RECENT EXPERIENCE IN ABDOMINAL 
SURGERY. 
SIXTEEN CONSECUTIVE CASES. 
BY 
J. E. SUMMERS, JR., M. D., 
Professor of Surgery OmaTia' Medical College-Surgeon 
to the Clarkson Memorial and the Immanuel 
Hospitals, Omaha, Nebraska. 
Reprint from The Omaha Clinic, March, 1891. RECENT EXPERIENCE IN ABDOM- 
INAL SURGERY -SIXTEEN CON- 
SECUTIVE CASES.* 
By J. E. Summers, Jr., M. D. 
Professor of Surgery Omaha Medical College-Surgeon to 
the Clarkson Memorial and the Immanuel Hospitals, Omaha, 
Nebraska. 
In calling attention to my experience 
in abdominal surgery, embraced within 
the period from March 13th, 1890, to 
February 28th, 1891, less than one year, 
I do not propose to go into the details 
of all the cases, but briefly mention such 
as seem worthy of comment. My cases 
number sixteen. Twelve of these recov- 
ered and four died. Twelve of myopera- 
tions were done in the Clarkson Mcmo- 
rial hospital, with ten recoveries. 
One was done in the Immanuel hos- 
pital, which recovered; and three 
were done in private dwellings with one 
recovery. All of the four deaths were 
from lesions of the intestines-two 
absolutely necessarily fatal from the 
lesions found, and the condition of the 
patients at the time of operation. 
The twelve successful cases were, with 
two exceptions, pathological conditions 
of the ovaries or of the ovaries and 
tubes. To tabulate: 
*Kead before the Medical Society of the Missouri Valley, March 
26,1891. 2 
Adhesions to the ovary....'. 1 
Ovarian tumors 4 
Encysted dropsy 1 
Pyosalpinx 2 
Chronic ovaritis with salpingitis 3 
Appendicitis 2 
Intestinal obstruction 1 
Sarcoma of the colon 1 
Umbilical hernia (strangulated) 1 
I wish to select for my remarks, five 
out of my twelve recoveries, and also the 
four fatal cases. The others were of 
such character, difficult or easy, as many 
of you have frequently had in your 
practice. 
Case II.-Mrs. S. aged 28 years had 
been an invalid for ten years, suffering 
with a long chain of symptoms refera- 
ble to the uterus and adnexa. Among 
the chief of these were pelvic pain and 
too frequent profuse menstruation. She 
had had a laceration of the cervix 
repaired, the uterus curetted, worn pes- 
saries and the changes in local and inter- 
nal treatment had been wrung dry, and 
I had assisted in the wringing. The 
diagnosis as to the true local condition 
of the adnexa was not positive. On May 
5th, (in the Clarkson Hospital) the 
abdomen was opened and after consid- 
erable difficulty the ovaries and distend- 
ed tubes were freed from extensive adhe- 
sions and removed. The convalescence 
from the operation was uninteresting. 3 
Menstruation has never returned but 
the old pain continued for many months, 
and it is only recently that it began to 
disappear and at present is nearly gone. 
If such operations were followed up with 
reports, on the results as to cure, it 
would doubtless be found that many 
patients were not benefitted by opera- 
tion, or if at all, only after the lapse of 
considerable time. Personally such 
cases are known to me, and one of them 
was reported before a State Medical 
Society by a distinguished gynaecologist 
as a cure, when to-day the woman is a 
confirmed invalid, menstruating and 
suffering pain as of yore. 
Case IV.-Mrs. J., aged 50-Multi- 
locular Ovarian Tumor-Operation Sep- 
tember 8, Clarkson Hospital. 
The adhesions were universal to intes- 
tines, stomach, liver and parietal perito- 
neum, and their separation required 
much time and rather rough handling. 
After ligation of the pedicle the abdomen 
was well irrigated with hot water to 
combat the shock and stop the oozing. 
A drainage tube was employed and 
removed on second day. There was a 
sharp attack of peritonitis which was 
controlled and recovery was rapid. 
Tumor weighed seventy pounds. This 
was the most difficult operation for the 4 
removal of an ovarian tumor I have ever 
seen, and the recovery of the patient was 
a surprise to the physicians present at 
the operation. 
