Nine Months' Work 
IN 
ABDOMINALSURGERY 
BY 
CLINTON CUSHING.. M. D. 
PROFESSOR OF GYNECOLOGY, COOPER ME3ICAL COLLEGE, 
San Francisco, Cal. 
REPRINT FROM 
Pacific Medical Journal 
JULY, 1890. i.No 1 
Name of 
Medical 
Attendant. 
Date 
of 
Operation. 
Married or 
Single 
Number of 
Children 
Size and Nature 
of 
Tumor. 
One or both 
Ovaries 
Adhesions 
Treat- 
ment 
of 
Pedicle. 
|Drainage 
Complica- 
tions. 
Hospital 
or 
Private. 
Result. 
Remarks. 
1 
Dr. Crabbe, 
July 
28, '89 
33 
M. 
None 
Intra -ligamen- 
One 
Universal 
Tied and 
Yes. 
Pyelitis and 
Private. 
Recovery 
Operation attended 
Millville 
tous papilloma- 
dropped 
cystitis, three 
with great diffleul- 
tous cyst, size of 
a b d o m i n al 
ty, ou account of 
adult head. 
hernias, and 
extent and number 
Dr. C. Cushing. 
San Francisco 
ascites. 
of adhesions. 
2 
Nov 
16, '89 
52 
M. 
None 
Cyst of both ova- 
Both 
Right one 
ll 
Yes. 
Rupture of 
Private 
Death. 
Died on 19th day 
ries, size two- 
adherent 
right cyst be- 
Hospital 
from purulent peri- 
thirds that of 
to vermi- 
fore operation 
tonitis. 
adult head. 
form ap- 
and develop- 
p e n d 1 x 
ment of acute 
3 
Dr. Wm. Jones, 
San Francisco 
Dec. 
9, '89 
14 
M. 
Eight 
Simple ovarian 
cyst, size of a 
One 
and bowel 
Slight. 
No. 
peritonitis. 
None. 
Private. 
Recovery 
water-bucket. 
ABDOMINAL SECTIONS FOR THE REMOVAL OF OVARIAN TUMORS. 
ABDOMINAL SECTIONS FOR REMOVAL OF UTERINE APPENDAGES NOT THE SEAT OF TUMOR. 
3 
o 
Name of 
Medical 
Attendant. 
Date 
of 
Operation. 
9®V 
Married or 
| Single 
Number of 
Children 
Pathological 
Condition or 
Symptoms 
necessitating 
Operation. 
| Duration of 
(Disease 
What 
Removed 
Adhesions... 
Treatment 
of Pedicle.... 
Drainage 
Hospital 
or 
Private. 
Recovery or 
Death 
Complica- 
tions before 
or after 
Operation. 
Remarks. 
Effect of Operation 
upon condition 
requiring it. 
1 
Dr.R.C. Meyers, 
June 20, '89 
32 
M. 
None 
Pyo-salpynx and 
5 yrs. 
Both 
Many. 
Tied 
Yes. 
Hospital 
Recov- 
Severe previ- 
Great emaciation 
San Francisco 
intra peritoneal 
tubes 
and 
ery. 
ous attacks 
from exhausting 
abscess in Doug- 
and 
drop'd. 
of pelvic in- 
discharge from pel- 
lass pouch. 
ovaries. 
flammation. 
vic abscess. Re- 
2 
Dr. Gross, 
Aug. 6, '89 
33 
M. 
None 
Enormous pyo- 
5 mos. 
Lft tube 
Many. 
44 
Yes. 
• „ 
44 
None. 
covery perfect. 
Recovery perfect. 
San Francisco 
salpynx, opening 
& cystic 
Dr. J. D. Whit- 
into rectum. 
ovary. 
3 
Aug. 6, '89 
41 
M. 
Three 
Double pyo-sal- 
6 mos. 
B >th 
Many. 
44 
Yes. 
44 
44 
Persistent 
Recovery perfect. 
ney, 
pynx, discharg- 
ing by rectum. 
tubes 
d i a r r h ce a 
San Francisco 
and 
and indiges- 
Dr.Louis Bazet, 
San Francisco 
ovaries. 
tion. 
4 
Aug. 21, '89 
38 
M. 
None 
Pyo-salpynx of 
right Fallopian 
9 yrs. 
