A Year's Work IN ABDOMINAL SURGERY BY CLINTON CUSHING, M. D. San Francisco, Cal. u REPRINT FROM Pacific Medical Journal" JULY, 1889. 3 p Name of Medical Attendant. Date of Operation. A&e Married or Single Number of Children Size and Nature of Tumor. |One or both Ovaries Adhesions Treat- ment of Pedicle. Drainage Complica- tions. Hospital or Private. Result. Remarks. 1 Dr. J. J. Tully, May 7, '88 35 M. None Inta ligamentous Both vfany ad- Tied and Yes. Subsequent Private. Recovery Operation extreme- Sierra City cyst, size of large h e s i o n s dropped. profuse dis- ly difficult on ac- cocoanut. from pap- charge of peri- count of universal i 11 o m a t- tone al fluid adhesions from / ous out- from opening p a p i 1 1 om a t o u s growth. left by drain- age tube. growth to all the pelvic organs and tissues. Recovery uninter- 2 Dr. McLay, July 26, '88 35 S. None Simple cyst of One None. CC No. None. cc CC San Francisco right ovary, size adult head. rupted. 3 Dr. R. C. Myers, San Francisco Sept. 11, '88 41 M. Five Cyst of right Both None. cc No. Small stitch CC CC Easy recovery. ovary, size of adult head; Cyst of left ovary, size hole abscess of abdominal wall. of small orange. 4 Dr. Card, Nov. 7, '88 20 S. None Simple cyst of left One Strong ad- cC No. None. CC CC Easy recovery. San Francisco ovary, size of h e s i o n x cocoanut. behind tu- rn o r re- Dr. C. Cushing, q u i r 1 n g ligature. 5 March 5, '89 35 M. None Ovarian cyst of One Slight ad- cc No. Pelvic peri- CC CC Took out two lower San Francisco right ovary, size hesion. tonitis in 10 stitches - opened of foetal head at days. abdomen -washed term. out pus cavity-re- moved ligature from stump. Re- 6 Dr. Bqyson, Mar. 11, '89 27 M. None Cyst of left ovary One None. cc No. Acute pleu- Hospital Death. covery rapid. Cause of death ac- V i&ucisco size ot cocoanut. risy in 36 hrs. cidental hemor- rhage from stump. 3 Date of Operation. Age -5> 5. • : P* : O Number of Children Pathological Condition or Symptoms necessitating Operation. Duration of jDisease What Removed Adhesions... Treatment of Pedicle Drainage Hospital or Private. Recovery or Death Complica- tions before or after Operation. Remarks. Effect of Operation upon condition requiring it. p Name of Medical Attendant. 1 Dr. Bazet, San Francisco Apr. 28, '88 22 M. None Pyosalpynx and intra peri- toneal absc's in Douglass pouch 5 yrs. Both tubes and ovaries. Many. Tied and drop'd Yes. Private. Recov- ery. Many attacks of pelvic i n- flamm ation, severe dys- menorrhea. Gonococci found in pus from tubes and in the urethral dis- charge from hus- band. 2 Dr. 0. Cushing, San Francisco Sept. 8, '88 27 M. Two Elastic and very tender mass. Douglass pouch with sever pain and backache, and meno rr- hagia. 4 yrs. Left tube and ovary. Moder- ately firm adhe- sions. ll No. CC CC None. Typical case of pro- lapsed and adher- ent hydrosalpynx. 3 Dr. C. Cushing, San Francisco Oct. 23, '88 29 M. Two Frequent recur- ring attack of pelvic periton- itis and pelvic abscess with gr't pelvic pain. 3 yrs. Both tubes and ovaries. Many. CC No. CC None. Symptoms much alleviated and health restored. 4 Dr. C. Cushing, San Francisco Apr. 1,'89 33 M. Two Chronic S a 1- pyngitis- recur- rin g pelvic peritonitis and pelvic hsema- tocele. 4 yrs. Both ovaries and tube. Uni- versal. cc Yes. Death. Fecal fistula formed two weeks after operation. Examination of d isch arge micro- scopically showed tuberci e bacilli. Death in 6th week. 5 Dr. Bazet, San Francisco Apr. 19, '89 18 S. None Hystero - E p i- lepsy occurring at menstrual periods. 14 mos. Both ovaries rem'vd. None. Cl No. Hospital Recov- ery. None. At present date, no pain and health much improved,no return of symptms. 6 Dr. C. Cushing, San Francisco Apr. 28, '89 31 M. None Severe pain in back and rec- tum - inability to stand or walk prolapse of left ovary. 13 yrs. Both ovaries. Uni- versal. Yes. Private. Recov- ery. Pelvic peri- tonitis neces- sitatingwash- ing out ab- dominal cav- ity through wound. Much improved. 3 p Name of Medical Attendant. Date of Operation Age-~" Married or | [Single Number of Children Pathological Condition or Symptoms necessitating Operation. Duration of Disease Il Nature of Operation. Adhesions... j Drainage Hospital or Private. Recovery or Death Complica- tions before and after. Remarks and Subsequent History. 1 Dr. C. Cushing. Mar. 14, '89 35 M. Four. Steady growth of solid tumor from posterior wall of uterus; sub- serous. 3 yrs. Removal of fundus of ut'rs through ab- dominal incis- ion. Elastic ligature. Yes. Yes. Hospital Death. Per s i stent v o m i tin g- peritonitis- slough of stump. Death from peri- tonitis and exhaus- tion. 1 Dr. C. Cushing. Aug. 21, '88 25 M. None Sarcoma of cer- vix involving post cervical por- tion of vagina. 1 yr. Removal of entire uterus per vaginam. None. Yes. Private. Death. Marked anae- mia and great feebleness of heart's action. Death apparently due to excessive feeblen'ssot heart's action. o Dr. C. Cushing. Mar. 7,'89 58 M. None Epithelioma of cervix. 