Case V.-Mrs. F., aged 35 years-Mul- 
tilocular Ovarian Tumor. 
The patient thought herself pregnant, 
felt foetal life, and as the tumor grew 
prepared for her accouchment, notifying 
her physician of the expected event. 
Some two months after this date, she 
called her physician to explain the cause 
of delay, when upon examination the 
uterus was found normal in size and an 
ovarian tumor present. Menstruation 
had been normal. Operation October 8, 
Clarkson Hospital. A large multilocular 
tumor was removed; adhesions were 
plentiful. Irrigation and drainage; the 
tube was removed in twenty-four hours. 
Recovery uninterrupted. 
Case VII.-Mrs. C., aged 24 years. 
Patient had been suffering with inflam- 
mation in the region of the vermiform 
appendix for two weeks. Temperature 
ranging from 100° to 102° F. For two 
or three days prior to my seeing the case, 
there had been an aggravation of all 
symptomsand believing that interference 
was called for, she was removed to the 
Clarkson Hospital the same evening 
(October 28th), on which I first saw 5 
her, and the abdomen opened at 10 
o'clock at night. Incision five inches in 
right linea semilunaris. Intestines were 
matted together and after gentle manip- 
ulation, a small collection of pus was 
found and removed'. The vermiform 
appendix could not be recognized. The 
upper half of rhe incision was closed, the 
peritoneum being sutured separately 
with cat-gut, and the region of the 
abscess and lower half of incision left 
open and packed with iodoform gauze. 
Recovery uninterrupted. 
Case XIII.-Mrs. G., aged 24. This 
woman was first seen by me during the 
fall of 1889, suffering with what seemed 
to be nephritic colic; the symptoms were 
apparently typical. She was seen again 
December 15, '90, and found practically 
bed-ridden from pain along the course of 
the right ureter extending down into 
the pelvis. On examination, a tumor 
the size of the fist was found on the right 
side of the uterus and intimately con- 
nected with it. The tumor was ex- 
quisitely sensitive; there was likewise a 
much smaller growth on the left side. 
Menstruation normal. The attacks were 
paroxysmal. When the woman 
attempted to stand the body was bent 
over on to the pelvis. It was noticed 
that pressure over McBurney's point 6 
caused considerable flinching. I decided 
to open the abdomen and investigate. 
The growths were found to be sessile 
sub-peritoneal fibroids; the right ovary 
was adherent low down behind the 
large fibroid with strong adhesions to 
the omentum and small intestines bind- 
ing it tightly against the growth; these 
were freed, the omentum being shortened 
by amputation. On account of its depth 
and position I could not remove the 
ovary. The right kidney was palpated 
and found normal and the vermiform 
appendix carefully examined and also 
found normal. Convalescence was satis- 
factory. I was recently informed that 
the patient was free from pain and is 
attending to her duties as a housekeeper. 
Case III-Mr.C., aged 54. I was tele- 
graphed to go to a city one hundred 
miles distant to operate for strangulated 
hernia. On arrival, I found a man 
weighing 350 lbs., with a large umbilical 
hernia which had been incarcerated for 
three days. After spending twenty-four 
hours at personal manipulation, the 
patient had sent for medical aid, and the 
gentleman called tried taxis on two 
occasions under chloroform. The skin 
over the hernia was oedematous, mostly 
I thought as a result of the taxis. I de- 
clined to operate as there were no posi- 7 
tive symptoms of strangulation, the 
man being free from pain and in excellent 
condition, saying he felt perfectly well. 
Temperature 99°, pulse 84. Ice was 
advised locally. Early next morning I 
was again summoned, and found an 
elevation of temperature and increased 
frequency of the pulse, tumor somewhat 
painful. I opened the sac and found an 
omental hernia, a small part of the 
omentum quite black and some other 
highly congested; this was amputated. 
There was also another hernial sac ad- 
herent to this one, having its exit from 
the abdomen just above it, the rings being 
separated by one-half inch of parietal 
wall. The coverings of these sacs were 
the same, the contents of the smaller 
being intestinal, and not strangulated. 