Right 
tube 
Many. 
44 
Yes. 
44 
None. 
Symptoms much 
alleviated and 
tube. Great pain 
and incapacitat'd 
and 
ovary. 
health restored. 
from exercise. 
5 
Dr. L. C. Lane, 
San Francisco 
Aug. 22, '89 
24 
M. 
None 
Pyo-saipynx and 
3 yrs. 
Lft tube 
Yes. 
44 
Yes. 
Private. 
44 
None. 
Gonococci found in 
acute peritonitis. 
and 
d i s c h a r ges from 
Dr. B. F.Clarke, 
ovary. 
cervical canal. 
6 
Aug. 26, '89 
32 
M. 
Two 
Retroversion and 
10 yrs. 
Left 
Many. 
44 
No. 
44 
*4 
Cystitis. 
Condition very 
Chico- 
fixation of uterus, 
enlargement and 
tube 
much improved. 
and 
fixation of left 
tube and ovary, 
ovary. 
with much pain, 
and chronic cys- 
Dr. Artiguez, 
titis. 
7 
Sept. 19, '89 
29 
M. 
One. 
Prolapse,enlarge- 
12 yrs. 
Both 
Uni- 
44 
No. 
Hospital 
44 
N e p h r i t is, 
Health restored. 
San Francisco 
ment and fixa- 
tubes 
versal. 
right kidney. 
tion of both ova- 
and 
Dr. Hund, 
ries. 
ovaries. 
8 
Sept. 24,'89 
34 
M. 
Two 
Prolapse,enlarge- 
1 yr. 
Left 
Many 
Ct 
Yes. 
Private 
44 
Pelvic a b- 
Uterus stitched to 
San Francisco 
ment and fixa- 
tube 
and 
Hospital 
scess 10 days 
anterior abdominal 
tion of left ovary. 
and 
firm. 
after opera- 
wall. Health ex- 
Dr. W. S. Taylor 
ovary. 
tion. 
cellent. 
9 
Aug. 7, '89 
u 
M. 
One. 
Uterus retrovert- 
Sever'l 
Both 
Many. 
44 
No. 
4C 
44 
None. 
Excellent recovery 
Livermore 
ed and fixed; ova- 
ries prolapsed, 
years 
tubes 
and 
ovaries. 
enlarged and 
fixed, with great 
pain. 
Extensive cystic 
10 
Dr. Henry Gib- 
Oct. 19, '89 
34 
M. 
Two 
12 yrs. 
Both 
Yes. 
44 
No. 
44 
44 
None. 
Excellent recovery 
bons, Jr. 
disease of ovaries 
tubes 
San Francisco 
some of cysts the 
and 
Dr. Hertzstein, 
size of hen's eggs. 
ovaries. 
11 
Nov. 18, '89 
38 
M. 
Four 
Prolapse,enlarge- 
3 yrs. 
Both 
Slight. 
ft 
No. 
44 
<4 
None. 
Local symptoms 
San Francisco 
ment and great 
ovaries 
relieved and health 
tenderness of 
and 
much improved. 
both ovaries ; re- 
r. reversion of 
uterus. 
tubes. 
12 
Dr. Perrone, 
San Francisco 
Dec. 16, '89 
23 
S. 
None 
Pyo-salpynx. 
1 yr. 
Both 
Many. 
44 
Yes. 
44 
44 
Repeated at- 
tubes 
tacks of pel- 
and 
vic peritoni- 
Dr. McNutt, 
ovaries. 
tis. 
13 
Dec. 16, '89 
28 
M. 
Two 
Prolapsed, en- 
4 vrs. 
Both 
Many. 
*» 
No. 
44 
44 
None. 
Performed Tait's 
San Francisco 
larged and adhe- 
tubes 
operation on peri- 
Dr. Martin, 
rent ovaries. 
and 
ovaries. 
n aeum at same 
time. 
14 
Jan. 28, '90 
31 
M. 
None 
Pyo-salpynx, 
10 yrs. 
Both 
Uni- 
44 
Yes. 
Hospital 
Death. 
Many at- 
San Francisco 
opening into rec- 
tubes 
versal. 
tacks of pel- 
turn for eight 
and 
vic i n fl a m- 
years. 
ovaries. 
mation. 
