremely beneficial. The symptoms are 
 cured, the growth is arrested, and in a considerable number of 
 cases the uterus gradually returns to its natural size. This 
 reduction may occur with great rapidity, sometimes accompanied 
 by a profuse watery discharge, or it may take six months or a 
 year. In our experience there is always a certain amount of 
 reduction in the size of a fibroid tumour after this operation. 
 
 There is always a hsemorrhagic discharge from the uterus, 
 commencing on the second or third day after this operation. 
 This is also seen after the operation of double ovariotomy, 
 and after the removal of the appendages for inflammatory 
 disease. Until this discharge comes on, and sometimes it 
 amounts to a flooding, there is usually some nervous disturbance. 
 On this account it is well not to operate immediately after 
 a menstrual period if the patient be very weak. The time to 
 select is midway between the periods ; the patient has then 
 made up some blood, and the tumour has not commenced to 
 swell. 
 
 On examination the ovaries can sometimes be felt through 
 the abdominal wall, and when this can be done the incision will 
 
REMOVAL OF THE OVARIES. 
 
 431 
 
 be made near the umbilicus or near the pubes, as is most 
 convenient. When they are not felt, the incision is to be made 
 over the centre of the tumour long enough to admit two fingers. 
 As soon as the broad ligament is reached, the fingers are passed 
 behind it and as deeply in the pelvis as possible, and then in 
 most cases the ovaries will be reached. The ovary is drawn up, 
 the tumour being rotated if necessary, the broad ligament is 
 transfixed as close to the tumour as possible and tied, and the 
 ovary and tube are cut away as near the ligature as is safe. As 
 soon as it is seen that there is not any bleeding the ends of the 
 ligatures are cut short. When one has confidence in the 
 method of tying, it is better not to leave a pair of forceps on 
 the stump while the other ovary is being treated, as some 
 tearing might result. The other ovary is ligatured and cut off 
 in the same way and the wound is closed. When the ovaries 
 are not at once come on, the fingers are to be passed over the 
 top of the tumour and swept round the back of it towards the 
 sides of the pelvis. In specially difficult cases the incision 
 may have to be enlarged, to admit the whole hand, but with 
 practice this is not often necessary. Some operators occasionally 
 find it convenient to turn out the tumour, remove the ovaries, 
 and then push back the growth into the abdomen or pelvis. 
 This is not a practice to be recommended. 
 
 To elevate a small tumour it is necessary to get the hand 
 well behind it, and if this can be done it will usually be possible 
 to bring the ovaries within reach by a little manipulation. 
 
 A lady thirty-seven years of age was seen early in the 
 summer of 1892 and gave the following history : — For years, the 
 monthly losses had been increasing till the periods became so 
 bad that she was hardly able to do anything. In the beginning 
 of the year she was treated by electricity, evidently not after Dr. 
 Apostoli’s directions, as great pain was caused, and the abdomen 
 was almost covered with numerous scars of burns caused 
 by the passage of the electrical current. No benefit resulted. 
 On examination a fibroid tumour of the uterus was found to 
 
432 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 extend to witliin two inches of the umbilicus ; the os admitted 
 the tip of the finger, and a submucous part of the tumour 
 could be felt attempting to become enucleated. The patient was 
 advised to wait and see if the tumour would enucleate properly, 
 as she did not wish to have more electricity, and absolutely 
 declined to have the ovaries removed. To check the violent 
 bleedings for a time the uterus v/as curetted. The lady came 
 back in November 1892, she had lost much ground in the 
 interval, she was thin, and the bleedings were worse than ever. 
 The face was yellow, eyelids and lips colourless. The tumour 
 was of the same size, the os was closed, and the sound showed 
 that there had been no attempt at enucleation since the former 
 visit. Eemoval of the ovaries was again advised and reluctantly 
 consented to, as the lady did not wish to go home uncured, 
 especially as her mother and brother were ill. The incision was 
 made over the centre of the tumour long enough to admit two 
 fingers, and the ovaries were reached and brought to the surface 
 Avith difficulty. Towards the end of the second day the usual 
 uterine discharge came on, it lasted five days and was not 
 excessive. 
 
 Before tlie patient went home on the nineteenth day after 
 the operation, the tumour had very sensibly diminished in size, 
 but when last heard of the bleedings were still going on. 
 
 A patient thirty-three years of age had known of the 
 presence of a tumour for five years. For the same length of 
 time she had suffered from great losses of blood every month. 
 
 On examination the tumour was found to extend to midway 
 between the pubes and umbilicus, rather more on the left than 
 on the right side. The pelvis was packed with the mass, Avhich 
 extended on both sides to the pelvic wall and filled up the 
 entire hollow of the sacrum. It was evident that the tumour 
 itself could not be removed, so it was agreed to take away the 
 ovaries if possible. The left one Avas to be felt high up on the 
 side of the tumour. On the right side there Avas a tender spot, 
 but no trace of ovary could be found. 
 
REMOVAL OF THE OVARIES. 
 
 433 
 
 The operation was performed in May 1886, the omentum 
 was spread out over the tumour and adherent to it, and with 
 some difficulty the left ovary was got hold of. The incision was 
 enlarged and the ovary was brought well into view. It was 
 fairly healthy, and the tube was dilated to the size of one’s 
 thumb. The broad ligament was transfixed as close to the 
 uterus as possible, the ligatures were tied and the parts removed. 
 The right ovary was deeply situated in the pelvis enclosed in 
 the layers of the broad ligament. By drawing up the tumour 
 and throwing light into the pelvis by means of the reflector, the 
 exact position of the ovary was seen. Eunning over it and 
 towards the bladder, which was drawn up and displaced to the 
 right, the ureter was detected. Under the circumstances it was 
 thought best to make no attempt at removal. The patient went 
 home in three weeks, and the haemorrhage was lessened for 
 a time, but when she came back in November 1887, the 
 bleedings were worse than before the operation, they lasted 
 one week and recurred twice in the month. The tumour 
 reached to the umbilicus. She was treated by electricity, 
 applications of an average strength of 145 milliamperes, for five 
 minutes at each sitting, being given. On 11th June 1889 
 her doctor wrote as follows : — “ She is looking a great deal better, 
 and has lost the anaemic appearance which she had. She says 
 that there has been no flooding for twelve months, she is quite 
 regular in her periods, and the discharge is natural and painless ; 
 and this has been the case since four months after ceasing the 
 treatment. The tumour is much the same as when I last 
 examined her — a large globular mass, tender in parts on pressure, 
 and as big as a five months’ pregnant uterus. Mrs. M. has just 
 been changing her residence, I found her working. She says 
 she has no more difficulty than she had seven years ago, when 
 her trouble first commenced, and can work all day without 
 distress.” 
 
 28 
 
434 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 Hystekectomy. 
 
 The operation of hysterectomy for a fibroid tumour or 
 myoma means the removal of part or the whole of the uterus 
 along with the tumour. The removal of a pediculated fibroid 
 tumour is an operation seldom required. In rare cases where 
 the size of a pediculated growth is large enough to cause 
 suffering, removal is necessary. In such a case the operation is 
 one of extreme simplicity unless the tumour be closely and 
 extensively adherent. 
 
 The incision is a long one, and after the tumour has 
 been exposed it is drawn out of the abdomen after getting 
 a firm hold of it with one or two corkscrews, or it is pressed out 
 by the hand passed behind it. One or more large sponges are 
 placed in the abdomen to prevent extrusion of the bowel 
 while the pedicle is being treated and the stitches put in. If 
 the pedicle be narrow enough to allow of its being transfixed 
 and tied with safety, the tumour is then cut off, the pedicle 
 dropped back, and except for the time taking in suturing the 
 long wound the operation is performed in a few minutes. 
 When the pedicle is thicker it may still be transfixed and 
 tied with silk, if the neck be thoroughly crushed either in 
 a clamp or in the grasp of a large pair of forceps. Should it 
 not be possible to do this a temporary elastic ligature is put 
 round the neck, but if this also cannot be done it is not of 
 much importance, as there is usuall}^ little circulation in these 
 tumours. The growth is cut off, leaving slightly curved anterior 
 and posterior flaps, so as to make the stump concave. Any 
 large vessels are tied. As a certain amount of pressure is 
 required to stop all oozing it is not suflicient simply to bring 
 together the edges of the flaps. Finest silk of undoubted purity 
 is threaded on a curved needle, and brings together the deeper 
 part of the stump, then the more superficial tissue is stitched in 
 like manner until finally the peritoneal edges are brought into 
 apposition. 
 
HYSTERECTOMY. 
 
 435 
 
 Another plan is to pass stitches from one edge to the other 
 through the whole thickness of the tissue, the silk never being 
 exposed. The stump is then dropped back, or if a temporary 
 ligature have been used, it must be removed and the stump 
 watched for a little before it is allowed to pass out of sight. 
 
 The cautery is not a satisfactory method of dealing with 
 these pedicles. Such operations are as simple as an uncom- 
 plicated ovariotomy, and the after treatment does not vary in 
 any way. 
 
 Hysterectomy is often and, especially in the cases where 
 operation is really necessary, a much more formidable operation. 
 Adhesions when they occur are always specially firm and 
 exceedingly vascular, and the haemorrhage which results from 
 their separation is sometimes exceedingly alarming. The reason 
 of this is that the capsule is the vascular part of the tumour, 
 and in it there may be sinuses of enormous size. The firmness 
 of the adhesions is often so great that the tumour cannot be 
 separated, and surrounding tissue may have to be removed 
 along with the growth. 
 
 As an example the following may be extracted from Dr. 
 Keith’s book on Hysterectomy : — ‘‘ The incision was upwards of 
 twenty inches, and was as near the ensiform cartilage as was of 
 any use. No line of demarcation could be made out between 
 the peritoneum of the tumour and the wall ; adhesion was 
 everywhere most intimate. The tumour was cut into without 
 any better result, and bleeding was free. The omentum also 
 came in between the tumour and wall, adherent to both ; and, as 
 all the tissues were cedematous, this only increased the difficulty. 
 The wall was rapidly cleared off the tumour by the free use 
 of scissors. The transverse colon was firmly attached all along 
 the upper margin ; and, in separating this, it was deprived of its 
 omentum and partly of its mesentery. Much force was necessary 
 to tear out the tumour, on account of the firmness of the adhesions 
 everywhere. These were temporarily secured by every available 
 pair of locking forceps, forty-nine in number. About seventy 
 
436 FIBROID TUMOURS OF THE UTERUS. 
 
 ligatures, partly of silk and partly of catgut, were left. The 
 omentum was so lacerated that most of it was cut away. In 
 some places the vascularity was great, especially where the 
 bladder was separated downwards off the tumour. Finally, 
 the stump was fixed in the lower angle of the wound along 
 with both ovaries, and the incision was closed by thirty-five 
 sutures. The peritoneum was so adherent to the tumour that 
 it was almost all stripped off the wall, and in places the 
 intestines were in contact with the muscles when the wound 
 was closed. The operation lasted nearly two hours. The 
 weight of the tumour was 35 lbs., and on examining it after 
 its removal from the body it was impossible to separate the 
 adherent peritoneum, even by careful dissection. Nearly the 
 whole of the parietal peritoneum, and in places cellular tissue, 
 remained on the tumour.” 
 
 It is not, however, so much the difficulty due to the presence 
 of adhesions that is to be feared, but the chief difficulty is owing 
 to the way in which the broad ligaments are affected by the 
 growth of the tumour. 
 
 Thirty j^ears ago Dr. Keith was asked to see a woman forty- 
 five years of age in Glasgow who had a very large tumour, which 
 was supposed to be ovarian. He found it to be a fibroid tumour 
 of the uterus which had opened up the folds of both broad 
 ligaments, and had spread itself out so closely to the walls of 
 the pelvis that he expressed the opinion that it could not be 
 removed. Some time after he was asked to reconsider his 
 opinion and to sanction an operation. The second examination 
 simply confirmed the first, but he suggested that the surgeon in 
 charge of the case should make an incision and satisfy himself. 
 The tumour could not be removed even when a second attempt 
 was made to do so fost mortem. 
 
 A reference to the separation of the broad ligament by intra- 
 ligamentous ovarian tumours will explain how this difficulty 
 arises. The position of the uterus in relation to the broad 
 ligaments also explains why this complication should be fre- 
 
HYSTERECTOMY. 
 
 437 
 
 quently met with. The two broad ligaments may he considered 
 as one ligament, in the centre of which is placed the uterus ; 
 the upper edge of this divided ligament reaches to the fundus 
 of the uterus. At the spot where the round ligament comes off, 
 the two folds of peritoneum may he said to be close together ; 
 as they pass down into the pelvis they become farther apart 
 until they finally leave one another, the one passing backwards, 
 the other forwards. The sides of the uterus are in direct 
 contact with the cellular tissue between these folds of the 
 ligament. It is therefore evident that any tumour of the 
 uterus, unless it arise from the fundus or as a pediculated 
 growth from the anterior or posterior surface, must, as it 
 increases in size, open up one or both broad ligaments to some 
 extent. The following case, operated on by Dr. Keith, is an 
 example of what occurs when a tumour commences to grow 
 low down on the side of the uterus. It will be noted that the 
 relations of the tumour were exactly the same as those in the 
 case of an ovarian tumour situated entirely outside the peri- 
 toneal cavity : — 
 
 “ A married lady, aged thirty-two, having got a diversity of 
 opinions in Glasgow as to the nature of an abdominal tumour 
 which was first noticed after her marriage, went to London to 
 consult the authorities there. All seem to have agreed that 
 the tumour was ovarian. She might have an operation when 
 she could not walk a mile, though at the time she could not 
 walk a hundred yards without discomfort ! She returned home 
 much discouraged, for she felt that whatever the nature of the 
 tumour might be, no one there seemed to care to have anything 
 to do with her. She then drifted here (Edinburgh), as many a 
 bad case has drifted before. She was fat, and seemed to be in 
 fair health. Two years ago she had several severe inflammatory 
 attacks with great pelvic pain, confining her to bed for weeks 
 at a time. The abdomen was distended by a soft fluctuating 
 tumour. Careful examination discovered the fundus of the 
 uterus in the left loin above the crest of the ilium. The uterus 
 
438 FIBROID TUMOURS OF THE UTERUS. 
 
 was tender, slightly movable, and of normal size. Internally, 
 the finger entered a narrow tubular vagina, directed to the left 
 and pushed forwards by the abdominal tumour which extended 
 down close to the anus. The posterior wall of the vagina was 
 very much stretched and felt very hard. The uterus could not 
 be reached; indeed, the finger point must have been eight or ten 
 inches from it. The local difficulties in the pelvis were evidently 
 very great. At first, the impression was that the tumour must be 
 one of those not uncommon ovarian cysts, where the right broad 
 ligament was opened up and the uterus pushed to the opposite 
 side ; but here the fundus of the uterus was felt so distinctly, 
 and was so very differently placed in every way from anything 
 that I had ever seen, and so apparently separated from the 
 cystic tumour, that I felt doubtful. I ventured, however, to 
 say that, whatever it was, it was not an ovarian tumour. After 
 a day or two I removed upwards of a hundred ounces of pure 
 blood serum from the cyst. This did not nearly empty it, and 
 the fluid came away, not in a full stream, but in a spasmodic 
 sort of way, as I have seen it do in cases of uterine fibrous cysts, 
 when these were punctured. The interior structure of the 
 fibrous cysts quite explains the way in which the fluid behaves. 
 But for the small and movable uterus, which, however, did 
 not in the slightest degree change its position downwards, I 
 would have said at once that the tumour was a uterine fibrous 
 cyst. Now I hesitated between that and some undescribed 
 form of retro-peritoneal tumour. 
 
 ‘ In the meantime, as some relief had been obtained, delay 
 was advised. In six weeks she was back again, having scarcely 
 been out of her room. The swelling was larger than ever. The 
 duliiess now reached to near the ensiform cartilage, and the 
 abdomen was generally fuller and broader-looking all over. 
 Tension on the pelvis, on the vagina, and rectum was, if 
 possible, greater than before. The uterus now touched the left 
 false ribs. All along, menstruation was regular and normal. 
 
 “ On 22nd October, a free incision was made from the um- 
 
HYSTERECTOMY. 
 
 439 
 
 bilicus downwards. The cavity was opened at the umbilicus, 
 as the position of the bladder was known to extend high up into 
 the abdomen. On putting in the hand it was arrested by the 
 bladder in front, and the same all round on both sides. The 
 uterus was found in the left lumbar region touching the ribs ; 
 the fundus, strangely free, was sticking out of the tumour like a 
 potato. The tumour was punctured at the umbilicus ; about 
 one hundred and fifty ounces of fluid were got away, but the 
 sac would not empty. Its upper part was now seized and 
 pulled forwards, and as it was dragged out the right healthy 
 ovary and tube were seen to be stretched on it. The position 
 of the ovary before the tapping must have been near the middle 
 line, and about half way between the umbilicus and the ensiform 
 cartilage. It was now seen that the whole of the tumour was 
 under the peritoneum, and the floor of the pelvis was pushed up 
 by the tumour almost to the sternum. The tapping puncture 
 was enlarged, and the hand introduced into a fibrous cellular 
 structure, with masses of fibroid here and there. The septa were 
 broken up, and as much fluid pressed out as was possible. The 
 thickness of the soft parts covering the cyst was remarkable. 
 The edges of the cyst were then seized, and the long and tedious 
 process of enucleation was begun. The solid portion extended 
 to the very floor of the pelvis on both sides, and its connections 
 everywhere were most close and firm, requiring all my strength 
 to separate there. It was impossible after the first few inches 
 of separation to bring any bleeding points into view. At last, 
 after it had given way in several places, the whole tumour was 
 turned out of the pelvis, and then its connection to the right 
 side of the uterus came into view, all being separated but this. 
 The point of departure of the cyst was immediately above the 
 cervix on the right side and under the peritoneum of the broad 
 ligament. There was no pedicle — only a broad thick connection. 
 The cautery clamp was put on, but the structure being hard 
 and dense, the crushing action of the blades made the tissues 
 fissure at the point of junction, and it was removed. Any 
 
440 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 bleeding points were tied with fine silk. There was now the 
 huge gap left to be dealt with. Sponges were stuffed in, pressure 
 was made, and the bleeding gradually diminished. The right 
 ovary and tube, as well as a large part of the very voluminous 
 capsule, were cut away. The edges were secured by numerous 
 ligatures, and then fixed in the wound. Some iodoform was 
 rubbed over the sac, a glass drainage tube put in, and the 
 wound closed. The operation lasted one hour and twenty 
 minutes. The patient made a good recovery.” 
 
 A somewhat similar case was reported by Mr. Doran not 
 long ago. When the tumour grows from the fundus and it is 
 possible to remove it without opening the uterine cavity, the 
 method of removal is exactly the same as that described when 
 speaking of pediculated outgrowths. 
 
 If the tumour cannot be removed without opening the 
 uterine cavity, one of two methods must be followed, the 
 choice of which will depend on whether the stump has to be 
 fixed outside or not. They are the extra-peritoneal, and the 
 intra-peritoneal plans of treatment, and much controversy has 
 arisen as to which plan is the better. The truth will be found 
 to lie not in the one or the other, but will be determined by 
 the circumstances of each case. Before describing these two 
 methods, it will be well to show how the separation of the 
 broad ligaments is to be effected. When the tumour is a large 
 one, perhaps 20 lbs. or 30 lbs., and it has been determined 
 after careful examination to remove the growth, there is not 
 the slightest use in beginning with a short incision of four or 
 five inches. Let the cut be long enough to get the tumour out 
 whether it be ten or twenty inches, and if care be taken the 
 peritoneum can often be opened with the first sweep of the 
 knife. The incision should not reach too near to the pubes, 
 and this is especially the case where the bladder is known to be 
 raised into the abdomen. At the lower angle, the peritoneum 
 must not be divided to the entire length of the skin incision. 
 As soon as the wall is divided an attempt is made to push the 
 
H YSTERECTOMY. 
 