9 mos. Removal of entire uterus per vaginam. None. No. Private. Recov- ery. None. Recovery rapid and uninten upted. 3 p Name of Medical Attendant. Date of Operation Married or Single Number of Children Pathological Condition or Symptoms necessitating Operation. Duration of Disease Nature of Operation. Drainage Hospital or Private. Recovery or Death Complica- tions before or after. Remarks and Subsequent History. 1 Dr. Pawlicki, San Francisco Oct. 30, '88 30 M. Two Pelvic abscess with emaciation. 3 mos. Abdominal section, sepa- ration of adhe- sion,free wash- ing of cavity. Yes. Private. Recov- ery. Free disch'rge of pus from two openings in roof of va- gina and into rectum. Recovery perfect. 2 Dr. E. Field, San Francisco Oct. 30, '88 20 S. None Purulent peritonitis. 5 w'ks Abdominal section, wash- ing out and drainage. Yes. Private. Death. Temp. 104, Pulse 140. Prognosis very bad. Operation was a for- lorn hope but was war- ranted by the symp- toms. Death in four hours from shock. 3 Dr. McLay, Nov. 5,'88 40 M. None Large fluid abdom- inal tumor, steadily Increasing in size. Uterine flbro-cyst. 5 yrs. Enucleation of cyst. Yes. Private. Death. During opera- tion, injury of bladder and rectum from extensive ad- hesions. Death in 5 days from excessive vomiting. 4 Dr.W. S.Taylor, Livermore. Dec. 5, '88 28 M. Two Intermittent dis- charge of offensive pus from rectum. Very high temperature and rapid emaciation. 2 mos. E x p 1 o r atory incision. No. Private. Death. History of d y sentery or proctitis. Exploratory Incision warranted on the theory of pyosalpynx of left Fallopian tube. 5 Dr. Trask, Austin, Nevada Jan. 31, '89 27 M. Two Obscure abdominal disease with contin- ued high temperature and steady emacia- tion. 3 mos. C h o 1 o cystot- omy and re- moval of gall stones. Yes. Private. Recov- ery. Chills, high fe v e r, much abdominal pain. Retro versed uterus stitched to a n t e r ior abdominal wall, slight discharge from lower angle of wound, neces- sitating the removal of stitch. 6 Dr. Pawlicki, San Francisco Mar. 2, '89 37 M. Seven Tumor in epigastric region and rapid emaciation. 1 yr. Exploratory incision. Yes. Private. Death. General adhe- sions. Sarcoma of pancreas. 7 Dr. C. Cushing, Feb. 5, '89 27 S. None Excessive menorrha- gia for 10 yrs; for 2 mos high temperature and emaciation. Pel- vic abscess for 2 mos. 10 yrs. Abdomi nal section and re- moval of both ovaries and tube. Yes. Private. Recov- ery. None. No history obtained. 8 Dr.LeTourneux Feb. 11, '89 24 M. Two Pelvic abscess in R. ovarian region open- ing into rectum. 2 yrs. L a p a r o tomy and removal of R. tube and ovary includ- ing pus cavity. Yes. Private. Recov- ery. None. Uninterrupted recov- ery. ABDOMINAL SECTION FOR REMOVAL OF UTERINE APPENDAGES NOT THE SEAT OF TUMOR. ABDOMINAL SECTIONS FOR THE REMOVAL OF OVARIAN TUMORS. LAPAROTOMIES FOR OTHER DISEASES OF ABDOMINAL ORGANS. ABDOMINAL HYSTERECTOMY. VAGINAL HYSTERECTOMY. A Year's Work IN Abdominal Surgery. By CLINTON CUSHING, M.D. San Francisco. Professor of Gynecology, Cooper Medical College, S. F. Fellow of The American Association of Obstetricians and Gynecologists. Fellow of The British Gynecological Society, etc., etc. (Read before the San Francisco Obstetrical Society June 13th, 1889. Gentlemen:-I present for your discussion this evening the accompanying tables, comprising all the cases of abdominal sur- gery which have occurred in my practice during the past year. It is unnecessary for me to take up in detail many of these cases, as there was nothing out of the usual in their history or treatment; but there are others which I deem of sufficient inter- est to narrate more fully. The percentage of deaths appears very high, but, as will be seen, some of them were necessarily fatal from the beginning, and the cases were only undertaken with the full understanding that it was a forlorn hope to undertake any surgical procedure. In two of the cases only has it seemed to me that blame could be attached to the operator, or his methods of treatment. One was a case of accidental hemor- rhage, and the other of fibro-cyst of the uterus. These points, however, will be gone into more fully after the narration of the more interesting cases. Under the head of " Laparotomy for the Removal of Ovarian Tumors," No. 1 of this series has already been reported to the San Francisco Medical Society, and was of unusual interest, inasmuch as it was a typical case of intra-ligamentary papillo- matous cyst of the left broad ligament with outgrowths affecting all the surrounding structures and lifting the peritoneum away from the pelvic excavation upon the left side, and necessitating the division of the peritoneal covering and the enucleation of the mass with the finger-tips. The right ovary was of the size 2 A Year's Work