ABDOMINAL HYSTERECTOMY. 
3 
p 
• 
Name of 
Medical 
Attendant. 
Date 
of 
Operation. 
Married or 
Single 
Number of 
Children 
Pathological 
Condition or 
Symptoms 
necessitating 
Operation. 
Duration of 
Disease 
Nature of 
Operation. 
Adhesions... 
Drainage 
Hospital 
or 
Private. 
Recovery or 
Death 
Complica- 
tions before 
and after. 
Remarks and 
Subsequent 
History. 
1 
Dr. Jas. Keeney 
San Francisco 
Aug. 6, '89 
40 
M. 
None 
Sub-mucous fi- 
broid, size of co- 
coanut ; uterine 
hemorrhage for 
thirteen years. 
13 yrs. 
Tumor and 
uterus removed 
through a b- 
dominal incis- 
ion, bleeding 
vessels ligated, 
excavation of 
stump of cervix 
and approxi- 
mation with 
catgut sutures. 
No. 
No. 
Private. 
Recov- 
ery. 
Hysteria. 
Excellent recovery 
2 
Dr. C. N. Ellin- 
wood, 
San Francisco 
Nov. 15, '89 
39 
M. 
Three 
Sub-mucous fi- 
broid, size of co- 
co a n ut, profuse 
uterine h e m o r- 
rhages. 
Fibro-cystic tu- 
rn o r o f uterus, 
rapid growth. 
4 yrs. 
Same as above 
case. 
No. 
Yes. 
Private 
Hospital 
Death. 
Faecal fistula 
on 9th day, 
and pelvic ab- 
scess. 
Death on 13th day 
from p e ri to nitis 
and exhaustion. 
3 
Dr. Pawlicki, 
San Francisco 
Jan. 21, '90 
42 
-J. 
Two 
3 yrs. 
Removal of 
uterus at inter- 
n a 1 os, with 
tubes and ova- 
ries. Intra-ab- 
dominal treat- 
mentof pedicle. 
No. 
No. 
Private. 
Recov- 
ery. 
Before opera- 
tion, great ir- 
ritab ility of 
stomach. 
1 
Dr. C. Cushing, 
San Francisco 
Oct. 24, '89 
19 
M. 
Two. 
Epithelioma of 
cervix and round 
cell sarcoma of 
body of uterus. 
1 yr. 
Removal of en- 
tire uterus per 
vaginam. 
None 
No. 
Private 
Hospital 
Recov- 
ery. 
Urine escaped 
from right 
ureter per va- 
ginam, on 9th 
day- contin- 
ued nve days. 
Excellent recovery 
VAGINAL HYSTERECTOMY. 
LAPAROTOMIES FOR OTHER DISEASES OF ABDOMINAL ORGANS. 
!!No 
Name of 
Medical 
Attendant. 
Date 
of 
Operation. 
> 
crc 
CD 
Married or 
i Single 
Number of 
Children 
Pathological 
Condition or 
Symptoms 
necessitating 
Operation. 
Duration of 
Disease 
Nature of 
Operation. 
Drainage 
Hospital 
or 
Private. 
Recovery or 
Death 
Complica- 
tions before 
or after. 
Remarks and 
Subsequent 
History. 
1 
Dr. Thos. Boy- 
son, 
San Francisco 
May 21, '89 
28 
S. 
None 
Large encysted 
pelvic haemato- 
cele, with much 
pain. 
1 yr. 
Exploratory i n c i sion 
and subsequent punc 
ture of h asm at oc e le 
from vagina; s e 1 f- r e - 
taining drainage tube. 
Yes. 
Hospital 
Recov- 
ery. 
None. • 
Well marked 
uterus bi-cornus. 
S 1 ight discharge 
from cavity of 
heematocele at end 
of 3 mos. Health 
2 
Dr. J. O.Hirsch- 
July 16, '89 
40 
M. 
None 
Ventral hernia. 
6 mos. 
Abdominal section, ex- 
No. 
Private. 
Recov- 
None. 
good. 
Cure. 
felder, 
San Francisco 
tirpation of loose tissue, 
and careful adjustment 
ery. 
3 
Dr. Trask, 
Aug. 12, '89 
28 
M. 
Two 
Fistula at lower 
6 mos. 
of opposing surfaces 
with silk-worm gut. 