 441 
 
 tumour out of the wound. This may be done, either by draw- 
 ing the wall back over it or by passing the hand behind the 
 growth and levering it out. Sometimes by rotating an irregular 
 mass the extraction may be facilitated. When the tumour is 
 small and of fairly firm consistence, a corkscrew with a wide 
 spiral is to be inserted into the growth, and if it hold extraction 
 is easily effected. In one case where there was great adhesion 
 at the upper part, the uterus was temporarily clamped with 
 forceps as the neck was thin, and the extraction was then 
 effected from below. When the tumour has been got more or 
 less out of the abdomen, several large sponges are put in to keep 
 back the intestines, or a few stitches may be inserted to reduce 
 the size of the wound and keep the bowel from getting in the 
 way. 
 
 If the bladder be not adherent, the broad ligaments are 
 separated in the following way : a large pair of catch forceps is 
 fixed on to the upper part of the broad ligament close to the 
 uterus, and a second pair alongside with just sufficient room to 
 cut between. Strong well made forceps do not require that any 
 tissue be left beyond their grasp. The part between is then 
 divided with scissors. Two pairs are fixed in the same way 
 lower down, the tissue is again divided, and this is repeated 
 until the separation is complete. The other broad ligament 
 is treated in the same way. When the separation of both is 
 finished, the broad ligaments are transfixed and tied with silk, 
 and when the separation has been extensive this will have to be 
 done in detachments. The forceps are allowed to remain on 
 the uterine end of the ligaments, and time need not be wasted 
 by tying them, as is sometimes done. If the bladder have been 
 raised up on the tumour, its separation is seldom difficult ; the 
 peritoneal covering of the tumour is cut through close above it, 
 and it is separated downwards, bleeding vessels being caught up 
 with forceps and tied. A neck or pedicle will now have been 
 formed with the loss of almost no blood. 
 
 Another way of forming this neck is to make a circular 
 
442 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 incision through the capsule or peritoneal covering of the 
 tumour at its widest diameter, forceps are fixed on to every 
 bleeding vessel, and the capsule is then separated downwards 
 all round until a neck is reached. In cases where the broad 
 ligaments reach high up on the tumour, they are usually 
 partially separated in the way previously described, before the 
 circular incision through the capsule is made. This separation 
 of the capsule causes great loss of blood, and does not appear 
 to have any special advantage over the other plan. It also 
 involves a certain amount of danger, as the separation may be 
 continued too low down, and in this way septic matter may be 
 
 Fig. 31 .— Keith’s Hysterectomy Clamp. 
 
 shut up in the tissues below the clamp or wire. When the 
 former method is used the clamp or wire fixed on to the neck is 
 in contact partly with the peritoneum at the back and front of 
 the uterus and partly with the raw surface at the sides ; while in 
 the latter method it is in contact with peritoneum all round. 
 
 The extra-peritoneal method consists in fixing the neck 
 which has been formed into the lower angle of the wound, and 
 before this can be done it must be constricted in one way or 
 another. It is best done by the clamp of which a diagram is 
 given. It is much the same shape as Wells’ ovariotomy clamp, 
 but is much longer, being nine inches in length including the 
 handles, thinner, and fitted with movable handles so arranged 
 that they cannot slip when tlie clamp is used. A single ligature 
 is placed round the stump to prevent it spreading out too much; 
 
HYSTERECTOMY. 
 
 443 
 
 tlie clamp is applied in the groove made by this ligature and 
 the blades are fixed by the screw, after being pressed closely 
 together. The tumour is then cut off, the return blood from 
 the growth being prevented from entering the abdominal cavity 
 by the assistant. The stump is trimmed, the opened uterine 
 cavity is cut out, and the parts round it are washed with a 
 strong antiseptic solution. The angles of the stump, where 
 most of the vessels are usually situated, are ligatured beyond 
 the clamp, and any large vessels in the capsule must also be 
 tied. Sponging is completed, and special care must be given to 
 the pouch which is formed in front of the pedicle. The stump 
 
 must be fixed in the wound in such a way that the peritoneum 
 is brought so closely round it that discharge cannot pass into the 
 abdominal cavity, and it is to assist in doing this that the 
 peritoneum at the lower part of the wound is not open to its 
 full extent. This can be done in the following way : one stitch 
 is passed through both sides of the abdominal wall immediately 
 below the stump and so close to it that the peritoneum is 
 brought firmly against it. The second stitch is put in above 
 the stump and also close to it, so as to bring the peritoneum 
 round the upper part and at the same time draw up the peri- 
 toneum of the sides of the wound. The peritoneal cavity is 
 thus closed to any discharge which might gravitate from the 
 cut surface of the stump. When all the stitches have been put 
 
444 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 in and tied, the dressing is arranged round the stump and under 
 the clamp. This in addition gives a certain amount of support, 
 preventing the stump being drawn into the abdomen, and 
 dispenses with the use of pins. It is neither wise nor advisable 
 to cover over the stump by stitching the peritoneal edges 
 together. 
 
 To the raw surface of the stump the saturated solution of 
 the perchloride of iron is freely applied, iodoform is sprinkled 
 over the dressing, and some absorbent wool is placed over all. 
 
 Instead of a clamp a wire serre-noeud is commonly employed. 
 The wire is passed round the stump, fastened and screwed up, 
 the tumour is then cut off as before described, pins are pushed 
 through the stump immediately above the wire to give support 
 and to prevent it being drawn into the abdomen. 
 
 Some illustrative cases may be given from Dr. Keith’s book 
 on Hysterectomy : — “ Mary C., aged twenty-eight, was sent into 
 the Eoyal Infirmary by Dr. Eobertson of Ardrossan. She had 
 sought relief in many quarters in vain. The tumour was very large, 
 and was first noticed five or six years before. She was wasted 
 about the chest and arms, like a case of old ovarian disease. 
 The abdomen measured forty-nine inches at the umbilicus ; the 
 tumour was firm and solid throughout. The ensiform cartilage 
 was turned upwards, and the growth extended under the sternum 
 and ribs ; close to the sternum there was a large projection the 
 size of a child’s head. Ko trace of the ovaries could be detected. 
 The greater part of the pelvis was occupied by the tumour. 
 There was no distinct cervix, only a small triangular projec- 
 tion drawn away to the left side, almost beyond reach of the 
 finger. For several years no great inconvenience had resulted ; 
 menstruation was never in excess, and for the last fifteen 
 months it had entirely ceased ; since then, the increase in 
 the size of the tumour had been rapid, and she could do 
 little or nothing on account of its weight. She sat all day 
 knitting; at twenty-eight her life prospects were anything but 
 bright. 
 
HYSTERECTOMY. 
 
 445 
 
 “ For obvious reasons, this patient was not taken down to the 
 large theatre, but was operated on in the ward, on 18th April 
 1881. Sulphuric ether was given and the operation was 
 performed under carbolic acid spray. The sponges, thirty 
 in number, had been lying for long in a 5 per cent, solution 
 of carbolic acid, they were washed in hot water, and then 
 put into a 2 per cent, solution, and wrung almost dry. 
 These were used over and over again, and were not washed 
 in any fresh solution during the operation. Dr. Wilson was 
 present from Glasgow, and there were about twenty visitors 
 and students. The first incision measured twelve inches ; it 
 terminated four inches above the pubes, so as to avoid the 
 bladder, which was known to be elevated on the tumour. 
 On the right side the broad ligament rose as high as the crest 
 of the ilium. The left broad ligament was largely spread over 
 the half of the tumour as high up as the ribs. The opening 
 was then enlarged to twenty-two inches, and, by dint of hard 
 pushing and patience, the huge mass was slowly moved forwards 
 as far as its connection on the left side would permit. The 
 right ovary was easily seen. On searching for the left, it 
 was found to be transformed into a long, tense, umbilical- 
 like cord, seven or eight inches in length. Here and there 
 along this tense band were several small cysts. It was so 
 embedded in the tumour that it could never have been removed. 
 The right broad ligament was transfixed by soft iron wires, 
 secured, and divided ; all bleeding from the tumour side was 
 prevented by a series of strong locking forceps. The fibroid 
 was now more easily dealt with. It was drawn forwards, 
 so as to put on the stretch its enormous connection on the 
 left side. About a dozen powerful locking forceps, ten inches 
 in length, were now applied to the broad ligament before and 
 behind. The whole was then cut downwards, and the mass 
 enucleated as low as possible. A strong soft iron ligature 
 embraced the base, which was of great thickness. The tumour 
 was then cut away, the stump showing a section of the cervix 
 
446 FIBROID TUMOURS OF THE UTERUS. 
 
 in the centre. The forceps were removed one by one, and 
 all bleeding vessels separately tied. Some of these were large, 
 and one threw blood over the assistant’s head. There was 
 much trouble in finding some bleeding points amongst the 
 loose cellular tissue of the huge gap now left. The hgemorrhage 
 was mostly venous. All present could see that this condition 
 was full of danger, and that secondary haemorrhage into this 
 loose tissue was not one of the smallest risks of this operation. 
 When all oozing seemed to have ceased, the stump (the 
 thickness of the leg) and the end of the right broad 
 ligament were secured, with much tension, outside ; a glass 
 drainage tube was fixed in above the stump, and the wound 
 closed by forty silk sutures. The operation lasted one 
 hour and three quarters. After much blood and serum had 
 escaped from the tumour, its weight was 42 lbs. The patient 
 recovered.” 
 
 “Mrs. B., aged thirty -nine, was transferred from Professor 
 Eraser’s wards in the medical house. Since the birth of her last 
 child three years before, the tumour had rapidly increased. It now 
 reached the ensiform cartilage, completely filling the abdomen. 
 Menstruation was frequent and profuse. Projecting from the 
 vagina were four distinct swellings; prolapsus of the vaginal 
 wall and bladder ; prolapsus of the rectum and posterior vaginal 
 wall. Between these were two large ulcerated swellings, like 
 two fists, exuding a foetid discharge. These were found to be 
 the lips of the cervix enormously enlarged; behind and pushing 
 outwards, was the tumour completely filling the pelvis. These 
 local wrongs had thoroughly broken down her health. Her life 
 was utterly useless, and her condition in every way was most 
 miserable. She was a nervous, excitable person, bedridden, 
 feeble, and emaciated. She was willing to run any risk to 
 obtain relief. The case was far from a promising one, and, 
 at first, the condition of the kidneys seemed to forbid any 
 interference. The urine was of low specific gravity, 1012. 
 The daily quantity passed during the week before operation 
 
HYSTERE CTO MY. 
 
 447 
 
 varied from eighty to one hundred ounces. There was a 
 little albumen, hut nothing else. 
 
 “ The operation was performed on 13th ISTovember, and lasted 
 one hour and twenty minutes. The incision was eighteen inches 
 long. This opening was scarcely large enough, and much force 
 was needed to push the tumour forwards, and especially to 
 dislodge and bring up the pelvic portion, which was tied down 
 by bands of adhesion everywhere in the pelvis. The steps of 
 the operation were the same as in the previous case. The 
 broad ligaments were stripped off and secured separately, and 
 everything fixed in the lower angle of the wound. On proceed- 
 ing now to remove the clots from the abdomen, a cystic tumour 
 of the right kidney, as big as a child’s head, was brouglit into 
 view. It was pushed under the ribs by the tumour, and as the 
 operation went on it came lower and lower into the abdomen. 
 It was covered by adherent mesentery, and was of a very dark 
 colour. It was not examined too curiously. The weight of the 
 tumour removed was 21 lbs. The patient looked very ill on 
 being placed in bed. Indeed, at this stage she presented a 
 very hopeless appearance. The interest of the case now centred 
 in the state of the kidneys, and in what would be the probable 
 effect of the carbolic acid spray on such a damaged organ. 
 Soon after the operation she was seized with severe pain, which 
 was relieved by drawing off a pint and a half of limpid urine, 
 slightly albuminous; in eight hours fifty -three ounces were 
 passed. The first night was fairly good, with an opiate. In the 
 morning the pulse was 104, and the temperature lOl'S. Fifty- 
 seven ounces of urine were passed during the day, making one 
 hundred and ten ounces in twenty-four hours. It was clear with 
 more albumen. The second night was bad. In the morning 
 she was flushed and intensely cyanotic ; the pulse was 134, and 
 the temperature 101*2°. The urine was smoky, and towards 
 evening it became bloody, and was loaded with albumen. The 
 quantity was fifty-seven ounces during the day. She complained 
 of intense headache, and was flushed and restless all day ; the 
 
448 FIBROID TUMOURS OF THE UTERUS. 
 
 pulse was 130, and the temperature 101°. The third night was 
 also had ; in the morning the pulse was 128, and the temperature 
 101 ‘4°, the urine was very bloody. The fourth and fifth nights 
 were also restless. The urine still contained much blood, and 
 some clots caused much distress in passing from the urethra. 
 On the sixth day the urine was free of blood but loaded 
 with albumen. On the next day there was a return of the 
 haemorrhage, with much pain. On the tenth day blood was 
 observed for the last time ; then came a week of great exhaus- 
 tion from diarrhoea; on the twenty -third day all trace of 
 albumen had disappeared. There was free suppuration round 
 the stump, though the wound healed well. She went home 
 seven weeks after the operation, looking clear and healthy. 
 She was freed from all lier troubles. The vaginal and rectal 
 prolapsus had disappeared. The cervix was tucked up under 
 the pubes. Strange to say, the kidney tumour has as yet — 
 now nearly four years after the operation — caused no incon- 
 venience, though it has slightly increased in size.” 
 
 “ A widow, thirty- eight years of age, from Scarborough, was 
 admitted into the Infirmary on 19th June 1883. She had 
 a very large uterine fibroid. There was oedema of the limbs 
 and of the abdominal wall, which was hard and horny, and 
 ulcerated in several places. The cedematous portion of the 
 wall below the umbilicus formed of itself a tumour as large 
 as the adult head — it reached to the knees. The tumour hung 
 over the pubes, filled the abdomen up to the sternum, and, after 
 some days, when the surface swelling had subsided, was seen to 
 move freely with respiration. The cervix was high up and of 
 moderate size. 
 
 “ The tumour had been noticed at least ten years ago. Its 
 growth of late had been rapid. She was obliged to work hard, 
 and she had worked on till she could now work no longer. 
 She was a thin, not unhealthy-looking woman, but the pulse 
 was extremely feeble. All these years menstruation had been 
 abundant, though never amounting to severe haemorrhage. 
 
HYSTERECTOMY. 
 
 449 
 
 ‘‘ After ten days’ rest, the swelling of the limbs and abdominal 
 wall having subsided, and the ulcerated patches having healed, 
 an operation was performed on the 30th of June. From the free 
 mobility of the tumour, a difficult operation was not anticipated. 
 An incision of about fourteen inches was made, and an attempt 
 made to push the tumour through it. It was necessary to en- 
 large the opening. After a good deal of pushing the tumour 
 only moved partly into the opening : perhaps one-third of it 
 projected. More force being applied, a red fringe of adhesion 
 began to appear all round the sides, the tumour then slowly 
 came out, but its posterior surface was simply covered with 
 adherent omentum, intestine, and mesentery, and the connection 
 was of such firmness that all adhesion had to be cut. It was 
 afterwards found that the raw surface on the tumour measured 
 30 X 31 inches. It was possible to put a clamp round the base, 
 and the tumour was then cut away ; then, bit by bit, this large 
 adherent surface was tied by catgut ligatures. An immense 
 number of these were used, and some of the vessels in the mes- 
 entery were very large. There was a curious cystic condition 
 of the mesentery, such as I have not seen before. There were 
 hundreds of small serous cysts, and as many of these adhered to 
 the tumour, it was no easy matter to get all the bleeding points 
 stopped amongst them. After an hour and a half, the wound 
 was closed by thirty-five stitches. The weight of the tumour 
 was 30 lbs. I regretted afterwards very much that I did not 
 drain. She was feeble from the beginning : four hours after 
 operation the pulse was 140, and it was only then that I became 
 aware how exceedingly thin she was. She had a fair night, but 
 was more feeble next day, the pulse continuing rapid. The 
 skin was moist, and the kidneys acted well. Flatus passed 
 early and easily. She took food and stimulants well. There 
 never was any pain or sickness, and on the fourth day we were 
 all hopeful. On the fifth day there was a sudden rise of tempera- 
 ture to 103°. A fine glass tube was pushed into the pelvis 
 above the stump of the pedicle, and six ounces of thick, black 
 29 
 
450 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 syrupy blood were removed. The fluid was quite sweet, and 
 contained no organisms. Nearly other four ounces were got 
 away in the evening. She gradually became weaker, and died 
 on the seventh day. Though almost hopeless about her when 
 put to bed after the operation, her chances would have been 
 better had drainage been carried out from the first. ” 
 
 The following case is a good example of the difficulties and 
 complications which may be met with. For six or seven years, 
 a patient forty-three years of age had suffered from menorrhagia, 
 and about two years afterwards an abdominal swelling was 
 discovered. For about three months before she was seen in 
 November 1892, the general health and strength had rapidly 
 failed, the patient having lost 14 lbs. in weight in one month. 
 A thoroughly competent gynsecologist was consulted, and after 
 several examinations a diagnosis was written of a fibroid tumour 
 in the abdomen, and a second tumour in the pelvis, probably 
 of a malimiant character and surrounding the bowels. 
 
 On examination an irregular uterine fibroid was felt extend- 
 ing to within two inches of the ribs. In the pelvis, the vaginal 
 walls were found to be very oedematous, and through them a 
 hard but not absolutely solid tumour could be felt. The cervix 
 was drawn completely out of reach, and movement of the 
 abdominal mass did not appear to affect the pelvic growth. 
 The patient looked ill and the pulse was 96. A definite 
 diagnosis was not made, and the patient was asked to come 
 back after the period was over. At the second examination the 
 pelvic portion was felt to have some slight lateral movement on 
 manipulating the abdominal tumour. The patient’s mother had 
 had a baby at the age of fifty-one. Eemoval of the tumour was 
 advised on account of the rapid decrease in strength. There 
 had been no feeling of chill or other symptom suggesting sup- 
 puration. 
 
 The incision extended from three inches above the umbilicus 
 to a similar distance above the pubes, and the tumour was partly 
 drawn forwards by the help of a couple of corkscrews. On 
 
HYSTERE CTO MY. 
 
 45 
 
 passing in the hand to discover why the growth would not come 
 out entirely, two great soft tubes the size of the wrist were found 
 to be connected to the tumour, and were also adherent to the 
 walls and bottom of the pelvis. Owing to their position behind 
 the tumour, the contents could not be emptied with the 
 aspirator ; and during the separation of the tubes both ruptured, 
 the contents being grumous pus without odour. The broad 
 ligaments were separated off the sides of the tumour, and still a 
 neck was not made. The capsule above the bladder was divided 
 transversely, and was enucleated downwards with difficulty, as 
 there had been old inflammatory matting together of the tissues. 
 Finally the clamp was got round the stump of the uterus, in- 
 cluding the left ovary, and the connections of the right ovary 
 and distended Fallopian tube were ligatured separately. The 
 pelvis was thoroughly washed out with warm water and a drain- 
 age tube, seven and a half inches in length, was placed in the 
 abdomen. The operation lasted one hour and forty minutes, and 
 the pulse was 116 when the patient was put back to bed. At 
 the end of thirty hours it had risen to 134. It commenced to 
 fall after the bowels were moved with the white mixture, and by 
 the fifth day the condition of the patient was perfectly satis- 
 factory : pulse 80 and temperature normal. She was seen on 
 the ninth day at ten p.m. and was then found to be very well. 
 About an hour afterwards she partially woke up out of her sleep, 
 sat up in bed, threw her arms out once or twice, gasped, and 
 expired, evidently from a heart-clot. 
 
