THE COLLEGE AND CLINICAL RECORD. 
210 
delivered in the natural way, should be 
relieved of subsequent pregnancies, which 
could be accomplished by removal of the 
uterus. In Porro's operation section of the 
uterus was performed, the foetus removed and 
then the uterus. This operation was modi- 
fied by Muller, who removed the uterus and its 
contents entire. In this way, the risk of the 
escape of fluids from the uterus into the cavity 
of the peritoneum was avoided. Removal of 
the uterus had been suggested some time pre- 
vious to the operation by Porro. Cavallini, of 
Florence, in 1768, had suggested it. Michael- 
is, of Marburg, in 1809, contended that as it 
could be done in animals, and as the organ 
was worse than useless to the woman, who 
was thus subjected to great risks, the question 
of amputation might be entertained. Blun- 
dell, in 1828, removed cancerous uteri per 
vaginam, and also removed the uterus by 
abdominal section in animals, without fatal 
results. Storer, of Boston, in 1869, in order 
to save the life of a patient, removed a preg- 
nant uterus, the operation having been com- 
menced to remove what was supposed to be 
an ovarian cyst. 
To compare the mortality of the old opera- 
tion with that of the operation as now per- 
formed, it will simply be necessary to state 
that for the hundred years preceding 1884 
not one successful case of Caesarean section 
had been performed in the hospitals of Vienna. 
From 1787 to about the same time a similar 
mortality had attended the operations per- 
formed in the Paris hospitals. In Italy, of 
sixty-two cases operated upon, fifty-nine 
died. 
The splendid results achieved in this opera- 
tion, as well as in those upon other organs of 
the abdomen, have been chiefly, if not entirely, 
accomplished through the introduction of 
antiseptic methods in the treatment of wounds, 
and all that the use of these methods imply. 
Operations on the uterus have been per- 
formed not only for the purpose of removing 
its contents in the pregnant condition, but 
also for the removal of tumors involving the 
substance of the organ. These tumors are 
usually of a fibroid character and occupy the 
external, middle or internal portions of the 
walls of the uterus, forming sub-peritoneal, 
mural and sub-mucous fibroid growths. The 
operations have been performed with such 
varying success, and the mortality has been 
so great, as to render it more unfavorable than 
those performed upon other portions of the 
uterus and its appendages. 
I need not detain you at this time with any 
extended remarks upon the operation for 
removal of diseased ovaries. These operations 
(Etinirat Ordure. 
ABDOMINAL SURGERY. 
Two Lectures Delivered at the Jefferson Medical College, 
BY J. EWING MEARS, M. D. 
Lecturer on Practical Surgery and Gynaecology. 
REPORTED BY WILLIAM H. MORRISON, M. D. 
LECTURE I. 
Gentlemen, I do not think it necessary to 
offer any apology for the occupation of the 
time in addressing you on the subject of 
abdominal surgery, since the great advances 
which have been made in this direction have 
attracted the attention of surgeons over the 
entire world. As most of the progress has 
been made within the last fifteen or twenty 
years, the subject is comparatively new. The 
operation of Ephraim McDowell, in 1809, 
upon Mrs. Crawford, opened the door, as it 
were, into the peritoneal cavity, through which 
surgeons have entered and have attacked the 
various organs occupying that cavity. It is 
true that operations upon the uterus had been 
performed long before this. The Caesarean 
section, with which you are familiar, is said to 
derive its name from Caesar, who is reported 
to have been delivered by abdominal section 
and section of the uterus. As Caesar lived 
one hundred years before Christ, of course 
this fact, if true, makes the operation a very 
old one. Within a very few years the 
methods of operating have been much im- 
proved, so that, instead of having a mortality 
rate of nearly, if not quite, one hundred per 
cent., it has been reduced to 56-57 per cent. 
This is due to the improvement made in the 
operation by Porro, of Italy, who, on May 21st, 
1876, performed the first premeditated opera- 
tion, in which he removed the entire uterus. 
