Compliments of the Author. A REVIEW OF ABDOMINAL SURGERY, WITH A Report of One Hundred and Twelve Cases, BY HORACE PACKARD, M.D. LECTURER ON SURGERY, BOSTON UNIVERSITY SCHOOL OF MEDICINE. Reprinted from Neu England Medical Gazette. BOSTON: CHAS. A. WHITE & CO.. Printers.. 1890. A REVIEW OF ABDOMINAL SURGERY, WITH A Report of One Hundred and Twelve Cases,. BY HORACE PACKARD, M.D. LECTURER ON SURGERY, BOSTON UNIVERSITY SCHOOL OF MEDICINE. Reprinted from New England Medical Gazette. CHAS. A. WHITE & CO., Printers. 1890. A Review of Abdominal Surgery, with a Report of One Hundred and Twelve Cases. BY HORACE PACKARD, M.D., BOSTON. A glance over the history of abdominal surgery reveals a progress which is not equalled in any other branch of the sur- geon's art. It is eighty years since the bold Ephraim McDow- ell, of Kentucky, cut open the abdomen and removed an ovarian tumor. Many years passed by ere much was accomplished in abdominal surgery, for it was not until 1848, that Angus Kim- ball of Lowell, made his first ovariotomy, in 1858 that Sir Spen- cer Wells began his career as an ovariotomist, and as late as 1872 that Charles Homans, of Boston, performed his first opera- tion of that kind. It is twenty-two years since the first ovariotomy was made in our Boston City Hospital, and fifteen years since the first opera- tion of this kind is recorded in the Massachusetts Homoeopathic Hospital. Loud and bitter was the denunciation of the pioneers in ab- dominal surgery, by the medical profession at large, for what was then looked on as human butchery. How different is the status of this branch of surgery today! In 1880 there was but a single laparotomy in the Massachu- setts Homoeopathic Hospital. In the last year, 1888, there were twenty-two. Fifteen years ago the laparotomists of the world scarcely numbered ten. To-day there is hardly a surgeon but can show a record of abdominal operations. During a period of three years beginning Jan. 1, 1886, there were thirteen hundred American laparotomies from the hands of eighty-two operators.1 Two years ago (1887), the first complete work on abdominal surgery appeared2 necessitating six hundred printed pages to adequately cover the subject. To-day there is scarcely an organ in the abdominal cavity but has been subjected to the surgeon's knife. The pylorus has been resected, long segments of the intestine cut out, adjacent loops fastened together for the purpose of accomplishing 1 Pittsburg Medical Review, Sept. 1889. 2 Abdominal Surgery by Grieg Smith. 4 ABDOMINAL SURGERY. anastomosis ; the gall bladder has been incised and excised ; the spleen and pancreas have not escaped the surgeon's knife ; the kidneys have been subjected to operation, both by incision as well as excision ; and the uterus, ovaries, and Fallopian tubes have furnished material for the widest scope of the most ambi- tious laparotomist. From the standpoint of the art of surgery, this is indeed a great conquest. The establishment of the facts that the once dreaded peritoneal cavity may be manipulated surgically without fear of inflammation, that a portion of the intestinal tract may be excluded without serious inconvenience to the patient, that the loss of a kidney is not necessarily fatal, that the gall bladder is not an essential part of the digestive apparatus, that the uterus and ovaries are not essential to the life of woman, are grand achievements. On the other hand, what can be said of this from the stand- point of the patient ? Has human life been saved or prolonged by the knowledge thus gained ; has suffering been averted ? We can easily arrive at a conclusion by briefly surveying the diseases and accidents to which the abdominal viscera are subject. The intestinal canal is subject to obstruction from cancerous and cicatricial stricture, intussusception, hernia, volvulus, and enterolites ; also to injury from penetrating gunshot and sabre wounds. From the former, death is sure to result if the obstruc- tion become complete; from the latter death as surely comes from escape of fecal matter into the peritoneal cavity. What surgery is able to accomplish for the relief of these dis- tressing conditions, one has only to read the literature of the last two years to learn. The experimental researches of Dr. Nicholas Senn,1 of Milwaukee, have shown that in total intesti- nal obstruction from cancer, a loop above may be quickly and safely united to a loop below, by his method of intestinal anas- tomosis, and the continuity of the intestinal canal thus re-estab- lished. Resection and union by lateral approximation, in all cases where a portion of the intestinal tract has been destroyed by gangrene or wound, is a safe procedure.2 Senn's method of insufflation of hydrogen gas for purposes of diagnosis in sus- pected intestinal perforation from gunshot or sabre wound in the abdomen, is a procedure which should always be adopted early, and if perforation exist, abdominal section and the sewing up of the intestinal wounds with the Lembert suture or some modification of it offers the greatest hope of relief.2 Cases of artificial anus from strangulated hernia, or otherwise, can be safely restored.3 1Senn's Intestinal Surgery. 2Neiu York Medical Journal, March 23, 1889, p. 314. Era, Chicago, January, 1890. ABDOMINAL SURGERY. 5 Affections of the gall cyst and duct are among the most pain- ful to which the human frame is subject. Modern surgery has shown that abdominal section and the removal of biliary calculi from both cyst and duct are not only possible, but should always be done if the gravity of the affection reach a point which en- dangers the patient's life. In cases of abscess and hydatid of the liver, laparotomy with incision of the liver substance, evacu- ation, drainage and suturing the edges of the liver wound to the parietal wound offers the greatest hope of relief and cure. Of the pancreas and spleen little can be said of operative measures, for the reason that they are rarely the seat of affec- tions calling for surgical interference. Tumors of both organs have been removed. Experimentation has shown that the spleen is not essential to the life of the individual. Hence in case of splenic cyst of a size jeopardizing the patient's life, total removal would be a justifiable operation. We have no knowl- edge as yet, which would justify us in the total removal of the pancreas for disease. There have been a few cases of extensive cystic degeneration of this organ which have been mistaken for ovarian cyst and operation attempted. If the cyst have developed at the splenic end of the organ and have a pedicle, its removal may be accomplished with safety ; if it have a large attachment and many adhesions, incision and drainage without attempt at removal is the best method. The kidneys are very tolerant of surgical manipulation. In renal calculi, abscess