 “ M. D., aged 37, had been under observation for four or five 
 years, with a large bleeding fibroid. The cavity was nine inches 
 in length, and everything in the way of remedies had been tried 
 in vain. The condition in the pelvis was so unfavourable that 
 no interference was recommended. She got gradually more and 
 more anmmic and feeble, until she could no longer find employ- 
 ment as a cook. She was friendless and her means were 
 exhausted. She was admitted into the hospital in August — 
 more to give her rest and good food than with the view of trying 
 
452 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 anything to effect a radical cure. She got worse instead of 
 better, and was even more blanched than before. The effect of 
 the good living seemed only to cause more blood to flow from 
 the uterus. There was a constant drip going on, varied every 
 now and then by a real haemorrhage. As she had still ten years 
 or more of invalidism to look forward to at the best, her position 
 was explained to her, and she agreed to anything being done 
 that might be deemed feasible. The tumour reached two inches 
 above the umbilicus. It was softer than any of the other cases, 
 and more so now than at any previous time, for it was well 
 drained by long-continued bleeding. There was no cervix, and 
 the mass filled up Douglas’s space nearly to the anus. The 
 operation was done on the 26 th October, after a residence of 
 nearly three months in the hospital. She had long suffered 
 from a chronic laryngitis, and the ether inhalation was difficult. 
 It was agreed to remove the ovaries should they be removable, 
 for great doubts were entertained as to the possibility of 
 removing the pelvic portion of the tumour. A free incision was 
 made, the ovaries could not be got at, and the tumour was 
 turned out. The ovaries were found high up and behind. They 
 were much enlarged, adherent, and embedded in the midst of 
 enormous varicose veins. They might have been ligatured close 
 to the tumour ; but then the pelvic part of the tumour, which 
 had been got up by much pulling, could never have been re- 
 placed again. The case looked pretty hopeless at this stage, 
 and it was evident that great enucleation would be necessary 
 before the wires could be placed under the pelvic portion of the 
 tumour. The bladder came half way up upon it, and the base 
 was as thick as the thigh, more than filling the opening of the 
 pelvis all round. The bladder was first detached ; the peritoneal 
 covering of the tumour was divided by scissors right across, a 
 little below a point corresponding to the situation of the umbilicus 
 before the tumour had been disturbed. Then each broad liga- 
 ment was ligatured by soft iron wires, and detached from the 
 tumour, strong locking forceps controlling all the bleeding. The 
 
HYSTERECTOMY. 
 
 453 
 
 separation was continued by the scissors all round until the top 
 of the vagina was reached, when a serre-noeud was applied as 
 low as possible. The tumour was then cut away, all bleeding in 
 the pelvis stopped, and the stump secured in the wound. The 
 tension was not greater than in the previous cases, wliile the 
 tissue embraced was smaller. There seemed to be nothing held 
 by the wires but the top of the vagina. The operation lasted 
 one hour and thirty-five minutes. The weight of the tumour 
 was 1 2 lbs. JSTo spray was used during this operation, and the 
 sponges were simply wrung out of hot water. 
 
 “ For the first week there was laryngeal irritation, followed by 
 slight bronchitis. Still, considering her feeble condition, con- 
 valescence was unusually rapid. The opening left after the wires 
 dropped off was not larger than in an ordinary clamp ovarian 
 operation ; not a trace of cervix could be felt by the finger. 
 The vagina ended in a simple cul-de-sac close to the cicatrix in 
 the abdominal wall. The whole organ had been removed.” 
 
 The following case is an example of hysterectomy performed 
 after the menopause. The patient, an unmarried lady of forty- 
 two years of age, was first seen towards the end of 1891 suffering 
 from fever, from pain and tenderness in the lower part of the 
 abdomen, and from great irritability of the bladder. Menstrua- 
 tion which had always been scanty and irregular had ceased for 
 about a year. The general health had never been good. 
 
 The fever, due evidently to an attack of pelvic peritonitis, 
 had lasted for six weeks and had been set up by a fall. On 
 examination the patient was found to be thin, the pulse was 
 soft and quick, and the temperature was 102°. The lower part 
 of the abdomen was exquisitely tender, and a tumour could 
 be seen bulging immediately above the pubes and extending 
 upwards for five inches. The cervix was very large, and the 
 pelvic contents were absolutely fixed. The diagnosis arrived at 
 was that there was a uterine fibroid with surrounding cellular 
 inflammation. 
 
 After a few days’ rest, treatment by electricity was com- 
 
454 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 menced, eighteen applications varying in strength from 60 
 to 90 milliaraperes being made between the beginning of 
 November and the middle of December. The size of the 
 abdominal swelling was not greatly reduced though the cervix 
 became much smaller. The symptoms were, however, entirely 
 relieved, and the patient went home. 
 
 In the following July she returned to town. She was better 
 generally, but an attack of pelvic peritonitis had greatly 
 discouraged her, and she found that she had to pass most of her 
 time on the sofa. She was very anxious to have the tumour 
 removed, more especially as she had the fear of future attacks 
 of fever constantly before her. The local state had changed 
 somewhat, the tumour itself was not tender to the touch, but 
 there was a sausage-shaped and very tender swelling projecting 
 from its left side. Hysterectomy was strongly recommended, as 
 the tumour had shown no signs of quieting down during nearly 
 two years after the cessation of menstruation. A consultation 
 was held at the desire of the friends, and an equally strong 
 opinion was given that the patient should be content to wait, 
 and hope for recovery without treatment. This she declined to 
 do, and the operation was performed in July 1892. The tumour 
 was universally adherent, the broad ligaments were opened up 
 to their full extent, and the sausage-shaped swelling was found 
 to be the broad ligament enormously distended by inflammatory 
 deposit. Shortly after the operation was begun the anaesthetist 
 said that the patient was becoming very much collapsed. The 
 stump was fixed outside in a clamp. The after progress was 
 slow on account of extreme feebleness, so great that even a 
 month after the operation the patient often felt as if she was 
 sinking through the bed. 
 
 At the end of six months there began to be some slight 
 return in strength, but it was fully another year before she could 
 say that she was really quite well. 
 
 The intra-peritoneal method may be carried out in three 
 different ways. 
 
HYSTERECTOMY. 
 
 455 
 
 The stump may be treated as already described by bringing 
 the two flaps together. The cervix may be brought into the 
 vagina by an incision through either the anterior or posterior 
 fornix. The whole of the uterus may be removed. 
 
 A number of slight modifications have been advocated 
 by various operators in the way in which the first of these 
 methods is to be carried out. It is impossible to describe 
 every little detail, nor is it necessary, because, when the 
 main features are understood, the exact way in which 
 they are carried out must be determined by the conditions 
 found at the time of operation. The two main objects to be 
 borne clearly in mind are, that bleeding must be arrested, 
 and that some means must be found to prevent the stump 
 from becoming septic. One direction which is usually given 
 is to commence by securing the ovarian artery, but how this 
 is to be managed when both broad ligaments are raised as 
 high as the ribs, it is difficult to imagine. When the ovarian 
 artery can be ligatured it is very evident that the case is one of 
 the simplest nature, and that the broad ligaments have not been 
 opened up to any extent. 
 
 The broad ligaments must first be divided between forceps 
 in the way already described until an elastic ligature can be put 
 round the neck. The tumour is then cut away. The cavity of 
 the uterus is carefully cut out, and the stump is so trimmed 
 that the anterior and posterior edges can be brought together. 
 All vessels which are visible in the capsule are carefully tied, 
 and the deeper parts of the stump are brought together by a 
 continuous silk suture. Additional layers of continuous sutures 
 are put in until the whole of the stump is doubled together, and 
 finally the peritoneal edges are brought into accurate apposition. 
 The elastic ligature is loosened, and if the vessels have been 
 properly tied no blood will escape. The elastic ligature can 
 be left in, if it can be covered by peritoneum, and when this 
 is done, fewer stitches are required. Buried sutures may be 
 passed deeply through both flaps instead of making several 
 
456 FIBROID TUMOURS OF THE UTERUS. 
 
 layers. The objection to this method lies in the possibility of 
 the stump becomiug infected through the cervical canal. Should 
 this occur the cervix will require to be dilated from the vagina, 
 to allow of free drainage. With the possibility of this in view, 
 it is well to notice at the time of operation how much of the 
 uterus has been removed. In any case some iodoform gauze 
 should be placed in the vagina to prevent any discharge from 
 the cervix becoming putrid. In other respects, the remainder 
 of the operation and the after treatment do not vary from that 
 of an ordinary ovariotomy, but it is well to leave a drainage 
 tube in the peritoneal cavity for twenty-four hours in case of 
 haemorrhage. 
 
 The object of drawing the cervix into the vagina is to 
 prevent risk of septic poisoning. After the vessels have been 
 tied, the stump is transfixed, and ligatured in several places. 
 A long pair of forceps is then passed into the vagina which has 
 been thoroughly disinfected, and is pressed against the anterior 
 or posterior fornix, whichever happens to be the more convenient. 
 An opening is then made from the abdominal cavity upon the 
 pair of forceps in the vagina, and, passing the forceps through 
 the opening, the stump is caught and drawn into the vagina. 
 This manipulation is by no means easy, it takes time, and it 
 cannot be made use of when the stump is very thick. On the 
 whole it is not to be recommended. 
 
 The third way of treating the stump in the intra-peritoneal 
 operation, is to go on with the enucleation until the whole of 
 the uterus has been removed, or more usually, by temporarily 
 clamping the neck, removing the tumour, and then going on 
 with the enucleation. The precautions are, to have the vagina 
 thoroughly clean, and to keep a careful look-out for the ureters. 
 The opening in the roof of the vagina is closed with catgut 
 stitches, and a plug of iodoform gauze is left in the vagina for 
 forty-eight hours. 
 
 The following is an example of a case treated intra- 
 peritoneally by Dr. Keith twelve years ago : — 
 
HYSTERECTOMY. 
 
 457 
 
 “Mrs. D., aged forty-six, a Frenchwoman, sent by Dr. 
 Thomson of St. Helier, was admitted into hospital, in August 
 1882, with a very large soft fibrous tumour. Dr. Thomson had 
 aspirated in various places without getting more than two or 
 three drachms of fluid at any point. The serum always 
 coagulated in the syringe. Since menstruation passed away, 
 the growth of the tumour had been rapid, her size having 
 doubled within the last twelve months. She had applied for 
 relief at various London hospitals. 
 
 “She was a little woman, thin and worn. The tumour 
 uniformly distended the abdomen, elevating the ribs ; no 
 movement could anywhere be detected. The cervix uteri was 
 very hard ; it lay low in the pelvis to the right side, and was 
 quite fixed. The upper pelvis was occupied by the tumour, and 
 it felt very hard on pressing upwards ; no movement of the 
 abdominal portion in any way affected the part felt in the 
 pelvis. Posteriorly, and better felt by the rectum, was a hard 
 cystic body, the size of a small orange. This was supposed to 
 be one of the ovaries. In prospect of an operation, the state of 
 the parts in the pelvis was far from satisfactory, and repeated 
 examinations threw no light on the local conditions. 
 
 “ Operation on 28th August. — The incision was gradually 
 extended to twenty inches, and the tumour was slowly pushed 
 towards the opening. By taking time it moulded considerably, 
 but could not be brought out on account of its extensive 
 connections. It had grown from the left side of the uterus, had 
 pushed aside the layers of the broad ligament, and forced 
 everything before it as it grew, so that the descending colon 
 was found on its right side ; only about two-thirds of the 
 tumour had a peritoneal covering; the rest required to be 
 separated from its cellular attachments. The separation was 
 begun by dividing with the scissors the serous covering at the 
 edge of the colon, which was pushed over to the right side of 
 the abdomen. Large vessels were secured by locking forceps. 
 When the tumour was turned out, the iliac vessels, the psoas 
 
458 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 muscles, and the loose cellular tissue nearly as high as the 
 diaphragm, were lying quite bare ; there was nothing like a neck 
 or pedicle. A temporary ligature was screwed tight, as low 
 down as possible, and the mass cut away. ISTearly an hour was 
 taken in stopping bleeding, and in hunting out vessels amongst 
 the numerous thrombi that had formed everywhere in the 
 cellular tissue. The base of the tumour could in no way be 
 secured externally, and it was only by the use of special com- 
 pressing clamps, which were expressly made for this case, and 
 by which the elasticity of the thick uterine tissue was destroyed, 
 that ligatures could be used with any hope of keeping a hold. 
 The uterus was divided obliquely. Some vessels were secured 
 singly, but the mass of the stump was tied in seven or eight 
 portions with strong silk. The difficulty at this stage was to 
 avoid injuring the bladder, which was very large, and drawn 
 upwards to the left on the abdominal wall. It was only by 
 keeping in a catheter and moving it about that the bladder 
 escaped injury. It had already been separated from the tumour, 
 and had got very rough handling. The gap left in the peri- 
 toneum was very large ; the descending colon and sigmoid 
 flexure were lying quite loose. A drainage tube was left in, 
 and the wound closed. The patient, when put in bed, was cold 
 and collapsed, the operation having lasted one hour and three 
 quarters. Clover’s small inhaler was employed ; one ounce and 
 three quarters of ether only were used. After drainage, the 
 weight of the tumour was 34 lbs. 
 
 “ Eecovery was for long doubtful. The after progress con- 
 trasted greatly with that of those cases in which the extra-peri- 
 toneal method was carried out. The outmost vigilance was 
 taken to prevent the stagnation of the fluids in the pelvis ; this 
 was the more necessary, as the cavity of the uterus was opened, 
 and the quantity of strangulated tissue was great. Ko very 
 unfavourable symptoms appeared till the end of the first week. 
 Fortunately, at that time, a collection of putrid blood-clot was 
 detected and opened by using the drainage tube as a probe and 
 
HYSTERE CTO MY. 
 
 459 
 
 pushing it about in the proper direction. In the second and 
 third week the pulse and temperature were sometimes high. 
 Little could be taken except stimulants ; for a long time 
 nourishment was given by the rectum, and the feebleness was 
 great. Many silk ligatures were washed away ; the discharge, 
 though never great in amount, continued for three months. 
 Long before this she was up and going about. After a residence 
 of nearly four months in the hospital, she left for Jersey, the 
 picture of health and contentment.” 
 
 Drainage of the abdominal cavity is used in the same way 
 as after ovariotomy. When the extra- peritoneal method is 
 employed, the end of the tube comes out between two stitches 
 a little way above the stump. 
 
 It is always better to remove the ovaries along with the 
 tumour. 
 
 The advantages of the intra-peritoneal method are, the con- 
 valescence is shortened, the patient is able to be out of bed as 
 soon as after an ordinary ovariotomy ; there is less risk of 
 septicaemia when the whole uterus is removed, though this risk 
 from the stump can be reduced to a minimum by the proper 
 drying of the cut surface with perchloride of iron, and by using 
 an antiseptic dressing ; the dragging pain in the back is avoided ; 
 there is no pouch in front in which fluid can collect ; the risk of 
 mechanical obstruction is avoided ; and when the entire uterus 
 is removed, there can be no growth from the stump, as has been 
 known to occur in at least one instance. 
 
 The advantages of the extra-peritoneal method are, that the 
 neck can be flxed in a clamp more quickly, and should bleeding 
 occur from the stump it will be external. 
 
 The operation should always be begun with the intention 
 of performing the intra-peritoneal method and removing the 
 whole organ if possible, but the operator must be prepared to 
 adopt any method, should it seem best to do so when the 
 exact conditions are found out during the progress of the 
 operation. 
 
46 o fibroid tumours OF THE UTERUS. 
 
 The after treatment, when the whole organ has been removed 
 by the intra-peritoneal method, does not differ from that pursued 
 after an ovariotomy. With the extra-peritoneal method, and 
 especially when there is much tension on the stump, there may 
 be difficulty in getting the flatus to pass downwards. Should 
 there be much distension, the dressing round the clamp may be 
 removed to allow the pedicle to sink in a little, or it may even 
 be necessary to remove the clamp, and support the stump either 
 with pins or wdth catch forceps. 
 
 “ A lodging-house keeper, forty years of age, was sent to me 
 by Dr. Joseph Bell. She had suffered for a very long time from 
 pelvic troubles caused by a solid tumour filling the pelvis. The 
 cervix uteri, enlarged and ulcerated, generally projected ex- 
 ternally. There was also cystocele and rectocele. Her suffer- 
 ings had lately been very much aggravated by the wearing of a 
 large guttapercha pessary, like a three-legged stool, which a 
 homceopathic practitioner had introduced to support the uterus. 
 Belief was obtained by the removal of this apparatus, and with 
 the help of hot water injections she was able to work on in 
 comparative comfort. The tumour could not be pushed out of 
 the pelvis, though it did not appear to be fixed. It reached half 
 way to the umbilicus. 
 
 “ About eighteen months after this, it was necessary that 
 something should be done. The tumour had increased ; the 
 pressure in the pelvis was greater and now the large cervix w^as 
 always outside, the tumour pressing downwards like a child’s 
 head on the stretched perinseum. The distress from prolapsus 
 of rectum and bladder was incessant. The tumour reached to 
 above the umbilicus. 
 
 “Operation was performed on 18th August 1883, and lasted 
 upwards of an hour. The bladder was drawn up in front and to 
 the left of the tumour. The tumour came easily out of the 
 pelvis ; the broad ligaments were, however, short and tight, en- 
 veloping nearly the whole of the tumour. They were separated, 
 secured by silk ligatures, and fixed outside as they were very 
 
HYSTERECTOMY. 
 
 461 
 
 voluminous, along with the stump. The tumour weighed 6 lbs., 
 and the cavity extended nearly the whole length of it. 
 
 ‘‘ Second day after operation. — The night was passed fairly 
 till five A.M., when she was seized with severe abdominal 
 pain. This continued, in spite of an opiate given by the nurse, 
 till I saw her at nine A.M. She was then restless from pain and 
 was flushed. Pulse 114, temperature 102°. Several hypo- 
 dermic injections were needed through the day, and by evening 
 she was easier. Her breathing, however, was rapid. The pulse 
 had risen to 124, temperature 104°. 
 
 “Third day. — Some disturbed sleep with an opiate. She is 
 very flushed. Temperature 103°, pulse 120. Some fulness at the 
 epigastrium. Much flatus coming up, with pain. In the after- 
 noon temperature rose to 105° ; the feet and legs had got cold, 
 and towards evening there was severe bilious vomiting. By 
 midnight she seemed better. Temperature 103'5°, pulse 122 ; 
 skin hot, flushed ; much flatus coming up, none down. 
 
 “Fourth day. — Not looking so well. Abdomen is fuller and 
 harder, but no pain ; no flatus has passed down. Temperature 
 102*5°, pulse 128. Severe vomiting all afternoon of dark browh 
 fluid, which comes up with much straining. At ten P.M. the 
 abdomen was a little softer. Face flushed ; much thirst ; mouth 
 and tongue very dry. She was distressed and restless. No 
 flatus had yet passed down ; much comes up. She takes whisky 
 and water freely. 
 
