DIAGNOSIS IN ABDOMINAL 
DISORDERS. 
' By JOSEPH EASTMAN, M.D., LL.D., 
Indianapolis, Ind. DIAGNOSIS IN ABDOMINAL DISORDERS.** 
“The science of diagnosis,” declared Lewis, the illustrious secretary 
of the French Academy of Surgery, “holds the highest rank among the 
different branches of the healing art. It is at once the most useful and 
the most difficult.” Whatever application his felicitous expression may 
have in the practice of general medicine and surgery, it has its full measure 
of significance when applied to intra-abdominal disorders. 
At the outset I ask to be pardoned for presenting to this scholarly 
body a theme, the matter of which is as familiar to many of you as to 
myself. My excuse is. that I desire to awaken an increased interest in 
an art which threatens to become a lost one, so great is our inclination 
to do exploratory abdominal section. If a tithe of the effort which the 
surgical aspirant uses to secure operative cases, and perfect surgical 
technic, could be directed toward diagnosis, surgery would soon have a 
stronger hold on the confidence of each and every community, and suf- 
fering humanity be largely the gainer. 
* Importance: “When we state that the abdomen has> repeatedly been 
opened with a view to performing ovariotomy, when not only no ovarian 
tumor but no other tumor was present; that the pregnant uterus, at nearly 
full term, has been tapped with a trocar with the intention of drawing 
off ovarian fluid, and even been opened after abdominal incision before 
the mistake was discovered; that the chastity of virgins has been impugned 
by the assertion of the medical attendant that pregnancy existed; that 
numerous and frequent mistakes are made in attempting to decide upon 
the character of abdominal tumors; we have said sufficient to show that 
the question of diagnosis in these cases is often one of serious difficulty 
and anxiety to the practitioner. The diagnosis not infrequently involves 
decision between life and death. Tf we leave a patient to die unrelieved 
because of our inability to determine the character of the tumor, and sub- 
sequently discover that an operation might have been performed with 
success; or if we attempt to operate upon a patient, exposing her to all 
the risks of a formidable operation when no tumor exists, or perhaps 
one unfitted for operative interference, we incur a grave responsibility.” 
After twelve years experience confined absolutely to pelvis and abdo- 
men, I recall many instances, for example in appendicitis, where the 
practitioner has relied upon medical treatment when indications for 
operative procedure were pronounced from the second day; other cases, 
where operation has been declared necessary no indications whatever 
existing; patients with intestinal obstruction, treated with drastic cathar- 
tics until in articulo mortis, when the symptoms of obstruction were as 
well defined as in strangulated hernia. In other cases strangulated hernia 
has been reduced by taxis, stercoraceous vomiting and obstruction re- 
maining. 
♦♦Read at Western Surgical and Gynecological Association. 
♦ “ Edis, Diseases of Women.” 
1 One might infer, in view of the great advantages which the prac- 
titioner of to-day enjoys, gleaning from his medical journals the mature 
thought of experts in abdominal surgery, and the frequent pilgrimage 
of the surgical aspirant to the post-graduate school, that errors in diagnosis 
would be rare; but our most accomplished abdominal surgeons err in 
diagnosis, and this should rebuke our pride and quicken our charity for 
those of equal talent but less experience. 
The rules laid down in our text books for differential diagnosis be- 
tween the different varieties of abdominal tumors are either so well 
understood or accessible to those desiring to master them, that I shall 
refer only to cases in which exceptions to these rides are much in evi- 
dence. Where I have observed errors in diagnosis, it has rarely been 
for the want of knowledge, but for the want of methods, energy, per- 
sistence and wisdom to apply knowledge. The procedure has been with- 
out method. The abdominal surgeon must be both born and made; he 
must have by birth and cultivation acute perceptive faculties and strong 
powers of observation, otherwise how shall he systematically accumulate 
subjective symptoms, arrange them in proper sequence and deduce and 
then secure the objective signs, arrange them in their proper order, and 
think broadly in his interpretation of their significance. A good rule 
suggested by Mr. Tait is to make a mental list of the different pathologic 
and physiologic conditions which might possibly exist; then reason per 
exclusionem. and arrive ultimately at the conclusion that a given form 
of neoplasm or pathologic condition is present, for the reason that it could 
not be anything else. 