of the. kidney, hydronephrosis, etc., much may be done to save life and relieve suffering. Total removal of the kidney for any of these conditions is not an advisable procedure, for the reason that experience has shown that a dis- eased kidney is better than none, provided free exit is given for any products of disease which may arise there. In the past few years, efforts have been made to fasten dislocated kidneys in place with sutures but without very satisfactory results. The greatest boon to humanity in the line of abdominal sur- gery, has been in operations on the ovaries for the removal of ovarian tumors. The lives saved annually in this way number thousands. With the present method of operating, every case of uncomplicated ovarian tumor should recover. Recent knowledge of diseases of the Fallopian tubes has enabled the surgeon to restore to health, by removal of the same, many cases which would otherwise be destined to life- long invalidism. Tumors of the uterus and the uterus itself are removed today with as little disturbance to the patient as fre- quently follows parturition. Large multiple fibroid tumors are as easily and safely removed as ovarian cysts. Have I presented an overdrawn picture of the present 6 ABDOMINAL SURGERY. status of abdominal surgery? I think not. True, patients die now and then following abdominal operation, but an analysis of the works of our best operators will show in every case that death has resulted, not because of the operation, but because the condition necessitating the operation had proceeded too far before the art of the surgeon was invoked. It is estimated that in ovariotomy alone, with the present percentage of recoveries, a series of one thousand cases, confers upon humanity a saving of twenty thousand years of life. In closing I will invite you to a brief review of my own work in abdominal surgery, including 112 consecutive cases. These are arranged in two series, the first being fifty cases prior to September, 1888,* the second, sixty-two cases occur- ring between the date above mentioned and September of this year. * See New England Medical Gazette, Sept., 1888. FIRST SERIES. A Report of Fifty Cases Operated on Prior to September, 1888. Of the fifty cases embodied in the following report, twenty were operated upon for ovarian tumors, five for the removal of ovaries not the seat of tumor, and twenty-five for miscellaneous purposes, such as total extirpation of the uterus per vaginam, removal of uterine fibroids, diseases of the kidney, umbilical and femoral herniae, pelvic abscess, opening of the gall-bladder, and incisions for purposes of exploration. The Ovarian Tumors.- Nineteen of the cases of ovarian tumor were completed operations, and of these eighteen recov- ered. The one death was in the case of an unmarried woman of twenty-nine years. There were no unfavorable complications at the time of operation, and every thing indicated a successful issue. No elevation of temperature followed, and there was a copious secretion of urine, but on the third day she sank into a heavy sleep which gradually became more profound, and died on the fourth day. The necropsy revealed little or nothing to account for the death. One kidney showed a small spot which was thought to be tuberculous, but the remainder of that kidney and all the tissue of the other seemed perfectly normal. The cause of death has remained an enigma to me to the present day. One uncompleted ovariotomy is included in the table, but it is my purpose to let that stand by itself and form one of a class. It was an enormous tumor of eighty pounds, and had a history of ten years' growth. The patient had been urgently advised eight years before by an ovariotomist to have it removed, but had steadfastly refused. When she came into my hands, opera- tion was sought as a last resort, and it proved to be the last, for the tumor in its long-continued growth had fastened itself to nearly all the abdominal viscera, and before it could be separated the patient succumbed. The fault in this case lay in the long delay. It is more than probable, that, had operation been attempted eight years before, success would have followed. Several of the eighteen successful cases present points of more than ordinary interest. Case vi. was a woman of sixty-four years. A vesico-ventral fistula made its appearance on the fourth day. A self-retaining silver catheter was placed in the bladder, but did not satisfac- torily drain away the urine, the latter continuing to bubble up 8 ABDOMINAL SURGERY. through the fistula. An artificial vesico-vaginal fistula was macle, and out through it came the silk ligature and a piece of necrotic tissue. After this the ventral fistula quickly closed, and the patient went to her home. She returned a few months after to have the vesico-vaginal fistula closed. It was then found that she had a stone in the bladder, which on removal was found to have for a nucleus a bit of silk ligature. Case vii. was what is popularly called a suppurating ovarian cyst, but properly speaking it was not, for, though the contents appeared to the unaided eye precisely like pus, yet the micro- scope showed it to be only fatty and sebaceous matter without any pus corpuscles whatever. In this case the adhesions were so extensive that enucleation was abandoned, and the opening in the sac was sutured to the edges of the abdominal wound. Recovery promptly followed. A few months after, the patient returned, exhibiting a ventral hernia at the site where the cyst wall was sutured to the abdominal wound.1 This is the only case in which this complication has followed. Hydrosalpinx. From Cases No. 5 and 7, respectively. Showing distention and convolution of the Fallopian tubes. Case viii. is of some interest in that, nine months after, an exploratory incision was made through the left linea semilunaris to determine the character of a bunch which had made its appearance in that locality. It was found to be cancer of the messentery, from which she afterwards died. 1 The hernia was repaired, pregnancy has since occurred, child carried to full term, and safe delivery effected. ABDOMINAL SURGERY. 9 Case xii. was a dermoid cyst of the left ovary, presenting teeth and hair imbedded in fat; on the right side was found an excellent specimen of hydrosalpinx. Case xiii. was another so-called suppurating cyst, but this time of both ovaries. It was a case presenting the most extensive adhesions that I ever attempted to operate on. The operation Dermoid Cyst. From Case No. 12, showing cyst wall, teeth, and hair. was performed in Farmington., Me. I have not seen the patient since, but the last report received was that she had so far recov- ered that she is able to attend to her usual household duties. Case xiv. presented, beside a parovarian cyst, another perfect specimen of hydrosalpinx. ABDOMINAL SURGERY. 