A REPORT OF SOME CASES OF ABDOMINAL SURGERY. 
BY J. M. BARTON, M. D., 
Surgeon to the Jefferson Medical College Hospital, Philadelphia, etc. 
(Read before the Philadelphia County Medical Society, and the specimens 
exhibited at a meeting held April 11, 1888.) 
:-By invitation of your Board of Directors I 
submit specimens this evening from cases of abdominal sur- 
gery, and present the following notes for your consideration : 
Abscess of liver. Free incision and drainage; recovery.- 
George B., aged thirty-eight years, was admitted to the medical 
wards of the Jefferson Medical College Hospital, July 29, under 
the care of my colleague Dr. Neff. The patient was suffering with 
an immense abscess of the liver, extending the area of the percus- 
sion dulness to below the umbilicus and to the left of it. At the 
request of Dr. Neff, I removed by aspiration more than a quart of 
" brick-dust " colored pus, wdth such relief that the patient was 
able to return to his home in the interior of the State. The ab- 
scess cavity rapidly refilled, and he returned to the hospital, when 
we decided to operate by the method of Dr. Ransohoff, of Cin- 
cinnati ; making an incision through the abdominal wall, five 
inches in length, at the outer edge of the right rectus muscle, per- 
mitting it to gap, fastening the edges of the wound by sutures to 
the liver, and when firm adhesions had taken place, opening the 
liver by the galvanic knife. When adhesions were found to have 
formed, and I attempted to divide the tissues of the liver with the 
galvanic knife it did not act well; at first, while white-hot, it would 
cut readily, but the resulting very free bleeding, quickly short-cir- 
cuited the current and the knife became instantly cold. After re- 
peated trials it still proved so unsatisfactory that an ordinary 
scalpel was substituted, with which the pus cavity was reached. 
An attempt to check the bleeding from the margins of the incis- 
ion, by the cautery knife, was also unsuccessful, and it was only 
by filling the wound with a number of rubber catheters, which 
happened to be at hand, that the hemorrhage was controlled. 
The abscess cavity was washed out daily with various antisep- 
tics ; it gradually closed, and the patient was discharged cured. 
When Dr. Neff saw him the following December, his weight was 
one hundred and fifty-six pounds, his pulse beat eighty to the; 
minute, and he had no evidence of hepatic disease. 2 
A REPdRT OF SOME CASES OF ABDOMINAL SURGERY. 
Epithelioma of the oesophagus; gastrostomy; death.-John 
T., aged forty-two years, a patient of Dr. Joseph Lopez, of Phila- 
delphia. was admitted to the Jefferson Medical College Hospital, 
December 5, 1884. He had suffered with difficulty in swallowing 
for one year, which had gradually increased until, at the time of 
admission, he had taken no nourishment whatever into his stomach 
for a week, and but little for the last two months. He was greatly 
emaciated. He could drink as much as three ounces of fluid, 
which would be immediately ejected with great force. A bougie 
could be passed readily to within four inches of the cardiac orifice 
of the stomach, when it was suddenly arrested. 
I performed gastrostomy December 9, assisted by Drs. S. W. 
Gross, Brinton, Pancoast, Hearn, and others. An incision two 
and a half inches long was made parallel to the margin of the ribs 
on the left side, and about one finger-breadth from them, beginning 
at the outer edge of the rectus muscle. As soon as the peritoneum 
was opened, the stomach appeared and its identity was verified by 
those present; six sutures were used to bring the viscus in contact 
with the abdominal opening, two at each side and one at each end. 
Each suture was made by placing two needles upon a fine silk 
thread ; one of them was carried between the muscular and mu- 
cous coats of the stomach for about one-third of an inch and 
brought out, both needles were then carried through the abdominal 
walls about one-third of an inch apart. Traction upon these 
sutures brought the walls of the stomach in close contact with the 
parietal peritoneum. None was tied until all the sutures were in 
in place. A silver wire suture was introduced through the outer 
coats of the stomach about the centre of the portion exposed, 
to serve as a guide when the stomach should be opened some days later. 
The patient suffered no pain or other inconvenience from the 
operation, and had no evidence of peritoneal inflammation, but not- 
withstanding that the nourishment by rectum was continued and 
well retained, he lost ground so rapidly and his exhaustion was so 
great, that we opened the stomach on the second day instead of 
waiting for the fourth or fifth day as is customary. Immediately 
on opening the stomach a rubber drainage-tube was introduced and, 
by a funnel inserted into the tube, several ounces of warm milk 
were at once given, and though this was repeated every few hours 
he continued to sink and died two days later, or four after the 
operation. 
Large uterine fibroid. Exploratory incision; universal ad- 
hesions preventing removal of uterus or of ovaries; recovery.- 
Miss Mary A., aged thirty-six years, school teacher, was sent to A REPORT OF SOME CASES OF ABDOMINAL SURGERY. 
3 
me by Dr. James Graham, in February, 1885. She had a large 
submucous fibroid, causing the uterus to rise above the umbilicus. 