 “Fifth day. — Very restless night. Temperature 102*1°, pulse 
 118. Skin very dry and yellow. Expression not good; rest- 
 lessness, in spite of opiates, is constant. Vomiting of yellow 
 bile in large quantity continued all day from time to time, with 
 much straining. Urine copious. Wound quite dry. Eemoved 
 dressing round clamp ; everything quite dry. There is great 
 depression of the clamp ; as the ligature round left broad liga- 
 ment, which is secured to the screw of the clamp, seemed to be 
 very tense, it was divided ; it slowly receded into the abdomen. 
 Temperature 103°, pulse 118. 
 
462 
 
 FIBROID TUMOURS OF THE UTERUS. 
 
 “ Sixth day. — Much better night. Flatus has passed down- 
 wards freely since two a.m. Temperature 102T°, pulse 110. By 
 evening temperature had risen to 103°, and flatus had ceased 
 to pass down ; much coming up. 
 
 “Seventh day. — Fair night. Abdomen much distended ; no 
 flatus has now passed for thirty hours. Enemata given and 
 returned without relief. All ordinary means had failed, and 
 everything was vomited. By evening temperature was 105°, 
 and pulse 140. Wound perfectly dry and healed, but much on 
 the stretch. 
 
 “ Eighth day. — Bad night ; hot and flushed. Pulse 136, tem- 
 perature 102‘5°. Much more feeble. Under cover of a hypo- 
 dermic injection of morphia, a large dose of castor-oil was 
 given and retained. Bowels were freely moved in afternoon. 
 Abdomen less full, though not much. 
 
 “ jSTinth day. — Night good with opiate. Free discharges from 
 the bowels. Temperature 102’6°, pulse 118. 
 
 “ Eleventh day. — Abdomen flat. Kemoved stitches. Wound 
 quite dry and healed ; dressing round clamp still quite dry. 
 Temperature 102°, pulse 104. 
 
 “ Sixteenth day. — Clamp came off ; opening left very small. 
 Temperature is still 102°, though there seems to be no cause 
 for it. 
 
 “ After this there was a rapid convalescence. Much mucus 
 came away from the rectum, but no pus was ever visible, and 
 there never were any indications of its presence in the pelvis. 
 She now enjoys perfect health, and is entirely free from all her 
 former troubles.” 
 
 Eor some days there is usually considerable pain of a 
 dragging character from the back. The dressing of the stump 
 need not be looked at for at least a week, unless there appear to 
 be any special reason for doing so. There is always some, but 
 not much, suppuration round the clamp. The tissues do not sepa- 
 rate for about three weeks ; should this process be very slow, 
 the clamp may be removed, and as much of the hard dried-up 
 
HYSTERECTOMY. 
 
 463 
 
 tissue cut away as possible. With the clamp there is much 
 less sloughing than when the serre-noeud is used, as the tissues 
 are spread out and not so much constricted. Sloughs are 
 removed without cutting if possible, and the wound is healed in 
 from five to seven or eight weeks. Sometimes one side of the 
 pedicle below the clamp may protrude, making a sort of hernia. 
 This is not of any special importance, and does not require 
 treatment, for it gradually sinks down after the clamp is 
 removed. 
 
 Kemoval of fibroid tumours not extending above the um- 
 bilicus by morcellement is recommended by Fean. The tumour 
 and uterus are removed in pieces through the vagina, as in the 
 removal of large submucous tumours. This plan does not appear 
 to us advisable. 
 
 The chief advantage in Apostoli’s treatment is its freedom from 
 risk and avoidance of mutilation; of removal of the ovaries, almost 
 entire freedom from risk, but accompanied by mutilation ; and 
 the operation of hysterectomy means absolute removal of the 
 uterus. 
 
 There are thus four ways of treating fibroid tumours of the 
 uterus, giving rise to troublesome symptoms. Best, diet, care of 
 the general health, and perhaps curetting, will be the treatment 
 when the patient is at or about fifty years of age, when the 
 symptoms are not very severe, and when the circumstances are 
 such that she can afford to take care of herself. Many such 
 cases at about this age do not require even this amount of 
 treatment; the general health of the patient is often so good 
 that even although the tumour be large, it is not necessary to do 
 anything. The practice of removing such tumours is bad ; no 
 woman ought to be allowed to run the risk at this age unless 
 under very exceptional circumstances. 
 
 Every tumour not large enough to cause disfigurement and 
 not giving rise to symptoms must be left alone. It must be 
 carefully watched, be seen three or four times a year, and its 
 relations to menstruation must be well kept in view. As long 
 
464 FIBROID TUMOURS OF THE UTERUS. 
 
 as it does not grow or increases very slowly it may be safely 
 left alone. 
 
 Electricity as applied by Dr. Apostoli is to be used in every 
 case of tumour extending not more than two inches into the 
 abdomen when the patient is not over forty years of age. The 
 only exceptions are, when there is ascitic fluid or a profuse 
 watery discharge not due simply to anaemia, or when the growth 
 is a fibro-cyst. 
 
 In such small tumours when the patient is over forty but 
 declines to have any operation. 
 
 In most cases where the tumour is larger and does not 
 extend above the umbilicus and the patient is under forty years 
 of age, the exception being when she cannot afford the time 
 necessary for treatment, when the tumour is cystic, when there 
 is ascites or profuse leucorrhoea, and in some of the very soft 
 cedematous tumours. 
 
 When the patient with one of these larger tumours is over 
 forty and declines operation. 
 
 In large tumours, say of 15 or 20 lbs., when the patient is 
 well up in years, for the purpose of tiding her over the meno- 
 pause ; or when operation is absolutely declined, or when the 
 operation would be one of special difficulty or danger, due either 
 to the amount of adhesions or of enucleation required, or to the 
 constitution of the patient, or to some intercurrent disease. 
 
 It may be used even as a preliminary treatment to hyste- 
 rectomy, when the health of the patient is much broken down. 
 
 Eemoval of the ovaries is to be advised in all cases where 
 the tumour does not rise much above the umbilicus, when the 
 patient is over forty years of age. 
 
 When one is not certain that the ovaries are closely adherent 
 to the tumour. 
 
 When a patient cannot afford the necessary time for 
 Apostoli’s treatment. 
 
 When Apostoli’s treatment has failed to cure a small 
 tumour. 
 
HYSTERECTOMY. 
 
 465 
 
 Hysterectomy is to be advised in large tumours in young 
 women. 
 
 In fibro-cystic tumours. 
 
 In soft cedematous tumours. 
 
 When there is ascitic fluid surrounding the tumour, or where 
 there is a profuse watery discharge not due to anaemia. 
 
 When both Apostoli’s treatment and removal of the ovaries 
 have failed. 
 
 It must always be borne in mind that every case of fibroid 
 tumour must be treated not solely as a lump to be got rid of, 
 as is the case with a tumour of the ovary, but after all the 
 circumstances of the growth itself, of the patient, and of her 
 surroundings have been taken into consideration. We have to 
 advise what is best under the circumstances. 
 
 For a woman over forty years of age, the mutilation involved 
 by the removal of the ovaries is a matter of very little moment, 
 and the risk to life is so slight, that the advantages of operation 
 seem to overbalance the disadvantages. For example, we have 
 within one week advised no treatment, electricity, removal of 
 the ovaries, and hysterectomy, to different patients. 
 
 In 1885 Dr. Keith wrote of hysterectomy as follows: — “For 
 myself I was slow to begin this operation. Many uterine 
 tumours of all kinds have passed through my hands. The 
 greater number of these gave little or no trouble at any time. 
 In some there were times of pain, and attacks of hsemorrhage, 
 and then long intervals of repose ; a few even entirely dis- 
 appeared of themselves, and many, I may say hundreds, got 
 over the menopause with little disturbance, though, as a rule, 
 menstruation was prolonged. But there were some who suffered 
 almost without ceasing year after year, and at the time death 
 would often have been welcome. Now, I sometimes see some 
 of those old bad cases of whom I was wearied, — and who, I am 
 sure, were equally tired of me, enjoying a fair amount of health, 
 and able to live like other people. Wishing to have their view 
 of the situation, I tell them that nowadays their tumour would 
 30 
 
466 FIBROID TUMOURS OF THE UTERUS. 
 
 be removed, and that, had they lived a little later, much of their 
 former sufferings would have been spared them. The reply has 
 invariably been, ‘ I am now so thankful that I had no opera- 
 tion.’ I meet the old fibroids in patients of all ages. I saw one 
 the other day in a healthy old lady of eighty-four. I see almost 
 daily in the street one whom I tended for years. She led a 
 dreadful life with her tumour for upwards of twenty years, till 
 it had reached an enormous size. Now it gives no trouble. 
 She is nearly seventy years of a,ge, and year by year her size is 
 becoming less and less perceptible : that some have dropped by 
 the way, unheard of, is likely enough.” 
 
CHAPTER V. 
 
 MALIGNANT DISEASE OF THE UTERUS, ETC. 
 
 For practical purposes malignant disease of the uterus can 
 usually be divided into two classes, the first and most common, 
 cancer of the cervix, and the second, cancer or sarcoma of the 
 body. 
 
 Causes of Cancer. 
 
 The causes are not well known, heredity plays an important 
 part, and the irritation of a lacerated cervix seems often to be the 
 starting point of the disease. Dr. Emmet says that he has never 
 seen cancer of the cervix except in women who have had either 
 a child or an abortion, and this has been also our experience. 
 The connection between these conditions is so close, that it is 
 advisable to close a small cervical tear in a woman with 
 a family history of cancer, even when the symptoms due to 
 the laceration are not otherwise severe enough to justify the 
 operation. 
 
 Diagnosis . — The diagnosis of cancer of the cervix is not 
 always easy in the very early stages, more especially as one has 
 seldom the opportunity of gaining experience by examining these 
 cases until the disease is well advanced. It occurs most fre- 
 quently at about the time of the menopause, and this is one and 
 probably the chief reason why patients so often do not apply for 
 relief until it is too late. At first the only symptom is often 
 some irregularity in menstruation, the flow becomes increased 
 
468 MALIGNANT DISEASE OF THE UTERUS, ETC. 
 
 and may last longer than usual, or it reappears if the patient 
 have passed the menopause. There may be some bloody dis- 
 charge on exertion, after straining at stool, or after a drive over a 
 rough road. When this is not accompanied by pain, the patient 
 pays little attention to it, as the common belief is, that cancer is 
 always accompanied by pain of a darting or shooting character. 
 This symptom, though common, may be entirely absent for a long 
 time, and it is even said to be sometimes wanting during the 
 whole course of the disease. After a time there is discharge due 
 to ulceration and breaking down of the tissues ; it is thin, not 
 purulent, looks like dirty water, has a most offensive odour, and 
 is only to be confounded with the discharge from a sloughing 
 fibroid tumour or polypus. As the disease progresses the general 
 health breaks down, the patient becomes emaciated, the pulse 
 quickens, and the appearance is that of one who is suffering 
 from a wasting or painful disease. 
 
 The diagnosis in an advanced case seldom presents any diffi- 
 culty ; the finger, which is to be dipped in glycerine or in a 
 mixture of soft soap and glycerine, comes upon an irregular 
 ulceration of the cervix, or on a soft, friable, cauliflower-like 
 mass. This latter condition is sometimes mistaken for a 
 sloughing submucous fibroid, projecting through the os uteri, 
 and which is to be differentiated by passing the finger upwards 
 until its connection is made out. Such cases do not come 
 within the scope of this work. In the early stage of the disease 
 little may be felt except some slight hardness. On exposing the 
 cervix with a Sims’, not a Ferguson’s, speculum, some increased 
 vascularity will be noticed, with a swollen condition of the 
 tissues ; what discharge there is may be rather more like mucus 
 than the ordinary watery fluid of the later stages. Should 
 there be a doubt, a piece of tissue must be cut out ; it is not 
 sufficient to take a scraping from the surface. Sections are to be 
 made of this tissue, and on thorough microscopic examination 
 it is probable that a positive diagnosis can be made. 
 
 The symptoms of cancer of the body do not differ from those 
 
VAGINAL HYSTERECTOMY. 
 
 469 
 
 of the same disease in the cervix. On examination the cervix 
 may feel perfectly natural, the uterus, however, will be too large, 
 and the diagnosis ought to be made by dilating the cervix, and 
 exploring the whole of the cavity with the finger, when, if there 
 be any doubt, a morsel of tissue can be removed for microscopic 
 examination. 
 
 When the disease is diagnosed in any part of the uterus, and 
 when the entire growth can be removed by vaginal hysterectomy, 
 the sooner it is taken away the better. The general contra- 
 indications to the operation consist in the state of health of the 
 patient. If she be debilitated from some reason not connected 
 with the malignant disease, or when some other serious disease, 
 as for example phthisis, exists, the operation of hysterectomy 
 ought not to be performed. Any fixing of the uterus or thick- 
 ening of the broad ligament is to be looked on with grave 
 suspicion. This condition ought not absolutely to veto the 
 operation, for a case of cancer of the body of the uterus was seen 
 in the end of 1883, when there was some slight fixation of the 
 organ, accompanied by thickening in the left broad ligament, 
 running apparently from a tear in the cervix. Under these 
 circumstances the patient was not strongly advised to undergo 
 the operation, and as she was not anxious to run the risk under 
 the circumstances, the operation was not performed. Eather 
 more than two years afterwards the disease was found to be still 
 limited to the uterus, the hardness in the broad ligament being 
 rather less than before. 
 
 Should the disease have spread from the cervix to the vagina 
 it is hopeless to look for a permanent result by hysterectomy. 
 
 Vaginal Hysterectomy. 
 
 The operation of vaginal hysterectomy, though performed 
 occasionally during the century, did not make any headway 
 until about twelve years ago. The uterus was at first removed 
 
470 MALIGNANT DISEASE OF THE UTERUS, ETC. 
 
 through the abdomen, but the mortality was so great that this 
 operation had to be soon given up in favour of the vaginal 
 method. Occasionally cases are met with where a combination 
 of those two operations will prove of service, as when a small 
 fibroid tumour has become infected with malignant disease and 
 where it cannot be removed xaginam. 
 
 The preparations for the operation are simple, a dose of 
 castor-oil and a thorough syringing of the vagina before the 
 operation are all that is required, for it is useless to attempt to 
 purify the vagina by injections given for some days before. The 
 bladder is emptied, and the patient is placed in the lithotomy 
 position. Clover’s crutch is very useful to keep the patient 
 steady, while it leaves the assistant with both hands free. No 
 special instruments are required, — scissors, forceps, short curved 
 needles and needle-holder, a sound, sponges, and sponge holders, 
 a speculum, tenacula, two strong vulselli with catch, along with 
 silk and catgut, being all that is necessary. Some operators 
 find retractors useful. 
 
 The first thiug to be done is to again disinfect the vulva, 
 vagina, and cervix with a 1-500 solution of perchloride of mer- 
 cury, the perinseum being drawn down so as to expose the whole 
 of the canal. The ease with which the operation is performed 
 will depend very much on whether the patient has borne children 
 or not, a torn or flabby perinseum greatly facilitating the 
 necessary manipulation. The cervix is firmly grasped by the 
 vulsellum and is drawn down as far as it will come ; the vaginal 
 mucous membrane is then divided round the cervix, keeping very 
 free of the disease if that part be affected. The tissues are sepa- 
 rated by clipping with scissors both in front and behind, care 
 being taken to keep close to the uterus. If there be any doubt 
 as to the position of the bladder, a sound may be passed, and kept 
 in, if thought advisable. As the traction on the cervix prevents 
 haemorrhage, it is well to relax occasionally and tie any vessels 
 which bleed. The peritoneum is first opened behind, and then 
 in front. The curved needle carrying a silk thread transfixes 
 
VAGINAL HYSTERECTOMY. 
 
 471 
 
 the lower part of the broad ligament, close to the uterus to avoid 
 the ureters, and after being tied, the tissue is divided on the 
 uterine side of the ligature ; a second piece of broad ligament 
 situated higher up is treated in the same way, and so on until 
 the whole has been tied, and the ligatures cut short. If there 
 be much bleeding from the uterus in spite of the traction, forceps 
 are fixed on to the side of the organ. The other broad ligament 
 is treated in the same way, and if possible the ovaries on both 
 sides are removed. All bleeding vessels are tied, a small sponge 
 is passed into the pelvic cavity to make sure that nothing has 
 escaped into it, and as it is withdrawn the peritoneal edges are 
 everted. It seems to be supposed that it is of little importance 
 whether the peritoneum is closed or not, but sutures ought 
 always to be put in. A drainage tube is not required. Iodoform 
 gauze is packed into the vagina to keep everything sweet, and to 
 give some support. 
 
 This is the most simple way of performing the operation, 
 but several modifications may be mentioned. After opening 
 the peritoneum behind and in front, the fundus is drawn 
 downwards through the posterior opening, either by the help 
 of a sound in the cavity, or by catching hold of the fundus 
 with a vulsellum. By this manipulation the broad ligaments 
 are brought lower down and are then transfixed and tied. The 
 disadvantage of this plan is that the cervix passes more or 
 less into the cavity of the peritoneum, and may possibly give 
 rise to some septic infection, in spite of every precaution. 
 Instead of tying the broad ligaments they are sometimes 
 secured in specially arranged clamps, or in long and narrow- 
 bladed catch forceps. These are left on for from twenty-four 
 to forty -eight hours, and they are usually removed with 
 considerable difficulty. The natural result is that the parts 
 of the broad ligament slough and give rise to putrid discharge. 
 This method is extremely simple and easy to perform, a finger 
 being put in front of, and one behind the broad ligaments to 
 act as a guide. It is bad surgery, and is resorted to only when 
 
472 MALIGNANT DISEASE OF THE UTERUS, ETC. 
 
 the operator is unable, or does not care to take the trouble to 
 tie the ligaments. 
 
 The after treatment does not vary from that of any other 
 abdominal operation, except that it is well to move the bowels 
 early, to avoid intestinal adhesions forming to the cut surface 
 of the peritoneum. The danger of this adhesion is, however, 
 lessened when the wound has been accurately sutured. 
 
 In 1882, Dr. Keith removed a uterus by the vagina for 
 epithelial cancer of the cervix. He thought of clamping the 
 broad ligaments, but did not consider the idea a good one. 
 The peritoneum was opened in front and behind, the uterus 
 was drawn downwards, the broad ligaments were transfixed, 
 tied, and divided on one side, leaving the ligatures on the 
 divided ligament long. The other broad ligament was treated 
 in the same way. The operation was a particularly easy one 
 on account of the great mobility of the uterus and the almost 
 total want of perinaeum. It was completed by bringing the 
 edges of the wound accurately together by ten stitches, and 
 some gauze was packed into the vagina. The ligatures were 
 drawn away from the broad ligaments with considerable 
 difficulty at the end of two weeks. There has been no return 
 of the disease. 
 
 In September 1890, the uterus was removed from a patient 
 aged fifty for cancer of the cervix. The patient made a good 
 recovery, but nineteen months after there was a slight return 
 in the scar, accompanied by some bleeding, and a feeling of 
 pelvic discomfort, scarcely amounting to pain. The patient 
 was anxious to try something, but as the return had shown 
 itself rather close to the base of the bladder an operation was 
 not possible, and the injection of pyoktanin was suggested. 
 The improvement in the general health under this treatment 
 was very marked, the bleeding and discomfort disappeared, 
 and at first there was rapid improvement in the local condition. 
 At the end of three months there seemed to be some increase 
 at one spot, and Dr. Mosetig was asked to come over from 
 
niSFLACEMENTS OF THE UTERUS. 
 