The fact being conceded that abdominal surgery has had its largest 
development from operations on women, our mental list of intra-abdominal 
conditions which are to be excluded should be headed by pregnancy. 
The laity are prone to criticise the general practitioner if he hesitates to 
say whether his patient has an abdominal tumor or is pregnant. Even 
some practitioners ridicule their more accomplished brother because he 
hesitates in deciding between pregnancy and tumor. 
Reports of genuine cases speak more forcibly than theorizing words; 
the former speak the 
“Language rife with rugged maxims hewn from life.” 
Case first—Mrs. C.. referred by Dr. Blount, of Wabash. Had enor- 
mously enlarged abdomen, which had existed so long that the cessation 
of her flow might have been attributed to the general debilitated and 
anemic condition. The doctor, a most accomplished practitioner, deter- 
mined to exclude pregnancy, but found a softened portio, with pronounced 
pulsations in its circular artery; softened mammae and wine-colored vagina. 
No emergency existing, ho gave the patient more time, and thought the 
mysterious case was clear after he had delivered the patient of a living 
child. Not so, however; for the abdomen was nearly as large as before. 
During her convalescence it seemed necessary to relieve pressure by tap- 
ping. A specimen of the fluid sent to me gave evidence of ovarian cyst, 
which cyst was removed, an uneventful recovery of the patient following. 
Case second—Mrs. Christie, care of Dr. Osborne, of New Winchester, 
able practitioner, who refused to take sides with the gossiping laity, 
which declared that the woman had either a tumor or was pregnant. 
2 Time solved the problem. She was delivered of a living child; was ad- 
mitted to my institution and relieved of her tumor, a cyst which, together 
with its contents, weighed twenty pounds. A good recovery. 
Case three (which was to me a puzzle bewitched)—Mrs. F., of Terre 
Haute, was first seen in consultation by Dr. Thos. Eastman, who found 
decided abdominal enlargement. Flow had been absent, but appeared 
with hemorrhage. Evidence of septicemia was also present. After a 
few months’ treatment for the septic condition, abdominal enlargement 
was reduced from the size of a human head to the size of one’s fist; 
patient regained comparative health for eight months, when her former 
symptoms reappeared, except the uterine hemorrhage, tumor filling up the 
abdomen as high as the umbilicus. Abdominal section disclosed fibroid 
tumor, involving nearly the entire fundus, especially the anterior wall 
of the uterus, and pregnancy at least two and one-lmlf months advanced 
An uneventful recovery followed. 
Case four—Mrs. L.; age, 45; married seven years. Marked abdominal 
enlargement, reaching as high as the umbilicus. The gradual cessation 
of her flow, together with her advanced age, suggested that she had 
reached the menopause. The irregular contour of the enlarged abdomen, 
positive evidence of ascitic fluid and the presence of acute pelvic periton- 
itis, together with rapid emaciation, enervation and marked anemia, were 
suggestive of malignant disease. Case No. 3 was to me at this moment 
a sort of guiding star, and the rule that we should always be on the look- 
out for pregnancy induced me to make a thorough examination, and far 
behind and to one side of inflamed exudate, which crowded down the 
anterior vaginal wall. I found a softened cervix. The anterior surface 
of the pelvic and abdominal mass was so dense that during the two 
months in which I had her under observation prior to the operation, 
neither expert obstetricians called in consultation nor I myself could detect 
fetal heart sounds. For the first five weeks under my care, the local 
peritonitis gave way and she improved, only to decline again as she 
reached a time six and one-lialf months after her flow had ceased. The 
abdomen was enormously distended, lifting up the costal and ensiform 
cartilages. The patient was aware of my belief that she was pregnant, 
and both she and her husband were emphatic in their demands that the 
child be saved alive. The sudden change in her condition was to me 
evidence that the child had been dead three days at the time of the opera- 
tion, which was made October 20. 1.897. Patient made an uneventful 
recovery. After her return home she sent her husband to procure the 
dead fetus and bury it in the family burying-ground; hence the specimen 
which I here present is minus that interesting feature—the fetus. One of 
the most interesting features disclosed by opening the abdomen in this cast1 
was that during the attack of pelvic peritonitis several coils of ileum 
became firmly adherent to the large fibroid masses shown in the specimen, 
which at that time occupied Douglas’s cul de sac. With the rapid de- 
velopment of the fibromata (which always takes place when a fibroid 
uterus becomes impregnated), and with the enormous development of 
the uterus necessary to its containing the fetus, together with an extra- 
ordinary amount of amniotic fluid, these coils of intestines were earned 
up to a position in front of the stomach and behind the ensiform cartilage, 
resulting in a tension upon these coils of bowel and their mesentery which 
3 ultimately produced dyspnoea and impaired her circulation, until the 
radial pulse “swung the red lantern in our faces, signaling a wreck ahead.” 