The increase in size was first noticed one year ago. She formerly 
had some irritability of the bladder, which had now ceased. Her 
menstrual periods usually lasted about ten days. The ergot which 
Dr. Graham had prescribed for her was continued, and operation 
not advised. The hemorrhage, however, gradually increased, until 
by the latter part of April, when I again saw her, she had been 
obliged to abandon her occupation, and had been unable to leave 
her house for a month. 
April 27, 1885, assisted by Drs. Da Costa, Edward and Percy 
Graham, and Dr. Koons, I made an exploratory incision in the 
median line, between six and seven inches in length. The bladder 
was found entirely above the symphysis, and in the line of the 
incision. By pushing it downward and increasing the incision 
upward, I was able to gain access to the pelvis. 
The uterus was greatly and irregularly enlarged and every- 
where adherent to the surrounding structures. The intestines were 
so firmly fastened together that we were unable to find or remove 
the ovaries. The abdomen was closed with silk in the usual 
manner. The patient made an uninterrupted recovery. Full anti- 
septic precautions had been taken. 
There are some points of interest connected with the sub- 
sequent history of this case. Though previous to the operation 
she almost invariably bled for ten days at each menstrual epoch, 
and at least twice between the menstrual flows, immediately after 
the operation the excessive bleeding ceased, and for nearly two 
years she regularly menstruated but three or four days ; she did 
not lose more than the one-fourth of the quantity each day that 
she had prior to the operation and there was no bleeding -whatever 
between the menstrual periods. 
Her menstrual periods have gradually and irregularly increased 
until now, nearly three years after the operation, I find in my last 
note made this year, " No bleeding between menstrual periods, 
menstruation lasts from three to ten days, when the latter the bleed- 
ing is slight most of the time." 
Her pains have ceased since the operation, her general health 
has greatly improved, and she looks much younger. Ever since 
the operation she has been, and is now, following her occupation as 
a school teacher. Nothing was done at the operation to account 
for this improvement, which is great enough to have been con- 
sidered quite a success, if the ovaries had been removed. 4 
A REPORT OF SOME CASES OF ABDOMINAL SURGERY. 
The tumor is gradually increasing in size, and is now beginning 
to interfere with respiration. 
The next case is one of so much interest that I am anxious to 
have it on record, though the principal part of the operative treat- 
ment was not performed by myself. The laparotomy was performed 
by my colleague, when I was a member of the staff of the German 
Hospital, Dr. F. H. Gross, during his term of service; the 
herniotomy by myself, during my term, though we were both 
present and took active part in both operations. I am indebted to 
Dr. Gross for permission to report this case. 
Strangulated hernia. Operation; loss of nine inches of in- 
testine; subsequent laparotomy; several feet of bowel found ob- 
structed by inflammatory deposits; bozvel above the obstruction 
joined to bowel below the obstruction; recovery.-Frank F., aged 
eighteen years, was admitted to the German Hospital on the evening 
of March 3, 1884, with a strangulated right inguinal hernia of 
eighteen hours' duration. On opening the sac of the hernia nine 
inches of the bowel were found to be in a sloughing condition.. 
The ring was nicked, the healthy ends of the bowel made to pro- 
trude, and the gangrenous portion incised. We proposed, on the 
next day, to freshen the edges of the healthy bowel and bring 
them together. By the following morning the patient had developed 
an intense peritonitis with a temperature of 104°, and the opera- 
tion was postponed. After a week of severe illness he recovered, 
the sloughing bowel having separated in the meantime. 
Some weeks later, as he was slowly emaciating, and the dis- 
charges looked as though the artificial anus was high up the bowel, 
operative interference was decided upon. The wound was enlarged 
directly upward, at first slightly, but ultimately to the extent of 
several inches, for the purpose of joining the divided ends of the 
bowel. 
In the neighborhood of the artificial anus, a portion, to an 
extent of two or three feet, of the intestine was found strongly 
matted together by inflammatory deposits ; small projecting loops 
of a few inches in length were found free with both ends termina- 
ting in the mass. The lower end of the bowel, from which the 
slough had separated, could not readily be distinguished from any 
of the other loops ; and it soon appeared that it would be useless to 
join it to the bowel which formed the artificial anus, as it was com- 
pletely obstructed at many points. As the colon was free, and a 
few inches of the ileum, at the suggestion of Dr. Weed, then one 
of the resident physicians, it was decided to join the bowel forming 
the artificial anus to the colon. For this purpose a small opening A REPORT OF SOME CASES OF ABDOMINAL SURGERY. 
5 
was made in the caecum, and one blade of Dupuytren's enterotome 
introduced, the other being carried into the bowel forming the 
artificial anus, and the two blades clamped together. A temporary 
ligature was placed around both intestines while the toilette of the 
peritoneum was made ; they were then fastened in position, and the 
wound, about six inches in length, closed. 
