Abdominal Section 
FOR 
DIAGNOSTIC PURPOSES. 
BY 
CLINTON CUSHING, M. D 
San Francisco, Cal. 
W. A. WOODWARD & CO.. PRINTERS, 12 SUTTER 8T. S. F. Abdominal Section 
FOR 
Diagnostic Purposes.1 
By CLINTON CUSHING, M. D., San Francisco, 
Professor of Gynecology in Cooper Medical College, Fellow of the American 
Association of Obstetricians and Gynecologists, Fellow of the 
British Gynecological Society, Consulting Surgeon to 
the French Hospital, etc. 
In the excellent book of J. G-reig Smith on “Abdominal Sur- 
gery,” he says, in speaking of exploratory incisions of the abdo- 
men, “no incision ought to be merely exploratory.” “The 
exploratory incision of the skilled surgeon is widely different 
from that of the tyro.” “Where the former will make a correct 
diagnosis in ninety-nine out of a hundred cases the latter will 
fail over his tenth case.” 
However skillful the surgeon may be I do not believe he can 
make an accurate and correct diagnosis in more than nine out 
of ten cases of abdominal disease, by any method of external 
examination, if we leave out of consideration cases of ovarian 
cysts and uterine fibroids. 
Therefore, I think that the author quoted is in error, and 
that his quoted statements should not be allow'ed to stand 
unchallenged. In spite of the fact that great progress has been 
made in later years, there still remain a considerable number of 
cases of abdominal disease of a serious character, the nature of 
which equally skillful and intelligent surgeons will disagree upon. 
This statement applies to cases of obstruction of the bowels, to 
disease of the vermiform appendix, to affections of the liver and 
gall-bladder, and of the kidneys, and to pus collections in any 
part of the abdominal cavity. 
The real facts in many cases of ruptured extra-uterine preg- 
nancy are only clearly made out at a post mortem examination. 
1 Read before the American Association of Obstetricians and Gynecologists 
at 8t. Louis, Missouri, September 22nd, 1892. Abdominal Section for Diagnostic Purposes. 
Exploratory incision is looked upon by Mr. Smith as a serious 
operation followed by a trying illness. 
In my hands it has not proven so; the serious part is the dis- 
ease that warrants the operation, and not the operation itself, 
for with due care and cleanliness there is not one chance in a 
hundred that any bad results will follow the opening of the 
peritoneal cavity for the purposes of diagnosis. 
I would not have it understood that I am an advocate of care- 
less or reckless work, but where the symptoms are grave and 
growing steadily worse, and the life is at stake, if the symptoms 
point to some obscure disease of the abdominal cavity there 
should certainly be no hesitation in clearing up all doubts by 
an exploratory incision if there be strength and vitality left to 
withstand the slight shock that attends the opening of the peri- 
toneal cavity. During the past few years a number of cases 
have come under my observation that warrant me in these 
opinions and I select from among them a few typical ones by way 
of illustration. 
In November, 1888, I was asked to take charge of a woman 
from Austin, Nevada. She was twenty-seven years of age, two 
children, youngest four years of age. She had suffered for many 
years a good deal of pain in region of ovaries and uterus, and 
when I first saw her was confined to bed and had a temperature 
of a hundred and two degrees. The symptoms were those of a 
mild attack of pelvic peritonitis, but a careful bi-manual exam- 
ination showed the pelvic organs to be freely movable, although 
tender to the touch. The uterus was retroverted. 
Under the use of opiates, rest and hot water vaginal injections 
and the free use of quinine the symptoms mended, and at the 
end of a month the temperature was normal and she was allowed 
to get out of bed. The digestion was poor and she complained 
of a feeling of distress in region of stomach and liver. At the 
end of ten days the fever returned with increased violence and 
the repetition of treatment gave only negative results. Mani- 
festly I had to deal with some serious malady the nature of 
which could not be clearly made out. She was now much ema- 
ciated and I advised an exploratory incision, giving as my rea- 
son that there was probably a small collection of pus in one or 
both Fallopian tubes. Prof. L. C. Lane saw the case in consul- 
tation and agreed with me as to the propriety of the abdominal 
section and the operation was done on January 31, 1889. Upon Abdominal Section for Diagnostic Purposes. 
3 
opening the abdomen the tubes were found to be normal. I 
then enlarged the incision and introducing the whole hand 
began a systematic examination of all the abdominal organs. 
Finally, I discovered on the under side of the liver a hard 
rounded tumor firmly fixed, about the size of a turkey’s egg. 