These cases emphasize the thought that in our process of reasoning by 
exclusion, we must occasionally accept the possibility that the physiologic 
condition of pregnac-y often complicates a pathologic one. 
These four cases call to mind the old adage that “Surgical cases 
always come in pairs.” When case No. 3 was convalescent, we believed 
it would be a long time before we would find the mate to it, but in our 
large amount of work it was only a few weeks in coming. 
The differential diagnosis between ovarian cystoma and uterine 
fibroma is not always so easy as some text books would have us believe. 
In the last four months I found an abdomen, which contained a multi- 
locular tumor, distended as high as the umbilicus. Lying in front was a 
cyst, containing dense gelatinous semi-solid substance, with no apparent 
fluctuation. Several other cysts so completely surrounded the uterus that 
by vaginal examination the uterus was inseparable from the mass, and 
the entire tumor was so completely moulded into the pelvis that one of 
the best surgeons in the West advised against operating so long that 
decomposition of the cyst in the region of the ureter made the ultimate 
recovery of the patient after the operation impossible. 
In such cases it matters very little what we call the tumors; they 
will not come by calling; they must be gone after. And since it is the gos- 
pel to women that fibroids can be removed with the same low rate of mor- 
tality as that which follows removal of ovarian cysts, and where the 
tumor is interfering with the health or happiness of the patient, a dif- 
ferential diagnosis before operating is useless. In such cases the language 
of Mr. Tait is in point: “Absolute accuracy of diagnosis is far from being 
possible; only the ignorant assert that it is, and only the fools wait for it.” 
That thorough anatomist, born surgeon and accomplished teacher, 
the lamented ITof. Chas. T. Parks, of Chicago, in his posthumous book, 
published by his widow, divides the abdominal cavity into two general 
divisions by means of a transverse line drawn through the umbilicus and 
this bisected by the median line gives four compartments. This trans- 
verse line is an arbitrary separation between those tumors which grow 
from below upwards and those which grow from above downwards. 
“Below this line,” says Parks, “the majority of tumors are not serious 
in character. Examination affords more accurate deductions. The tumors 
are amenable to common treatment. Mortality is not high primarily and 
surgical interference gives permanent relief. The exceptions to this rule 
are cases of malignant tumors of the uterus and ovaries. Above this 
line abdominal tumors, as a rule, are serious in character; deductions 
drawn from facts observed in examinations are less accurate; operative 
procedure is accompanied by higher mortality, and results obtained are 
apt not to be permanent. (Exceptions of this statement are to be found 
in tumors of the gall bladder, cysts of the pancreas and some abscesses 
and cysts of the liver.) Comparison being the key to all definite knowl- 
edge, one must be thoroughly familiar with the normal anatomy of the 
abdominal organs and the relation they bear to one another. The normal 
shape of the organ and the manner of its attachment determine in some 
degree the character of the development and the direction of the growth. 