This form of double sac is much less 
common than that variety where there 
are two necks to the same sac, which 
results (Wood) "from the remains of the 
uracus and hypogastric arteries at the 
upper part of the superior false ligament 
of the bladder, traversing the interior 
of the sac to the navel cicatrix, with ad- 
hesions to the neck, and with a pouch on 
each side, one of which may contain 
omentum, and the other large or small 
intestines. The suspensory ligament of 
the liver has been seen to form a similar 
division of the sac." It was not easy to 8 
reduce the omental hernia, so its ring 
was enlarged both downwards and up- 
wards into the ring of the smaller hernia. 
The operation was completed by at- 
tempting a radical cure. The patient 
rallied well from the operation, but 
gradually sank, dying forty-eight hours 
later. The post mortem showed the intes- 
tines normal, omental stump congested, 
and a circle of inflamed parietal perito- 
neum three inches in diameter surround- 
ing the sutured rings-Primary union. 
What killed this man? Those whose 
experience has given them a variety of 
subjects, know that it is in the obese 
that a prolonged operation is dangerous 
at best, and most frequently fatal. The 
attending physician counseled operation 
on my first visit-the result proved his 
judgment better than my own. 
Ca.se XI-Mrs. C., aged 35 years, was 
first seen' by me September 25, 1890. 
Her condition was hectic, symptoms 
referable to the pelvis. Examination re- 
vealed an apparently typical old-fash- 
ioned "pelvic cellulitis." I urged im- 
mediate operation as giving the only 
hope. Consent was finally obtained. 
Patient would not go into a hospital, 
so the operation was done at her home, 
October 3. On opening the abdomen, 
after breaking up a few adhesions, a 9 
gangrenous stinking tumor was exposed 
and thought to be a tube, but on at- 
tempting its separation it broke down 
and a large new growth involving the 
meso-colon and three-fourths of the 
lumen of the large intestine had to be 
removed. There was no backing out, 
in the crumbling of the gangrenous mass 
the sigmoid flexure was widely opened. 
I therefore did Madelung's operation, 
removing some ten inches of the gut 
with its mesentery, and because of the 
tension had to establish the artificial 
anus at the upper angle of my incision. 
It was only owing to the cleverness of 
my assistants that I was able to get the 
patient into her bed alive. She rallied 
somewhat, but died on the third day. 
Post mortem not allowed. Growth 
proved to be a sarcoma. 
Case XIV.-Mrs. C. aged 36 was first 
seen by me about the last of November. 
There was a history of obstruction of 
the bowels commencing two months 
previously. The attack had been sudden 
and no efforts had availed for one month 
to produce an evacuation. At the end 
of that period several small, lose, thin 
movements took place and from that 
time to date there had been no move- 
ments, except on two or three occasions 
after the use of enemas, but these move- 10 
ments had been very small. The classi- 
cal symptoms of chronic intussusception, 
so well described by Treves, were 
marked. The intussusception could just 
be reached in the rectum, and the point 
through which the movements had 
taken place, recognized as a kind of 
dimple. The woman's condition was 
very bad. There was constant vomiting 
of a feculent character, and no nourish- 
ment could be retained. Three plans 
suggested themselves. 1. Lumbar Col- 
otomy-2. Inguinal Colotomy-3. Ab- 
dominal Section for the purpose of, if 
possible, reducing the invagination, fail- 
ing this, to establish an artificial anus. 
On December 7th, (Clarkson Hospital) I 
chose the third. Nothing could be done 
to overcome the obstruction, in fact, 
because of the distention of the large in- 
testine above the intussusception it was 
most difficult to recognize the different 
parts of the colon. Neither the caecum, 
ascending or descending colon were 
where they usually belonged. A pro- 
longed examination was out of question, 
so I closed my median incision and did a 
left inguinal colotomy (Littre's opera- 
tion). The bowel was fastened in the 
incision but not opened. I did not want 
to open the bowel for four or five days, 
but the patient's condition was such, 
that at the end of fourty-eight hours I 11 
did so, the relief was wonderful. Late 
at night of the day on which I opened 
the bowel, while straining and having 
an enormous movement the woman was 
seized with intense pain, and when I saw 
her and could clear away the faeces suf- 
ficiently to make a careful examination 
the cause was evident-a suture at the 
upper angle of the incision had given 
way and allowed a leakage into the 
peritoneal cavity. I immediately closed 
the opening into the gut, and did what 
I could but the damage had been done, 
and death followed the next night. No 
post morten could be obtained. 