in Abdominal Surgery. of a small orange, and covered with papillary outgrowths. When this large cyst was removed from the left broad ligament, it left an ugly looking cavity, exposing the iliac and psoas muscles, the ureter and the uterine artery. Following the advice of Olshausen, the peritoneal opening was not closed, but a drainage tube was inserted to the bottom of the denuded por- tion and the abdominal wound closed in the usual way. The case recovered, with the exception that a small opening remained at the side of the drainage tube, from which there escaped from time to time considerable quantities of peritoneal fluid. The woman died eight months later, apparently from valvular disease of the heart and disease of the stomach, from which she had suffered for many years. Had I another similar case I would shut the peritoneal cavity off from the denuded surface, by suturing the cut surfaces of the peritoneum with cat-gut, and drain the cavity from which the cyst was removed into the vagina by means of a self-retaining drainage tube. No. 6 of the same table was a simple cyst of the left ovary without adhesions or complications of any kind. The pedicle was perforated in the usual manner and then tied with the Staffordshire knot, as is my custom. The operation occu- pied about twenty minutes, and was done in the operating am- phitheater of the City and County Hospital, and the statement made to the students that this case would undoubtedly get well; that if death occurred it must be from some wholly unforeseen complication, or from some fault in the operator or his methods. At the end of twenty-four hours there was no fever and no pain. At the end of thirty-six hours an acute pleuritis developed in the right side, accompanied, as is usual, with difficult breathing and great pain. There was no pain nor discomfort complained of in the abdomen, and the temperature was only one degree above the normal. The pulse, however, was 150 per minute; she had a distressed countenance, and the breathing was very labored and painful. I attributed the rapid action of the heart to the pleuritis and difficult breathing. She died the following night. As soon as I learned of her death I became convinced that the fatal result was due to acci- dental hemorrhage, and stated my opinion to the gentleman who was to make the post mortem examination. This turned out to be true, as the lower part of the abdomen was found A Year's Work in Abdominal Surgery. 3 filled with blood, a clot having formed directly over the stump of the pedicle. The uterus and the pedicle were removed and brought to me. I found the ligatiire intact where it had been placed, and while it was difficult to say positively from what part the hemorrhage had occurred, I am inclined to think that the bleeding took place from the puncture made in the broad ligament where the ligature passed through it. Had the real cause of death not been masked by the occurrence of the acute pleuritis, this case would undoubtedly have been saved by re-opening the abdomen and religating the pedicle. Under the head of " Laparotomy for the Removal of Uterine Appendages not the Site of Tumor," No. 1 represents a class of cases which are believed to be quite common; that is, infec- tion of the Fallopian tube by the gono-cocci, as the pus from the tubes contained the specific germ in the great numbers. No. 2 of the same table presents this peculiarity: upon digital examination of her vagina an elastic mass was found in Doug- lass' pouch, firmly adherent and immovable, and extremely tender to the touch. The diagnosis was made of prolapsed and inflamed cystic ovary; whereas an abdominal section showed very clearly that it was simply a case of a prolapsed and drop- sical Fallopian tube. The tube and ovary were removed with relief to the symptoms. No. 4 of the same table had suffered for four years from pelvic disease. During this time she had seven attacks of pelvic peri- tonitis, confining her to bed for several weeks each time. The uterus was immovably fixed. The diagnosis was made of probable pyo-salpynx. The abdo- men was opened, the ovaries found cystic, and all the pelvic contents adherent on every side. The right Fallopian tube was much enlarged, and contained about six ounces of broken down blood-clot mixed with pus. The left tube was also enlarged, its wall much thickened, and contained an ounce of muco-puru- lent secretion. After thorough washing of the pelvic cavity with hydro-naphthol and hot water, the abdomen was closed in the usual way, leaving a drainage tube at the lower angle of the wound. The discharge from the drainage tube having practically ceased in three days, it was removed. At the end of three days more, owing to increase in temperature, the drainage tube was re-in- 4 A Year's Work in Abdominal Surgery. troduced and the pelvic cavity washed out. The temperature immediately fell to below