Dilatation of biliary 
No. 
Private. 
Recov- 
None. 
Recovery excel- 
Austin, Nev. 
angle of former 
abdominal incis- 
ion, caused by 
silk suture; dis- 
fistula and removal of 
gall stone from gall 
bladder. Abdominal 
section and removal of 
ery. 
lent. 
4 
Dr. M.A.Cachot 
San Francisco 
Aug. 28, '89 
30 
M. 
charge from bil- 
iary fistula 
Suppurating pel- 
vic haematocele. 
6 mos. 
cause of fistula. 
Abdominal section, 
separation of adhe- 
sions, removal of clots, 
Yes. 
Hospital 
Death. 
Adhesions 
universal and 
very firm. In- 
Case des perate; 
great exhaustion 
and emaciation. 
free irrigation. 
jury to rec- 
tum in sepa- 
rating ad he- 
sions. 
5 
Dr. O. Perrone, 
San Francisco 
Aug. 11, '89 
20 
M. 
None 
Strangulated in- 
guinal hernia, 
right side. 
3 days 
Exploratory incision in 
median line, for diag- 
nostic purposes. Divis- 
ion of tissues over stran- 
gulated gut and return 
of bowel. 
No. 
Private. 
Recov- 
ery. 
Miscarriage of 
3 mos. preg- 
nancy after 3 
days. Fee cal 
fistula at site 
of hernia on 
7th day. 
Perfect recovery 
at the end of a 
month. 
6 
Dr. Z. W. Saun- 
ders, 
S'n Luis Obispo 
Sept. 20, '89 
24 
M. 
One 
Extra -uterine 
pregnancy of six 
months duration. 
6 mos. 
Abdominal section, li- 
gation of broad liga- 
ment and adhesions, 
removal of sac and con- 
tents complete. 
Yes. 
Hospital 
Death. 
Marked sh'ck 
tro u blesome 
oozing from 
denuded sur- 
face in Doug- 
lass pouch. 
Cause of death, 
peritonitis. Foetus 
living at the time 
of removal. 
7 
Dr. Gross, 
San Francisco 
Dec. 22, '89 
10 
M. 
Eight 
Abdominal ab- 
scess extending 
5 w'ks. 
Abdominal section, re- 
moval of left tube and 
Yes. 
Private. 
Recov- 
ery. 
None. 
from region of 
liver to Douglass 
ovary; free opening 
made into abscess cavi- 
8 
Dr. J. D. Whit- 
ney, 
Jan 20, '90 
51 
M. 
None 
pouch. 
Intra-1 i g a m e n- 
tous cyst. 
1 yr. 
ty; insertion of four 
drainage tubes. 
Enucleation of cyst. 
Yes. 
Private. 
Death. 
Universal; 
small i ntes- 
Death from shock 
and exhaustion. 
San Francisco 
tines and 
bladder in- 
jured. 
Recovery perfect. 
9 
Dr. Black, 
Jan. 22, '90 
53 
M. 
Ten 
Complete pro- 
5 yrs. 
Ventral fixation of 
No. 
Private 
Recov- 
None, 
San Francisco 
lapse of uterus 
and bladder. 
uterus. 
Hospital 
ery. NINE MONTHS' WORK 
IN 
Abdominal Surgery. 
By CLINTON CUSHING, M. D. 
Professor of Gynecology, Cooper Medical College, San Francisco. 
[Read before the San Francisco Obstetrical Society, May 8th, 1890.] 
(Reprinted from "Pacific Medical Journal," July, 1890.) 
Gentlemen:-The accompanying table embraces all the cases 
of abdominal or intra-peritoneal surgery, that I have oper- 
ated upon during the nine months ending January 31st, 1890. 
Many of the cases were desperate, and the operation was under- 
taken as a forlorn hope; but the rapid recovery of the larger 
proportion of even the worst cases, shows conclusively the wis- 
dom of the procedure. Certain it is that speedy death was 
inevitable in a considerable number of cases, except for the 
prompt surgical interference, and I must confess that a number 
of bad cases recovered where no hope whatever was held out to 
relatives or friends. 
If I was asked upon what the success of abdominal surgery 
depends, I would say as I did in the article published last year, 
" perfect cleanliness, and personal skill due to familiarity with 
the work." 