While manipulating it between the thumb and finger I found 
movable masses within and at once concluded that I had to deal 
with an enlarged and inflamed gall-bladder filled with gall- 
stones. I at once sutured the retroverted uterus to the anterior 
abdominal wall and closed the incision in the abdomen. I then 
laid open the abdomen by a free incision near the lower bor- 
der of the ribs and with the finger tips loosened the adhesions 
of the gall-bladder from the surrounding structures and drew it 
up and stitched it to the edge of the abdominal wound, laid it 
open and removed a small handful of biliary calculi, leaving in 
the viscus a small drainage tube for one week. The improve- 
ment was remarkable, the fever and pain immediately left her, 
and in six weeks she had regained her normal weight. A small 
biliary fistula remained for three months which healed at once 
upon removal of another gall-stone which had been left in the 
bladder at the time of the operation, or had worked its way 
down from the ducts subsequently. 
The gall-bladder contained also purulent matter and this, 
together with the local peritonitis, was doubtless the cause of 
the fever. The only symptom that would lead to the suspicion 
that such disease existed was the indigestion and the sense of 
uneasiness and pain in the region, but this was no greater than 
is often seen in those who have suffered from habitual dyspep- 
sia. The external examination gave no clue, for the gall-bladder 
was firmly fixed high up under the border of the liver. One year 
after the operation the uterus retained its normal position and 
she remained in good health. 
Mrs. W. F.,aged twenty-four, one child, one abortion, came 
to San Francisco from Honolulu in the Summer of 1891, and for 
three months was under the care of two competent medical 
men who treated her for some obscure and painful affection 
of the pelvic organs. But little good attended their efforts and 
I was asked to take charge of the case. Upon examination the 
abdomen was found to be distended with gas and very tender on 
pressure. The uterus was moderately fixed, retroverted and 
sensitive to the touch, cervix slightly Iterated, bladder irrita^ 4 
Abdominal Section for Diagnostic Purposes. 
ble and urination painful. Temperature 105°; a purge of 10 
grs. of calomel was given which acted freely but without relief 
to symptoms. Manifestly there was some serious trouble in the 
abdominal cavity, probably a pyo-salpynx, and an exploratory 
incision was advised and, after setting forth the facts in the case, 
the plan was agreed to and the patient was removed to my pri- 
vate hospital and the abdomen opened. It was then found that 
the patient was suffering from general peritonitis. The vermi- 
form appendix was enlarged, contained several small particles 
of hard fecal matter the size of small peas and two openings or 
ulcerations existed extending from the cavity of the appendix 
into the peritoneal cavity. The appendix was slightly adherent 
to the adjacent structures by bands of lymph. The right Fal- 
lopian tube contained two ounces of pus. The appendix and 
Fallopian tube were ligated and removed, the abdomen washed 
out with hot water and a drainage tube left in for forty-eight 
hours. Recovery was uninterrupted and she returned to her 
home on the twenty-first day following the operation. In this 
case there was no suspicion of disease of the appendix before 
the exploration, and had the operation been delayed she would 
doubtless have died promptly, whereas from the moment of open- 
ing the abdomen I was master of the situation and recovery was 
at once almost a certainty. 
On November 16, 1891,1 saw in consultation with Dr. B. F. 
Clark a women twenty one years of age, one child and one mis- 
carriage, who was suffering from some obscure and painful dis- 
ease of the abdominal cavity following an attack of pelvic peri- 
tonitis. From the history, symptoms and examination it was 
concluded that it was a case of pelvic abscess, such a case as in 
former years I would have punctured through the roof of the 
vagina, but it was decided to make an exploratory incision and 
clear up all uncertainties. On the following day the plan was 
carried out and in addition to a double pyo-salpynx we found 
near the umbilicus a mass the size of the closed fist consisting of 
omentum and small intestines firmly agglutinated together. I 
began cautiously to break up the adhesion and dissect the vari- 
ous layers apart with my finger nails and in the center of the 
mass I came upon an abscess containing two ounces of ill- 
smelling pus, the walls of which were gangrenous in appearance. 
The tube and ovaries were removed and the parts thoroughly 
washed, a drainage tube inserted for three days, after which Abdominal Section for Diagnostic Purposes. 
5 
recovery was uninterrupted. In this case any procedure short 
of abdominal surgery would have been of little use. 