10 Case xv. is of importance in that the peritoneum was found, at the time of the operation, studded with tubercles. The exter- nal wound was slow in healing, and even now, three months from the date of the operation, a sinus still persists. She has, however, steadily gained in strength and flesh, and, according to other reports of similar cases, the abdominal section may have a beneficial effect on the peritoneal tuberculosis. Case xix. was a perfect specimen of a dermoid cyst. In the preparation of the specimen for preservation, the fat has been dissolved and drained away, and the cyst wall pre- served in glycerine and HgCh solution. Special mention should also be made of the finely formed teeth presented. (See cut.) The Removal of Ovaries.- There are but five cases in this class to report, and all recovered from the operation ; not all, however, recovered from the trouble for which the ovaries were removed. All are now living, three of whom are much im- proved, while the other two have not been benefited at all. Case xxi. had the ovaries removed to check the growth of a fibroid tumor. At the time of the operation both tubes were found distended and filled with pus, yielding the most exquisite examples of pyosalpinx. Pyosalpinx. From Case No. 13. The left has been laid open and the pus evacuated, while the right remains as at time of removal. Case xxiv. was one in which a pelvic abscess of each side had been opened and drained per vaginam, several months before ; large accumulations of dense tissue still persisted on either side, giving rise to constant pain. On abdominal section, ABDOMINAL SURGERY. 11 no tubes or ovaries could be found, all apparently being imbedded in these masses of plastic tissue. Both sides were dug out, a sort of pedicle formed and ligated, and drainage-tubes adjusted. A slow but perfect recovery has followed. Fibro-Cystic Tumor of Uterus. From Case No. 29. Showing solid and cystic portion, the whole strangely simulating in appearance a placenta and its membranes. Miscellaneous Operations. - A much larger mortality will be observed in this class than in the preceding ; and such would naturally be expected, for the list covers a great variety of con- ditions, many of them of the greatest gravity. Some of them were among my earliest operations, when, as is so bluntly stated by another operator, "I was learning how and doubtless with ABDOMINAL SURGERY. 12 the riper experience now gained, and improved methods of oper- ating, the same cases might be carried safely through. Case xxxix. is worthy of special mention. It was an enor- mous solid fibroid tumor, with a pedicle less than two inches in diameter. It was treated intra-peritoneally with many buried catgut sutures. Recovery was rapid and uninterrupted. Case xl. was similar to the above, except that the larger part of the tumor was a simple cyst with a very thin and fragile wall, and the solid portion, near the pedicle, was about the size and shape of a placenta, so that the whole, with contents evacuated, bore a most striking resemblance to a placenta and its membranes. The pedicle was treated in the same way, and every thing went well until the fifth day, when with tempera- ture normal, and scarcely any discharge from the drainage-tube, the latter was removed. The patient died three days after, from peritonitis. My mistake lay in too early removal of the drainage- tube. It is now my invariable rule to leave the drainage-tube until the tenth day. Of Operations on the Kidney, two are recorded. Case xxxvi.-Nephorraphy was followed by the happiest results. The patient had suffered all the discomforts which usually accompany movable kidney. A lumbar incision was made down to the organ, and with many catgut sutures it was fastened well back into its original resting place, where it has since remained, much to the relief of its owner. Case xix. - Nephrectomy was performed on an old lady of sixty-four years. The kidney was dislocated, much enlarged, and very tender and painful. She had passed great numbers of renal calculi. The lumbar incision was made, and the kidney removed. The patient lived but ten hours. A necropsy showed absence of the other kidney. In a similar case I should now open such a kidney, sew its edges to the lumbar wound, and drain. I have but little doubt, had this course been pur- sued, the patient would have recovered, and great relief followed. My dependence, however, was upon the other kidney, which the necropsy showed was not there. Total Extirpation of the Uterus per Vaginam.-Five cases of this operation are recorded for the relief of cancer of the cervix. It is my belief that this operation has a great future. It appears that epithelioma of the cervix begins purely as a local disease, even as much so as epithelioma of the lip in the male. Why cannot equally brilliant results be obtained if early and thorough removal be effected ? I do not believe that vaginal extirpation of the uterus in itself is a specially dangerous operation. The high mortality and early recurrence of the disease recorded by many authors are caused by the almost ABDOMINAL SURGERY. 13 invariably advanced stage of the disease. The great error is in allowing valuable time to slip away while resorting to temporizing measures. In the list here presented, three out of the five recovered from the operation promptly and without com- plication. One fell into my hands early in the progress of the disease, and, as a consequence, is now in perfect health with no sign of a return of the trouble. The other two were far ad- vanced ; and though there has been much improvement of the general health, the disease already shows indications of return, and there is but little prospect that life will be much prolonged by the operation. Umbilical Hernia. From Case No. 27. Enormous hernial protrusion of the intestines, of fifteen years' standing. Hernle.