A serious mistake made constantly by professional men, is to 
wait, before interference, until the patient is nearly in "articulo 
mortis." This is an error of judgment as far as the patient is 
concerned, and is scarcely fair to the surgeon, to ask of him im- 
possibilities. 
The added experience of the past nine months has still 
farther convinced me of the truth of the statement made in 
former papers, " that the peritoneum, if properly treated, and 
not infected, could be handled, opened, and examined with 
very slight risk." 
It is very difficult for a man who was educated twenty-five 
years ago, and was " brought up in the fear of God, and the 
peritoneum," to understand how it can be possible to open the 2 
Nine Months' Work in Abdominal Surgery. 
abdomen and introduce the hand and arm and make a thorough 
examination, and this, practically, without risk; and especially 
is it difficult of comprehension, if he has not seen frequent ex- 
amples of abdominal surgery. To such I would say, the new 
gospel of cleanliness has made many things possible that were 
never dreamed of when we were students of medicine. Whether 
we term it Listerism or antisepticism, it matters little,so long as 
the dirt and filth, and the germs of putrefaction and disease are 
not allowed to come in contact with the wound or the serous 
cavity; and I doubt not the name of Joseph Lister will in the 
future be classed among the greatest benefactors of his race, by 
reason of his labors in the direction of the aseptic treatment of 
wounds. 
To have the hands of the surgeon, and his instruments and 
appliances perfectly clean may seem a very simple matter, but 
in fact it is not so. To have hands and sponges, instruments 
and appliances, the surface to be operated on, and the water 
used in the operation, all free from putrefactive germs, requires 
a sleepless vigilance, and an amount of time and attention to 
detail, that is but partially appreciated by a large number of 
the profession, and I venture the opinion that no surgeon, how- 
ever skillful he may be as an operator, need ever hope for any 
marked success in opening the large serous cavities, whether it 
be the knee-joint or the peritoneum, unless antisepticism is car- 
ried out in its fullest details; and these can only be learned by 
a sad experience with fatal cases, or by observation in the large 
centers of population, where they have been perfected by men 
who have been untiring in their devotion to its principles. 
As far as practicable, then, strict Listerism has been practiced 
in the cases reported; but in operations in private houses, 
especially in the houses of the poor, perfectly organized methods 
are not always easy. 
Some of the cases in the tables are of sufficient interest to 
warrant especial mention on account of unusual symptoms or 
treatment. 
Under the head of "Abdominal section for removal of ovarian 
tumor," No. 1 presented the following curious history: 
Five years ago she had removed by a surgeon in Kansas a 
cystic tumor of the right ovary; she recovered easily, and 
shortly after a tumor began to'appear in region of the left ovary. 
The surgeon, one year after the first operation, re-opened the Nine}Months' Work in Abdominal Surgery. 
3 
abdomen but found the tumor so firmly fixed by adhesion that 
he feared to undertake its removal and closed the abdomen. 
Four years later she was referred to me by Dr. Crabb of 
Millville, California. Her condition was now deplorable. Her 
abdomen was enormously distended by ascitic fluid. She had 
three large ventral hernias, one above the umbilicus, one below 
the umbilicus in the median line, and one in the right inguinal 
region; a solid, or semi-solid tumor the size of the adult head, 
occupied the left ovarian region. She had been tapped thirteen 
times during the previous four years, several gallons being 
removed each time. She was much emaciated and had the 
cachectic appearance of a person suffering from malignant 
disease. She had much pain in the region of the bladder, and 
the urine was loaded with pus. A careful examination of the 
urine disclosed pyelitis and cystitis, believed to be due to pres- 
sure. Four gallons of ascitic fluid were drawn off with great 
relief of symptoms, and after ten days treatment the kidney and 
bladder symptoms were improved sufficiently to warrant the 
effort to remove the tumor. The adhesions were nearly univer- 
sal. The tumor, intra-ligamentous of left ovary, was removed 
with difficulty, and the hernias repaired. The patient made 
an excellent recovery, without interruption. 
My assistant, Dr. W. F. Cheney, has reported this case in 
full at a former meeting of this society. It is a good example 
of what may be done in a difficult and desperate case. 