a hundred. The discharge from the drainage tube was quite profuse for several days. At the end of four days from the introduction of the tube it was removed, the discharge continuing through the lower angle of the abdomi- nal wound. The prospects were now excellent for her recovery. At the end of two weeks from the date of the operation, however, faecal matter began to escape with the discharges from the ab- dominal wound. Judging from some former experience in tubercular peritonitis I became suspicious that the opening in the intestine was due to the existence in its wall of tubercular deposit; and examination of the discharges by the microscope revealed the existence of the bacilli of tubercle. All hope was at once abandoned of saving the woman's life. She died six weeks after the operation from exhaustion. No. 5 of this table was a well marked case of hysteria, with epileptiform convulsions coming on at the menstrual periods. She had been confined to bed for fourteen months, and had suffered an inordinate amount of pain, requiring large doses of morphia subcutaneously for its relief. The ovaries and tubes were removed two months ago, since which the health has immensely improved, there has been no return of the hysterical or convulsive symptoms, and there has not been sufficient pain to require the use of anodynes. It is hoped that this case will make a perfect recovery, but it is too soon yet to determine with certainty. No. 6, under the heading of "Removal of Uterine Append- ages not the Seat of Tumor," was undertaken on account of a prolapsed and firmly adherent left ovary, with persistent and troublesome pain in rectum, and throughout pelvis. The suf- fering began fourteen years before, following a severe attack of pelvic inflammation, since which time the patient has been more or less an invalid, and her usefulness much impaired. Upon opening the abdomen both ovaries were found to be about three times the normal size and composed almost wholly of cysts and firmly bound to the intestines and adjacent structures by band of organized lymph from the former peritonitis. The left ovary was so firmly attached to the rectum that considerable force was required and there was danger that the gut would be lacerated. Both ovaries and tubes were removed, the abdomen washed out and closed in the usual manner. At the end of three A Year's Work in Abdominal Surgery. 5 days the temperature began to rise and was accompanied by a well marked chill. The two lower stitches were removed from the abdominal wound and a quantity of blood-tinged serum washed out, and a drainage tube inserted which was left in for four days. Slight fever remained for two weeks, but not suf- ficient pain to require anodynes. At the end of ten days the left leg became considerably swol- len, and it was now evident that some inflammation in the left side of the pelvis had involved the veins returning the blood from the left leg; this subsided in a few days, and the patient is now perfectly well, except occasionally a return of the feeling of discomfort in the rectum. In this case I am satisfied from the character of the fluid re- moved by the washing done at the time of the re-opening of the abdomen, that a more thorough washing at the time of the oper- ation might have prevented the subsequent trouble. I find the best plan is to take a Davidson's syringe and pass the long tube down into Douglass' pouch and pump in a satu- rated solution of hydro-naphthol in water as hot as can be com- fortably borne by the hand, until the water returns clear, and by introducing two fingers and moving the intestines about freely, it is surprising how much blood, clots and debris float out with the water. Under the head of " Laparotomy for Other Diseases of the Abdominal Organs," No. 2 was an exploratory incision in a case of purulent peritonitis that was in a moribund condition at the time of the operation. The abdomen was washed out and drained, giving exit to a quantity of pus, death following three hours afterward. Had the operation been done earlier it is possible that a better result would have been shown. No. 3 of this table is of more than usual interest. This pa- tient had suffered for several years from poor health, referable principally to disease of the abdominal cavity, more especially to pain in the region of the pelvic organs. The uterus and ovaries were extremely sensitive to touch, and there was slight displacement of the uterus downwards and backwards. In November she went to bed with high fever, which was sup- posed at one time to be typhoid, and afterwards to be caused by pelvic peritonitis. At the end of six weeks the temperature became normal and the case bade fair to recover. She was up every day for a short time for two weeks; then a renewal of the 6 A Year's Work in Abdominal Surgery. high temperature took place, and the abdominal pain returned. In spite of