 473 
 
 Vienna to see the patient. He strongly advised the continu- 
 ance of the treatment, and this was done by the patient’s own 
 medical man in Ireland, but it failed to check the disease. In 
 1891, an unmarried lady, fifty-two years of age, was seen. 
 Menstruation had ceased for six years. For two years before 
 there had been some irregular bloody discharge from the 
 uterus. This was at first thought little of, but the patient 
 gradually became emaciated and cachectic. On examination, 
 the vagina was narrow, the cervix natural, the uterus slightly 
 enlarged, and the discharge was very offensive. Eemoval of 
 the organ was strongly advised, but was declined, as some 
 friend had promised to cure the disease with the Mattei 
 remedies. When next seen some six weeks afterwards, the 
 uterus was much larger, and at the operation it was found 
 difficult to bring down the enlarged organ through the narrow 
 vagina. The operation would have been simplified by making 
 an incision through the abdominal wall, and could have been 
 finished much more quickly. The disease was entirely confined 
 to the body, the cervix not being affected. The patient died on 
 the second day. Her chances of recovery would have been 
 much better had it not been for the time wasted, for the 
 strength was diminished and the difficulty of the operation 
 increased by the delay. 
 
 Displacements of the Uterus. 
 
 Displacement of the uterus must sometimes require to be 
 treated by an abdominal operation when the patient is suffering, 
 and all other treatment has been tried and has failed. Eetro- 
 version and prolapse are the conditions which may require 
 such treatment. 
 
 It is not necessary to enter into the symptoms caused by 
 a retroversion, and it is very seldom that the operation ought 
 to be required when there is no accompanying disease of the 
 uterine appendages. 
 
474 MALIGNANT DISEASE OF THE UTERUS, ETC. 
 
 The operation is not suitable for all cases of prolapse, only 
 for those where there is little rectocele or cystocele. The 
 diagnosis of the exact condition is made by pushing the uterus 
 into the normal position, and preventing its descent with the 
 finger, while the patient bears down. Should the pelvic 
 contents not come down the case is one suitable for 
 abdominal operation. 
 
 The operation for both these cases consists in making a 
 short median abdominal incision, and fixing the uterus to the 
 abdominal wall. This is done in various ways, the best is to 
 make an artificial pedicle with the right broad ligament, clamp 
 it with an ordinary ovariotomy clamp below the ovary, and 
 fix it in the wound, the ovary of course being removed. 
 Should the patient be near the menopause, the left ovary may 
 also be taken away and the stump allowed to drop back into 
 the abdominal cavity. Examination made shortly after the 
 operation shows that the uterus is fixed, but after a few months 
 it becomes completely movable and never reverts to its old 
 position. The first operation we know of was performed by 
 Dr. Keith in 1869. The following is a good example. A lady 
 twenty-six years of age had been under the treatment of several 
 of the best specialists in America, but had received only tem- 
 porary benefit. When she saw Dr. Keith in 1880, he found 
 that the uterus was large, heavy, and retroverted, and that the 
 ovaries appeared to be healthy. The lady could do almost 
 nothing on account of pain in the back. Dr. Keith sent her 
 home to rest for a year. She returned after two additional 
 years of treatment. Both ovaries were removed, and the 
 pedicle of the right was fixed in a clamp to the abdominal 
 wall. The patient got quite well, and there was no return 
 of the pelvic trouble up to her death, which occurred eight 
 years after the operation. 
 
 A patient forty -eight years of age had suffered from 
 constant pain in the right side since the birth of her first 
 child eleven years before; the pain and discomfort were so 
 
OBSTRUCTION TO LABOUR. 
 
 475 
 
 great that she found life a burden. Almost the whole of the 
 uterus lay outside the vagina, and there was little prolapse 
 either of the bladder or rectum. The right ovary and tube 
 were enlarged. At the operation in April 1886, the left 
 ovary, although it was healthy, was removed on account of 
 the age of the patient ; the pedicle of the right ovary and tube 
 was fixed in a clamp. The clamp came off at the end of the 
 third week, but the patient was not allowed to get out of bed 
 for an additional fortnight. Four months after the operation 
 she was perfectly well, and able to walk a long distance. 
 When heard of in 1892, six years after the operation, there had 
 been no return of the prolapse. 
 
 Instead of fixing the uterus up to the abdominal wall by 
 means of the broad ligament, various other plans are adopted ; 
 the median incision is made as before, a silk suture is passed 
 beneath the round ligament close to the uterus and then through 
 the peritoneum and is tied ; a second suture fixes the other 
 round ligament to the peritoneum in the same way. 
 
 The uterus may be sutured directly to the peritoneum, or, in 
 cases of retroversion alone, the anterior part of the uterus and 
 the anterior surface of both round ligaments are scarified, the 
 parts over the round ligament being folded across and on to the 
 uterus, and in this position they are stitched together. A pucker 
 may also be made in the round ligaments. The objection to all 
 these plans is, that in time the uterus almost always breaks 
 away, and the old condition of affairs returns. To make the 
 operation justifiable the mortality must be almost nil. 
 
 Obstkuction to Labour. 
 
 Obstructions to the passage of a child through the pelvis are 
 seldom so absolute in this country as to make it necessary to 
 resort to a cutting operation. When the maternal outlet is so 
 small that it is impossible to extract even a mutilated child, one 
 of four operations will have to be resorted to. The causes which 
 
476 MALIGNANT DISEASE OE THE UTERUS, ETC. 
 
 necessitate the performance of any of these operations are, either 
 a contraction of the bony walls of the pelvis from malformation 
 or from the presence of a tumour growing from the bones, or a 
 diminution of the space required for the passage of the infant by 
 a fibroid tumour of the uterus, or cancer of the cervix, or even 
 by simple swelling in the pelvic cellular tissue. It is considered 
 that anything under an antero-posterior diameter of one inch and 
 a half with less than three inches in the transverse diameter 
 necessitates surgical interference. It is quite an open question 
 whether it would not he better and safer for the mother to 
 operate when the diameter is two or even two inches and a half, 
 rather than to perform craniotomy. 
 
 There are four operations : the Csesarean, or the extraction of 
 the child through the wall of the uterus. 
 
 Porro’s operation, or the removal of the uterus with the child. 
 
 Laparo-electrotomy, or the extraction of the child through 
 the natural os and through an incision made into the top of the 
 vagina from the outside above Poupart’s ligament. 
 
 Symphysiotomy, or the old operation, recently revived, of 
 dividing the pelvis through the pubic symphysis so as to 
 increase the space and allow the extraction of the child 'per mas 
 naturales. 
 
 The choice will depend partly on the nature of the case, and 
 partly on the experience of the operator. It will be seen that 
 either of the first two may be resorted to in any case, while the 
 field for laparo-electrotomy and symphysiotomy is to a certain 
 extent limited. 
 
 At full term the uterus will be found to have raised and 
 stretched the broad ligaments to a great extent, and the condition 
 is somewhat the same as that of a fibroid tumour of the uterus 
 which has grown between the layers of the broad ligaments. 
 The entire pelvic peritoneum is raised so much that an incision 
 made immediately above the pelvic brim is below the level of 
 the peritoneal cavity, the base of the broad ligaments being 
 higher than the upper borders were before the commencement 
 
CESAREAN SECTION. 
 
 477 
 
 of pregnancy. The upper border, which in the unimpregnated 
 condition has an almost horizontal direction, has now become 
 almost vertical, running from the side of the fundus of the 
 uterus to the brim of the pelvis. The cellular tissue becomes 
 loose and allows of considerable movement and stretching of the 
 broad ligaments. 
 
 CESAREAN Section. 
 
 The Caesarean operation is the extraction of the child through 
 an incision in the uterus. No special instruments are required 
 for its performance, a bistoury and a needle and thread will 
 suffice ; in addition, a pair of scissors, catch forceps, and sponges 
 will be found useful. Two assistants are required in addition to 
 the anaesthetist. Before commencing the operation it is well to 
 make out the position of the head, and to assure oneself that the 
 infant is living. 
 
 When a choice of the time for operation can be made, it 
 should be arranged for at full term, as near the commencement 
 of labour as possible, and before the membranes have ruptured. 
 
 It is impossible to give exact directions as to the position of 
 the median incision through the abdominal wall, it must be 
 made entirely in regard to the situation and size of the uterus, 
 keeping in mind that the section of that organ is to extend 
 downwards from close to the fundus. The external incision 
 may therefore be partly above and partly below the umbilicus, 
 or might even be wholly above ; in length it will vary from four 
 to six inches, depending on the thickness of the abdominal wall. 
 The incision ought to be carried right through the umbilicus, 
 and here, as also when large solid tumours are being removed, 
 it assists greatly in the accurate stitching of the wound if one or 
 two lines are made across the linea alba with an aniline or 
 nitrate of silver pencil, the latter being the better. After the 
 peritoneum has been opened to the full extent of the wound, it 
 is necessary to be quite certain that the uterus is not twisted 
 upon itself, and this is effected by inserting the finger and 
 
478 MALIGNANT DISEASE OF THE UTERUS, ETC. 
 
 making out the position of the Fallopian tubes. One assistant 
 then presses the uterus well forwards from the outside so that 
 there cannot be any escape of blood or fluid into the peritoneal 
 cavity, and an incision of from one to two inches is made through 
 the middle line of the uterus, commencing close to the fundus. 
 The thickness of the uterine wall to be divided will probably be 
 at least one inch, and the incision may be made to that depth 
 with the first cut. As soon as the membrane is reached — and 
 its white glistening appearance is unmistakable — the incision is 
 to be extended downwards with scissors to the extent of about 
 four inches, the exact length of the wound depending on the 
 size of the child. The making of the uterine incision and the 
 extraction of the child must be done quickly, and it is not 
 necessary to spend more than a couple of minutes in completely 
 emptying the uterus from the time of commencement of making 
 the skin incision. It is therefore of little importance whether 
 the membranes are ruptured or not. If the incision be completed 
 without rupture of the membranes, the head is grasped through 
 them, and they are ruptured during the extraction of the child ; 
 on the other hand, should the membranes be broken before the 
 incision is finished, it is to be at once completed, and the hand 
 passed into the uterus quickly extracts the child by the head. 
 It is best to seize the head and not endeavour to deliver by the 
 feet, for if the uterus contract very rapidly or the surgeon be not 
 quick enough in his manipulation, the after-coming head may be 
 grasped by the contracting uterus. As the child is withdrawn 
 the collapsed uterus is pushed forward by the assistant, who has 
 been making steady pressure from the loins, and the upper and 
 lower halves of the uterine incision are grasped by the right and 
 left hands of the other assistant. This plan is immensely 
 superior in every way to attempting to arrest the haemorrhage 
 by constricting the neck either with the hands or by a ligature. 
 In this way bleeding is entirely arrested. As soon as the child 
 has been delivered the cord is temporarily constricted by two 
 pairs of forceps and is divided between them. The infant is 
 
CESAREAN SECTION 
 
 479 
 
 handed over to the nurse, who ties the cord in the usual way. 
 A large sponge is inserted into the upper part of the abdomen 
 to shut off the peritoneal cavity from all exposure, and the hand 
 is passed into the uterus to remove the placenta while the 
 assistant slightly relaxes the wall. 
 
 Sponging ought not to be necessary, but if required it must 
 be done at this stage. A part of the uterus will now be lying 
 slightly outside the abdominal cavity, and it is not necessary to 
 draw it farther than is required for convenience in stitching ; 
 turning out the whole uterus before the child has been extracted, 
 or at any other stage in the operation, is entirely unnecessary. 
 The stitching of the uterus is begun, the peritoneal covering 
 
 being turned inwards, and if there be any difficulty in doing this, 
 it may be slightly dissected off. A single needle threaded with 
 silk is used, and each stitch is tied as it is introduced, no clots 
 being allowed to remain between the lips of the wound. Before 
 the stitches are introduced into the uterus, the finger must be 
 passed into its interior to be certain that the cervix is open, and 
 if necessary it must be slightly dilated. Three deep stitches 
 are required to the inch, and if necessary, superficial ones also 
 may be put in. The stitches are to be passed deeply into the 
 substance of the uterus without entering the cavity, and care 
 must be taken to avoid the common mistake of tying them too 
 tightly. After all the stitches have been secured, the sponge is 
 taken out, the uterus dried, and the abdominal wall closed with 
 a large number of sutures. Drainage of the peritoneal cavity is 
 not required, and the after treatment is conducted on general 
 principles. 
 
480 MALIGNANT DISEASE OF THE UTERUS, ETC. 
 
 Various plans have been adopted for closing the uterine 
 wound, and one other may be given. The deep stitches, two to 
 the inch, are introduced a quarter of an inch from the edge of 
 the wound, and are passed through the uterine muscle as before, 
 taking care not to enter the uterine cavity. After they have been 
 tied a superficial silk stitch is introduced between each. The 
 peritoneum is picked up by a stitch half an inch from its now 
 turned-in edge, on the one side, and at the same distance on the 
 other ; as these stitches are tightened, the peritoneum is inverted 
 over the deep sutures which are thus completely buried. 
 
 If the uterus does not contract well, a sponge or two wrung 
 out of hot water may be introduced into the cavity, or a dose of 
 ergot injected hypodermically may be given, this latter being 
 always good practice as soon as the child is extracted, or simple 
 kneadiug may cause contraction, or the use of the galvanic 
 current may be necessary. Should contraction not take place 
 Porro’s operation would be required. 
 
 Before commencing a Caesarean section, one has to make up 
 one’s mind on the question of whether future pregnancies are to 
 be allowed or not. It is a difficult question to decide what is 
 the proper course to follow ; if the patient be willing to run the 
 risk of operative interference a second time the matter is settled, 
 and on the whole it will be best to be guided by her wishes on 
 the subject. Whether the ovaries are to be removed or an 
 excision made of a piece of the Fallopian tubes will depend on 
 the age of the patient ; for the artificial menopause which results 
 from the removal of the ovaries gives rise to many distressing 
 nervous symptoms. 
 
 Porro’s Operation. 
 
 Porro’s operation is the removal of the uterus either in its 
 entirety or at the neck. It is to be performed when there is 
 cancer of the uterus or a large fibroid tumour, and under similar 
 pelvic conditions as the Caesarean section. The first steps of the 
 operation are the same, the uterus may be incised and the child 
 
LAPARO-ELECTROTOMY. 
 
 48 1 
 
 extracted, or the abdominal incision may be made longer and 
 the uterus turned out whole. If the child be extracted when 
 the uterus is in the abdominal cavity, it is not necessary to wait 
 for the separation of the placenta, but the uterus is drawn out- 
 side at once. This is done by hooking a finger into each end of 
 the uterine wound and pulling, while the assistant pushes from 
 behind. As soon as the uterus is turned out some sponges are 
 packed into the abdomen and a ligature is quickly tied round 
 the neck; a clamp or wire is fixed on, as in supra- vaginal 
 hysterectomy, or the broad ligaments are enucleated downwards, 
 and the whole of the uterus removed. In either case the steps 
 do not differ in any detail from the description given in the 
 chapter on the treatment of uterine fibroids. Instead of remov- 
 ing the child in sitn, it will be better to turn out the uterus, 
 quickly tie an elastic ligature round the neck and cut it off. 
 The assistant , opens the uterus and removes the child. The 
 advantages of turning out the uterus entire are, the prevention 
 of fluid escaping into the peritoneum, and of the loss of blood 
 which occurs when an incision is first made. The disadvantage 
 is the longer abdominal incision. The stump is either fixed in 
 a clamp, or the cervix is enucleated as before. There is nothing 
 peculiar in the after treatment. 
 
 Laparo-Electkotomy. 
 
 The next operation, that of laparo-electrotomy, differs from 
 the other two in that neither the peritoneum nor the uterus is 
 opened. The object of the operation is to extract the child 
 above the brim of the pelvis. Before the operation is commenced 
 the os must be dilated either naturally or with Barnes’ bags. 
 When there is difficulty in doing this on account of the position 
 of the os or contraction of the vagina, it can be done at a later 
 stage through the incision. 
 
 The extraction is accomplished by making an incision in one 
 or other groin, reaching from one and a half inches to the outside of 
 31 
 
482 MALIGNANT DISEASE OF THE UTERUS, ETC. 
 
 the spine of the pubes to one inch above the anterior superior iliac 
 spine. It runs with a slight curve, the concavity looking up- 
 wards, about one inch above Poupart’s ligament, and may be 
 made on either side, the right being the more convenient. The 
 epigastric artery is the only vessel of any size divided by the 
 incision. On getting near the peritoneum, it may bulge into 
 the wound, and must be kept out of the way by the assistant. 
 The vagina is opened as low down as possible to avoid the large 
 veins which are present near the cervix, and also to keep clear 
 of the ureters. Until the vagina is opened, a sound should be 
 kept in the bladder to avoid injury of that viscus, though such 
 an injury is more likely to occur during the extraction of the 
 child. The vagina is to be pressed up into the bottom of the 
 wound by the finger introduced into the passage, and an opening 
 is made from the wound on to the finger with scissors. The 
 opening is enlarged by tearing, and the child is delivered either 
 by forceps or by turning through the upper part of the vagina 
 and the abdominal wound, thus entirely avoiding the pelvis. 
 The placenta is extracted in the ordinary way. There is not 
 much trouble from bleeding ; any vessels may be tied, and should 
 there be persistent oozing which does not stop after the stitches 
 have been introduced and tied, the vagina must be packed with 
 iodoform gauze and pressure made against that. Before closing 
 the wound a weak solution of permanganate of potash is injected 
 into the bladder, and if there be any injury to that organ it 
 must be closed at once. The stitches are introduced as in any 
 abdominal wound, and the dressing is the same as usual. A 
 bladder opening has shown itself some days after the operation, 
 but no harm has been known to result, and operation has not 
 been required, as the fistula has healed in a few weeks. 
 
 This operation has not been performed at all frequently, 
 possibly because the description appears to imply that great 
 surgical skill and anatomical knowledge are required. 
 
^ YMPHYSIOTOMY. 
 
 483 
 
 Symphysiotomy. 
 
 Eeceiitly the old operation of division of the symphysis 
 pubis has been revived. The possibilities of this operation are 
 limited to those cases of diminished pelvic outlet where the 
 conjugate is not less than two and three quarter inches, and it 
 is therefore a question whether the operation ought to be resorted 
 to rather than the induction of premature labour. This is, how- 
 ever, a point which must be decided by the obstetricians, and 
 it is only necessary here to describe the indications for the 
 operation and the mode of its performance. 
 
 It has been found, that when the cartilage at the symphysis 
 is divided in a woman who has died during labour, the two bones 
 may be separated fully two inches without causing any injury. 
 
 Dr. Harris of Philadelphia gives the following directions for 
 the applicability of this operation : — “ As the foetus is to be 
 delivered ^er vias naturales, great care must be taken to get 
 a proper measure of the sacro-pubic diameter of the pelvis, 
 and to determine if a normal condition of the sacro-iliac 
 symphysis exists. The operation is not practicable in a 
 Eobert or Haegele pelvis, or in one where there is a coxalgic 
 ankylosis from disease in childhood. It is also impracticable 
 in cancer of the cervix uteri, in cases where the cervix will not 
 dilate, and in obstructions of the pelvis by exostoses, cervical 
 and sacral tumours, and other forms of abnormal growths. It 
 should be borne in mind that the shorter the sacro-pubic diameter 
 the greater must be the strain on the sacro-iliac symphysis, 
 and that the pubic separation, when the fcetal head is large, 
 will be much greater than when it is small ; a large cranium has 
 to occupy deeply, with one parietal protuberance, the inter-pubic 
 opening. If rachitic dwarfs bore children of a size in proportion 
 to themselves there would be less difficulty in their delivery ; 
 but the foetus is often influenced by the size of tlie father, who 
 may be a large man, and it will weigh from 8 lbs. to even 14 lbs.” 
 