Case No. 2 of the same table admirably illustrates a phase of 
disease that I think, as yet, is not generally appreciated or un- 
derstood. The woman presented herself in fair health, with a 
cystic tumor in each ovary, the size of a child's head. The day 
for operation was set six days later, and upon her return at the 
agreed time she seemed to be laboring under great depression. 
Upon opening the abdomen it was found that the cyst of the 
right ovary had burst, and its contents, resembling pea soup, 
had been disseminated throughout the abdominal cavity, set- 
ting up general peritonitis. The cysts were removed, and the 
peritoneal cavity thoroughly washed out by repeated flushing 
with hydro-naphthol and water, and a drainage tube left in the 
lower angle of the wound. 
As near as could be judged, from three to four quarts of peri- 
toneal fluid escaped from the tube during the first three days. 
The discharge was clear and without odor, and the tube was Nine Months' Work in Abdominal Surgery. 
4 
removed on the fourth day. The wound healed kindly and no 
untoward symptoms supervened for sixteen days after the 
operation, when she was allowed to sit up in a chair. She had 
slight pain in abdomen, slept well, had no appetite, and temper- 
ature at no time was more than one degree above the normal, 
and most of the time normal. Her pulse, however, was quick 
and feeble, and the expression of face was not good; the bowels 
were regular, and urine passed freely. The abdomen was 
moderately distended, and felt boggy. 
Manifestly there was something seriously wrong. An open- 
ing was made with the point of a dressing forceps at the site 
where the drainage tube had been, and now there escaped from 
three to four pints of offensive pus. The abdomen was now 
thoroughly washed out, but the patient never rallied and died 
in four hours on the nineteenth day after the original operation. 
The point I wish to call attention to is, that it can be possible 
to have in the peritoneum, for days, a large quantity of fetid 
pus, with only a slight rise in temperature. 
Had the abdomen been reopened a week sooner and the parts 
thoroughly cleaned, the chances for recovery would have been 
good. The lesson taught by this case is self-evident. 
The treatment of pyosalpynx, and of pelvic abscess due to dis- 
ease of the Fallopian tubes, by abdominal section, has been very 
satisfactory. As will be seen from the table, but one death has 
occurred, and this in a most unpromising case of many years 
standing. The results are so satisfactory that this operation has 
without doubt a brilliant future. 
Several cases are reported where the uterus was found bound 
down in the position of retroversion, by strong adhesions, the 
result of former attacks of pelvic peritonitis. One or both ova- 
ries were found prolapsed, adherent and extremely tender to 
touch. The health and comfort of the woman were seriously 
impaired, and no local treatment or force that could be safely 
used was of any avail. In such cases, after the efforts to relieve 
by local treatment, such as tamponing, efforts to replace organs 
by rectum and uterine sound, the abdomen has been opened, 
the adhesions broken up, the ovaries, if diseased, removed, and 
the fundus of the uterus stitched to the anterior' abdominal 
wall. Some of the cases have shown excellent results and all 
have been benefited. Time is needed to determine the ultimate 
good; in any event, I know of no other resource in bad cases, 
and the risk to life is slight if properly done. Nine Months' Work in Abdominal Surgery. 
5 
The treatment of larger fibroid tumors of the uterus by elec- 
tricity has not been satisfactory in my hands, and in bad cases 
when the symptoms are severe or the woman is much under 
forty years of age and the tumor increasing rapidly in size, the 
resort to the knife will probably be our best resource until our 
knowledge of the causes shall be made more perfect. If a uter- 
ine fibroid is causing no untoward symptoms, is not increasing 
materially in size, and especially if the woman is approaching 
the menopause, certainly no interference is warrantable. 
I believe the intraperitoneal treatment of the stump in extirpa- 
tion of the uterus for fibroid tumor is the most rational, as I 
believe it will be the method of the future. It is coming more 
and more into favor in Germany, and an improved technique is 
giving increasing good results. 
The intraperitoneal method was pursued in the cases re- 
ported in the accompanying table. 
The fatal case occurred in a woman who was almost entirely 
bloodless at the time of the operation. An intraperitoneal 
abscess occurred at the end of a week, and her vitality was at so 
low an ebb that she was unable to rally from the added drain 
upon her strength. The abscess was due to a small slough of 
the small intestine consequent upon a fold being caught in the 
bite of a pair of haemostatic forceps that were applied to the 
broad ligaments on the right side to temporarily control exces- 
sive venous hemorrhage. 