Case XVI.-Mrs E. aged thirty-eight 
-was admitted into the Clarkson Hos- 
pital February 21st-she was uncon- 
scious, pupils widely dilated and did not 
respond to light. Copious loose involun- 
tary evacuations from the bowels. 
Thighs flexed onto the the abdomen. 
Tempeature 102° F.-pulse 110. The 
uterus was fixed and there was plainly 
some peritoneal inflammation. She had 
been sick one week, and under the care 
of physicians, who had, I understood, 
gotten the impression that the woman 
had taken opium in poisonous quantity, 
and it was quite evident that belladonna 
had been given her. Under symptomatic 
treatment she became conscious in two 12 
days, and the temperature went down 
to 99°F., but frightful pain was com- 
plained of radiating all over the abdomen 
most acute over the uterus. Digital ex- 
amination revealed a mass in Douglas' 
pouch on the left of the uterus. I did 
not see the case for nearly two days- 
when I did her condition was generally 
bad, pain continuing, her cries keeping 
the whole house disturbed. Examina- 
tion with consultants found the mass 
larger and extending to the right. Not 
much tympanites. Diagnosis-pus in 
the pelvis from most likely a fallopian 
tube, possibly from a masked appendici- 
tis. This opinion was given to those 
present before I opened the abdomen 
which I did February 28th. There was 
a general peritonitis. An abscess 
around the region of the location of the 
appendix containing about two ounces 
of putrid pus was evacuated and 
another, distinctly separate from this, 
was opened deep down behind the 
uterus. This contained quite a large 
amount of the same kind of pus. 
Leakage had I think, already taken 
place, before operation. Most careful 
and copious irrigation was used, and in 
addition to a tube, iodoform gauze was 
packed into the pelvis and the positions 
of the abscesses. It was evident to all 
when the peritoneum was opened that 13 
there was no hope, still a careful at- 
tempt to save life was made. Death 
in thirty hours. The post mortem ex- 
amination showed the tubes not involv- 
ed, and a gangrenous appendix, mostly 
destroyed. I do not think it was possi- 
ble to recognize the true lesion, under all 
the circumstances, early enough to have 
had surgery do any good. The phys- 
ical signs were of pyosalpinx. 
Remarks.-I use no chemicals in irri- 
gating, simply hot, boiled water, and 
gauze, either iodoform or sterilized for 
sponging. Drainage whenever I have 
irrigated. Operating as rapidly as con- 
sistent with careful work, and although 
not a particularly rapid operator, I have 
succeeded in removing successfully both 
of the ovaries and their tubes in twenty 
minutes from the commencement of my 
incision until it was closed by the tying 
of the last suture. Silk is used for ty- 
ing pedicles, cat-gut for blood vessels. 
These few cases are given to illustrate 
abdominal surgery happening in the 
practice of a general surgeon, other than 
which I do not claim to be, although, 
according to my best information, the 
total number of my abdominal sections 
to date is about double that of any 
other operator in Nebraska, yet they are 14 
so few when compared with those of our 
well-known specialists in the East that 
they are scarcely worth consideration. 
Still, from my limited experience and a 
liberal clinical observation and ac- 
quaintance with the published work of 
others, the standpoint from which most 
of us must view these cases, the follow- 
ing rules seem common sense: 
1. Never operate upon a practically 
moribund patient, whose disease is 
chronic. 
2. The same rule applies to all acute 
diseases or injury except where hemor- 
rhage is the depressing or suspecte.dly 
depressing cause. 
3. Never hesitate to operate upon 
otherwise hopeless cases, if experience 
has proven success to have followed in- 
terference, even if in only a very small 
percentage. 
4. Use all the principles of modern anti- 
septic surgery before opening the abdo- 
men, those of aseptic surgery after wards. 
5. Drain only after irrigation, evacuate 
the tube frequently and remove it early. 
6. No nourishment by the mouth for 
twenty-four hours, giving hot water in 
small quantities to allay thirst. 15 
7. Peritonitis should be treated by 
large doses of calomel and copious tur- 
pentine enemas. In intestinal lesions, 
splinting the bowel by opium may be 
the proper practice. 
8. Use whatever technique is simplest 
and easiest, thereby diminishing shock 
and lessening the dangers of an always 
possible infection.