full doses of quinine and antipyrin, the high temper- ature persisted, varying from 100 to 104 in the twenty four hours. At no time was there any very marked tympanitis, but there was general abdominal tenderness. There was no appe- tite, and digestion was poor. There was no jaundice, and the bowels were always easily acted upon by laxatives. Emaciation became marked and death seemed inevitable, unless some relief from the high temperature was gained. Upon consultation with Professor Levi C. Lane, it was agreed that we had to deal with some obscure abdominal disease 9 probably pyo-salpynx, but the exact nature of which we were unable to determine positively, and an exploratory incision was advised. The abdomen was opened in the usual manner in the linea alba, and the pelvic organs found in very nearly a normal con- dition. Manifestly the cause of the high temperature was not in the pelvis. The abdominal incision was enlarged, the whole hand introduced, and the exploration of the entire abdominal cavity begun. The kidneys, the spleen, the stomach were all manipulated, but without result; but on the under side of the liver was found a hard, firm mass the size of a turkey's egg, in the location where the gall-bladder should have been. This mass to the touch was as firm, apparently, as the tissue of the uterus. Upon squeezing it firmly between the thumb and finger, hard masses were found to move against each other, and it was at once decided that this was an enormously thickened gall-bladder containing gall-stones. The incision in the linea alba was at once closed, and an incision made through the abdominal wall parallel with the edge of the ribs and directly over the gall-bladder. It was now found that the stomach, the pylorus, the gall-bladder, and the liver were adherent to each other by moderately firm adhesions, which had undergone rather a cheesy degeneration. Apparently there had been numerous attacks of localized peritonitis, caused by the enlarging gall- bladder acting as the irritant. The adhesions were broken up with the fingers, and the gall-bladder separated from the surround- ing structures sufficiently to enable it to be drawn to the surface. A piece of rubber dam such as is used by dentists, with a minute hole cut in its center, was now passed over the gall-bladder so as to prevent any of its secretions passing into the peritoneal A Year's Work in Abdominal Surgery. 7 cavity. The gall-bladder was now opened, and was found to be packed with a number of gall-stones, some of them as large as hazel-nuts. After the removal of the stones with forceps, the gall-bladder was stitched to the abdominal wound, and a small rubber drainage tube left in its cavity. No untoward symptoms supervened; the patient made a rapid recovery; the temperature soon became normal, and at this writing the patient weighs more than at any time in her life. Before closing the wound in the lower part of the abdomen, the fundus of the uterus was stitched to the anterior abdominal wall with a strong silk suture. This resulted in the discharge of a few drops of pus from the lower angle of the abdominal wound, and at the next visit of the patient to the city I expect to slightly enlarge the opening and remove this stitch. The point of interest about this case lies in the absence of jaundice or of any symptom that especially attracted attention toward the region of the liver or gall-bladder. There was little more complaint of pain in this particular part of the abdomen than in any other; but on the contrary the pelvic organs seemed to be the site of the most suffering. No. 5 of this table was a case of exploratory incision in a woman where the symptoms indicated a speedy death unless relief was at once obtained. The history, extending over several months, indicated some serious disease of the rectum and pelvic organs. There had been a discharge of pus and blood from the rectum, coming on at irregular times and attended with great pain and emaciation. The bimanual examination showed a mass in the left ovarian region, Soft to the touch and very tender. An examination by the rectum gave no additional information, and there was a strong suspicion that the cause of the discharges from the rectum lay in some chronic disease of the Fallopian tube, proba- bly pyo-salpynx. n consultation with the attending physician, Dr. W. S. Tay- lor, it was advised that an exploratory incision be made to settle the question. This was carried out, and the Fallopian tubes and ovaries were found in a normal condition, but the rectum about the sigm oid flexure and the colon above were found to be enormously thickened and softened, giving the impression to the finger of malignancy. The abdomen was at once closed and the patient grew 8 A Year's Work in Abdominal Surgery. ally weaker, and died the following day. Dr. Taylor's report of the post mortem examination showed great thickening