 The only special instrument which is advisable is a Galbiati’s 
 
484 MALIGNANT DISEASE OE THE UTERUS, ETC. 
 
 probe -pointed bistoury, but a strong, probe -pointed, curved 
 bistoury will do instead. The pubes must be shaved in this 
 operation alone of all abdominal operations and the parts about 
 the vulva must be disinfected by the surgeon with the very 
 greatest care. The patient is placed on the back with the knees 
 drawn up and separated as far as possible, and a rigid catheter 
 is passed into the bladder and is given in charge of an assistant 
 to depress the urethra and draw it to the side, and thus prevent 
 its injury when the section is made. A vertical incision is made 
 through the skin and superficial tissues, about two inches in 
 length, the lower end being rather less than an inch above the 
 symphysis pubis. The incision is deepened with scissors down to 
 the symphysis in the direction of the notch, which can be easily 
 felt at this stage if there has been any difficulty before the skin 
 was divided. The bone having been reached, the left forefinger 
 is passed down behind the symphysis, the palmar surface lying 
 against it. Galbiati’s knife is passed along the finger until it 
 hooks round the lower part of the symphysis, which it cuts in a 
 direction from within outwards, and from below upwards. As 
 soon as the division is made, the bones are at once separated. 
 If the assistant is not very careful in keeping the urethra well 
 depressed, and to the right side while the symphysis is being 
 divided, the canal runs a great risk of being injured. The wound 
 is temporarily dressed, while the child is being extracted. While 
 this is being done an assistant must prevent too great separation 
 of the pelvis. The wound is closed with the usual silk sutures, 
 and a bandage is put firmly round the hips to keep the pelvis 
 absolutely quiet. The tendency appears to be to allow the 
 patient to get out of bed too soon. It seems to be a mistake, 
 however, to run the risk of any movement of the pelvis by per- 
 mitting the patient to get up at the end of a week, although it 
 appears to be customary to treat the cases very much as if no 
 operation had been performed. 
 
 In considering the question of which of these four operations 
 is to be performed, it is necessary to take into consideration all 
 
6' YMPHYSIOTOM Y. 
 
 485 
 
 the circumstances of the case, and there is no one operation 
 which can be recommended under every condition. The scope of 
 symphysiotomy has already been referred to. Its application is 
 limited, and it cannot be of service when the contraction of the 
 pelvis is great. 
 
 Symphysiotomy and laparo-electrotomy may be first com- 
 pared, as in neither is the peritoneum opened. With the small 
 experience there has been of laparo-electrotomy it appears that 
 this operation is to be preferred. Neither can be chosen when 
 there is cancer of the cervix, nor when there is a fibroid tumour 
 of the uterus preventing labour, for in the first case no cure can 
 be obtained by the operations, and when a fibroid is present 
 an abdominal operation can cure the disease at the same time. 
 They cannot be used by those who consider it unjustifiable to 
 allow a woman with a pelvis contracted from one cause or 
 another, to run the risk of future pregnancies. It is said that 
 laparo-electrotomy cannot be performed oftener than twice on 
 the same patient, first on one side and then on the other, but it 
 is difficult to understand why this should be so, although one can 
 easily see that there might be some extra difficulty in making 
 the incision. The advantages of both are, that there is little loss 
 of blood, and that the peritoneum is not opened. The disadvan- 
 tages are, that they are not suitable for every case, that there is 
 risk of injuring the bladder by tearing as the child is delivered, 
 or the urethra during division of the symphysis, and that future 
 impregnations cannot be prevented should this be desired. 
 
 Comparing the two intra-peritoneal operations the preference 
 will be given, as a rule, to the Caesarean section. It is certainly 
 more easy to perform than the Porro, and the risk to the patient 
 is very much less. It allows of future pregnancies, the operation 
 having been performed several times on the same patient, and 
 there is not the inconvenient stump to be dealt with, as in the 
 case of the Porro, when performed in the usual way. It will be 
 preferred except in cases where there is inertia of the uterus, 
 where there is a large fibroid, and in cases of cancer of the 
 
486 MALIGNANT DISEASE OF THE UTERUS, ETC. 
 
 cervix when the uterus and the whole of the disease can be 
 removed. 
 
 Each case must be treated by the operator in the way which 
 appears to be most suitable under the circumstances, and it is 
 probable that the Csesarean section will become the operation 
 of election. The child may be allowed to suckle if the patient 
 be delivered at full term, and in every other respect the treat- 
 ment to be followed does not differ from that of a usual confine- 
 ment. 
 
 Euptuke of the Uterus. 
 
 Complete rupture of the uterus is an accident which fortu- 
 nately does not occur frequently. It is usually caused by some 
 weakness in the muscular wall of the uterus, due to obstruction 
 to the passage of the child, the result being that the lower seg- 
 ment of the uterus is drawn up into the abdomen and thinned 
 out ; or by some external injury during pregnancy ; or by some 
 injury during an attempt at delivery, either by the hand while 
 turning, or with the forceps. Strangely enough the symptoms 
 are not always well marked, hut as a rule there are signs of 
 collapse and hemorrhage; there may he sudden and severe 
 pain, and on examination the part which was presented will 
 usually have disappeared. Hemorrhage from the vagina 
 frequently occurs. The patient feels as if something had given 
 way, and the noise made by the tear is at times heard by those 
 present in the room. The symptoms may not come on immedi- 
 ately. If the hand be passed into the uterus, it may he found 
 that the foetus has partly or wholly passed into the peritoneal 
 cavity, or the uterus may he found to he contracted, showing 
 that the foetus has disappeared through a rent. 
 
 When the accident has occurred, an incision into the 
 abdominal cavity through the middle line must always be made, 
 for to do nothing means death. Both the foetus and the placenta 
 must he removed if they have passed into the peritoneal cavity. 
 The rent in the uterus must he looked for, and it will usually be 
 
EXTRA-UTERINE PREGNANCY. 
 
 487 
 
 found at the lower part ; a rupture at the fundus is rare, for as 
 the uterus contracts the walls of the upper part thicken, while 
 the lower zone is stretched and thinned. On account of the 
 usual position of the tear, and also from the irregularity and 
 bruising of the edges, it is seldom possible to repair the rent, and 
 the whole organ must be removed. This is done in the way 
 described under Porro’s operation, the abdomen is well washed 
 out and sponged, care being taken to dry the pouch which is 
 formed behind the pubes. . A drainage tube is to be left in, and 
 the wound is closed. 
 
 Extra-Uterine Pregnancy. 
 
 The proper and natural resting-place for a foetus during the 
 whole nine months of pregnancy is in the cavity of the uterus. 
 When the foetus is situated outside this cavity, the pregnancy is 
 said to be extra-uterine, and this describes the condition exactly. 
 The desire for the manufacture of new names has led to the 
 adoption of a new term to describe the abnormal position, and 
 the phrase, ectopic gestation, is often used. It matters nothing 
 to the patient what term is employed, and we shall continue to 
 use the old name as comprising every case of pregnancy outside 
 the uterine cavity. The great majority, if not all, of these 
 cases, occur primarily in the Fallopian tube. There is still a 
 certain amount of doubt in regard to the question whether the 
 impregnation may not occur in the ovary. During an operation, 
 and especially when bleeding is going on freely, one has to 
 think rather of the patient than of the exact pathological 
 condition, and observations made at the time require corroboration 
 not only by examination of the specimen removed, but also it 
 may be from post mortem examination. Opportunities of 
 making exact observations during a post mortem examination are 
 fortunately not often met with, and this may account in part at 
 least for the doubt whicli surrounds the question of ovarian 
 pregnancy. It is quite possible to see how it may occur, l)ut it 
 
488 MALIGNANT DISEASE OF THE UTERUS, ETC. 
 
 may be that an ovary or small ovarian tumour forms part of the 
 sac, the remainder consisting of the fimbriated end of the tube 
 which has become adherent. In any case it is not of practical 
 importance. While it is at least probable that every case of 
 extra-uterine pregnancy commences in the tube, the foetus does 
 not remain in that position long, rupture occurs, usually before 
 the third month, either into the abdominal cavity or between 
 the layers of the broad ligament. When the fertilised ovum is 
 arrested in the tube as it passes through the uterine wall, the 
 foetus may grow in that situation until the end of the pregnane}^ 
 and apparently the child may be delivered naturally ; or rupture 
 may occur about the fifth or sixth month. 
 
 The rupture may take place in one of two directions. It 
 may be either through the part of the tube which is in direct 
 contact with the peritoneal cavity ; or through the part which 
 lies between the layers of the broad ligament, and thus in direct 
 connection with the cellular tissue of the pelvis. 
 
 When the rupture is through the part of the tube in direct 
 communication with the peritoneal cavity, the foetus passes 
 directly into the abdomen. The result of this is, either that the 
 patient dies of haemorrhage ; or the foetus dies and disappears in 
 the intra-peritoneal haernatocele resulting from the bleeding ; 
 or the foetus lives, forms an adventitious sac, goes on to full 
 time, dies, becomes formed into a lithopaedion, and may 
 eventually be got rid of either through the abdomen or any of 
 the abdominal viscera. 
 
 When the rupture takes place in the part of the tube 
 situated between the layers of the broad ligament, the foetus 
 passes into the cellular tissue, and if it die early it disappears 
 in the extra-peritoneal haematocele which is formed. If the 
 pregnancy be further advanced, the foetus does not disappear, 
 but is apt to cause suppuration. If it live in this situation it 
 may go on to full term and eventually dry up into a lithopsedion. 
 If a second rupture take place from the interior of the broad 
 ligament into the peritoneal cavity, the results are similar to 
 
EXTRA-UTERINE PREGNANCY. 
 
 489 
 
 those which occur when the rupture into the peritoneal cavity 
 has been primary instead of secondary. 
 
 Sym'ptoms . — It is seldom that one has an opportunity of 
 diagnosing an extra-uterine foetation before rupture of the tube 
 has taken place. There is nothing to make the woman suspect 
 that there is anything the matter, and she may have no idea 
 that she is pregnant. This is not to be wondered at, for these 
 cases occur as a rule in women who have been sterile, or 
 who have not had a child for some time. There is frequently 
 some previous history of pelvic trouble, and the most likely 
 symptom to draw attention to the condition is irregularity in 
 menstruation combined wdth some of the usual symptoms of 
 pregnancy. A cast of the uterus is probably always thrown off, 
 but may not be noticed by the patient. On examination the 
 uterus is found to be enlarged, and to be pushed either forwards 
 or to one side by a soft well-defined oval swelling. In the 
 region of this swelling and running towards the uterus marked 
 pulsation is felt. The swelling differs from an ordinary pyo- or 
 hydrosalpinx in conveying the feeling that something has been 
 inserted into the tube at one spot. There is no special 
 tenderness. 
 
 When the rupture takes place through the part of the tube 
 in direct communication with the peritoneal cavity, alarming 
 signs of haemorrhage may be the first and only symptom. The 
 haemorrhage may be so great that the patient may die simply 
 from the loss of blood. When the patient is seen the signs of 
 haemorrhage are well marked. She is cold, collapsed, restless, 
 and anaemic. On examining the abdomen the presence of fluid 
 may be detected, or an ill-defined swelling may be present. In 
 the pelvis there may be nothing definite, simply some slight 
 bulging, and more than the ordinary amount of resistance. 
 Although the condition is most alarming, the patient does not 
 necessarily die. 
 
 When the child lives in the abdominal cavity it becomes 
 surrounded by a sac, although in one notable case the foetus was 
 
490 MALIGNANT DISEASE OF THE UTERUS, ETC. 
 
 simply lifted out from amongst the intestine when the abdomen 
 was opened. The diagnosis of the presence of a foetus outside 
 the uterus is extremely difficult, and reliance must not be 
 placed on the apparent want of the uterine wall, for in cases of 
 normal pregnancy it is not uncommon to feel the foetus lying 
 apparently immediately beneath the abdominal wall. The 
 main points to guide us are the history of the attack when the 
 rupture occurred, the irregular uterine discharge, and the cast 
 if it be obtained. The examination shows a body in the 
 position of the uterus, which organ is somewhat enlarged, partly 
 fixed, and is not in its natural position. The sound must not 
 of course be passed if there be any suspicion of pregnancy. 
 
 When the tube ruptures into the broad ligament, and a 
 rupture into this situation or into the abdominal cavity usually 
 occurs while the patient is making some slight exertion as 
 putting on her clothes, great and sudden pain is experienced in 
 the lower part of the abdomen. If there be much haemorrhage 
 into the broad ligament the pain will be of a tearing character, and 
 there may be collapse with the usual signs of the loss of blood. 
 An examination made at this time or shortly afterwards will 
 show the uterus much as before, but the lateral swelling will 
 not be so defined. The swelling will be much larger than it 
 was, pulsation will be evident, and the mass will be decidedly 
 tender to the touch. 
 
 If the foetus be absorbed the swelling which is practically a 
 heematocele in the broad ligament quickly disappears. 
 
 Should the foetus be too far advanced to allow of its 
 absorption, suppuration may occur, and from the anatomical 
 relations of the pelvic cellular tissue it will be seen that rupture 
 will take place, into the rectum, vagina, bladder, or through 
 the abdominal wall, the foetal bones being discharged among 
 the debris. Before this rupture takes place symptoms may be 
 noticed, there may be vesical irritability if the abscess be going 
 to open into the bladder, or diarrhoea or tenesmus if the rectum 
 be the site chosen. 
 
EXTRA-UTERINE PREGNANCY, 
 
 491 
 
 When the fcetus lives after the tube has ruptured into the 
 broad ligament, and has not passed into the abdomen through a 
 second rupture, it continues to grow, and if left alone goes on to 
 full term. There is then an attempt at labour, the uterus 
 which has become considerably enlarged contracts and causes 
 spurious labour pains. The foetus soon dies, the amniotic fluid 
 is gradually absorbed, and the placental circulation diminishes 
 and finally ceases. These phenomena are accompanied by 
 diminution in the size of the swelling. In time the foetus 
 becomes disorganised and is transformed into a lithopsedion. 
 This may lie quiescent for many years, but may at any time 
 begin to discharge itself through the abdominal wall or any 
 abdominal organ. 
 
 When secondary rupture of a living foetus takes place from 
 the broad ligament into the peritoneal cavity the haBmorrhage 
 will be severe. If the foetus die and is too far developed to be 
 absorbed it becomes encysted, and the sac may rupture into any 
 abdominal organ. 
 
 When the foetus lives, and it is more likely to do so than 
 when it has passed into the abdomen after a primary rupture of 
 the tube, because it is in that case usually older, the after 
 history is the same as already described. 
 
 When an adventitious sac has been formed, there is 
 practically no difference from the case of a foetus enclosed in 
 the expanded broad ligament, except that the opened-up broad 
 ligament raises the uterus into the abdomen, and when rupture 
 occurs the contents are more likely to pass in the direction 
 allowed by the anatomical relations of the cellular tissue. 
 
 Treatment . — If a diagnosis of tubal pregnancy be made 
 before rupture, treatment is of the simplest, and removal of the 
 tube should always be advised. Of the less heroic methods of 
 treatment, electricity is the only one which has been at all 
 successful. But as the abdominal operation must be invariably 
 preferred, it is unnecessary to describe any of the other methods 
 which have been used. 
 
492 MALIGNANT NIST AST OT THT UTTRUS, TTC. 
 
 The abdominal incision is made as usual in the middle line ; 
 as soon as the fingers reach the uterus they are passed outwards 
 and immediately come on the swelling. This is gently brought 
 up to the wound, and the broad ligament below it is transfixed 
 and tied. The operation need not last more than a few minutes. 
 Before the wound is closed the ovary and tube on the other 
 side are to be examined, and if unhealth}^ must be removed. 
 When the rupture has taken place directly from the tube into 
 the peritoneal cavity, immediate operation is called for, on 
 account of the danger due to haemorrhage, which seems to have 
 little tendency to cease. Whenever this diagnosis has been 
 made, nothing must be allowed to come in the way of immediate 
 operation. To see a patient in the evening and to fix the time 
 of operation for some hour next morning is a practice which is 
 impossible to understand, though it is sometimes done. In the 
 hurry of an operation performed at a moment’s notice some pre- 
 caution is apt to be omitted. While no unnecessary delay can be 
 allowed, a few minutes may be devoted to the thorough cleansing 
 of the abdomen, and also to procuring several hot bottles with 
 which to surround the patient during the operation, as the sudden 
 loss of blood will have made her specially liable to chill. 
 
 The incision two or three inches in length is made through 
 the wall, and the fingers are at once passed down to the uterus 
 and along one broad ligament. If it be healthy the other one is 
 drawn upwards, is ligatured as close to the uterus as possible, 
 and the ovary and tube are removed. The tissues are friable, 
 and the ligature must not be unnecessarily fine. Having in 
 this way stopped the bleeding, clots of blood are to be removed 
 from the cavity, and the best way of doing this is by thorough 
 washing out with warm water. It is well to leave in a drainage 
 tube for twenty-four hours. The after treatment resembles that 
 of any abdominal operation when the patient is much debilitated. 
 A moderate amount of stimulants will be required, and copious 
 rectal enemata of warm milk and thin soup will be quickly 
 absorbed. When the operation has been performed after a large 
 
EXTRA-UTERINE PREGNANCY. 
 
 493 
 
 quantity of blood has been lost, transfusion may be required. 
 When the foetus has passed between the layers of the broad 
 ligament, the symptoms of hoemorrhage are not so marked, and 
 it is not likely that there will be any cause for immediate 
 operation. The patient must be kept absolutely quiet in bed 
 with the extremities warm, and the pain should be relieved by 
 injections of morphia. If no urgent symptoms supervene, and 
 the growth be not increasing in size, time may be given to see 
 what nature will do. If the swelling be enlarging no time should 
 be lost in advising its removal. In this case we can choose on 
 what day or hour of the day the operation is to be performed. 
 
 The operation is not so simple as when a primary rupture of 
 the tube into the peritoneal cavity has been dealt with, as the 
 foetus has to be removed by enucleation from the broad ligament, 
 and bleeding is likely to be free. If it be impossible to ligature 
 the base of the broad ligament below the bleeding, the sac 
 formed by the opened-up folds of the broad ligament must be 
 stitched to the abdominal wound if possible, and the cavity 
 plugged with iodoform gauze. If this cannot be done, and if 
 the hsemorrhage cannot be arrested by the pressure of sponges 
 wrung out of hot water, gauze must be packed into the pelvis, 
 even although this is a most unworkmanlike and unsurgical 
 proceeding. When the sac is large enough to be seen through 
 the abdominal wound, the position of the placenta may be 
 noticed, and if so it should be avoided if possible. When 
 a secondary rupture occurs from the broad ligament into the 
 abdominal cavity, the treatment will be similar to that adopted 
 when the rupture in this position has been a primary one. 
 Immediate operation is almost certainly called for. 
 
 When the foetus grows in the abdominal cavity, opinions 
 differ as to whether it is better to operate early, or to allow the 
 pregnancy to go on until the child is viable and remove it them 
 The safer plan is to remove the foetus as soon as the sac can be 
 fixed to the abdominal wall. 
 