The patient did well after the operation, though it was found 
necessary to reapply the enterotome twice before a satisfactory open- 
ing was obtained, three times in all. The fecal fistula rapidly 
contracted, and when I last saw him he was able to wear a pad over 
it for a week without removal; his bowels acted naturally, he was 
free from pain, gaining flesh, and was working as elevator boy at 
the hospital. 
I heard afterward that another surgeon had attempted, though 
unsuccessfully, to close the fistula. 
Ruptured ovarian cyst. Ovariotomy; death on the fourth 
day.-Mrs. D., aged fifty-four years, a patient of Dr. Hogue, of 
Houtzdale, Clearfield Co., Pa., had suffered for some years with a 
large ovarian tumor, and though she had been advised by many 
physicians to have an operation performed, she refused until symp- 
toms of suffocation appeared, when I was hurriedly summoned to 
come and operate. 
The abdomen was enormously distended, but did not present 
the typical diagnostic points which usually accompany ovarian 
tumor. 
Dr. Hogue, of Houtzdale, his brother, Dr. Hogue, of Utahville, 
and two of their office students were present and assisted at the 
operation. On incising the peritoneum, at once the contents of 
the ruptured cyst appeared in the wound. This material would 
not flow through a canula, and it was not until the incision had been 
increased to six inches that I was able to draw the glucose-like 
mass out; even then it would not run, but had to be lifted and 
drawn out by the hand. Of this substance there were in all about 
sixty pints. The abdomen was cleaned with great difficulty, the 
material was adherent to everything and had penetrated to all por- 
tions of the cavity. Both visceral and parietal layers of peritoneum 
were thickened, roughened and nodular. The cyst was ruptured 
in many places,and had probably been ruptured for a longtime. It 
had but few adhesions and these to the omentum, its pedicle was long 
and had the operation been performed before rupture it would have 
been quite a favorable case. The pedicle was tied with silk, dropped, 
and the abdomen closed. The patient scarcely suffered from shock, 
though the operation was quite prolonged. After the operation 6 
A REPORT OF SOME CASES OF ABDOMINAL SURGERY. 
she did well for two days, some of the cyst contents passing 
through the drain, but she perished on the fourth day, probably 
with septic peritonitis. 
Encysted pelvic abscess. Abdominal and visceral peritoneum 
stitched together, abscess emptied and drained; recovery.-Morris 
S., aged thirty-one years, was admitted to the Jefferson Medical 
College Hospital, June 17, 1886. He had a tumor about the size of 
the adult fist, deep in the right iliac fossa, just to the right of the 
median line. It was regular in its outline, not very painful, though 
tender on deep pressure, and it was covered by the intestines. 
He stated that he had noticed it for two years, and that it was 
nearly its present size when first discovered. He had lost flesh, but 
was still in quite fair health. No pulsation and no murmur could 
be detected. His temperature, though normal in the morning, ran 
up to 102° each evening. It was now considered as probably an 
encysted, purulent collection, although there were no evidences of 
any disease of the spine or kidneys. 
With the assistance of my colleague, Dr. 0. H. Allis, and the 
house staff, I made an incision four inches in length, beginning one 
inch above and one inch to the left of the anterior superior spinous 
process, then carried it downward and inward parallel to Poupart's 
ligament; about the same incision as is used for the ligation of the 
iliac arteries. After the muscles were divided, the transversalis 
fascia was separated until we were close to the growth, when fluctua- 
tion was readily detected. Carrying our incision toward the 
mass it was found that the parietal layer of peritoneum and that 
covering the abscess, though in contact, were not adherent. A series 
of catgut sutures and some silk ones were introduced, fastening the 
two layers of peritoneum together and surrounding the proposed 
point of incision. After verifying our diagnosis by the exploring 
needle, a free incision was made giving exit to about eight ounces 
of healthy, odorless pus. A finger introduced into the abscess 
cavity failed to discover the cause of the collection. A large 
drainage-tube was introduced, by means of which the cavity was 
daily irrigated with antiseptic solutions, the discharge gradually 
ceased, and he was sent out cured, July 26, 1886. 
Double ovariotomy; multilocular cysts about, forty pounds in 
iveight; recovery.-Mrs. Sarah McC. was sent to me by Dr. James 
Graham. She was twenty-eight years of age, married, no children,, 
and no miscarriages. She always menstruated regularly previous 
to this year; during this year she had bled two or three times each 
month. After postponing the operation once or twice in conse- 
quence of unexpected bleeding, the third time it was performed; A REPORT OF SOME CASES OF ABDOMINAL SURGERY. 
7 
though she bled on the night before and was bleeding during the 
operation. She had had no leucorrhoea, but little difficulty in 
micturition, no oedema in limbs or abdomen, no nausea and no 
vomiting. She first noticed the tumor one year ago in the right 
iliac fossa, the abdominal enlargement was characteristic, the veins 
were enlarged, the wave was well transmitted, the uterus was small 
and anteverted. 