We have, moreover, a standard with which to compare the pathologic 
4 conditions, their size, density, shape and location, following the rules of 
physical diagnosis, namely, inspection, palpation, auscultation and percus- 
sion. Where tumors grow from above downwards we can, by inspection 
above the transverse line, note that the tumor is affected by the move- 
ments of the abdomen, unless the growth is post-peritoneal or its attach- 
ments are very firm. Enlargement of the liver or spleen can generally 
be made out by dipping the hand under the abrupt inner margin of these 
viscera. I have noted, however, exceptions to these rules. In a case, 
from which I removed an ovarian abscess, I subsequently found the 
spleen hanging over the promontory of the sacrum. Four years later, 
when I removed tins spleen, I found that it had been resting upon the 
floor of the pelvis, adherent; and had I not recognized it as the spleen 
in a former examination, would have made my incision below the um- 
bilicus, instead of above. This operation was necessitated because of a 
dragging sensation in the left side. She was able to return home in two 
weeks after the splenectomy. She came to Denver for tuberculosis, dying 
six months later. 
Differential diagnosis between a prolapsed and floating kidney and 
distended gall bladder are, as a rule, easy of accomplishment; the dis- 
placed kidney swaying from side to side, but easily reverting to a position 
under the liver; the gall bladder pointing in the direction of the umbilicus, 
swaying from side to side, but not allowing itself to be replaced under 
the liver. 
In twenty-four operations for distended gall bladder, and many opera- 
tions upon the kidney, I have found some marked exceptions to this 
rule. I recall a case, which I reported some years ago in the Journal 
of the American Medical Association, in which an irregular tumor in 
the region of the gall bladder, as large as a human head, and the extremely 
jaundiced condition of the patient induced me to conclude that nearly 
all of the evidence pointed to cirrhosis of the liver. I left, however, 
a loop-hole, that exploratory incision alone could complete the diagnosis. 
Abdominal section disclosed an enormous fibro-cystic kidney, containing 
a quart or more of pus and urine, which had so compressed the gall 
bladder and liver as to cause the absorption of the coloring matter of the 
bile and the extreme jaundice. Patient lived five years. 
In the case of Mrs. M., a very fleshy woman, I could detect no en- 
largement in the immediate region of the gall bladder, but by palpation 
and percussion found decided tumefaction in the region of the right 
kidney. Examination of the urine disclosed some albumen and mucoid 
substance, which, together with the discoloration of the skin, hectic fever 
and chills, led me to believe that I had to deal with a pyonephrosis. Con- 
sultation with a genito-urinary surgeon confirmed this diagnosis. The 
usual lumbar incision was made. Sweeping the finger over the tumor, 
with a view of going beneath, it burst and poured out coagulated gall 
and pus in large quantities, which, by its pressure, had produced gangrene 
of the major portion of the gall bladder. A gall stone was found in the 
mouth of the cystic duct. Having noted in many instances extreme 
enlargement of the liver accompanying obstruction of the gall ducts, I 
passed my fingers into the peritoneal cavity, after removing the frag- 
ments of necrotic gall cyst, and found the left lobe enlarged to at least 
five times its normal size. The dimensions of the right lobe were not 
5 materially increased. In this case there was no absorption of biliary 
coloring matter and no jaundice. The abnormal condition of the urine 
was due, doubtless, to pressure upon the right kidney. 
The disorders of the abdomen are so many, their pathology so intri- 
cate, their diagnosis so important, that years might be profitably taken 
for their study. I hasten, therefore, to those pathologic conditions, the 
diagnosis of which have interested me most in recent years. Four years 
ago a patient came to me, suffering with an enormous ventral hernia. 
Twelve years previous Prof. Parvin and myself had relieved her of an 
ovarian cyst by incision from the umbilicus to the pubis. While operating 
for this hernia, my attention was called to the extreme stretching of 
the mesentery of both the small and large intestines. In fact, the hernia 
extended half way to the patient’s knees, when she stood upon her feet. 
The hernial opening being closed, the abdominal wall above the umbilicus 
projected forwards as large as an ordinary water bucket. 
A little later I saw another case, in consultation, where, protruding 
through a ventral hernia, following an abdominal section, the stretched 
mesentery admitted the formation of a mass of intestines, reaching more 
than half way to the patient’s knees. Since my observation in these cases, 
I have noticed when working in the abdomen some very remarkable 
displacements, due to the stretching of the mesentery. For example, 
within the past few weeks I demonstrated to my assistants the perfect 
ease with which the descending colon and sigmoid flexure could be placed 
over in the right iliac fossa, with a finger’s length of meso colon to spare; 
and one week ago to-day, while operating in northern Indiana, I found 
the descending colon reaching across over an immense tubal abscess into 
the right iliac fossa, firmly anchored near the right end of the right 
ligament of Poupart, then dipping deeply down into the pelvis, where it 
terminated in the rectum. I have a number of times found the cecum 
anchored by its vermiform appendix in the left iliac fossa, where I had 
first supposed it to be the descending colon, until investigation proved to 
the contrary. 