 The operation is by no means a difficult one. The 
 
494 MALIGNANT DISEASE OF THE UTERUS, ETC. 
 
 peritoneum is opened, the sac is aspirated after sponges have 
 been packed round if much fluid be present, and it is then laid 
 freely open. The foetus is removed, the cord tied, and the sac 
 stitched to the abdominal wall. The placenta is not to be 
 interfered with. A rubber drainage tube is left in, or the 
 cavity is packed with gauze should the placenta have been 
 injured. When the patient progresses satisfactorily, the gauze 
 may be left in for ten days or a fortnight, and must be removed 
 with extreme caution, as the haemorrhage which may occur 
 when this is being done may be of a most alarming nature. 
 Within a second blood may be pouring over both sides of the 
 abdomen, while a third stream is flowing over the pubes, and it 
 is well to have some fresh gauze at hand with which the cavity 
 can be again plugged. 
 
 When suppuration follows death of the foetus in the broad 
 ligament, the treatment will be similar to that of ordinary 
 abscess in that position. 
 
 Pelvic Hj^matocele. 
 
 A pelvic heematocele is a collection of blood in the pelvis. 
 More commonly it is situated in the pelvic cellular tissue and is 
 thus extra-peritoneal, or the haemorrhage may have taken place 
 into the peritoneal cavity and be thus intra-peritoneal. The 
 first class is caused by a primary rupture of an extra-uterine 
 foetation into the broad ligament, or by the rupture of a vein in 
 any part of the cellular tissue. 
 
 The second variety is caused by a reflux of blood from the 
 uterus and Pallopian tubes, the rupture of an extra-uterine 
 foetation into the peritoneal cavity, or the rupture of any dilated 
 blood vessel, resulting usually from an injury. 
 
 The immediate danger of an extra-peritoneal hsematocele is 
 much less than when the rupture has taken place into the 
 peritoneal cavity, as in the first case, the pressure of the tissues 
 as they distend tends to arrest the flow of blood. 
 
PEL VIC ABSCESS. 
 
 495 
 
 Symptoms . — These are due to the loss of blood, and in the 
 extra-peritoneal variety there will also be pain of a severe 
 tearing nature. On examination the signs will resemble those 
 already described under extra-uterine pregnancy. 
 
 Treatment . — This consists in absolute rest in bed, in the 
 application of warmth to the feet and cold to the abdomen, and 
 in the injection of morphia if necessary. The majority of cases 
 do not require any further treatment, if the patient be careful 
 to avoid getting a chill until the swelling has disappeared. In 
 a certain number of cases where the hsemorrhage is so great that 
 the life of the patient is endangered simply by the loss of blood, 
 and where it is apparent that the hsemorrhage is still going on, 
 the abdomen must be opened without delay. 
 
 When the blood is not absorbed, and suppuration super- 
 venes, the treatment will be similar to that of any pelvic 
 abscess. 
 
 Pelvic Abscess. 
 
 A collection of pus in the pelvis results from an acute 
 attack of pelvic inflammation, it may also follow extra-uterine 
 pregnancy or hsematocele, or it may be connected in some way 
 with the Fallopian tubes. 
 
 The pus usually burrows between the rectum and vagina, 
 and it may open into one, more frequently into both, of these 
 passages ; or it may pass upwards outside the peritoneum and 
 point in the groin, but its exact direction will depend on its 
 relation to the anatomical structures of the pelvis. 
 
 Symptoms . — The symptoms are usually those of an abscess 
 elsewhere, combined not infrequently at the commencement 
 with the passage of large quantities of mucus from the rectum. 
 Sometimes pelvic suppuration gives rise to very slight symptoms. 
 
 If the pus approach the bladder there may be symptoms of 
 irritation, and if it open into the bladder these symptoms will 
 be much aggravated. 
 
 Pelvic examination may show nothing but a general matting 
 
496 MALIGNANT DISEASE OF THE UTERUS, ETC. 
 
 together of the tissues, or a distinct fluctuating or boggy swelling 
 may he felt, and the exact situation and position of the uterus 
 will depend on the size and position of the abscess. 
 
 Treatment . — When pus is present the sooner it is evacuated 
 the better, and the position of the incision will depend on the 
 size and position of the swelling. When it can be easily 
 reached from the vagina it ought always to be opened from 
 below, when it lies beneath the abdominal wall the incision 
 must be made from above. In a doubtful case the better plan 
 is to open the abscess in the way which will allow of the most 
 satisfactory drainage. 
 
 When the abscess has resulted from the suppuration of 
 a collection of blood inside the peritoneum, the symptoms and 
 treatment will not differ from those already described. 
 
 Such cases may occur in men as well as in women. 
 
 Heart-Clot 
 
 Any of the usual surgical accidents, as for example tetanus, 
 may follow on an abdominal operation. There is one, however, 
 about which little is known, which may be specially mentioned, 
 more especially as the result does not seem to be so fatal as is 
 usually supposed. 
 
 In giving a prognosis in even the simplest of abdominal 
 operations, accidental risks have to be borne in mind, and we 
 are thus prevented from describing even an exploratory incision 
 or the removal of a non-adherent ovarian tumour as an operation 
 entailing absolutely no risk. 
 
 The special accident referred to is that known as heart- 
 clot. 
 
 This accident, the exact causation of which it is difficult to 
 explain, is without exception the most distressing which can 
 happen. A haemorrhage is due to a want of care or a want of 
 skill on the part of the operator, and he knows that the pre- 
 vention of such an accident lies with himself, but when a 
 
HEART-CLOT. 
 
 497 
 
 patient dies after a heart-clot the operator has no guarantee 
 that a similar accident will not occur after his next operation. 
 He does not know the cause of the accident, he consequently 
 does not know how to prevent it, and the patient may be dead 
 even before a messenger can be sent for him. He may have 
 seen the patient in perfect health only a few minutes before, 
 and the next he hears is that death has come without a 
 moment’s warning. 
 
 The usual history is that the patient, who has been doing 
 well, and who is considered to be completely out of danger, 
 suddenly and without warning, somewhere about the tenth 
 day, starts up, struggles for breath, and without even being 
 able to speak, may be dead before the nurse can reach the bed. 
 The usual impression seems to be that the patient almost in- 
 variably dies. 
 
 In our own experience, taking in addition all of Dr. Keith’s 
 cases, this accident has happened five times, two only of the 
 patients having died. Of the two fatal cases one is referred to 
 under the operation of hysterectomy, the patient dying almost 
 without waking on the ninth day, the other happened after a 
 comparatively simple ovariotomy. No trouble followed the 
 operation, and about four o’clock on the morning of the tenth 
 day, the patient started out of her sleep, was able to call out for 
 air, and died, the nurse thought, in about two minutes. Instead 
 of giving the symptoms common to cases which recovered, 
 it seems better to describe minutely one of these cases, and 
 to refer to the other two where they differ in any way. A 
 patient was sent home from Gibraltar in March of this year, 
 the presence of an ovarian tumour having been diagnosed. 
 On examination a multilocular non-adherent ovarian tumour 
 was found, and at the operation performed on the 19th of 
 March the tumour and a small cystic enlargement of the second 
 ovary were removed, the pedicles being ligatured. A large vein 
 which ran across the wound had to be divided, one end being 
 ligatured with catgut. The operation lasted barely twenty 
 32 
 
498 iWALIGNANT DISEASE OF THE UTERUS, ETC. 
 
 minutes. The progress of the patient was completely satis- 
 factory, and the stitches were removed at the end of a week, the 
 wound being perfectly dry. Early on the morning of the 23rd, 
 three and a half days after the operation, the patient twice 
 complained of a feeling of chilliness down the back. On the 
 28th (tenth day) she was seen about four o’clock in the afternoon, 
 and was found to be perfectly natural and well. Suddenly, 
 about 5.30, she gave a cry, put her hands over her heart 
 and her breathing became rapid and grasping. The nurse said 
 that she was completely collapsed, no pulse could be felt, the 
 surface became deathly cold, the face became ghastly white and 
 the lips purple. Brandy was given very freely, the patient was 
 surrounded with hot bottles, and a mustard plaster was put over 
 her heart ; as soon as she could speak she complained of great 
 pain and a feeling of tightness across her chest. 
 
 She was seen at 6.15. She was then restless, was throwing 
 about her arms, the voice was weak, the face was deeply 
 cyanosed and pinched, an occasional pulsation was felt at the 
 wrist, the heart sounds were faint and between 140 and 150. 
 The whole surface of the body was cold and the breath very 
 markedly so. The breathing was shallow, sighing and 40 to 
 the minute. One-sixth of a grain of morphia was injected to 
 quiet the restlessness. At seven o’clock there was a decided 
 improvement. The lips were still congested, but the pulse had 
 fallen to 124, and the respirations were deeper and less frequent. 
 During the night the patient was stimulated freely by the bowel 
 as there was some tendency to sickness, and one-tenth of a grain 
 of morphia was given twice. At four A.M. the temperature was 
 96*2°, and it did not rise to normal until noon. The patient’s 
 condition remained critical for two days, showing but a slight 
 improvement. On the 30th the patient complained of some 
 pain in the calf of the left leg, and by next day the pain was 
 also felt in the thigh. The whole of the limb was slightly 
 swollen, being nearly one inch larger than the other; it was 
 wrapped in cotton wool and raised on a pillow, no more active 
 
HEART-CLOT. 
 
 499 
 
 treatment being required. By the 1st of April the pulse had 
 fallen to 80, and the temperature, which had been slightly 
 elevated, was normal. Early next morning there was a slight 
 rigor, rather more marked than the two feelings of chill which 
 there had been on the 23rd ult. About one o’clock in the 
 afternoon there was a very slight recurrence of the alarming 
 chest symptoms ; pain was complained of, the face became 
 slightly cyanosed, and the pulse rose to 100 ; next day the pulse 
 had fallen to 86, in the evening the temperature was 100’4°, and 
 the patient was troubled with a tickling cough with slight 
 frothy expectoration. Until 11th April the evening temperature 
 was usually about 100, but on that evening it rose to 102°, and 
 the expectoration became slightly rusty ; there was no marked 
 increase in the respirations, and the pulse was 'from 80 to 90, 
 Being afraid to move the patient, and as the condition was by no 
 means alarming, no examination of the lungs posteriorly was made, 
 but it was evident that there was a slight attack of pneumonia, as 
 might have been expected. The temperature fell to normal on 18th 
 April, and the swelling in the leg had entirely passed away by 
 that time. After this date the progress of the case was quite 
 satisfactory. 
 
 From the time of the operation abdominal symptoms were 
 entirely absent, and it seems impossible to come to any other 
 conclusion than that the case was one of heart-clot, and that the 
 life of the patient was saved by the stimulation which was so 
 promptly given by the nurse at the moment of the attack. One 
 of the other cases occurred after an operation for the radical 
 cure of a femoral hernia. The wound had healed without a trace 
 of suppuration, the stitches had been removed on the eighth day, 
 and about seven o’clock on the morning of the tenth day the 
 patient was seized with symptoms identical with those already 
 recorded, and the treatment adopted by the nurse was the same, 
 brandy, mustard, and hot bottles. The patient rallied very 
 quickly, and by 9.30 seemed to be much as usual, except that 
 the pulse was 110. At 12.30 there was a similar though not 
 
500 MALIGNANT DISEASE OF THE UTERUS, ETC. 
 
 so severe attack. The pulse became feeble, rapid, and irregular, 
 and the heart sounds very indistinct, the patient becoming deeply 
 cyanosed. The gasping for breath continued for ten minutes. 
 The patient rallied quickly, although for some days the face 
 looked pinched and the pulse was quick, eventually she com- 
 pletely recovered. The third case, and strangely enough the 
 only one of the five which occurred in Dr. Keith’s practice, 
 resembled the second one except that there was only one attack, 
 and for several days after, the pulse continued very irregular 
 and ran up from 120 to 130 on the very slightest exertion. 
 
GENEEAL INDEX. 
 
GENEEAL INDEX 
 
 PAGE 
 
 Abdomen, General Examination of, 2 
 
 Abdominal Belt, , . . 70, 92 
 
 ,, Operations, History of, 341 
 
 ,, Surgery, History of, 341 
 
 ,, Wound, Closure of, 53 
 
 ,, ,, Dressing of, 54 
 
 Abscess in Abdominal Wall . 93 
 
 ,, Kidney, . 
 
 „ Liver, 
 
 „ Ovary, 
 
 ,, Pelvis, 
 
 „ Perinepliritic, . 
 
 „ Splenic, . 
 
 „ Stitch, 
 
 Adhesions, 
 
 After Treatment, 
 
 Amussat’s Operation 
 Anaesthetics, . 
 
 Anastomosis, Intestinal, . 
 
 Anatomy, General, . 
 
 „ of Appendix 
 
 „ Broad Ligaments, 
 „ Gall-Bladder, . 
 
 „ Intestines, 
 
 „ Kidneys, 
 
 „ Liver, 
 
 „ Pancreas, 
 
 „ Peritoneum, 
 
 „ Spleen, . 
 
 „ Stomach, . 
 
 Aneurism, of Aorta, 
 
 ,, Coeliac axis 
 
 Antiseptics, 
 
 Anus, Artificial 
 Apostoli, 
 
 Appendicitis, . 
 
 „ Causes, . 
 
 „ Clinical Groups, 
 
 „ Diagnosis of. 
 
 288 
 232 
 382 
 495 
 296 
 303 
 54, 91 
 47 
 56 
 
 187, 191 
 44 
 163 
 5 
 
 206 
 436 
 231 
 143 
 255 
 230 
 312 
 107 
 302 
 105 
 13 
 9 
 55 
 161 
 392, 404 
 205 
 208 
 212 
 218 
 
 PAGE 
 
 Appendicitis, Diagnosis from Faecal 
 
 Impaction, . 222 
 
 „ ,, Obstruction, . 219 
 
 ,, ,, Perinepliritic Ab- 
 scess, . 222 
 
 ,, ,, Psoas Abscess, 222 
 
 ,, ,, Salpingitis, . 222 
 
 ,, ,, Tubercular Disease, 221 
 
 ,, ,, Tumour of Caecum, 222 
 
 „ ,, Typhoid Fever, 221 
 
 „ Pathological Condi- 
 tions, . . 209 
 
 „ Eupture after Forma- 
 tion of Adhesions, 217 
 
 „ „ outside Peritoneum, 218 
 
 „ Symptoms of, . 213 
 
 ,, Treatment of, . 223 
 
 Appendix, Anatomy of, . . 206 
 
 Ascites, Diagnosis of, . . 18, 84 
 
 „ In Young Women, . 89 
 
 „ Eesult of General Disease, 85 
 ,, Treatment of, . . 90 
 
 Aspiration of Fluids, . . 24 
 
 Atlee, 344 
 
 Battey, ..... 381 
 
 Bell, John, .... 342 
 
 Bladder, Distension of, . .14,114 
 
 Blundell, . . . . 3^ 
 
 Bowels, Movement after Operation, 70 
 Broad Ligaments, Cysts of, . 378 
 
 , , , , Opening up of, 
 
 330, 337, 367, 440 
 
 „ ,, Tumours con- 
 
 nected with, 379 
 Brown (Baker), . . 344, 345 
 
 Bryant, ..... 189 
 
 Caecum, Anatomy, . . 206 
 
504 
 
 GENERAL INDEX. 
 
 PAGE 
 
 Caesarean Section, 
 
 
 477 
 
 „ Compared with Porro, 
 
 485 
 
 „ Haemorrhage in. 
 
 
 478 
 
 ,, Pregnancy after. 
 
 
 480 
 
 „ Suture of Uterus, 
 
 
 479 
 
 Calculi, Biliary, 
 
 
 242 
 
 „ Renal, 
 
 
 266 
 
 Cancer, Kidney. 
 
 
 296 
 
 ,, Large Intestine, . 
 
 
 186 
 
 „ CEsophagus, 
 
 
 111 
 
 „ Ovary, 
 
 
 335 
 
 „ Pancreas, 
 
 
 313 
 
 „ Pylorus, 
 
 
 135 
 
 „ Stomach, 
 
 
 134 
 
 „ Uterus, 
 
 
 467 
 
 Castor Oil, 
 
 . 37, 56 
 
 Catheterisation 
 
 
 38 
 
 Cautery, .... 
 
 
 359 
 
 Chloroform, 
 
 
 44 
 
 Cholecystectomy, 
 
 249, 
 
 252 
 
 Cholecystotomy, 
 
 
 249 
 
 Cholelithotomy, 
 
 
 249 
 
 Cholelithotrity, 
 
 Clamp, Brown’s Cautery, 
 
 
 249 
 
 
 354 
 
 ,, Keith’s Hysterectomy, 
 
 
 442 
 
 Clay, .... 
 
 
 344 
 
 Closure of Abdominal Wound, 
 
 
 53 
 
 Clothing of Patient, 
 
 
 37 
 
 Clover’s Crutch, 
 
 
 470 
 
 Cceliac Axis, Aneurism, . 
 
 
 9 
 
 Colic, Appendicular, 
 
 
 213 
 
 „ Biliary, 
 
 
 243 
 
 „ Renal, . 
 
 
 269 
 
 Colon, .... 
 
 
 11 
 
 Colotomy, 
 
 187, 191 
 
 „ Inguinal, 
 
 
 194 
 
 ,, Lumbar, . 
 
 
 191 
 
 Consultations, 
 
 
 33 
 
 Clipping, 
 
 
 71 
 
 Curetting, 
 
 
 421 
 
 Cysts, General Examination of. 
 
 
 16 
 
 „ of Broad Ligament 
 
 
 378 
 
 „ Kidney, 
 
 
 279 
 
 ,, Mesentery, 
 
 
 100 
 
 „ Omentum, 
 
 
 97 
 
 ,, Ovary, . 
 
 
 319 
 
 ,, Pancreas, 
 
 
 313 
 
 „ Spleen, 
 
 
 304 
 
 PAGE 
 
 Doran, . . . . 440 
 
 Drainage, .... 52, 68 
 Dressing, . . . . 54 
 
 Dropsy, Encysted, . . . 83 
 
 Duodenum, . . . . 143 
 
 Ectopic Gestation, . 
 
 Elastic Ligature in Hysterectomy, 
 Electricity in Extra - Uterine 
 Pregnancy, . 
 
 , , Fibroid Tumours 
 
 of Uterus, 
 
 „ Inflammatory Dis- 
 ease of Ovaries, 
 Enemata, Nutrient, . 
 
 Enteroliths, .... 
 Enterorraphy, 
 
 Epigastric Eegion, . 
 
 Ether, ..... 
 Examination of Abdomen, General, 
 ,, of Fluids, 
 
 Exploratory Incision, 
 
 Extra-Uterine Pregnancy, 
 
 „ Electricity in, 
 
 „ Primary Rupture 
 
 into Peritoneum, 
 
 ,, Rupture into Cellular 
 
 Tissue, 
 
 „ Secondary Rupture 
 
 into Peritoneum, 
 
 „ Symptoms, . 
 
 ,, Treatment, . 
 
 487 
 
 455 
 
 491 
 
 404 
 
 392 
 
 58 
 
 173 
 
 162 
 
 6 
 
 44 
 
 2 
 
 28 
 
 31 
 
 487 
 491 
 
 488 
 
 490 
 
 491 
 
 489 
 491 
 
 Faecal Accumulation, . . 13, 184 
 
 ,, ,, Treatment, 187 
 
 ,, Fistula, Formation of, . 161 
 
 Fallopian Tubes, Diseases of, . 381 
 
 Fibroid Tumours of Ovary, . 378 
 
 ,, ,, Uterus, . 397 
 
 Flatus, Passage of, . . . 59 
 
 Fluids, Aspiration of, . . 24 
 
 Food after Operation, . . 58 
 
 „ Peptonised, ... 80 
 
 Forceps, Cyst, . . . 352 
 
 ,, Keith’s Pressure, . 41 
 
 ,, Lister’s, ... 42 
 
 ,, Nelaton’s . . . 352 
 
 Foulis’ Cells, .... 29 
 
 Dermoid Ovarian Tumours, 
 Diagnosis, General, . 
 