His modification consisted in the removal of 
the uterus, and the procedure was based upon 
reasoning and experimental vivisection, on the 
knowledge of the causes of the fatality to the 
mother in the old operation, and, finally, on 
the belief that a woman who, by reason of 
contracted pelvis or other cause, could not be THE COLLEGE AND CLINICAL RECORD. 
211 
have been performed so often that, no doubt, 
you are familiar with the methods and their 
results. It will be interesting simply to record 
the experience of one operator, Sir Spencer 
Wells, who has performed ovariotomy over 
one thousand times, and who, by this opera- 
tion, it is asserted, has contributed not less 
than twenty thousand years to the life of the 
women operated upon, and who has saved 
nearly nine hundred of the cases on whom 
it has been performed. 
After the uterus and its appendages, the 
next organ attacked by the surgeon was the 
spleen. Extirpation of the spleen was first per- 
formed in 1826, by Quittenbaum, of Rostock. 
Kiichler, of Darmstadt, performed a similar 
operation in 1855. From 1826 to 1881. 
thirty cases were recorded, of which nine 
recovered. The great mortality which has 
attended the operation of splenectomy is as- 
serted not to be due so much to the opera- 
tion itself, but to the effect upon the patient 
from the removal of an organ the function of 
which is so closely associated with the trans- 
formation of the white blood corpuscles into 
the red. It has been supposed that the 
patients who died after operation for the 
removal of the spleen, in whom the function 
of the organ had not been entirely destroyed 
by disease, have died as a result of the sudden 
interference with the function of this organ. 
In some instances, it has been observed that 
after the removal of the spleen swelling of 
the thyroid gland has occurred. From this 
fact, it has been inferred that the function of 
the spleen has been performed vicariously by 
this body. In the cases in which the entire 
organ was involved, death has been attributed 
to the effect of the operation rather than to 
interference with the function of the organ, 
as the system of the patient is supposed to 
have been accustomed to the loss of the 
organ by reason of the disease which had so 
long involved it. 
Operations upon the liver have been limited 
to the evacuation of abscesses and hydatid cysts. 
The old method consisted in section of the 
overlying tissues to the peritoneum, stuffing 
the wound in order that adhesions should 
form between the peritoneum and the surface 
of the liver, and then incision of this 
membrane and of the wall of the abscess in 
the liver. In this way, the contents of the 
abscess were prevented from entering the 
peritoneal eavity. Later, puncture of the 
cyst with the aspirating needle has been per- 
formed, with the removal of the purulent col- 
lection and also the fluid contained in hydatid 
cysts. 
Thudichum suggested, in 1859, operation on 
the gall bladder, for hepatic colic and for 
obstruction occurring in the duct. The first 
operation, however, was performed in 1867, 
by Dr. John S. Bobbs, of Indianapolis, 
Indiana, who opened the gall bladder, 
removed fifty gall stones, sutured the opening 
in the sac, returned it to the abdominal cavity 
and closed the incision. In 1878 Dr. Marion 
Sims performed a similar operation, removing 
sixty-six stones and twenty-four ounces of 
bile. He, however, formed a biliary fistula 
by sewing the edges of the sac to the abdom- 
inal incision. The operation ofcholecystotomy, 
opening the gall bladder, as well as cholecys- 
tectomy, removal of the gall bladder, have 
become established operations in surgery, 
and have been performed with success in a 
number of instances. 
Extensive surgical operations upon the 
stomach have been performed. Gastrostomy, 
the making of a fistulous opening into the 
stomach, for the purpose of feeding a patient, 
has been performed in a number of instances. 
Gastrotomy, the operation for opening the 
stomach for the removal of foreign bodies or 
for dilatation of the cardiac or pyloric orifice, 
is, however, of rather recent origin. In a 
number of cases, it has been performed for 
the removal of masses of hair and foreign 
bodies ingested by the patients. Pylorectomy 
is an operation which has been performed for 
the removal of the pyloric portion of the 
stomach when this has become the seat of dis- 
ease. After gastrotomy dilatation of the orifice 
may be performed; the index finger, and if 
necessary, the middle and ring finger, are in- 
troduced and the orifice forcibly stretched. 