These cases of elongated mesentery have been extremely interesting 
to me, for the reason that they have been, in several instances, an im- 
pediment to diagnosis in intra-abdominal conditions. I hope, in the dis- 
cussion, some gentlemen will either confirm or disprove my idea, that fecal 
impaction in cocuin and sigmoid may stand in a causative relation to 
elongation of the meso-colon. I am quite sure that these enlongations 
of the mesentery have stood in a causative relation to cases of intestinal 
obstruction, enabling intestines to float about and become entangled in 
false ligaments (the result of peritoneal adhesions), fallopian tubes, vermi- 
form appendix, etc. In one case of volvulus, upon which I operated, 
the mesentery of the descending colon was surely two-thirds longer than 
normal. 
There is nothing so calculated to contribute to a lower mortality, 
in operations for intestinal obstruction, strangulated hernia and appendi- 
citis, as an early, carefully made and correct diagnosis. Appendicitis 
often produces intestinal .obstruction by way of its sequential peritonitis. 
I have often wondered, when called to cases of acute obstruction, why 
the practitioner did not bring to bear in the case, his knowledge obtained 
in cases of strangulated hernia, the symptoms of which are almost iden- 
6 tical with those of obstruction. Such cases are seized more or less sud- 
denly with severe abdominal pain. This pain may be constant or more 
or less distinctly intermittent; the longer the pain lasts the more does it 
become constant and continuous. The patient has vomited, the substance 
may be stereoraceous, in which case it must come from the large in- 
testines, as the contents of the small intestines are fluid, or semi-solid in 
the lower ileum. There is more or less absolute constipation with some 
distention of the abdomen. The general condition may vary from slight 
oppression to profound shock. Symptoms such as these, says Mr. Treeves, 
may depend upon the following different forms of acute obstruction: 
(a) Strangulation by bands or through apertures, (b) volvulus of the colon, 
(c) acute intussusception, (d) some form of obstruction by foreign sub- 
stance. A good example is the case from which I removed this enterolith 
from the ileum, a yard at least from the ileo-cecal valve. From this case 
1 inferred that the prolonged irritation of the stone resulted in paralysis 
of the nerve supply to the bowel; closing its lumen by shrinkage on the 
foreign body. I can in no other way account for acute obstruction in 
the ileum by a foreign body, which must have been months or even years 
in forming. I can only refer to the general significance of the leading 
symptoms of acute obstruction. 
Shock—The degrees of shock observed in acute obstruction do not 
so much depend upon the occlusion of the bowel as upon the injury in- 
flicted upon the peritoneum and intestinal walls by the strangulated 
agent. The shock in these cases is identical with that which attends 
other injuries to the abdomen; such as perforation in typhoid fever or 
gun-shot wounds; and the degree of shock will depend upon the amount 
of peritoneum or intestine involved in the lesion. If we have acute 
peritonitis, it will, as a rule, be marked by elevation of temperature and 
a pulse unmistakable. It is stated that this symptom is most marked 
in the very young or the very old; profound cases have been observed 
by competent surgeons in adults in middle life. Individual peculiarities 
exert their influence; the stamina, as the great Flint used to call it (power 
of resistance), varies materially in different individuals. 
Strangulation of the small bowels is attended with much greater 
shock, because of their direct association with the nerves of the great 
sympathetic ganglia of the abdomen. 
Fain—This symptom is often misunderstood. The word colic some- 
times answers as a soporilic to the anxiety of the patient and friends, 
and too often as a cloak to cover the ignorance of the attending physician. 
The colic-like pains are due to the irregular and peristaltic wave excited 
in the intestine. The peristaltic wave is arrested at the seat of obstruction. 