 „ Auscultation, . 
 
 „ Inspection, 
 
 „ Microscopic Examin- 
 
 ation of Fluids, 
 
 „ Palpation, 
 
 ,, Percussion, 
 
 „ Rectal Examination, 
 
 „ Removal of Fluids, . 
 
 „ Vaginal Examination, 
 
 331 
 
 3 
 
 4 
 3 
 
 28 
 
 3 
 
 4 
 3 
 
 20 
 
 3 
 
 Gall-Bladder, Anatomy of. 
 
 231 
 
 ,, Distension of. 
 
 245 
 
 ,, Operations on. 
 
 249 
 
 ,, Situation of. 
 
 6 
 
 ,, Suppuration of. 
 
 248, 254 
 
 ,, Wounds of. 
 
 254 
 
 Gall Stones, . 
 
 242 
 
 Gastrectomy, . 
 
 134 
 
 Gastro-enterostomy, 
 
 135 
 
 Gastrorraphy, 
 
 120 
 
 , , Food after, . 
 
 123 
 
GENERAL INDEX. 
 
 505 
 
 PAGE 
 
 Gastrostomy, .... 
 
 111 
 
 , , Mortality, , 
 
 114 
 
 ,, Witzer’s Modification, 
 
 Gastrotomy, .... 
 
 119 
 
 125 
 
 Hsematocele, Pelvic, 
 
 494 
 
 ,, Perinephric,. 
 
 Haematosalpinx, 
 
 301 
 
 382 
 
 Harris, on Symphysiotomy, 
 
 483 
 
 Heart-Clot after Operation, 
 
 496 
 
 Hegar, ..... 
 
 381 
 
 Hepatic Abscess, 
 
 232 
 
 , , Colic, 
 
 243 
 
 Hepatotomy, .... 
 
 235 
 
 Hernia of Abdominal Wall, 
 
 91 
 
 History of Abdominal Surgery, 
 
 341 
 
 Houstoun, . . . 
 
 Hydatids of Kidney,' 
 
 341 
 
 291 
 
 ,, Liver, 
 
 238 
 
 ,, Omentum, 
 
 98 
 
 ,, Peritoneum, . 
 
 98 
 
 , , Spleen, 
 
 305 
 
 Hydramnios, .... 
 
 17 
 
 Hydrogen Gas, 
 
 157 
 
 Hydronephrosis, 
 
 282 
 
 Hydrosalpinx, 
 
 382 
 
 Hypochondriac Kegion, 
 
 5, 9 
 
 Hypogastric Kegion, 
 
 14 
 
 Hysterectomy for Fibroid, 
 
 434 
 
 ,, Adhesions, 
 
 ,, After Menopause, 
 
 435 
 
 453 
 
 ,, Cases of, . 435, 
 
 , , Cautery, 
 
 444 
 
 435 
 
 ,, Complicated by Pus 
 
 Tubes, 
 
 450 
 
 ,, Drainage in, . 
 
 459 
 
 ,, Extraction of Tumour, 
 
 441 
 
 , , Extra-peritoneal 
 
 Treatment, . 
 
 442 
 
 ,, Heart-Clot in. 
 
 451 
 
 ,, Intra-peritoneal Treat- 
 
 ment, . 
 
 455 
 
 ,, Intra- and Extra- 
 
 peritoneal Compared, 
 
 459 
 
 , , Morcellement, 
 
 463 
 
 ,, Separation of Broad 
 
 Ligaments, . 
 
 441 
 
 , , Stitching of Stump, 
 
 434 
 
 ,, Vaginal, . 
 
 469 
 
 Ice, for Thirst, 
 
 57 
 
 , , to reduce Temperature 
 
 75 
 
 Ileum, ..... 
 
 144 
 
 Iliac Region, . . . .13 
 
 !, 16 
 
 Incision, Exploratory, 
 
 31 
 
 ,, Length of. 
 
 46 
 
 „ Parietal, . 
 
 45 
 
 Instruments and Appliances, . 
 
 38 
 
 Intestine, Anastomosis, 
 
 163 
 
 „ Anatomy, 
 
 143 
 
 PAGE 
 
 Intestine, Cancer, . . . 186 
 
 
 Cicatricial Contraction, 
 
 183 
 
 „ 
 
 Gangrene, 161, 170, 
 
 , 179 
 
 
 Lateral Implantation, 
 
 163 
 
 
 Malignant Disease, . 
 
 183 
 
 
 Management of. 
 
 59 
 
 ,, 
 
 Obstruction, 
 
 147 
 
 ,, 
 
 Operation for Ulceration, 197 
 
 „ 
 
 Polypi, . 
 
 184 
 
 5) 
 
 Puncture, 
 
 181 
 
 „ 
 
 Rupture, . 
 
 201 
 
 
 Sarcoma, 
 
 185 
 
 ,, 
 
 Wounds, Gunshot, . 
 
 198 
 
 >5 
 
 ,, Puncture, . 
 
 200 
 
 Intussusception, 
 
 151 
 
 Jaundice 
 
 9 • . • • 
 
 284 
 
 Jeafferson, .... 
 
 344 
 
 Jejunum, 
 
 
 144 
 
 Keith, 
 
 . 48, 52, 345, 435 
 
 Kidneys, 
 
 Anatomy, 
 
 255 
 
 3 3 
 
 Calculi, 
 
 266 
 
 3 3 
 
 Enlargements, . 
 
 279 
 
 3 3 
 
 Displaced, . 
 
 259 
 
 3 3 
 
 Floating, . 
 
 259 
 
 53 
 
 Hydatids, . 
 
 291 
 
 3 3 
 
 Hydronephrosis, 
 
 282 
 
 5 3 
 
 Malformations, . 
 
 265 
 
 3 3 
 
 Malignant Disease, 
 
 296 
 
 3 3 
 
 Management of, 
 
 71 
 
 
 Movable, . 
 
 258 
 
 3 5 
 
 Pyelitis, . 
 
 299 
 
 3 J 
 
 Pyelonephritis, . 
 
 300 
 
 3 3 
 
 Pyonephrosis, 
 
 288 
 
 3 3 
 
 Rupture, . 
 
 300 
 
 3 3 
 
 Sim2)le Cysts, 
 
 280 
 
 
 Solid Tumours, . 
 
 293 
 
 3 3 
 
 Tubercular Disease, 
 
 293 
 
 3 3 
 
 Wounds, . 
 
 300 
 
 Kimball, 
 
 . 
 
 395 
 
 Koeberlee, .... 
 
 347 
 
 Lai^aro-Electrotomy, 
 
 481 
 
 Compared with 
 Symphysio- 
 
 tomy. 
 
 484 
 
 L’Aummonier, 
 
 342 
 
 Lembert, 
 
 121 
 
 Ligatures, 
 
 43 
 
 Lipoma behind Peritoneum, 
 
 96 
 
 List, .... 
 
 347 
 
 Littre’s Operation, . 
 
 187, 194 
 
 Liver Abscess, 
 
 232 
 
 ,, Anatomy, 
 
 230 
 
 ,, Cancer, . 
 
 „ Hydatids, 
 
 241 
 
 238 
 
 ,, Situation of, . 
 
 6 
 
 Lizars, .... 
 
 344 
 
 Loreta’s Operation, 
 
 140 
 
5o6 
 
 GENERAL INDEX. 
 
 PAGE 
 
 Lumbar Region, . . . 10, 1-3 
 
 Magnesia for Flatulence, . . 61 
 
 Malignant Cells, ... 29 
 
 ,, Disease of Abdominal Wall, 94 
 ,, ,, Intestine, . 183 
 
 ,, ,, Kidney, . 296 
 
 ,, ,, Liver, . 241 
 
 ,, j} Ovary, . 335 
 
 ,, ,, Pancreas, . 313 
 
 ,. ,, Pylorus, . 135 
 
 Retro-peritoneal, 95 
 
 ,, ,, Stomach, . 134 
 
 ,, ,, Uterus, . 467 
 
 Maydl’s Operation for Colotomy, 196 
 
 McBurney’s Point . . . 15, 214 
 
 M ‘Dowell, .... 341 
 
 Menstruation, .... 422 
 
 Mesentery, Tumours of, . . 100 
 
 Mikulicz, Gauze Drain, . . 89, 91 
 
 Mineral Springs, . . . 244 
 
 Morphia, . . . .62, 150 
 
 Needle-Holder, . . . 263 
 
 Nelaton’s Forceps, . . . 352 
 
 Nephrectomy, for Cystic Growths, 284 
 
 „ • Solid Growths, 297. 
 
 Nephro-Lithotomy, . . . 273 
 
 Nephrorraphy, . . . 262 
 
 Nurse, 36 
 
 Obstruction, Intestinal, Acute, 147 
 
 ,, „ Concretions, 173 
 
 ,, ,, Diverticula, 168 
 
 ,, ,, Due to Bauds, etc. 165 
 
 ,, ,, Heruiae, . 147 
 
 ,, ,, Nervous Exhaus- 
 tion, . 148 
 
 ,, ,, Volvulus, . 171 
 
 ., Chronic, . . 181 
 
 ,,» Differential Diagnosis, 175 
 
 ,, Intussusception, . 151 
 
 CEsophagus, Absence of, . . Ill 
 
 ,, Auscultation, . 112 
 
 ,, Foreign Body in, . 128 
 
 ,, Length of, . . 112 
 
 ,, Malignant Stricture, 111 
 
 ,, Simple Stricture, . Ill 
 
 Omentum, . . . . 97, 98 
 
 Opium, ..... 62 
 
 Ovary, Anatomy, . . . 317 
 
 ,, Fibroid Tumours, . . 378 
 
 ,, Inflammatory Diseases, . 381 
 
 ,, Removal of, . . 394 
 
 Ovarian Tumours, . . . 319 
 
 ,, „ Aspiration, . 348 
 
 ,, „ Dermoid, . 331 
 
 ,, „ Diagnosis, . 322 
 
 ,, ,, Intra-Ligamentous 330 
 
 ,, „ Malignant, . 335 
 
 PAGE 
 
 Ovarian Tumours, Rotation of, , 
 
 331 
 
 5 ? 
 
 ,, Rupture of, . 
 
 333 
 
 3 3 
 
 ,, Signs and 
 
 
 
 Symptoms, . 
 
 319 
 
 5 , 
 
 ,, Suppuration, . 
 
 334 
 
 3 3 
 
 , , Treatment, . 
 
 347 
 
 3 3 
 
 ,, With Preg- 
 
 
 
 nancy, 
 
 338 
 
 Ovariotomy, 
 
 Adhesions, . 
 
 363 
 
 33 
 
 Cautery in, . 
 
 359 
 
 33 
 
 Examination of 
 
 
 
 Second Ovary, . 
 
 362 
 
 ,5 
 
 History of, . 
 
 341 
 
 3 3 
 
 Incomplete Operations, 
 
 375 
 
 33 
 
 Intra-Ligamentous 
 
 
 
 Tumours, . 
 
 367 
 
 33 
 
 Ligature of Pedicle, 
 
 357 
 
 3 3 
 
 Operation for, 
 Preparations before. 
 
 355 
 
 3 3 
 
 351 
 
 ,, Prognosis, 
 
 Pancreas, Anatomy, 
 
 ,,. Cysts, 
 
 ,, Malignant Disease, 
 
 , , Situation, 
 
 Parietal Incision, 
 
 ,, ,, Closure of, 
 
 ,, ,, Dressing of, 
 
 Parietes, Abscess 
 ,, Hernia, 
 
 , , Tumours, . 
 
 Parovarian Cysts, 
 
 Patient, Examination of, . 
 
 ,, Clothing, 
 
 ,, Position during Examina- 
 
 tion, ... 2 
 
 ,, Preparation before Opera- 
 tion, . . . 37 
 
 Pean, ..... 463 
 
 Peaslee, ..... 344 
 
 Pedicle in Hysterectomy, . . 434 
 
 ,, Nephrectomy, . . 285 
 
 ,, Ovariotomy, . . 318 
 
 ,, Splenectomy, . . 309 
 
 Pelvic Abscess .... 495 
 
 Perinephric Hsematocele, . . 301 
 
 Perinephritic Abscess, . . 296 
 
 Peritoneum, Encysted Dropsy, . 83 
 
 ,, Hydatids, . . 98 
 
 ,, Relations of, . . 107 
 
 ,, Toilet, ... 48 
 
 ,, Washing out, . 51 
 
 Peritonitis, Acute, . . . 77 
 
 ,, Chronic, . . 82 
 
 ,, Temperature in, . 81 
 
 ,, Tubercular, . . 86 
 
 Perityphlitis, .... 205 
 
 Phantom Tumours, . . . 19, 328 
 
 Pilocarpine, . . . . 71 
 
 Polypi of Intestine, . . . 184 
 
 Porro’s Operation, . . . 480 
 
 336 
 
 312 
 
 313 
 313 
 
 8 
 
 45. 
 
 53 
 
 54 
 93 
 91 
 93 
 
 378 
 
 1 
 
 37 
 
GENERAL INDEX. 507 
 
 Porro’s Compared with Caesarean 
 Section, . 
 
 PAGE 
 
 485 
 
 Pregnancy, Diagnosis, 
 
 
 323 
 
 ,, Extra- Uterine, 
 
 
 487 
 
 , , Ovarian, 
 
 
 487 
 
 Pyelitis, 
 
 
 299 
 
 Pyelo-Nephritis, 
 
 
 300 
 
 Pylorectomy, 
 
 
 138 
 
 Pylorojdasty, . 
 
 
 141 
 
 Pylorus, Malignant Stricture, 
 
 
 135 
 
 , , Position, . 
 
 
 106 
 
 ,, Simple Stricture, 
 
 
 133 
 
 Pyonephrosis, . 
 
 
 288 
 
 Quinine, .... 
 
 
 61, 63 
 
 Rectal Feeding, 
 
 
 58 
 
 Recto-Vesical Fistula, 
 
 
 189 
 
 Rectum, Malignant Disease, 
 
 
 189 
 
 ,, Treatment of Ulceration, 
 
 188 
 
 Renal Calculi, 
 
 
 266 
 
 ,, Colic, 
 
 
 . 269 
 
 Rupture of Gall-Bladder, . 
 
 
 254 
 
 , , Intestine, 
 
 
 201 
 
 , , Kidney, 
 
 
 300 
 
 ,, Ovarian Tumour, 
 
 
 333 
 
 ,, Spleen, . 
 
 
 310 
 
 Salpingitis, 
 
 Senn’s Bone Plates, 
 
 
 382 
 
 
 136 
 
 ,, Distension of Intestine, 
 Septicaemia, 
 
 
 157 
 
 
 65 
 
 Serre-Noeud, . 
 
 
 443 
 
 Silk, Preparation of. 
 
 
 43 
 
 Sims, Cholecystotomy, 
 
 
 248 
 
 ,, Needle Holder, 
 
 
 263 
 
 Skin, Management of. 
 
 
 71 
 
 Smith, Alban, . 
 
 
 343 
 
 ,, Nathan, 
 
 
 343 
 
 Spleen, Anatomy, 
 
 
 302 
 
 ,, Cysts, . 
 
 
 304 
 
 , , Displacements, 
 
 
 305 
 
 ,, Hydatids, . 
 
 
 305 
 
 , , Inflammation and Supp 
 
 lura 
 
 
 tion. 
 
 
 303 
 
 ,, Malignant Disease, 
 
 
 310 
 
 ,, Situation, 
 
 
 9 
 
 ,, Solid Enlargements, 
 
 
 306 
 
 ,, Wounds, 
 
 
 310 
 
 Splenectomy, . 
 
 
 308 
 
 Sponges, 
 
 
 39 
 
 Stimulants after Operation, 
 
 
 58 
 
 Stitch Abscess, 
 
 
 54, 91 
 
 Stitches, Removal, . 
 
 
 70 
 
 Stomach, Anatomy, 
 
 
 105 
 
 ,, Distension, 
 
 
 142 
 
 ,, ,, Method of. 
 
 126 
 
 ,, Foreign Bodies in. 
 
 
 125 
 
 ,, Malignant Disease, 
 
 
 134 
 
 ,, Operations on, . 
 
 
 110 
 
 PAGE 
 
 Stomach, Perforating Ulcer, . 123 
 
 ,, Stitching, , , 121 
 
 SuiDpurating Ovarian Cyst, . 334 
 
 Suture of Abdominal Wound, . 53 
 
 Symphysiotomy, , ’ . . 483 
 
 ,, Compared with Laparo- 
 
 Electrotomy, 485 
 
 Table, Operating, . . , 38 
 
 Tait, ,381 
 
 Talamon, on Appendicitis, 209, 212 
 Tapping, .... 20 
 
 Temperature, ... 74 
 
 Thirst, . . . . 57 
 
 Thornton, .... 278 
 
 Toilet of the Peritoneum, . . 48 
 
 Treatment after Operations, . 56 
 
 Trendelenburg, . . . 395 
 
 Trenholme, .... 430 
 
 Treves, . . . . 168 
 
 Trocars, . . . . 22 
 
 Tubercular, Peritonitis, . . 86 
 
 Tumours in Abdominal Wall, . 93 
 
 ,, Behind Peritoneum, 95 
 
 ,, of Broad Ligament, . 378 
 
 ,, Intestines, *. . 183 
 
 ,, Kidney, . . 279 
 
 ,, Liver, . . . 241 
 
 ,, Ovary, ... 319 
 
 ,, Pancreas, . . 313 
 
 ,, Phantom, . . 19, 328 
 
 ,, Spleen, . . . 304 
 
 ,, Stomach, . . 134 
 
 ,, Uterus, . . . 397 
 
 Twisting of Ovarian Pedicle, . 331 
 
 Tympanites, .... 60 
 
 Typhlitis, .... 205 
 
 Typhoid Ulceration of Intestine, 198 
 
 Ulcerations, the Result of Burns, 197 
 
 ,, Gastric, . . 123 
 
 ,, Syphilitic, . . 198 
 
 ,, Tubercular, . . 197 
 
 „ Typhoid, . . 198 
 
 Umbilical Hernia, ... 93 
 
 ,, Region, . . . 12 
 
 Urachus, Cysts of, . . , 97 
 
 Urine, Suppression from Calculus, 270 
 
 Uterine Appendages, . . 381 
 
 Uterus, Displacements, . . 473 
 
 ,, Fibrocysts, . . . 401 
 
 ,, Fibroid Tumours, . 397 
 
 ,, Malignant Disease, . 467 
 
 ,, Rupture, . . . 486 
 
 ,, Treatment by Operation, 469 
 
 Volvulus, . . . . 171 
 
 Vomiting, .... 64 
 
5o8 
 
 GENERAL INDEX. 
 
 PAGE 
 
 Wells, 
 
 345 
 
 Wounds of Gall-bladder 
 
 Winslow, Foramen of, 
 
 109 
 
 „ Intestines, 
 
 ,, „ Hernia into, 
 
 168 
 
 ,, Kidneys, 
 
 Witzer’s Modification of Gas- 
 
 
 „ Mesentery, 
 
 trostomy, 
 
 119 
 
 ,, Spleen, . 
 
 Wounds of Abdominal Wall, 
 
 200 
 
 
 PAGE 
 
 254 
 
 198 
 
 300 
 
 200 
 
 310 
 
 THE END.