and soft- ening of the colon, the tissues being so disorganized that the wall of the intestines permitted the puncture of its walls by only moderate pressure with the end of the finger. The exploratory incision had practically nothing to do in causing the death of the patient. The case of abdominal hysterectomy reported might be con- sidered a very bad one from the outset. The tumor was firmly fixed in the pelvic excavation, very generally adherent on every side, and in the attempt at removal the bleeding was very pro- fuse. The growth of the tumor was rapid, and it partook more of the nature of sarcoma than of fibroma. The stump was treated with the elastic ligature, extra peritoneally, and the cause of death, as was shown by the post mortem examination, was the sloughing of the stump of the tumor below the elastic ligature, and the consequent septicemia and attending peritonitis. Had I to deal with a similar case in the future, I should tie off the broad ligament more thoroughly and enucleate the tumor more completely, for the post mortem examination demonstrated that this would have been a feasable procedure. Case No. 6 of this table was an exploratory incision on ac- count of a rapidly growing tumor the size of a cocoa-nut, in the epigastric region, in a woman thirty-seven years of age. Ema- ciation was progressing rapidly. In consultation with Drs. Lane, Pawlicki and Burgess, it was agreed that the diagnosis lay between some malignant disease of the liver or spleen and a cyst from the echinococcus; and an ex- ploratory incision was advised. Upon opening the abdomen in the median line between the umbilicus and the ensiform cartilage, I came at once upon the growth, which had pushed the stomach upward and to the right. The tumor was of a dark, purplish color, and in attempting to examine its attachments with the finger, it broke down and began to discharge profusely blood and softened gelatinous material. It was manifestly malignant, and the question imme- diately arose as to the best plan of procedure. Should the abdo- men be closed, with this discharge of blood and broken-down tissue escaping into the cavity? or should the growth, so far as possible, be removed and the hemorrhage controlled ? The later seemed the only reasonable plan. The larger portion of A Year's Work in Abdominal Surgery. 9 the tumor was removed, there being considerable loss of blood, the bleeding points tied, the abdomen washed out and the incis- ion closed, leaving in a drainage tube. The woman died a week later from exhaustion. Had not the fragile tumor broken down while the examination was being made, the abdomen would have been closed without further operative procedure, and the woman would probably have re- covered at once from the effects of the exploratory incision, and her length of life would not have been lessened. Of the cases of vaginal hysterectomy, the first one was at- tended with unusual difficulty. The sarcoma, while involving but a very trifling part of the posterior lip of the cervix and of the adjacent vagina posteriorily, after the operation was begun it was found that the disease had involved the peritoneum in Douglass' pouch to such a degree that the separation of the uterus posteriorily involved great danger to the rectum. The operation, however, was successfully completed, after consider- able delay on account of the excessive bleeding. The heart's action became very rapid, the pulse being from 140 to 150 per minute, and until the death of the patient occurred, eight days later, the pulse was never below 130 per minute, she dying ap- parently from shock and exhaustion. It should be here stated that eight months before, while on a visit to the East, for several months her pulse was 150 per min- ute, and the physicians in attendance told the family that she would probably not live to reach California. She was very anaemic, and there was manifestly some serious fault with the innervation of the heart. Nausea and vomiting persisted, in spite of any treatment adopted for its relief. There was only very slight rise in temperature during the continuance of the case, until the day before her death. In case No. 2 no ligatures were used, and the uterus was very rapidly and easily removed by using accupressure forceps to the stumps of the broad ligaments. The b ladder was opened in sep- arating it from the uterus. This opening was closed with cat- gut sutures and gave no further trouble. The accupressure forceps were allowed to remain in situ for forty-eight hours. They were then removed and the surfaces dusted with iodoform. The recovery was rapid and uninterrupted, and the patient remains well at this writing. In looking back over these cases it would naturally be said 10 A Year's Work in Abdominal Surgery. that the case from accidental hemorrhage should not have oc- cured. Nevertheless, probably there are very few ovariotomists of