- It would perhaps be claimed that operations for the radical cure of hernia should not be included under the gen- eral head of abdominal surgery ; yet this operation involves the opening of the peritoneal cavity, and equally careful prepara- tions are made as for the most dangerous laparotomy. Case xxxviii. was certainly as difficult and dangerous as any laparotomy it has been my fortune to perform. __ An enormous 14 ABDOMINAL SuRGERY. hernial protrusion of the intestines existed at the site of the umbilicus, having burrowed its way beneath the skin in all di- rections, especially downward, pushing the peritoneum and omentum before it until, as the patient occupied the sitting posture, it rested upon the thighs, reaching about half way to the knees. The intestines were in a complete tangle, adherent to the omentum, peritoneum, and to each other. The knot was finally, and with much difficulty, unravelled, and the huge mass gradually worked back into its natural cavity. Several square feet of omentum were ligated and cut off, and the umbilicial opening drawn together with strong silver wires which were allowed to remain permanently. The hernial sac was thoroughly dissected out, the redundant skin cut away, and the external wound closed. Very complete and satisfactory recovery followed. Case xxxii. is of interest in that it was in a woman of seventy-four years, who made an excellent recovery. The hernia was small in comparison with the preceding. Operation on the Gall-Bladder. - Case l. - Chole- cystotomy. This operation consisted in the opening of the gall- cyst for the relief of an extremely acute and painful affection which had arisen presumably as a result of occlusion of the cystic duct. Twice prior to the operation the aspirator needle was inserted, and over forty ounces each time of a sero-purulent fluid drawn off. The edges of the opening in the gall-cyst were sutured to the external wound, and drainage-tubes inserted. Complete relief has followed, and the prospects seem excellent for a rapid recovery. Of late I have departed from the time-honored custom of administering a cathartic to patients prior to an abdominal operation. A thorough enema is given, and evacuatian of the bowels secured, in the morning before the operation. I believe that much of the griping and gaseous distension which so frequently occurs during the first day or two is often due to an unwisely administered cathartic. The strictest aseptic and antiseptic precautions are used in the preparation of the field of operation, instruments, sponges, hands, and dressings. The field of operation is thoroughly scrubbed with soap and a I : 1000 bichloride-of-mercury solu- tion. The hands of operator and assistants are scrubbed for one minute with soap and warm water, then one minute in a i : 1000 bichloride-of-mercury solution. Sponges are thorough- ly washed, then macerated in a weak solution of hydrochloric acid for six hours, one-half an hour in permanganate of potash, bleached in a solution of sulphate of soda for two hours, washed and placed in a bag and hung in a dry place. The day ABDOMINAL SURGERY, 15 before they are to be used, one dozen are counted and placed in a five-per-cent solution of carbolic acid, and allowed to remain over night. The morning of the operation, they, with all the instruments, are placed in a steam sterilizing tank for one hour. The operations are usually appointed for half-past nine ; and the assistants are expected to be on hand twenty minutes before that hour, and ready for duty on the minute. One person has exclusive charge of instruments and dressings, and does nothing else. Another has as his duty the preparation of the field of operation, removal of hair, supervision of sponges, towels, hot sheets, and solutions, with one nurse under him as assistant. Two assistants stand at the table, one opposite and the other at the left of the operator. 16 ABDOMINAL SURGERY. Date of 0 75 s ■*? M-4 0 c SIZE AND NATURE ions. ■ CS 0 , *4 fl O O Reported No. PATIENT OF Age. o'S. & 5 S Drain REMARKS. Elsewhere. Operation. g - 0 *=■ s Of TUMOR. One Ov 9 ◄ >-1 00 - -0 I Private. Sept. 19, '85. 64 M. 4 0 7 mos. Ovarian tumor, 14 Both None No H. R. Convalesence rapid and N. E. Med. pounds. uncomplicated. Gazette, 1885. 2 Dr. I. E. Chase, Jan. 31, '87. 34 M. 1 0 - Parovarian cyst. - Yes Yes H. R. Severe attack of pneu- Not. Haverhill, Mass. monia third day after op- eration. 3 Dr. A. D. Smith, Jan. 17, '87. 48 M. 2 2 7 yrs. Enormous multiloc- One Every- - H. D. Tumor in its growth Not. South Boston, Mass. ular ovarian cys- where had fastened on to all toma. Operation adjacent viscera with not completed. such tenacity that opera- tion could not be com- Both pleted. 4 Dr. H. L. Chase, Feb. 17, '87. 29 S. - O ii mos. Multilocular ovarian None No H. D. On third day became Not. Cambridgeport, Mass. cyst. very stupid, fell into a comatose state, and died Both fourth day. Autopsy did not reveal cause of death. No peritonitis. 5 Dr. J. A. Burpee, June 25, '87. 44 M. 3 O 3 mos. Papilloma of right Yes Yes H. R. Patient lived nine N. E. Med. Malden, Mass. ovary. Simple cyst of left ovary. months. Gazette, 1888. 6 Dr. L. M. Willis, July 30, '87. 64 M. 5 O 6 mos. Multilocular ovarian Both Yes No H. R. Silk ligature sloughed N. E. Med. Charlestown, Mass. cyst. through into bladder. Vesico-ventral fistula fol- Gazette, 1888. lowed. 7 Dr. C. A. Nordstrom Aug. 15, '87. 4° M. I O 1 yr. Suppurating ovarian - Yes Yes H. R. Cyst wall not removed. N. E. Med. Malden, Mass. tumor. Sutured to abdominal wound, and permanent drainage adopted. Gazette, 1888. 8 Dr. C. C. Ellis, Somerville, Mass. Nov. 10, '87. 38 M. 0 O 2 yrs. Multilocular ovarian Both Yes No H. R. Patient died afterwards N. E. Med. cyst. (five month later) from cancer of bowel. Gazette, 1888. TABULAR VIEW. -First Series. I. - Operations for the Removal of Ovarian and Parovarian Tumors. ABDOMINAL SURGERY. 17 9 IO Dr. M. E. Mann, Boston, Mass. Dr. F. A. Warner, Lowell, Mass. Nov. 14, '87. Nov. 21, '87. 35 42 S. M. 3 0 0 ? 9 mos. Small parovarian cyst. Simple ovarian cyst. Both Both None None No No H. H. R. R. Convaiesence retarded by irritation of silk liga- ture on left side. Convalescence rapid and uncomplicated. N. E. Med. Gazette, 1888. N. E. Med. Gazette, 1888. fi Dr. D. A. Babcock, Fall River, Mass. Feb. 3, '88. 41 M. 2 0 Small cyst of right ovary. One None No H. R. Convalescence rapid and uncomplicated. Not. 12 Dr. Alden W. Brown Boston, Mass. Feb. 13, '88. 34 M. I 0 « Dermoid cyst of left ovary and hydro- salpinx. (See cut.) One Dense Yes H. R. Cyst wall contained bone with several well- formed teeth, and a mass of hair imbedded in fat. Not. 13 Dr. F. 0. Lyford, Farmington, Me. Feb. 26, '88. - - - I - Suppurating cyst of both ovaries. Both Dense Yes P. R. Each ovary was but a sac filled with pus. Not. '4 Dr. H. C. Clapp, Boston, Mass. April 18, '88. 32 M. 0 0 Small parovarian cyst of right side and hydrosalpinx. One Many Yes H. R. Convalescence rapid and uncomplicated. (See cut.) Not. >5 Dr. J. K. Culver, Boston, Mass. May 3, '88. 4i M. 0 0 11 mos. Multilocular ovarian cyst of both ovaries. Both Yes Yes H. R. Omentum was studded with tubercles. Conva- lescence very slow. Not. 16 Dr. F. W. Moore, Brookline, Mass. May 10, '88. 5° M. 5 0 3 mos. Multilocular ovarian cyst. One None No H. R. Convalescence rapid and uncomplicated. Both tubes filled with Not. Not. 17 Private. May 11, '88. 22 M. 2 0 1 year. Ovarian cyst of both sides and pyosal- pinx. Both Yes Yes H. R. thick yellow fluid, and dis- tended like sausages. Convalescence rapid Not. 18 Dr. C. A. Barnard, Centredale, R. I. May 23, '88. 40 S. 2 2 yrs. 14 lbs. right side, and small cyst, left side. Both Yes Yes H. R. and uncomplicated. Convalescence rapid Not. '9 Dr. A. Mitchell, Medfield, Mass. April 25, '88. 