Operation October 18, 1886; present Drs. J. C. Da Costa, 
Fisher, Graham, Koons, and Gardner. The abdomen had been 
prepared the day before with turpentine and mercury, the latter 
being still on. A two per cent, solution of carbolic acid was used 
on the sponges and instruments. The incision was four inches 
in length, there was some ascitic fluid in the abdominal cavity, the 
cyst was multilocular and had no adhesions. Its contents were 
(piite gummy, preventing the use of the canula,the pedicle was short 
and belonged to the left ovary, it was tied with silk, severed and 
dropped. 
Another cyst, springing from the right ovary and about eight 
inches in diameter, was found lying posterior to the first, it was also 
without adhesion and was removed in the same manner. The 
abdomen was cleansed with carbolic acid sponges and closed with 
silk as usual. 
The stitches were removed on the fifth and sixth days, the 
bowels were moved by enema on the eighth day. Her recovery was 
uninterrupted, the temperature never rising above 100° after the 
evening of the operation. The two cysts and their contents weighed 
about forty pounds. 
The patient was able to walk about her room at the end of 
three weeks. 
Large fibroma of the uterus. Removal of uterus and ovaries 
by abdominal section; death on the fourth day.-Mrs. S., aged thirty- 
two years, a patient of Drs. Skilling and MacOscar, of this city, had 
been ill for two years' and had been bleeding for sixteen months. 
During the last six months she had never been free from bleeding 
more than a week at any one time, and during the last ten weeks, 
she stated, she had bled daily from two to sixteen ounces, the latter 
amount only after exertion ; this confined her constantly to-her bed 
or lounge. She had a good appetite, good digestion, and was well 
nourished though exceedingly blanched. 
The diagnosis of large submucous fibroid was made when I 
first saw her, six months before, and full doses of ergot had been 
taken constantly during all that time, without effect. 
At the time of operation, the enlarged uterus reached above 8 
A REPORT OF SOME CASES OF ABDOMINAL SURGERY. 
the umbilicus, was perfectly smooth and regular in its outline and 
quite movable. 
On Decembei* 9, 1886, with the assistance of Drs. J. C. Da 
Costa, Porter, Skilling and Fisher, the operation was performed. 
I made a long median incision from the pubes to some inches above 
the umbilicus; there were no adhesions. The uterus was readily 
elevated and a short "Thomas" clamp placed upon its neck. 
After the broad ligaments had been tied and divided, the body 
of the uterus was removed about an inch above the clamp. 
As the abdomen was quite deep and its walls quite thick, it 
was utterly impossible to bring the pedicle outside, a strong silk 
ligature was passed through the neck, below the clamp, and tied on 
each side. 
When the clamp was removed the parts above the ligature were 
found to consist of uterine wall, enclosing a section of the tumor; 
on removing the latter the uterine walls required but little attention 
to make very perfect flaps, they came together without tension and 
were held in position, with their peritoneal surfaces in close contact, 
by a continuous catgut suture. The toilette of the peritoneum was 
carefully made and the abdomen closed. 
The uterus removed was about seven inches in diameter, and 
contained a submucous fibroid, attached to nearly the entire inner 
wall; in size and attachments it is nearly identical with one, also 
removed by abdominal section, which I presented to this Society 
some years ago. 
The patient rallied well from the shock of the operation, and 
by the following day was quite cheerful, with good pulse and tem- 
perature, but she had secreted very little urine. On the third day 
some regurgitation of bloody fluid occurred from the stomach, the 
temperature increased and the urine was still scanty. There was 
no abdominal tenderness or distention. By evening delirium 
occurred,and death ensued the following day. The nurse assured 
me that only three ounces of urine had been secreted during the 
four days. 
On post-mortem examination there were no evidences of 
peritonitis except slight adhesions of the bowel lying in contact 
with the uterine stump. The ureters and the bladder were 
uninjured, no bleeding had occurred, the uterine stump had 
remained well closed. The uterine wound was quite clean, no de- 
composing or offensive fluids were present. Some small portions 
of the very edges of the flaps looked as though they were beginning 
to slough, though very much less than I feared would happen when 
I ligated the neck. I think, in future, I shall content myself with A REPORT OF SOME CASES OF ABDOMINAL SURGERY. 
9 
ligating the arteries of supply and omit the ligation of the uterine neck. 
Stricture of the ileo-caecal valve; chronic obstruction of the 
bowels. Laparotomy; digital dilatation of the stricture ; recovery. 
-Mrs. Ann H., aged thirty-seven years, a patient of Dr. D. S. 
Jones, of Plymouth, Pennsylvania, was admitted to the Jefferson 
Medical College Hospital in April, 1887. She had been in good health 
until the birth of a child in May, 1886. Since then she had had 
repeated and increasing attacks of obstruction of the bowels, during 
which there were entire loss of appetite, obstinate constipation, 
constant vomiting, great abdominal pain and tenesmus, similar, she 
stated, to labor pains. Lately there had appeared at these times a 
tumor in the lower part of the abdomen, about the size of the adult 
fist; these attacks occurred about once a month, and as they lasted 
three weeks she had but a short interval of comfort between them. 