much experience who have not lost one or more cases in this manner. This was my first experience of the kind, and I believe that this case would not have been lost had it not been for the attack of acute pleuritis, which complicated the case in such a way as to distract attention from the real source of danger. Had this woman's abdomen been re-opened on the morning of the second day when the pulse became so rapid, the pedicle tied again and the abdomen washed out, the chances would have been all in favor of her recovery. The loss of this case was all the more annoying to me, for it is the only case I have ever lost following an abdominal section for an ovarian cystic tumor. The method of tying the pedicle in this case was the one very generally adopted, with the added precaution of searing over the cut portion of the pedicle with a hot iron; and at the time the abdomen was closed, and for twenty-four hours afterwards, there was no bleeding. Since this fatal case I have taken the addi- tional precaution of passing the ligature again around the ped- icle and tying a second knot on the opposite side as a matter of safety. My examination of the pedicle after death with the ligature still in situ led me to the conclusion that it had slipped somewhat after the first knot was tied, and I believe that if the ligature had been again passed around the whole stump and firmly tied, no bleeding would have occurred. In the case of the uterine fibro-cyst, the adhesions to the sur- rounding organs were so universal that the most skilled and daring operator might well have hesitated before undertaking its removal; and the subsequent fatal result would seem to show that it would have been wiser to have closed the abdomen and left the mass untouched with the knife; but having once opened the peritoneal cavity, the temptation was very strong to under- take the enucleation of the mass, even if attended with great risk, on account of its rapid growth. It has been often said with truth that our failures teach us more than our successes. Had I to deal with a similar case in the future, I should pass a large rectal bougie up to and above the sigmoid flexure before attempting any separation of the tumor from the rectum. I should also pass a large-sized sound into the bladder, and in this way have some definite guide to protect these two organs from injury. A Year's Work in Abdominal Surgery. 11 It is only of late that I have fully appreciated the importance of the proper preparation of the patient before an abdominal section. By this I mean the very thorough and efficient empty- ing of the intestinal tract by the systematic use of laxatives, administered night and morning in sufficient doses to produce at least two large and free movements every twenty-four hours. For the last forty-eight hours before the operation no food is allowed, excepting a well boiled gruel made with flour and milk and water. This is used ad libitum. The necessity of this pre- paration was made evident to me by the fact that in several of my patients very troublesome symptoms, such as tympanitis and persistent vomiting supervened, which were entirely relieved by purgatives, which caused enormous discharges of foecal matter. When vomiting is persistent for forty-eight hours after an abdominal section, I have found nothing which seemed to be so certain a means of relief as the administration of two grains of calomel in a teaspoonful of water every two hours until a move- ment of the bowels occurred; for the moment that peristalsis through the entire canal had become established, usually the vomiting ceased, or at least became amenable to treatment, and it has seemed to me that in all cases where the vomiting is per- sistent it is almost invariably due to a paralysis of the intestine. An injection into the rectum of a teacupful of tepid milk and a teaspoonful of turpentine has seemed of much service in stimu- lating the contraction of the intestine and the expulsion of flatus. I put nothing into the stomach excepting a teaspoonful of water once an hour until peristalsis has been established. If there should be demand for nutrition or stimulant, I give an enema of peptonized milk and brandy every five hours. The less opium given the better, and a considerable propor- tion of my cases now get no opium from the beginning to the end of the case. The opium prevents the peristalsis, and tends to perpetuate the nausea and vomiting; furthermore, it decreases the action of the kidneys and thus cripples a valuable excreting organ. If the temperature goes steadily up, indicating the existence of pus, I never hesitate to take out two of the lower stitches of the abdominal wound and introduce my finger and make an exam- ination; and invariably where the symptoms have been at all 12 A Year's Work in Abdominal Sj/ngery. serious, I have found pus, and have washed out the abdominal cavity with large