It is necessary to say that this operation is 
only admissible in stenosis of the pylorus due 
to benign growths. In carcinomatous affec- 
tions, it should not be performed. 
Excision of the pyloric portion of the 
stomach for disease has been performed, the 
edges of the wound approximated and su- 
tured, and in this way the continuity of the 
stomach and intestine is restored. 
Operations upon the pancreas have also 
been performed by the surgeon, particularly 
for cystic disease involving the duct of the 
pancreas. This operation consists in open- 
ing the abdominal cavity, evacuating the cyst 
and stitching the edges of the wound to the 
abdominal incision. The cavity of the cyst 
may then be treated by drainage and injec- 
tions. 
Operations upon the intestinal canal have 
been performed for many years, such as 
colotomy, to relieve obstruction by the form - 
ation of an artificial anus, but the recent opera- 
tions have be/ much more extended, and THE COLLEGE AND CLINICAL RECORD. 
212 
include the opening of the abdominal cavity 
to relieve strictures of the intestine, to suture 
gunshot wounds, and to remove foreign 
bodies. In 1843, the late Professor S. D. 
Gross performed a number of experiments 
on animals in order to ascertain which was 
the best form of suture to be employed in 
cases of wounds of the intestine. Recently 
Dr. Parkes, of Chicago, performed a number 
of experiments upon dogs with the view of 
ascertaining the results following gunshot 
wounds of the abdominal cavity, involving 
the intestines. These animals were subjected 
to gunshot wounds and the abdominal cav- 
ity opened. Wounds of the intestines were 
sought for and sutured, and the cavity cleaned 
and closed. The animal was killed after 
repair had taken place, and examination made 
to determine the condition of the parts. If 
death occurred immediately after the opera- 
tion, examinations were also made, to deter- 
mine the cause of death. It is now the opin- 
ion of surgeons, from the results of the 
experiments which have been made, that in 
cases of gunshot injuries of the abdomen, it 
is proper, when the symptoms indicate wound- 
ing of the intestine, to open the cavity and seek 
for the wounded intestine and close the open- 
ings with sutures. It is also considered advis- 
able, in cases of suspected stricture of the in- 
testine, to open the cavity, seek for the stric- 
ture and, if possible, relieve it. In the remark- 
able instance reported by Kceberle, six feet 
of the intestine were removed, the ends 
sutured, thus restoring the continuity of the 
canal, and the patient recovered, showing 
that this operation can be performed with 
success. 
The abdominal cavity has also been opened 
by the surgeon for the purpose of removing 
growths connected with the mesentery and 
omentum and for the ligature of the abdom- 
inal vessels in the case of aneurism. 
Finally, it has been regarded as proper to 
open the cavity and introduce a drainage 
tube in cases of suppurative peritonitis. This 
operation has been done a number of times 
with success. The cavity has been treated as 
an abscess cavity. After the drainage tube has 
been introduced, antiseptic solutions have been 
thrown in, and in this way the cavity cleansed. 
I have performed this operation twice. In 
the first case, which occurred twelve years 
ago, I opened the abdominal cavity and 
washed it out by introducing antiseptic solu- 
tions through a catheter. The patient recov- 
ered and lived some ten years. Recently I 
was called in consultation, and performed the 
operation for the second time, in a case of 
suppurative peritonitis. Theabdominal cav- 
ity was opened and a glass tube similar to that 
used in ovariotomy was introduced. To this 
was attached a rubber tube which was con- 
veyed to a receptacle under the bed, the end 
of the tube being immersed in liquid to pre- 
vent the entrance of air into the cavity. An- 
tiseptic precautions were employed through- 
out the operation. The cavity was washed 
out with a weak solution of carbolic acid, and 
free drainage obtained. 
At the next lecture, I shall discuss the 
various operations which have been per- 
formed for the relief of affections of the 
kidneys. December 1,1885.I 
Vol. VI. No. 12. j 
THE COLLEGE AND CLINICAL RECORD. 