When free from the attack, she stated, that the tumor returned 
to the right iliac fossa, where she thought she could distinguish it 
by palpation and its tenderness on pressure. I was unable, how- 
ever, to recognise, at this time, any unusual mass in this situation. 
I kept her under observation until an attack should occur. 
On May 1 an attack began, and her sufferings fully verified her 
statements. The tumor appeared between the umbilicus and the 
pubes; it was about the size and very nearly the shape of the adult 
kidney. 
On May 2, 1887, in the presence of Professors Gross, Parvin, 
Brinton and several other physicians, I made a median incision 
about four inches in length and exposed the mass; it proved to be 
an intussusception of the ileum into the colon with a thickened and 
-contracted ileo-csecal valve forming the apex of the intussusceptum. 
There was slight adhesions between the contiguous layers of 
peritoneum covering the bowel, which were readily broken up, and 
the intussusception reduced. 
On examining the ileo-ciecal valve by a finger invaginating a 
fold of the colon, it was found to be hard and contracted. A 
longitudinal incision was made in the colon about one inch in 
length, and three from the valve, through which I passed my finger 
and found the valve contracted to about the size of a crow's quill 
(one-fifth of an inch). It was slightly thickened, quite hard, white 
in color, and did not bleed during the examination or subsequent 
manipulations. It was considered by'all present to be a case of 
cicatricial stenosis, due to some previous inflammatory action, and 
certainly not malignant. It was dilated, with considerable diffi- 
culty, by the introduction of the little finger, the index finger was 
then carried through its entire length. 10 
A REPORT OF SOME CASES OF ABDOMINAL SURGERY. 
The wound in the bowel was closed by a double line of sutures,., 
the first being a continuous silk suture, including only the mucous 
membrane; the second was a continuous silk Lembert suture, bring- 
ing the peritoneal coats in apposition. 
All the operative procedures upon the bowel were performed out- 
side of the abdominal cavity,the abdominal wound being kept closed 
by sponges. The portion of bowel outside was thoroughly washed 
and returned, and the abdominal wound closed in the usual manner. 
There was some vomiting after the operation, the patient was 
kept slightly under the influence of morphia for a few days, and on 
a milk and broth diet. The bowels opened naturally on the eighth 
day, the stitches were removed on the fifth and sixth days; the 
temperature never rose above 100°. She returned to her home 
entirely free from all her previous symptoms, and remained free 
for several months. 
[Her subsequent history appears later in this paper, j 
Obstruction of the pylorus. Digital dilatation by Loreta's 
nu-thod; death from exhaustion.-George H., german, aged fifty- 
eight years, a blacksmith. His health had always been good until 
the last year. At the time he came under my care he had the 
typical symptoms of complete pyloric obstruction, with a well- 
marked tumor at the usual situation; it was not very large nor 
hard, had no marked outlines, and presented the characters of 
pyloric thickening more than those of a malignant growth. The 
microscopical examination of the matters vomited gave no evidence 
of malignancy, and no vomiting of blood had occurred. He was 
greatly emaciated, and so feeble that at first I refused any operative 
interference; the operation had, however, been explained to him,, 
and its performance promised before he came under my care, and 
he insisted so strongly on having a chance for prolonging his life 
that I consented. 
The operation was performed at Jefferson Medical College 
Hospital, May 22, 1887, in the presence and with the assistance of 
Professor Brinton, Dr. Wirgman, and quite a number of others. 
As the patient's condition warranted no further interference 
than mere dilatation of the pyloric orifice, and as the usual incision 
to the right of the median line would have exposed the stomach 
nearer to the pyloric orifice (as shown by the position of the tumor) 
than I desired, I made the incision directly in the median line, and 
about three inches in length, beginning an inch and a half below 
the ensiform cartilage. 
The stomach was readily exposed three inches from the pylorus- 
The examination of its exterior threw no new light on the character A REPORT OF SOME CASES OF ABDOMINAL SURGERY. 
11 
of the growth, though the stomach at this point was found to be 
slightly adherent to the structures beneath An incision, a little 
over one inch in length and three inches from the pyloric orifice, 
was made in the stomach, parallel to and directly beneath the 
abdominal incision. The coats of the stomach were much thickened. 
Complete stenosis of the pyloric orifice was found when the finger 
was introduced, this was readily dilated with the little finger, while 
the tumor was supported outside the abdominal w\alls with the left 
hand. The orifice was then further dilated by the index finger. 
The thickening and infiltration of the walls of the stomach at 
the point of incision, prevented the use of the Lembert suture, their 
softened condition evidently required the suture to pass through 
all the coats. As the abdominal wound was directly over that in 
the stomach, the latter was closed and brought in contact with the 
abdominal wound, so that the visceral and parietal peritoneum 
might adhere, and if any of the contents of the stomach should 
escape or any pus form, they might readily drain outside and not 
into the general peritoneal cavity. Fine silk with two needles 
were used, these were carried from within outward through all the 
coats of the stomach, one needle through each lip, then crossed and 
one brought through each lip of the abdominal wound, a few were 
carried directly without crossing. Before these were tied the rest of 
the abdominal wound was closed. The sutures passing through both 
stomach and abdominal wound were brought together but lightly. 