The peristaltic wave passing down the walls of the intestine is hurled 
against the obstruction, returning up the center like a piston sent down 
a cylinder, which lias an opening in its center, through which air and fluids 
return above obstruction; fluids accumulate: peristaltic wave is toward 
the pylorus, and vomiting occurs. 
Character of the Fain—In cases where the obstruction is complete 
the pain is constant; in cases where the obstruction is but partial, the 
pain is distinctly intermittent. In the interval the patient may be free 
from suffering. The lengthening of the interval of ease would suggest 
tlie partial release of obstruction; the shortening of the interval between 
7 8 the pains would indicate that the obstruction was becoming complete. 
In the earlier stage of obstruction pressure of the hands may not be 
attended with increase of pain or even with tenderness; pain may be 
relieved by pressure. Tenderness or increase of pain by pressure is in- 
dicative of hyperemia of the peritoneum or beginning peritonitis. Dim- 
inution in the severity of the pain, accompanied by other symptoms of a 
fatal termination, has no favorable significance. 
Situation of Pain—The small intestines are abundantly supplied by 
and intimately associated with the great sympathetic ganglia. These 
fickle-minded sympathetic nerves have no geographical sense; hence a 
pain coming from an obstruction in any part of the small intestine is 
expressed in the solar plexus of the sympathetic or superior mesentery 
ganglia. This holds true with other intra-abdominal conditions. In a 
large per cent, of cases of appendicitis a careful review of the history of 
the pain will show that it was first expressed above the umbilicus in the 
region of the superior mesenteric ganglia. 
As time will not permit reference to symptoms pertaining to the 
different varieties of intestinal obstruction, I can do no better than to 
emphasize the advantages of early and correct diagnosis of inflammatory 
conditions in the right iliac fossa. 
The question whether the larger number of ’cases of appendicitis, 
with resulting perityphlitic abscess, recover under medical or surgical 
treatment can never be answered with justice to the abdominal surgeon 
until he, as well as the physician, shall be permitted to bring to bear, 
during the first three days, his knowledge of diagnosis and prognosis. 
It is not only the adaptation of the right remedy to the disease, but to 
the particular stage of the disease, that determines success or failure. 
In many rapidly progressive diseases like appendicitis, which may 
ultimately require surgical interference, the abdominal surgeon should 
share the responsibility from the onset. That there are cases which 
should be entrusted to medical treatment from the beginning, I affirm: 
that the practicing physician is as capable as the experienced abdominal 
surgeon to select such cases, I most emphatically deny. At all events, 
the two should share the responsibility from the beginning and decide 
upon the following of either medical or surgical lines, and confer together 
during the progress of the case as to the most favorable moment for 
operative interference, and stop that murderous compromise—surgery when 
medicine fails. 
In intestinal obstruction, strangulated hernia and appendicitis this 
fatal compromise—surgery when medicine fails—should be avoided. “Sur- 
gery should be the hand-maid of medicine, not supplanting her mistress, 
nor yet usurping her rights, but rather assisting her to maintain them.” 
IIow often is the expert in pelvic and abdominal surgery called to 
see cases of intestinal obstruction, the diagnosis of which was as clear 
and easy as that of strangulated hernia, where the physician had used 
all manner of drastic cathartics, until the circulation and general con- 
dition of the patient drove liim in despair to ask for surgical aid. In the 
language of the lamented Lusk, “The resources of surgery are rarely suc- 
cessful when practiced on the dying.” 
1 recall an instance of strangulated hernia, where the physician had 
given cathartics for three days, and then was asked by the wife of the 
9 patient if it were possible that this old hernia had become strangulated, 
lie found and reduced, as he believed, a hernia; vomiting still continuing. 
Five days later a consultant was called. He, not daring to take the 
responsibility of so serious a case, telegraphed; I responded to liis call; 
opened the abdomen, only to find a hook of bowel, gangrenous and still 
tightly constricted by a portion of the greater omentum. I refer to this 
case, not to cast reflection upon the physician, but because I have seen 
so many similar, and for our instruction, and to take the opportunity to 
say that no incarcerated or strangulated hernia should ever be reduced 
by taxis; and that the teaching in works on surgical anatomy and in 
the surgical text books as to cutting with a button-pointed knife, so as 
to nick the band of construction, should all be rewritten; that in most 
of these cases the abdominal surgeon should make an incision free enough 
at the time of the incarceration or strangulation to diagnose the con- 
dition of the intestine we put back into the abdomen, the greater omentum 
as well, this being not infrequently associated in the hernial protrusion. 