223 
OinirM lecture. 
opening the peritoneal cavity. The dissec- 
tion which I have here will show you the 
structures which must be divided in order to 
reach the organ by this route. The subject 
being in a prone position, with the vertebral 
column arched, the kidney is forced toward 
the surface, and this position will develop 
the region in which it lies. In the dissection, 
the first structure reflected is the integument, 
next the superficial fascia, then the deep fas- 
cia, then the aponeurosis of the latissimus 
dorsi and the external oblique, next that of 
the internal oblique and the transversalis 
muscle, and then the transversalis fascia. 
This exposes the kidney in its position. 
It is necessary, however, to call your atten- 
tion to the three layers of the vertebral 
aponeurosis of the transversalis muscle, which 
embrace, between the posterior and middle 
leaflets, the erector spinae mass, and between 
the middle and anterior leaflets, the quad- 
ratus lumborum muscle. Near to the bodies 
of the lumbar vertebrae rests the psoas mag- 
nus muscle, and upon the psoas magnus and 
quadratus lumborum muscles is placed the 
kidney, surrounded by a mass of fat. Some- 
times this fat is absent, as in this subject. In 
other instances the mass of fat surrounding 
the kidney measures one or two inches in 
thickness. In performing the lumbar opera- 
tion the incision should be made along the 
border of the erector spinae mass, dividing 
the structures which have been observed in 
the dissection, and in this way reaching the 
kidney without the section of any important 
muscular structures, blood vessels or nerves. 
The causes of death which have followed the 
lumbar operation are stated to be, shock, ex- 
haustion, septicaemia, pyaemia, anuria, and 
secondary hemorrhage from the stump of the 
kidney. 
The morbid conditions which require opera- 
tive treatment are displacement of the kidney, 
forming what is described as the floating kid- 
ney, or when it becomes the seat of pain, the 
painful floating kidney ; dropsy of the kidney, 
designated as hydronephrosis; suppurative 
lesions, as pyonephrosis, abscess in the sub- 
stance of the organ, pyelitis or inflammation 
of the pelvis of the kidney, simple or due to 
the presence of a stone, constituting in the 
latter case calculous pyelitis ; cysts of the kid- 
ney occurring in its substance; tubercular 
kidney; tumors of the kidney, either benign, 
chiefly adenomata, or malignant, such as car- 
cinomatous tumors or semi-malignant growths, 
as sarcomata, and finally ureteral fistula. 
The operations performed upon the kidney 
are designated as nephrorrhaphy, or suture of 
the kidney; nephrotomy, or section of the 
ABDOMINAL SURGERY. 
Two Lectures Delivered at the Jefferson Medical College, 
BY J. EWING MEARS, M. D., 
Lecturer on Practical Surgery and Gynaecology. 
REPORTED BY WILLIAM H. MORRISON, M. D. 
LECTURE II. 
OPERATIONS ON THE KIDNEY. 
Gentlemen, at my last lecture I gave 
you a resume of the operations which have 
been performed upon the various organs con- 
tained within the abdominal cavity, reserving 
for to-day the consideration of those done 
upon the kidney. I propose to take up these 
operations in a systematic order, first review- 
ing the surgical anatomy of this organ, then 
the different diseases for which operations 
have been performed, and finally the different 
methods of operation. 
I assume that most of you are sufficiently 
advanced in your anatomical studies to be 
familiar with the anatomy of the kidneys. 
1'hey are two in number, placed along the 
vertebral column, and extend from the 
eleventh rib to nearly the crest of the ilium. 
They measure from four to five inches in 
length, two inches in breadth and one inch 
in thickness, and are usually enveloped by 
masses of fat, and held in position by attach- 
ments to the large blood vessels, the aorta 
and ascending vena cava, branches of which 
are distributed to them. A dissection of 
the kidney will show that it lies behind the 
peritoneum, and that it may be reached 
by two methods of operation, one through 
the abdominal cavity, known as the ventral 
method, and the other through the lumbar or 
loin region, known as the lumbar method. 