Nothing was given for the first twenty-four hours by the 
stomach, the rectal nourishment upon which he had relied previous 
to the operation being continued. No vomiting occurred during 
the four days that he lived. On the second day milk and hot water 
were given in small doses at regular intervals, and as they were well 
borne they were increased in quantity and frequency. Notwith- 
standing the fact that he took over a quart of milk per day, besides 
rectal nourishment, he sank and died exhausted on the fourth day 
after the operation. There had been no elevation of temperature. 
At the autopsy the stomach was found firmly fastened to the 
abdominal wall; there was no evidence of any peritonitis. In the 
interior of the stomach it was difficult to find the point at which 
the incision had been made, the sutures being completely buried in 
the folds of the mucous membrane. The pyloric thickening was 
inflammatory in character, and not due to any malignant growth. 
There was complete obstruction previous to the operation, there 
was none after, and had the patient been subjected to operative 
interference earlier there is no reason why his life might not have 
been greatly prolonged. 12 
A REPORT OF SOME CASES OF ABDOMINAL SURGERY. 
Ovarian tumor. Removal; recovery.-Miss A., aged thirty- 
eight years, had noticed a painless abdominal enlargement for a 
few months. On examination I found a small ovarian cyst, lying 
in the median line and rising slightly above the umbilicus. On 
May 23,1887, with the assistance of Drs. Da Costa. Edward Graham, 
Sweet and Fisher it was removed. The incision was about three 
inches in length, the tumor was non-adherent. It was tapped, 
drained, and removed in the usual manner; its pedicle was tied 
with silk and dropped. 
The peritoneum was brought together with chromicized catgut, 
the interrupted silk suture being used for the other tissues. The 
patient made an uninterrupted recovery, her temperature never 
rising above 99°. The tumor weighed about fifteen pounds. 
Two penetrating stab wounds, one puncturing the liver and one 
the transverse colon. Laparotomy; recovery.-Michael H., aged 
twenty-five years, was admitted to the Jefferson Medical College 
Hospital at 3 p.m., of September 9, 1887. About three hours 
previously he bad been stabbed twice with a small and pointed 
amputating knife, during a quarrel in a house of ill-fame. 
There were two wounds, both penetrating the abdominal cavity, 
both at the outer edge of the right rectus muscle and both running 
diagonally toward the median line, and penetrating the peritoneum 
at that point. The upper was one and a quarter inches long and 
was just below the edge of the ribs, it terminated in the left lobe 
of the liver. From it there was free venous bleeding. 
The lower wound was three-quarters of an inch long ; it was 
three inches below the upper and just above the level of the um- 
bilicus. After hurried antiseptic preparations, I opened the abdo- 
men in the median line from the ensiform cartilage to the umbilicus, 
and found an opening about five-eighths of an inch in length in the 
transverse colon parallel to its length and near its mesenteric 
attachment; this was closed by the continuous silk Lembert suture. 
The suture failed to control a small artery in this wound, but a 
separate stitch carried under it and tied secured it. 
The wound in the liver was small, it had ceased oozing, and 
as its lips were in fair contact no suture was used. The abdomen 
was cleansed, the wound closed and dressed in the usual manner. 
The following morning his temperature was 101° and in the 
evening 100°; after that, though it kept quite low, varying from 
98|° to 99|°, he had a sharp attack of peritonitis, lasting three 
days, during which time there was constant regurgitation of bloody 
fluid. The abdomen was painful and greatly distended with gas, 
requiring the constant use of the long rectal tube to relieve him. A REPORT OF SOME CASES OF ABDOMINAL SURGERY. 
13 
The stitches were removed on the fourth and fifth days, and the 
abdomen supported by adhesive plaster. He was discharged, 
cured, on September 29, having been in the hospital twenty 
days. 
Epithelioma of the ileo-c&cal valve. Resection of three inches 
of intestine ; recovery.-Mrs. H., aged thirty-eight years, the same 
patient whose ileo-ca?cal valve was dilated seven months before 
(see preceding page), came complaining of a return of her former 
symptoms, her sufferings were slight, but were evidently of the 
same character as before the first operation. 
November 1, 1887, with the assistance of Drs. Allis, Kendigr 
Stillwell, and the resident staff, I again opened the abdomen. A 
straight incision parallel to the median line was made. It was 
three inches in length, terminating at a point one inch outside the 
middle of Poupart's ligament. The incision was made at this 
point as the nearest to the portion of bowel I wished to attack, 
because I feared adhesions might have formed after the last opera- 
tion, rendering it inaccessible from any distant incision; and, fur- 
ther, if it became necessary to form an artificial anus, it would be 
a convenient point. 