35 M. 3 O 10 yrs. Dermoid cyst (see cut.) One No No H. R. and uncomplicated. (See cut.) 20 Private. June 1, '88. 61 M. 7 O 18 mos. Multilocular ovarian cyst. One No No H. R. Convalescence rapid and uncomplicated. Not. 18 ABDOMINAL SURGERY. No. PATIENT OF Date of Operation. Age. Married or Single. No. of Children. - - Duration of Disease. Pathological Condition or Symptoms Necessitating Operation. One or both Ovaries. Drainage. Hospital or Private. 1 Result (Recov- ery or Death.) Effect of Operation on Condition Requiring it. REMARKS. Reported Elsewhere. 21 Private. Nov. 24, '86 38 M. 0 1 year. Fibroid tumor of uterus, and double pyosalpinx. Both No No H. R. Improve- ment to date. Operation was insti- tuted for removal of ova- ries to check growth of tumor. Has menstruated since. Not. 22 Dr. H. B. Eaton, Rockland, Me. Jan. 10, '87 28 S. 0 4 yrs. Chorea and chron- ic pain and tender- ness in left ovary. Both No No H. R. Cure of chorea and pain. Operation was per- formed only after failure of long-continued treat- ment. Has not men- struated since. Not. 23 Dr. F. C. Richard- son, E. Boston, Mass. Jan. 22, '87 33 M. 2 - Chronic ovaralgia. Complete prostra- tion of system. Both Yes No H. R. None. Patient was not im- proved in her general condition by the opera- tion. Not. 24 Private. May 4, '87 33 M. 0 2 yrs. Abscess of both tubes and tubo-vagi- nal sinuses. Pre- viously opened per vaginam and drained. Both Ye s Yes H. R. Cure. Convalescence slow, on account of persist- ence of sinuses in track of drainage tubes. Not. 25 Private. Jan. n, '88 44 M. 3 4 yrs. Lon g-continued pain and tenderness in left ovary. Both No No H. R. Relieved but not eradicated Patient was treated for two years with hope of cure before operation. Not. II. - Operations for the Removal of Ovaries not the Seat of Tumor. ABDOMINAL SURGERY. 19 No. PATIENT OF Date of Operation. Sex. Age. Duration of Disease. Pathological Condition or Symptoms Necessitating Operation. Nature of Operation. Drainage. Hospital or Private. Result, (Recov- ery or Death.) Effect of Operation on Condition Requiring it. REMARKS. Reported Elsewhere. 26 Private. Feb. 23, '85. F. 34 2 yrs. Interstitial uterine fibroid. Supra-cervi- cal amputa- tion. No. H. D. Stump treated intra- peritoneally. Death from hemorrhage. Not. 27 Private. April 27, '85. F. 48 - Multiple fibroid of uterus, and small ovarian cyst. Enucleation. No. H. D. - Peritonitis occurred third day. Not. 28 Private. April 2, '88. F. 30 3 yrs- Ascites and ova- rian sarcoma. Exploratory incision. Yes. H. R. Death occurred ten weeks after from original disease. 29 30 Private. Private. Jan. 24, '87. Mar. 21, '87. F. F. 64 33 6 yrs. (?) Movable kidney, enlarged and pain- ful. Had passed many renal calculi. Pelvic abscess. Nephrecto- my (lumbar incision.) Laparotomy. Drainage tube passed down throughDoug- las's pouch. Yes. Yes. H. H. D. R. Cure. Autopsy showed absence of other kidney. 31 Private. Mar. 25, '87. F. 4'' 7 yrs- Large multilocu- lar ovarian cyst. Enormous adhesions. Exploratory incision. No. H. R. Patient still living, and in fair general health. 32 Dr. C. C. Ellis, Somerville, Mass. Sept. 6, '87. F. 73 15 yrs. Umbilical hernia. Operation for radical cure. No. H. R. Patient had barely escaped death a few weeks before from strangulation of gut. N. E. Med. Gazette, 1888 33 Dr. S. P. Hammond, Boston, Mass. Oct. 5, '87. F. 48 3 mos. Epithelioma of cervix. Total extir- pation per vaginam. Yes. H. R. Cure. Ten months from time of operation is in robust health, with no signs of re- turn of disease. N. E. Med. Gazette, 1888. III. - Operations for Other Purposes than the Removal of Ovaries. 20 ABDOMINAL SURGERY. No. PATIENT OF Date of Operation. Sex. Age. Duration of Disease. Pathological Condition or Symptoms Necessitating Operation. Nature of Operation. Drainage. Hospital or Private. Result, (Recov- ery or Death Effect of Operation on Condition Requiring it. REMARKS. Reported Elsewhere. 34 Dr. G. F. Walker, Nov. 9, '87. F. 3° 5 mos. Umbilical hernia. Operation for No. H. R. Cure. Several months af- N. E. Med. Boston, Mass. radical cure. ter operation, patient rolled out of bed and Gazette, 1888. reproduced rupture. Has worn pad since. N. E. Med. 35 Dr. Francis Brick, Oct. 26, '87. F. 5° 6 mos. Epithelioma cer- Total extirpa- Yes. H. D. - Patient succumbed Gazette, 1888. Worcester, Mass. vix. tion pervaginam. two hours after oper- ation from shock. N. E. Med. 36 Private. Dec. 2, '87. F. 47 2 yrs. Movable kidney. Nephrorraphy. Yes. H. R. Cure. Kidney remains in place, and patient in perfect hea th. Gazette, 1888. 37 Private. Jan. 25, '88. F. 33 7 yrs. Epithelioma cer- Total extirpa- Yes. H. D. - Patient survived Not. vix. tion per vaginam. five days. Death from exhaustion. 38 Dr. A. B. Sherburn, Feb. 1, '88. F. 42 15 yrs. Umbilical hernia, Operation for Yes. H. R. Cure. Hernial opening at Not. Portsmouth, N. H. enormous in size. radical cure. least two inches in (See cut.) diameter. Enormous protrusion of intes- tines. (See cut.) 39 Private. Feb. 15, '88. F. 53 5 yrs- Fibroid tumor of Removal. In- Yes. H. R. Cure. Pedicle about two Not. uterus, 17 pounds. tra-p e r i 10 n e a 1 inches in diameter, treatment of and secured with pedicle. buried catgut sutures. 4" Dr. H. M. Hunter, Feb. 29, '88. F. 47 i year. Fibro-cystic tu- Removal. In- Yes. 11. D. - Patient did excel- Not. Lowell, Mass. mor of uterus. (See tra-p e r i 10 n e a 1 lently well until sixth cut.) treatment of stump. day, when drainage tube was removed. Peritonitis after- wards set in, causing death. (See cut.) 41 Dr. C. A. Nordstrom, Mar. 16, '88. F. 40 3 mos. Ventral hernia. Operation for No. H. R. Cure. Malden, Mass. Sequel to operation in Case 7, Table I. radical cure. III.-Operations for other Purposes than the Removal of Ovaries.-Continued. ABDOMINAL SURGERY. 21 42 Dr. N. R. Perkins, Winchendon, Mass. Apr. i2, '88. F. 42 4 yrs- Ascites and mul- tiple fibroid of uter- us. Supra - cervical amputation of uterus. Extra- peritoneal treat- ment of stump. No. H. D. - Patient died from exhaustion. Rapid return of ascites, in- dicating serious por- tal obstruction. 