In order to reach the kidney through the 
cavity of the abdomen, it is necessary, as can 
be readily seen from the models and the dis- 
section before you, to open the abdominal 
cavity and push aside the overlying intestines, 
and when the posterior wall of the cavity is 
reached, to divide the layer of peritoneum 
behind which the kidney is placed. By this 
method the two layers of peritoneum are 
divided and the cavity of the abdomen opened, 
thus subjecting the patient to the dangers re- 
sulting from exposure of this structure of this 
large cavity. The conditions which are liable 
to follow operations on the kidney through 
the abdomen are, shock, peritonitis, septic 
peritonitis, pulmonary embolism, primary 
hemorrhage and uraemia. 
In the operation through the lumbar re- 
gion, the kidney can be reached without 224 
THE COLLEGE AND CLINICAL RECORD. 
kidney ; nephrectomy, or excision of the kid- 
ney, and nephro-lithotomy, or section of the 
otherwise healthy kidney for the removal of a 
stone. These various operations and the con- 
ditions demanding them have been carefully 
studied and tabulated by Professor S. W. 
Gross, a paper upon which subject was read 
by him before the American Surgical Asso- 
ciation at its last meeting. In this paper he 
has collected 233 cases of extirpation of the 
kidney, with 129 recoveries and 104 deaths, a 
mortality of 44.63 per cent. He has further 
tabulated the mortality in each of the condi- 
tions described. The general results of his 
investigations have shown that of the two 
operations, the lumbar is safer than the ventral 
operation, and " that primary extirpation of 
the kidney is indicated in sarcoma occurring 
in adults, benign growths at any age, the early 
stage of tubercular disease, rupture of the 
ureter occurring during operation and in 
ureteral fistula. Nephrectomy should not be 
resorted to as a primary operation in painful 
floating kidney, in calculous pyeletis in a 
healthy kidney, in hydronephrosis, in cysts, 
in suppurative lesions and in injuries of the 
kidney and ureter. Nephrectomy should 
never be performed in sarcoma in children, 
nor in carcinoma at any age, unless in a 
very early stage, and finally, it should not be 
performed in advanced tubercular disease." 
Taking up the different conditions in order, 
I shall first speak of the displacement of the 
kidney known as painful floating kidney. 
As a result of severe exertion, as in lifting 
heavy weights, or during parturition, the kid- 
ney may become displaced and its attach- 
ments to the large vascular trunks of the 
abdomen become elongated and the organ 
floats in the abdominal cavity. This elon- 
gated attachment is described as the meso- 
nephron. On making external examination 
the surgeon will frequently be enabled to seize 
the organ and determine its outline, and thus 
arrive at an accurate diagnosis as to the 
nature of the trouble. In some instances the 
floating kidney has been mistaken for a solid 
tumor of the ovary, and abdominal section 
performed for the removal of the supposed 
tumor. When the diagnosis has been made, 
and the conditions of pain are such as to war- 
rant operative interference, the operation of 
nephrorrhaphy may be performed. The kid- 
ney is to be exposed by the lumbar incision, 
extending from the eleventh rib to the crest 
of the ilium, and if necessary, the straight in- 
cision may be enlarged by a curvilinear in- 
cision along the lower border of the twelfth 
rib. When the incision has been completed, 
the kidney should be forced back into posi- 
tion by pressure through the abdominal pa- 
rietes. The organ being exposed, it is seized, 
and by means of sutures introduced through 
its capsule, attached to the edges of the lum- 
bar incision. The wound is then closed, with 
the expectation that adhesions will occur and 
the kidney be retained in its normal position. 
After the operation of nephrorrhaphy, it 
sometimes happens that the kidney again 
becomes displaced. In 18 of these opera- 
tions reported by Professor Gross in the 
paper referred to, there was but one fatal 
case, with four entire failures and three par- 
tial failures, making seven failures in the 18 
cases. It is regarded as proper to perform 
nephrorrhaphy as a primary operation in 
painful floating kidney, and if, as in a recent 
case operated on by Professor Agnew, the 
operation fails to secure the kidney in place, 
nephrectomy should then be performed. 