I had decided that if it should prove to be a recontraction of 
the stricture, to make a longitudinal incision about two inches in 
length carried through ileum, ileo-ciecal valve and caecum, bringing 
the two ends of the wound together and sewing it up transversely ; 
this would best be made on what would be the under surface of 
the bowel when the patient stands erect. I tried this on the 
cadaver and found it practicable, and that it increased the circum- 
ference of the bowel, at that point, about two inches. 
The head of the colon was readily found, there was no return 
of the intussusception, no adhesions had formed, though in re- 
ducing the intestine at the first operation there had been slight 
bleeding at a number of points where adhesions were torn. The 
scar of the original intestinal incision was scarcely perceptible. At 
the ileo-caecal valve, however, there was now a decided tumor, and 
it was now evidently epitheliomatous. 
An incision was carried into the mass, verifying the diagnosis. 
The entire valve had become an irregular mass of epitheliomatous 
tissue varying in thickness from half an inch to an inch, entirely 
obstructing the gut except an aperture in the centre, about one- 
third of an inch in diameter. The circumference of the valve was 
less thickened by the disease than the centre. 
The abominal wound was now closed by sponges, leaving the 
diseased parts outside; three inches of the bowel, including the 14 
A REPORT OF SOME CASES OF ABDOMINAL SURGERY. 
disease, were removed, no clamps were used, the bowels being held 
in the hands of an assistant; a few vessels were tied. 
As the mortality is very high when the separated ends of the 
bowel, in these operations, are sewed together and returned, I had 
decided if it became necessary to excise, to establish a temporary 
artificial anus and begin at once the proceedings for its cure. With 
this end in view, immediately after the removal of the diseased 
bowel and the ligation of the bleeding vessels, one blade of 
Dupuytren's enterotome was introduced into each portion of bowel, 
viz., one into the ileum and one into the colon, the two blades were 
brought together and the screw run down firmly. A strong liga- 
ture was placed on the ends of the bowel, including the enterotome, 
to prevent the escape of feces during the subsequent manipulations. 
The bowel was washed, placed in position at the lower angle of 
the wound and fastened there with a continuous silk suture. The 
abdominal wound was closed, covered with cheese cloth saturated 
with mercurial solution, and this in turn with patent lint soaked 
in sweet oil. This is the best method that 1 have found to protect 
abdominal wounds close to an artificial anus. 
The heavy ligature around the ends of the bowel was now re- 
moved. A ring of cotton soaked in oil was placed around the 
artificial anus, the outer extremity of the enterotome supported by 
oakum, and a wide bandage pinned over it. 
Morphine was used hypodermically during the first forty-eight 
hours and then discontinued ; vomiting occurred during the first 
two days and then ceased. Some feces appeared on the evening of 
the operation, and full quantities two days later. 
On the eighth day the enterotome was found loose, and was 
removed ; its removal was preceded by a passage of feces from the 
natural outlet. The stitches were removed on the third and fourth 
days, and the wound supported by adhesive plaster. After the 
removal of the clamp the patient was permitted to rise, and all re- 
strictions removed from her diet. 
The bowels acted naturally for a few times, when all the feces 
came again from the artificial anus. The clamp was again applied 
on the 17th, and came away on the '25th. Its removal was again fol- 
lowed by a few natural passages. As these ceased in a few days the 
clamp was applied for the third time with a precisely similar result. 
As this had proved ineffectual, the methodof Mr. Banks, of 
Liverpool, was used. A strong ligature was fastened to the middle 
of a heavy piece of rubber gas-tubing about six inches in length, 
one end of the tube was passed into one bowel, the other end of 
the tube into the other bowel, the middle of the tube pressing 
against the spur. The position of the bowel in this case was such 
that the rubber tube was retained with difficulty. After trying it 
for ten days without success, I substituted the apparatus which I 
here show, consisting of two pieces of very heavy rubber gas- 
tubing joined together like the letter *[*• The upper part of the T 
is about one and a half inches long, and presses directly against 
the spur; the other tube is three inches long, and merely serves to 
keep the first in position. The large base is circular, is three 
inches in diameter, and serves as a pad to prevent the escape of A REPORT OF SOME CASES OF ABDOMINAL SURGERY. 
15 
feces from the artificial anus. The three pieces of rubber are 
joined firmly by a strong wire running from the first to the last 
piece, and twisted tight. This method proved at once satisfactory, 
and a large proportion of the feces began at once to pass by the 
natural outlet, and continued to do so. The patient is now in the 
hospital, but I shall make no attempt to close the fistula until it is 
seen if the bowels will continue to act naturally. 
During the prolonged treatment, fearing that the colon, from 
disuse, might contract, I directed that she should be given an in- 
jection of a quart of water daily, and I was surprised to hear that 
when a pint had been given it appeared at the artificial anus. By 
continuing these injections the capacity of the colon was rapidly 
increased, and when last tried it held three pints; of course when 
the bowels began to act naturally this was discontinued. 