43 44 Private. Private. Apr. 30, '88. Apr. 27, '88. F. F. 54 53 13 yrs. 7 yrs. Femoral hernia. Umbilical hernia. Ligating neck of sac, and sutur- ing edges of ring. Operation for Yes. Yes. H. H. R. D. An abscess formed 45 Dr. C. C. Ellis, Apr. 28, '88. F. 39 Carcinoma of mes- radical cure. Exploratory in- No. P. D. at the site of opera- tion. Death appar- ently from exhaus- tion. Death occurred 46 Somerville, Mass. Dr. W. H. Lougee, May 2, '88. F. 37 5 mos. entery. Epithelioma of cision. Total extirpa- Yes. H. R. from progress of dis- ease. 47 48 Lawrence, Mass. Dr. R. A. Lawrence, Boston. Dr. R. A. Lawrence, May 16, '88. June 1, '88. F. F. 45 34 6 mos. 9 mos. cervix. Epithelioma of cervix. Uterine fibroid. tion of uterus per vaginam. Total extirpa- tion of uterus. Exploratory in- Yes. No. H. H. R. R. - Tumor complica- 49 5° Boston. Private. Dr. J. S. Shaw, Boston. May 10, '88. Aug. '88. F. M. 42 14 yrs. Umbilical hernia. Occlusion of cys- tic duct. cision. Operation for radical cure. Cholecystotomy. Yes. Yes. H. H. R. R. Cure. Cure. ted with pregnancy. Miscarriage two weeks after. No. Recoveries. Deaths. Mortality. Completed laparotomies for ovarian tumors, and removal of ovaries and appendages 24 23 I 4J per cent. Total completed abdominal operations of all classes 49 39 IO 2OA " " SUMMARY. SECOND SERIES. A Report of Sixty-two Cases Operated on between September, 1888, and September, 1889. In the series here tabulated, it will be seen that of ovarioto- mies and tubo oophorectomies there are twenty-four, with but one death. This death occurred on the eighteenth day, long after it was supposed that the patient was out of danger. Au- topsy showed a very severe suppurative nephritis of long stand- ing. The left kidney evidently had been functionless a long time, for there was but little more than a sack remaining, filled with pus. I should not have subjected this patient to operation had I known the condition of the kidneys. This should have been discovered by examination of the urine, but the person to whom was delegated that important responsibility either for- got or neglected it, consequently it was unknown. Eight cases of uterine fibroid tumors are recorded in the table with but one death. These were all large tumors which had, with one exception (Case XIII), encroached on the abdominal cavity in their growth, and were multiple or interstitial, and necessitated supra cervical amputation of the uterus. It is a marvel how promptly patients recuperate after such a severe operation. The method which I follow is a long abdominal incision, sufficient to readily turn the tumor out, transfixion of the cervix with a common knitting needle, three or four turns of a 3-16 inch diameter elastic ligature about the cervix below the needle and the severance of the tumor. All this need take but a few minutes. The ovaries and tubes are usually found well up on the sides of the tumor and are removed with it. I have in a few cases ligated the broad ligaments separately, but do not favor the method if they can be gathered in the elastic ligature. The parietal peritoneum is sewn to the edges of the skin about the stump, and the rest of the wound closed as after an ovariotomy. Nothing is gained by sewing the parietal peri- toneum to the stump, as has been practiced by some surgeons, for when brought closely in contact as in the method described above, adhesions quickly form. The stump is sopped with a 1 to 1000 bichloride of mercury solution, dressed with a plen- tiful supply of iodoform gauze and mercurialized cotton and the whole fastened in place by broad adhesive straps. The dress- ing is not disturbed for one week if everything goes well. At the end of that time the elastic ligature is taken off, the stump cut away and the sutures removed. In some cases the stump simply mummifies, in others it undergoes moist gangrene and ABDOMINAL SURGERY. 23 comes away like a slough. After removal of the stump the remainder of the cervix falls back into the pelvis and the open- ing quickly fills with granulations and closes. So simple is the operation and excellent the results, that I have come to look upon it in suitable cases, as safe as ovariotomy. The death found recorded in the table was from secondary hemorrhage and occurred on account of a varicocele of the left broad ligament. As the tumor was lifted out, the varicocele was seen and was so large, that on first thought it seemed like a loop of intestine attached to the tumor. On examination its true character was discovered and it was carefully ligated. Probably on account of the frailty of the enlarged veins, the ligature cut through. Three operations on the intestinal tract will be found recorded in the table, all of which recovered. One worthy of special mention was for the relief of an artificial anus located just above the pubis. All the fecal discharges from the bowels as well as the gaseous contents, occurred through this opening. The condition was one not dangerous to life, but accompanied with much misery. After making successful preliminary operations on dogs, of a similar nature to that proposed for her relief, I opened her abdomen along side the artificial anus, and found a loop of the ascending colon firmly adherent to the abdominal wall at that point. It was cardfully torn away and drawn out. So much of the wall of the intestine was lacking that simple suturing the edges of the rent did not seem justifiable, hence a segment was cut out and with it a wedge-shaped portion of the messentery. The remaining steps of the operation were after the method of Senn,* and are well illustrated by the accompanying cut. Large uterine fibroid tumor, with variocele of the left broad ligament. * Vide Senn's Intestinal Surgery. 24 ABDOMINAL SURGERY. 1. Artificial anus in site of old cicatrice. 2. Rent in the colon - dotted lines show portion excised. 3. Ends of segments turned in and sewed. 4. Bone plates zn sz'Zzz. 5. Lateral approximation of segments, showing manner of re-establishment of continuity of intestinal canal. Recovery followed without interruption. Gas passed per rec- tum the third day, and on the eighteenth day the patient had a stool via naturalis. Abdominal Section for Removal of Testicular Cyst. This case was unique in that it presented all the characteris- tics of an ovarian tumor. The abdomen was much distended and distinct fluctuation could be felt. A small portion of fluid was withdrawn and subjected to microscopical examina- tion. It also presented the symptoms considered pathag- nomonic of ovarian cyst. Each step of the operation was precisely the same as in ovariotomy, even to the use of the cyst trocar for evacuating the fluid. The testicle with contents weighed two and a half pounds. Recovery promptly followed. A recent examination of the patient, nine months from the date of the operation, shows some new growth in the abdomen. This leads me to believe that the tumor was a form of sarcoma, and that there is now a return of the disease in some Efdjacent tissue. Coesarcan Ovaro-Hystcrectomy. Mother and Child Saved. This case is interesting on account of the rarity of the opera- tion as well as the successful issue. The patient, age thirty-two; German ; had undergone crani- otomy twice, once eight years ago in my own hands and once prior to that time in Germany. She had suffered induced ABDOMINAL SURGERY. 