Suppurative lesions, as pyonephrosis, pye- 
litis and abscess, are conditions for which the 
kidney has been extirpated. It is, however, 
now regarded as proper in these cases to 
make a lumbar incision, evacuate the purulent 
collection and drain the cavity by the intro- 
duction of a drainage tube. Fistulous tracks 
frequently follow this operation, which may 
afterward require operation. In some instan- 
ces, the kidney entirely disappears, by reason 
of the continuance of the suppurative action, 
leaving but a shell behind, and in these cases, 
if the fistulous tracks remain permanent, ne- 
phrectomy can be resorted to, and in that way 
the remaining structure removed. 
Hydronephrosis, or dropsy of the kidney, 
is another affection for which nephrectomy 
has been performed. Recent investigations 
have, however, shown that in this condition, 
incision with drainage is the preferable opera- 
tion. Of the cases reported by Professor 
Gross, 25 were cases in which incision with 
drainage was performed. Of this number, 
four died, making a mortality of 16 per cent. 
Fourteen of these operations were by the 
ventral incision, and of this number three 
died. Eleven were by the lumbar incision, 
and of this number one died. Out of twenty 
operations, urinary fistula occurred in eleven. 
As a preliminary procedure in the conditions 
just mentioned, aspiration may be resorted to, 
in order to evacuate the fluid. In cysts of 
the kidney, nephrectomy has also been per- 
formed. Of fifteen of these cases seven died. 
In all these cases the operation was performed 
by the ventral incision. In seven instances 
nephrotomy was performed, with no deaths. 
In tubercular kidney, nephrectomy has also 
been performed, but it is now a question 
claiming the attention of surgeons, whether THE COLLEGE AND CLINICAL RECORD. 
225 
or not this operation is proper, by reason of 
the fact that it is difficult to ascertain the lim- 
itation of the disease to one kidney. If the 
disease is recognized in its early stage, ne- 
phrectomy may be performed with a prospect 
of success. The operation is not to be re- 
sorted to in the advanced stages. 
Nephrectomy has also been performed for 
removal of a calculus in the kidney. It is now 
recognized that the proper operation in these 
cases is nephro-lithotomy, of which twenty- 
one cases have been reported. In this opera- 
tion, the kidney is exposed and its structure 
divided with a knife, or preferably with Pa- 
quelin's cautery, the stone extracted and the 
surfaces apposed. Union takes place and the 
function of the kidney is restored, which may 
seem remarkable after an injury so severe 
in character as that inflicted by the operation. 
Nephrectomy has been performed for the 
relief of tumors of the kidney, both benign 
and malignant, but the mortality attending 
these operations has been such as to limit the 
procedure to certain conditions and periods of 
life. Experience has shown that nephrec- 
tomy should not be performed in carcinoma, 
especially in an advanced stage, or in sarcoma 
in children, but it may be performed in 
sarcoma in adults. 
Ureteral fistulae occur as a result of 
injury of the ureter during operations for 
the removal of the ovaries or uterus, and 
as the result of gunshot wounds, and in 
these cases the fistula may open into the 
vagina or uterus or upon the abdominal 
wall. The practice has been to attach the 
walls of the ureter to the abdominal incision, 
thus producing a permanent ureteral fistula. 
In these cases the annoyance to the patient is 
sometimes so great as to justify the surgeon 
in resorting to nephrectomy. If the ureter is 
injured during operations on the ovaries or 
uterus, it is deemed advisable not to perform 
nephrectomy as a primary operation, but to 
simply establish a fistula and, if the opera- 
tion becomes necessary at some subsequent 
time, perform nephrectomy. 
-In a severe case of gastralgia without any 
assignable cause, occurring in a girl aged 19, 
Prof. DaCosta directed that she should take 
no food except milk, from three pints to two 
quarts per day; in addition two soft boiled 
eggs mighs- be taken. Lime water to be 
added to the milk, if necessary. Fowler's 
sol., gtt. iij ter die, to be increased to gtt. v. 
For the pain give- 
R. Opii, • gr. | 
Ext. cannab. indie., gr. |. M. 
Ft. chart, j.