Chronic obstruction of the bowels by encephaloid tumor. Explo- 
ratory laparotomy; artificial anus established; recovery from the 
operation; death fourteen days later from obstructive peritonitis 
arising from tumor.-Francis 0. B.,aged thirty-eight years, Irish, 
■carpet porter, a patient of Dr. James Robinson, with whom I saw 
him January 18, 1888. He was in perfect health until June, 1887, 
when he began to have slight cramps, once or twice daily, and 
occasionally at night, in the left iliac fossa. He continued working 
until December 24, 1887,and bad been confined to bed since. His 
attacks had not increased greatly in severity, but he was getting 
much weaker. He had lost fifty pounds in weight; he vomited 
once or twice a week; it was not stercoraceous. He suffered 
greatly with tenesmus, which produced from ten to fifteen passages 
during the night, each being a small, hard, white mass about the 
size of a cherry. 
The left iliac fossa was slightly tender. The abdomen was dis- 
tended with gas. The pulse was 104, and the temperature normal. 
His pain was uninfluenced by food. He had never passed blood by 
the bowel. The rectum was found empty and unobstructed. 
Later I removed him to Jefferson Medical College Hospital, by 
which time his pain was nearly constant, and he was unable to sleep 
without large doses of morphine. Some days after admission, his 
temperature increased to 103° ; there was increased abdominal ten- 
derness and other evidences of a slight attack of peritonitis, which 
disappeared in forty-eight hours. On the 28th he passed wind by 
the penis, and again on the 30th. 
On January 30, 1888, with the assistance of Drs. Allis, Xan- 
crede and Robinson, and the house staff, I opened the abdomen. A 
median incision about four inches in length was made, and a lobu- 
lated tumor the size of an orange was found in the angle between 
the bladder and the spine. The sigmoid flexure of the colon was 
tightly adherent to and partly buried in the tumor. The caecum 
was carried toward the median line, and was also adherent to the 
tumor. The lower end of the ileum was closely adherent, and its 
calibre nearly obliterated. 
The colon was contracted and collapsed ; the bowels above the 
point of obstruction in the ileum were greatly distended. 
As nothing could be done with the growth, a fold of the ileum A REPORT OF SOME CASES,OF ABDOMINAL SURGERY. 
16 
a few inches above the point of obstruction was brought ont of the 
wound and fastened in its lower angle by a few silk sutures, a rubber 
drain was introduced, as a glass one failed to reach the desired 
point, and the abdomen closed. The drain was removed about 
twelve hours later, as I feared to have it remain in such close prox- 
imity to the artificial anus. Twenty-four hours after the operation 
the fold of bowel in the wound was opened, and the artificial anus 
established. 
On the second day the patient was placed upon his usual food, 
stimulants, etc. The stitches were removed on the fourth and fifth 
days ; the wound healed promptly. It was successfully kept from 
contamination by the fecal discharges, by the method described in 
a case reported above. 
At the operation a fold of bowel was brought entirely out of 
the wound ; this was adopted as a modification of the method of 
entirely cutting off the bowel, closing the lower end with sutures, 
and using the upper to form the artificial anus. 
The method here adopted has the advantage of rapidity, and 
less danger of contaminating the cavity with fecal matter, as the 
opening of the bowel may be postponed until firm adhesions have 
formed. It permits any gases or other material that may be impris- 
oned in the lower bowel to escape, and quite as effectually prevents 
any material passing the artificial anus into the lower bowel. 
The patient was relieved of his pain, the vomiting ceased, and 
he slept well; had a fair appetite and improved in appearance. All 
fecal discharges, and they were very copious, came from the artifi- 
cial anus, and none by the natural outlet after the first twenty-four 
hours. 
On the thirteenth day there was a slight elevation of temper- 
ature, and all fecal discharges suddenly ceased, injections of warm 
water carried some distance above the opening by a soft catheter 
were without effect; by evening vomiting and other symptoms of 
acute obstruction occurred, and he died twenty-four hours later, or 
fourteen days after the operation. 
The post-mortem examination was made on the same day. The 
abdominal wound was solidly healed; the bowel at the artificial 
anus was firmly attached to the abdominal opening. The abdomi- 
nal cavity contained quite a quantity of opaque serum; the opacity 
was greatest near the tumor, and on pressing the tumor, thick, 
purulent-looking fluid exuded from it. This was probably the origin 
of the fatal peritonitis. The bowels were but slightly congested, 
and at one point only, about twelve inches above the artificial anus, 
were adherent. The bowel at this point was sharply flexed upon 
itself, and adherent for about three inches, causing complete 
obstruction. This adhesion was readily broken down by the finger, 
and it would probably have yielded to an active saline. 
The condition of the bowels, as found at the time of the oper- 
ation, was verified. The tumor was broken down, and had ulcerated 
into the sigmoid flexure; a large number of secondary nodules were 
scattered through the liver. The microscopical examination was 
made by Dr. Longstreth ; the tumor and the nodules from the liver 
were reported by him to be encephaloid.