On June 15th, 1892, I was asked by Dr. Myers, of Union 
Street, to see a case with him. She was twenty-seven years of 
age; had been married ten months and eight days before I saw 
her had suffered a miscarriage of six weeks’ pregnancy. Fol- 
lowing the abortion fever developed, and when I saw her, her 
temperature was She was bathed in perspiration, the 
abdomen greatly distended and the suffering intense. The ex- 
pression of the face was the peculiar pinched anxious look so 
familiar to those who have much to do with cases of abdominal 
surgery. Upon examination, it was found that a large solid 
tumor the size of a child’s head occupied the pelvic cavity. An 
offensive discharge was escaping from the os uteri, and the 
uterine cavity measured six inches. An important question at 
once presented itself, Was the woman suffering from septicae- 
mia due to absorption from a decomposing placenta, or had she 
already a general peritonitis from extension of disease along 
the Fallopian tube into the peritoneal cavity ? If the former, 
the curetting of the uterine cavity might prove of service; if 
the latter, it would do no good. An exploratory incision was 
decided upon, and the following day I opened the abdomen, 
and at once found purulent general peritonitis and a large 
sloughy-looking uterine fibroid. During the examination, pus 
was seen flowing freely into the peritoneal cavity from the free 
opening of the Fallopian tube. I at once tied off the broad 
ligaments, ligated the uterine arteries, removed the tumor, 
tubes, and ovaries, leaving the stump of the cervix closed in by 
flaps, and a whip-stitch of catgut after the method of Schroeder. 
The abdominal cavity'was washed and drained, the temperature 
at once went down to 100°, and there was but little shock. 
The recovery was uueventful, except that the abdominal 
wound did, not unite, owing to the infection during the opera- 
tion by the purulent discharge, and that in order to secure 
more perfect drainage, on the fifth day I passed a rubber tube 
from the abdominal wound through the stump of the cervix into 
and out of the vagina. *The patient was out of bed in five weeks 
and walking about a week later, having gained very materially 
in weight during her confinement to bed. 
With these facts before us, can there be any question in the 
mind of any intelligent surgeon of the proper course to pursue? 6 
Abdominal Section for Diagnostic Purposes. 
Certainly, courage and prompt action are necessary if good 
results are to follow. 
On July 26th, an Italian woman twenty years of age 
was brought to my private hospital in a greatly emaciated con- 
dition, her temperature was 102°, and pulse 160°. She had 
borne one child two years before. 
Eight months before I saw her she had an attack, which, 
from the history, I should judge was pelvic peritonitis. Since 
which time there had been steadily failing health and progres- 
sive emaciation accompanied with much abdominal pain, fever, 
and profuse perspiration. She had been having for several 
weeks a discharge of pus daily from the rectum. 
A bimanual examination showed the pelvic organs firmly fixed 
and tender, the abdomen not distended, and no marked thick- 
ening at any point that would indicate a circumscribed pus col- 
lection. 
With the assistance of Dr. B. F. Clark, the abdomen was 
opened on the following day, and we found the peritoneum 
enormously thickened. The moment the cavity was opened, a 
gush of pus occurred, and this was followed by the discharge of 
fully three quarts of yellow and grumous pus of very fetid odor. 
The sac was now washed out with several gallons of hot water, 
and the whole surface mopped over with a mixture of equal 
parts of compound tincture of iodine and carbolic acid. 
An examination showed that the pus cavity extended from 
Douglas’ pouch to the ensiform cartilage. No pelvic or abdomi- 
nal organs were anywhere in sight, all being buried in lymph 
and pushed in every direction by the encroaching pus sac. 
Two drainage tubes were fastened in, and every twenty-four 
hours the cavity was thoroughly washed out with a half ounce 
of compound tincture of iodine to a gallon of hot water. Rectal 
injections of whisky and milk and five grains of quinine every 
five hours administered by the mouth produced a marked effect. 
At this writing, convalescence is fully established with every 
prospect of return to health. 
Had tentative measures been employed here, or some imper- 
fect system of drainage, I believe the result would nave been 
disastrous. There was no way of learning from the external 
examination of the great extent of the disease, and the wonder 
is that any poor human being could live and carry about such a 
dreadful load of filth. Abdominal Sectioji for Diagnostic Purposes. 
7 
It might be said that the cases reported are exceptional. 
In answer, I would say that similar cases are coming under 
my observation constantly, and every year adds strength to the 
conviction that in properly selected cases exploratory incision 
of the peritoneal cavity is one of the most valuable additions to 
surgery that has been made in later years, and that when a 
patient dies after an abdominal section, the fault lies with the 
disorder that warranted it, and not with the operation, provid- 
ing, of course, that the surgical work has been done properly, 
and with the strict observation of cleanliness.