quantities of hot water and hydro-naphthol, introduced into the peritoneal cavity by means of a Davidson's syringe, and have never seen cause to regret this action; but on the contrary, I am quite sure that several of my cases would otherwise have died. The signal for the administration of fluid nourishment is the return of the peristalsis and the expulsion of gas or faecal matter from the rectum. Squibbs' ether is invariably used as the anaesthetic, believing, as I do, that it is the safest remedy of the kind, particularly if the operation be a prolonged one. As far as possible, the operation is done antiseptically. I pre- pare my sponges with my own hands and with the greatest care. They are kept tied up in bags, after being thoroughly dried near a hot stove. All the vessels used for sponges and instru- ments I take with me to the house, where, if possible, I have all the water boiled that is used in the operation. For the past three years I have used hydro-naphthol exclusively as an anti- septic, and have every reason to be satisfied with it. It is not poisonous, it does not irritate the skin and does not injure the instruments. I have repeatedly filled the abdominal c avity with a saturated solution of hot water and hydro-naphthol and have not i-een any ill effects following. I believe that the fewer persons present at the operation, ex- cepting the needed assistants, the better for the patient. The rate of mortality in the cases ieported seems high; but if from these are deducted the cases of malignant and tubercular disease, and the exploratory incisions in cases that were almost necessarily fatal, the death-rate will be very materially de- creased. There has been no disposition to select cases, but in every instance the operation has been undertaken where the life was at stake, the health and usefulness seriously impaired, or the prospect of a cure seemed warranted by the history. "Wherever possible a consultation -was held, and all the facts, risks and dangers fully set forth to the patient or her friends. If the family and the patient, after fully understanding all the reasons for and against an abdominal section, decide that the surgeon be allowed to use his own judgment in the case, then I believe that it is cowardly on his part to neglect to give the patient the benefit of the advantages which come from an ab- A Year's Work in Abdominal Surgery. 13 dominal section, when there is a reasonable prospect that the life may be saved thereby. As several of the gentlemen present can testify, some of the most unpromising cases that they have seen with me have gone on to recovery after the abd omen was opened and the disease removed. So true is this that I feel warranted in recommend- ing an exploratory incision in all, except malignant disease of the abdominal cavity, where the life is at stake. I am quite of the opinion of Dr. Vanderveer of Albany, that the time is coming, and that quickly, when there will be in every large community men who, by reason of their opportunity and experience, will be especially qualified to undertake cases of abdominal surgery. The conditions and relations of the organs in abdominal diseases so constantly vary, the surgeon is so often surprised when he least expects it by complications of various kinds, that no one but a skilled man may hope to meet success- fully the many difficulties that may confront him. There is one other point to which I desire to call the attention of the members of the Society. I have been annoyed in several cases by the occurrence of small abscesses in the abdominal tissues at the site of the sutures used in closing the abdominal wound, and this, too, in spite of all my precautions for insuring perfect cleanliness and an aseptic condition of the suture ma- terial, sponges and instruments. The occurrence of these abscesses is a misfortune in more ways than one. In the first place the presence of pus here interferes seriously with the union of the cut surfaces, and so weakens the scar and predis- poses to hernia. In the next place the temperature and chill that often accompany these small collections of pus, cause anxiety on the part of the surgeon lest his patient be developing some serious inflammatory trouble with the abdominal cavity. O f late I have been using the silk-worm gut instead of thread for suture material, and have introduced the sutures from with- in outwards, each end of the suture having a separate needle. In this way we avoid carrying into the abdominal tissues any of the epithelium of the skin covering the abdomen, or any of the glandular tissue of the skin structure. Whatever the explana- tion may be, since I have used the silk-worm gut and introduced the sutures from within outwards, I have had no stitch-hole abscesses. Possibly equally good results would follow with a properly prepared silk thread, if this also was introduced from within outwards.