The omentum by twisting or adhesion may maintain its constriction of a 
loop of bowel after the same has been put back in the abdomen. The 
old teaching with regard to taxis and cutting with a button knife is a 
relic of the time when the peritoneal cavity was the noli-me-tangere, 
and is repulsive to the mind of men who have hundreds of times made 
and closed much larger abdominal wounds than it would require to make 
sui’e of the condition of the hernial viscera, to return these to the abdomen, 
and to cure the hernia by Halstead’s or some other radical operation. 
Exploratory Abdominal Section—When we open the abdominal cavity 
for some well-defined tumor or pathologic condition, it is very different 
from engaging in something the beginning and ending of which can not 
be known. Any one can slash open the peritoneal cavity, but a master 
in his art will give the patient many more chances of life than the 
amateur, because his knowledge of anatomical structures and physiological 
functions added to pathological conditions, and his experience, will enable 
him to give the patient the benefit of everything known to the surgery 
of the abdomen, and nine times out of ten what we put into the abdomen 
contributes more to our death roll than what we take out; and four times 
out of five it is the dirty hands put into the abdomen which do the 
mischief. 
The great objection to any chemical sterilization of the hands and 
field of operation lies in the probable neglect of that greater virtue which 
lies in soft water, soft soap and softened elbow grease by much tritura- 
tion of microbes. Cleaning nails, five minutes scrubbing; cleaning nails 
again, five minutes more scrubbing; then a tablespoonful of powdered 
chloride of lime, until the heat of the lime begins to lessen; then sal soda 
until the hands are cooled; then immersing in alcohol. I have lost faith 
in the permangangate and oxalic acid. It leaves an acid on the hands 
last, the lime and soda an alkali last; and hands that are in the abdomen 
every day, and several times a day. will tolerate the lime and soda, 
whereas the potash and oxalic acid have proven in my work very hard 
upon the skin; and, further, bacteriological investigation by able eastern 
surgeons, as well as in our own laboratory, have shown a decided prefer- 
ence for the free chlorine produced by the lime and soda. All instru- 
ments and dressings can be boiled. Trendelenburg position can be im- 
10 provised by tipping up an ordinary slat-backed chair upon the table. 
This position is of much advantage by enabling us to throw light to the 
very bottom of the pelvis, when the patient is tipped up before the small 
window of the farm house or village cottage. 
Let the operator reflect, what am 1 going after, where do I expect 
to lind it, how shall 1 deal with it after I do lind it, and what are the 
patient’s chances of life after I’ve done my best? After making the 
incision, there should be some system in the procedure. First hunt for 
the greater omentum, drawing it gently up toward the wound to see if 
perchance a coil of bowel has not slipped through a rent in this frail 
fabric; or if it has not slipped over into one corner of the pelvis and 
produced constriction by an adhesion or being tangled with Fallopian 
tube or vermiform appendix. Next, the vermiform appendix should be 
sought for by lifting up the cecum. In women, of course, the Fallopian 
tubes should be interrogated. To do this the whereabouts of the uterus 
should first be determined. 
Great care should be taken in cases of large tumors, lest the bladder 
has become adherent, and I have repeatedly found coils of intestines 
adherent between abdominal wall and tumor, so exceedingly careful 
manipulation during the first steps of our investigation may help us out 
materially. 
Tracing the bowels from their beginning to their ending is bad prac- 
tice, conducive to shock, and will not teach us as much as going definitely 
down with fingers into those localities where pathologic conditions are 
most likely to be found. In short, every business success is only attain- 
able by minute attention to details. 
Careful, conscientious attention and skillfully doing the thousand and 
one little things make the sum total of success in pelvic abdominal sur- 
gery. He succeeds most whose diagnostic acumen is best. 
11