25 miscarriage five times. Eighteen months prior to the Caesarean section I curetted the uterus for the relief of excessive metrorrhagia and repaired a deep laceration of the cervix. The patient came to me early in her pregnancy for the induction of miscarriage, which I refused to do, for the reason that I felt con- vinced that Caesarean section after the Porro method presented no greater danger to the mother than supracervical amputation of the uterus in fibro myomata, which my experience had shown me was the minimum. Caesarean section also gave the foetus a chance. The mother was physically apparently in per- fect health. The only deformity seemed to be the narrow pel- vis, congugate diameter two and one-fourth inches. She had been subject during each previous pregnancy to epileptiform convulsions, which always ceased after delivery. During this pregnancy she had but one attack and this seemed to have been excited by over eating and too little exercise. On the morning of Aug. 26th, I was summoned to her about nine o'clock, and found her in the beginning of labor, cervix soft and dilatable. I immediately transferred her to the Hospital and prepared for operation. At 11.30 the patient was anaesthet- ized ready for operation, two minutes later the first cut was made and in six minutes more the child was delivered. The uterus promptly contracted and was turned out of the abdomi- nal wound by my assistants. A rubber ligature about the cervix controlled all hemorrhage. The succeeding steps in the opera- tion were precisely those described above in supra-cervical am- putation of the uterus for fibroids. The child was quickly resus- sitated and in half an hour from the commencement of the oper- ation, mother and child were in bed with no more indications of having passed through the trying ordeal of Caesarean section than after an ordinary confinement when an anaesthetic has been used. A review of the literature of Caeasrean ovaro-hysterectomy shows that this operation has been performed but ten times in the United States (mine being the tenth case) with four women and eight children saved, (this being the fourth case where both mother and child survived.) Evidently the important conditions for mother as well as child are early operation, i. e. before the mother has become exhausted by long and tedious labor-and expedition in the per- formance of the operation. The merits of the Porro method seem too evident to need mention. The removal of the uterus is certainly a God-send to a woman with a narrow pelvis, for it puts an end to all future chance of pregnancy, and repetition of craniotomy on Caesarean section. It is a simple operation that any dexterous practi- tioner ought to be able to perform. 26 ABDOMINAL SURGERY. No. PATIENT OE Date of Age. 0 © .a *5) G © u 0 ~ ©*S. ime e first ticed. SIZE AND NATURE or both iries. 1 ■ inage. pital or ivate. Lilt Of •ation. REMARKS. 0 - If Operation. SB S N Chi he© c Of TUMOR. So 0 oS Q £ a -O i Dr. W. H. Lougee, Sept. 19, '88. 44 M. 0 0 5 yrs- Large cyst of ovary. k No.' No. H. R. Lawrence, Mass. 26 lbs. 2 Dr. E. L. Melius, Sept. 26, '88. 42 M. 0 I 4 yrs. Ovarian cyst 1. 10% I No. No H. R. Worcester, Mass. lbs. 3 Dr. W. O. Jenkins, Oct. 2, '88. 48 M. 4 0 3 yrs. Ovarian cyst. 23 lbs. 2 Yes. Yes. P. R. Greenland, N.H. Mullilocular. 4 Dr. L. A. Phillips, Oct. 18, '88. 36 M. 2 0 1 yr- Solid ovarian tumor. I Yes. Yes. P. R. Death seven months after. Boston, Mass. Dr. W. H. Stone, Nov. 7, '88. 36 M. 4 0 4 mos. Small cyst of left I Yes. Yes. H. R. Providence, R. I. ovary. Double parovarian 6 Hospital Nov. 19, '88. 33 M. 0 0 1 yr- 2 Yes. Yes. H. R. cyst. 7 Hospital. Nov. 21, '88. 36 M. 1 0 3 yrs. Double ovarian pap- 2 Yes. Yes. H. R. illoma. 8 Dr. G. E. E. Sparhawk, Nov. 28, '88. 23 M. 2 0 2 mos. Parovarian cyst. I No. No. H. R. Burlington, Vt. Large ovarian cyst 9 Dr. M. H. Baynum, Nov. 30, '88. 42 M. 0 0 10 yrs. i Yes. Yes. H. R. Boston, Mass. Extensive adhesions Weight, 34 lbs. IO Hospital. Dec. 12, '88. 65 M. 6 0 (?) Small cyst. Many O Yes. Yes. H. R. Cyst not removed. Permanent adhesions. Drainage. 11 Dr. F. M. Bennett, Dec. 13, '88. 20 S. 0 0 3 mos. Monocystic tumor I No. No. P. R. Cyst developed soon after ty- Chicopee, Mass. of r. ovary. phoid fever. 12 Dr. M. E. Mann, Dec. 14, '88. 40 M. 4 0 5 yrs. Small tnmor of each 2 No. No. P. R. Boston, Mass. side. 13 Dr. J. M. Barton, Dec. 14, '88. 36 M. 0 0 (?) Small cyst of r. ovary O No. No. H. R. Worcester, Mass. 14 Dr. J. S. Harris, Roxbury, Mass. Jan. 28, '89. 35 M. 1 3 8 yrs. Cyst of r. ovary, firm and extensive adhes. O Yes. Yes. H. D. Death 18th day from pre-exist- ing kidney disease which had been overlooked prior to op. '5 Dr. I. E. Chase, Haverhill, Mass. Feb. 6, '89. 55 M. 2 5 8 yrs. Cyst. 16 lbs. O No. No. H. R. Time of op. from first incision to complete closure of wound, 16 16 min. Hospital. Feb. 20, '89. 38 M. 3 0 2 yrs. Cyst of 1. ovary. 6 I No. No. P. R. lbs. TABULAR VIEW. -Second Series. I. - Operations for the Removal of Ovarian and Parovarian Tumors ABDOMINAL SURGERY. 27 «7 i8 Dr. Walter Wesselhoeft, Cambridge, Mass. Dr. H. E. Spaulding, Boston, Mass. Apr. 3, '89. May 8, '89. 44 24 s. M. 0 0 I O 5 mos. (?) Cyst of r. ovary. Large. Cyst of r. ovary. 6 lbs. I I Yes. Yes. Yes. Yes. P. H. R. R. A very suspicious growth in an adjacent loop of the intestine was found simulating cancer. '9 Dr. J. A. B. Russell, Malden, Mass. June 19, '89. 18 S. 0 O 4 mos. Cyst of r. ovary, ad- hesions (cancerous.) I Yes. Yes. P. R. There has since been a return of the disease, . very diffuse, and death. 20 Dr. H. H. Cobb, Cambridge, Mass. July 1, '89. S3 M. 2 O 5 yrs. Cyst of r. ovary. 7 lbs. I Yes. Yes. P. R. No. PATIENT OF Date of Operation. Age. 1 Married or I Single. No of Children. Duration of Disease. Pathological Condition or Symptoms Necessitating Operation. One or both Ovaries. | Adhesions. Drainage. Hospital or Private. Result (Recov- ery or Death.) Effect of Operation on Condition Requiring it. REMARKS. Reported Elsewhere. ! I Dr.W. H. Lougee, Oct. it, '88. 37 M. 2 9 yrs. Small cyst of each 2 Yes. Yes. H. R. Much relieved for several weeks Lawrence, Mass. ovary and both mat- following op. Injudicious ex- ted to the tubes by ertion induced severe uterine strong adhesions. hemorrhages after. 2 Dr. F. S. Davis, Dec. 26, '88. 35 M. 0 Extensive disease of 2 Yes. Yes. H. R. Cured. Quincy, Mass. both ovaries and tubes. 3 Hospital. Mar. 20, '89. 23 S. 0 3 mos. Both ovaries and tubes involved in ex- tensive inflam. Gon- 2 Yes. Yes. H. R. Cured. orrheal. II. - Operations for the Removal of Ovaries not the Seat of Tumor. 28 ABDOMINAL SURGERY No. PATIENT OF Date of Operation. Sex. Age. Duration of Disease. Pathological Condition or Symptoms Necessitating Operation. Nature of Operation. Drainage. Hospital or Private. Result, (Recov- j ery or Death.) Effect of ■ Operation on Condition ■ Requiring it. REMARKS. Reported Elsewhere. Miscellaneous. I Dr. W. B. Whiting, Oct. 22, '88. F. 3i yrs. Hydro, salping. Removed. Yes. p. R. Cure. Malden, Mass. 2 Hospital. Nov. 30, '88. F. 23 10 mos. Ventral fibr'd tumor just above r. groin. Extirpation. Yes. H. R. Cure. 3 Dr. F. D. Leslie, Dec. 21, '88. M. 4i 5 yrs- Cyst of undescended Extirpation. Yes. P. R. Weight 2J lbs. Abdom- Milton, Mass. testicle. Weight 2J inal incision. Each step lbs. (Sarcomatous.) of op. same as in ovari- otomy. Death eleven months after. 4 Dr. G. E. McCarthy, Mar. 20, '89. F. 3° 3 mos. Left tubal preg- R e m 0 v ed by Yes. H. R. Cure. Foetus dead at about 2nd Ipswich, Mass. nancy. abd. section. month. Not suspected prior to operation. 5 Dr. Conrad Wesselhoeft, Apr. 24, '89. F. 30 6 mos. Renal abscess. Lumbar incis. Yes. P. R. Cure. Boston, Mass. Drainage. 6 Dr. A. W. Swett, June 22, '89. F. 36 2 yrs. Double pvosalpinx. Removal of Yes. H. R. Cure. Bangor, Me. Abscess cysts re- both abscess moved. sacks. Fibroid Tumors of Uterus. 7 Dr. I. E. Chase, Nov. 13, '88. F. 55 1 yr- Fibroid of 1. broad R e m 0 v e d by Yes. P. R. Haverhill, Mass. ligament. abd. section. 8 Dr. S. A. Sylvester, Dec. 26, '88. F. 59 e> Small pediculated Abd. incision. No. H. R. Thought to be pyosalpinx Newton Centre, Mass. fibroid of uterus. prior to op. on account of persistent purulent dis- charge from uterus. 9 Dr. S. P. Hammond, Jan. 9, '89. F. 28 3 yrs. Large uterine fibroid Supra vaginal No. H. R. Cure. Weight, 6 lbs. Boston, Mass. tumor. hysterectomy. IO Dr. David Foss, Newburvport, Mass. Jan. 16, '89. F. 26 ii yrs. Large uterine fibroid Supra vaginal No. H. R. Cure. Weight, 8 lbs. tumor. hysterectomy. Multiple fibroid, (7 tu- 11 Dr. J. E. Kinney. Feb. 20, '89. F. 40 7 yrs. Large uterine fibroid Supra vaginal No. H. R. Cure. Grove Hall, Mass. tumor. hysterectomy. mors. 12 Dr. D. S. Coles, Feb. 27, '89. F. 48 10 yrs. Large uterine fibroid Supra vaginal No- H. D. Death from hemorrhage Wakefield, Mass. tumor. hysterectomy. caused by varicocle of 1. bd. lig. (See cut.) III. - Operations for Other Purposes than the Removal of Ovaries. ABDOMINAL SURGERY. 29 13 14 Dr. J. H. Sherman, So. Boston, Mass. Dr. G. A. Tower, Watertown, Mass. Mar. 27, '89. Apr. 17, '89. F. F. 5° (?) 12 yrs. Large uterine fibroid tumor. Large uterine fibroid tumor. Spom. saw. by vagina. Supra vaginal hysterectomy. Yes. Yes. H. II. R. R. Cure. Cure. Operations on Intestinal Tract r. IS Dr. W. L. Hunt, Mar. 6, '89. F. 52 21 mos. Artificial anus just R e s e c tion of No. H. R. Cure. Operation by Senn's Bangor, Me. above pelvis. colon and lat- Method. Perfect cure. eral approxi- mation by bone plates. Strangulated hernia orig- 16 Hospital. Apr. 20, '89. F. 44 18 mos. Entero-ventral fis- Suture of rent Yes. II. R. Cure. tula of r. groin. in colon. inal cause of fistula. Per- fect cure. 17 Dr. A. C. Alexander, May 10, '89. M. 61 7 mos. Epithelcoma of rec- Extirpation. Yes. P. R. Cure. No evidence of return Penacook, N. H. tum. six months after opera- tion. But little trouble from incontinuance of fecus. i8 Dr. I. B. Cushing, Brookline, Mass. Sept. 19, '88. M. 49 30 yrs. Strangulated inguinal hernia. Mace wen. Yes. H. R. Cure. 19 Dr. F. C. Richardson, Sept. 29, '88. F. 68 20 yrs. Umbilical hernia. * ' Yes. H. R. Cure. E. Boston, Mass. 20 Dr. L. M. Willis, Oct. 5, '88. M. 74 Strangulated r. in- Yes. P. R. Cure. Charlestown, Mass. guinal hernia. 21 Dr. M. E. Mann, Nov. 14, '88. F. 17 2 yrs. Inguinal hernia r. Yes. H. R. Cure. Boston, Mass. 22 Dr. D. S. Coles, Dec. 28, '88. F. 48 29 yrs. Yes. H. R. Cure. Wakefield, Mass. 23 Dr. A. S. Morse. Feb. 1, '89. F. 62 (?) Right inguinal stran- Yes. P. R. Cure. There has since been a Gloucester, Mass. gulated hernia. recurrence of the hernia 24 Dr. H. L. F. Wright, Mar. 5, '89. F. 37 Umbilical hernia. necessitating a truss. Boston, Mass. (C Ves. H. R. Cure. 25 Private. Mar. 19, '89. F. 55 18 yrs. Umbilical hernia. t( Yes. P. R. Cure. 26 Dr. D. A. Babcock. June 3, '89. M. Left inguinal hernia. c< No. P. R. Cure. Contents of sack, ovrum- Fall River, Mass. tum, from which had developed a peculiar tu- mor formation. Hernias. 30 ABDOMINAL SURGERY. No. PATIENT OF Date of Operation. Sex. Age. Duration of Disease. Pathological Condition or Symptoms Necessitating Operation. Nature of Operation. Drainage. Hospital or Private. Q « gw Effect of Operation on Condition 1 Requiring it. ; REMARKS. Reported | Elsewhere. !, 27 Dr. A. M. Hines, Milford, N. H. Nov. 27, '88. F. 5i 3 mos. Epithlioma vix. of cer- Total extirpa- tion of uterus per vaginan. Total extirpa- Yes. P- R. Death 14 mos. after op. 28 Dr. Isabelle Hayward. Mar. 5, '89. F. 40 4 mos. Epithlioma of cer- Yes. P. R. In good health 10 mos. Lynn, Mass. vix. tion of uterus after operation. No evi- per vaginan. dence of return of disease. 29 Dr. A. H. Tompkins, Jamaica Plain. Mar. 14, '89. F. 72 1 yr. Epithlioma of cer- Total extirpa- Yes. P- D. May 11, '89. vix. tion of uterus per vaginan. In fair general health 9 3° Dr. Walter Wesselhoeft, F. 32 s yrs, Carcinoma of fun- Total extirpa- Yes. P- R. mos. after operation. No Cambridge, Mass. dus. tion of uterus evidence of return of dis- per vaginan. ease. Indications good for re- 3t Dr. Robert G. Reed. June 5, '89. F. 41 10 yrs. Epithlioma of cer- Total extirpa- Yes. P. D. covery at time of opera- Woonsocket, R. I. vix. tion of uterus tion. Death from pelvic per vaginam. peritonitis, due probably to accidental introduction of septic material during operation. Indications good for re- 32 Dr. A. W. Brown, June 22, '89. F. (?) Epithlioma of cer- Yes. P. D. covery at time of opera- Providence, R. I. vix. tion. Death from pelvic peritonitis due probably to accidental introduction of septic material during operation. Vaginal Hysterotomy. ABDOMINAL SURGERY. 31 33 Dr. J. B. Robinson, East Boston. Nov. 7, '88. F. 25 (?) Entro vesical fistula. Exploratory. Yes. H. 0 0 Death 10 mos. after op. 34 Dr. P. B. Carpenter. Feb. 27, '89. F. 23 21 mos. Carcinoma of ovren- Exploratory. Yes. H. 0 0 Has since died. Providence, R. I. tum. 35 Dr. H. E. Spalding, Mar. 27, '89. F. 42 1 yr. Peritonitis with enor- Exploratory. Yes. H. D. 0 Death from exhaustion. Boston, Mass. mous ventral hernia. 36 Dr. I. E. Chase, Apr. 18, '89. F. S3 6 mos. Abd. tumor. Partial remov- Yes. P. D. Death from exhaustion. Haverhill, Mass. al of tumor. 37 Private. Apr. 27, '89. F. 36 5 mos. Ascites. Left ovary re- Yes. H. R. Death has since occurred moved and from tubercular peritoni- drainage. tis. 38 Dr. H. E. Spalding, May 11, '89. F. 48 8 mos. Multiple cyst of Evacuation of Yes. P. D. Death from exhaustion. Boston, Mass. ovary. contents and drainage. 39 1 Private. I Aug. 26, '89. 1 F. 1 32 1 I Contracted pelvis. I No. 1 H. I R. 1 1 Mother and child 1 1 1 1 1 1 | Porro's Illi 1 saved. ist series. 2d series. Total. Deaths. Mortality. Ovariotomies and Tubo-oophorectomies, . . 24 26 5° 2 4% Abdominal Operations of all kinds • • 5° 62 112 O i Mortality in ist series, 20%. Mortality in 2d series, 11 % • Exploratory Incisions. Caesarean Setion. SUMMARY.