The case of vaginal hysterectomy was interesting, inasmuch 
as there existed a commencing epithelioma of the cervix, and a 
sarcoma of the posterior wall of the body of the uterus. No 
ligatures were used, the arteries being controlled by pressure 
forceps to the stumps of the broad ligaments. The forceps 
were left in situ for forty-eight hours. 
At the end of nine days urine began to escape from the right 
ureter, but this ceased in five days and the case went on to an 
excellent recovery. The injury to the ureter was probably 
caused by a suture introduced to approximate the opening left 
in the roof of the vagina caused by the removal of the uterus. 
Under the heading " Laparotomy for Other Diseases of the 
Abdominal Organs," are several cases of interest. No. 1 was a 
well marked elastic pelvic tumor which crowded the uterus 
over to the right side. An exploratory incision showed it to be 
an encysted hsematocele, which caused much pelvic pain on 6 
Nine Months' Work in Abdominal Surgery. 
account of pressure on the tissues of the broad ligament in 
which it lay. 
The woman had a well marked double uterus, united at the 
cervix, with but one external os uteri. 
The abdomen was closed and the cavity containing the blood 
opened from below through the roof of the vagina with the dilat- 
ing trocar, the sac thoroughly washed out and a self-retaining 
drainage tube left in. The patient was out of bed in two weeks 
and health restored. There was a slight discharge from the 
sac at the end of three months. Case No. 4 of the same table 
was in a most desperate condition at the time of operation, and 
that a fatal result followed is not surprising. It was a long 
standing case of peritonitis with universal adhesions; large col- 
lections of pus and extreme weakness to begin with. 
The adhesions were broken up and the two pus sacs removed 
after much time and effort, resulting in injury to both bladder 
and rectum. 
The injuries were repaired, but the patient never fully rallied 
from the shock, and died in twenty-four hours. For the credit 
of surgery it would have been better to have left the woman to 
her fate, but we now see so many most unpromising cases re- 
cover after abdominal sections, that we are warranted in giving 
nearly all who apply for relief the benefit of the doubt. 
Certain it is that the first duty of the surgeon should be to 
make as gallant a struggle as possible to save the lives of those 
who trust and rely upon his skill and courage, rather than to 
shape his course to the making of a favorable " record." 
Case No. 5 of same table was a strangulated inguinal hernia 
in a woman three months pregnant. On account of the adhesions 
about the neck of the sac, as well as on account of some obscur- 
ity in the diagnosis, the abdomen was opened in the median 
line, and the constricting ring afterwards divided by a second 
incision over the protruding portion of the gut. At the end of 
three days an abortion occurred necessitating the cleaning out of 
the uterus with curette and abortion forceps. Two days later a 
small portion of the gut sloughed at the site of constriction and 
a fecal fistula was established at the wound over inguinal ring. 
The opening in bowels healed in two weeks and thereafter the 
recovery was uninterrupted. The patient was delicate and 
emaciated at the outset, and the complications following the 
operation rendered the result very doubtful for several weeks, 
and her recovery was a credit to the art of surgery. Nine Months' Work in Abdominal Surgery. 
7 
Case 6 I think ought to have recovered; it was an extrauterine 
pregnancy of six or seven months on the left side of and firmly 
attached to the uterus. The patient's health was a good deal 
impaired by repeated attacks of pelvic pain and local peritoni- 
tis. Her physicians in San Luis Obispo and in Santa Bar- 
bara had correctly diagnosed the case before sending her to me. 
The abdomen was opened in the usual manner and the sac 
separated from the adjacent structures to which it was attached 
by firm adhesions. After the application of a number of liga- 
tures, the whole was peeled out and removed, but not before 
there had been a partial escape of the contents of the sac into 
the peritoneal cavity. The shock was very marked and I was 
forced to close the abdominal cavity before the oozing of blood 
from the separated surfaces was fully stopped. 
A drainage tube was left in the lower angle of the wound and 
acting under instructions, the gentleman in charge threw into 
the drainage tube an ounce of a twenty per cent solution of Mon- 
sel's salt (ferri persulph.) to counteract the bleeding. This 
was effective in putting a stop to the hemorrhage, but it formed 
a sticky clot that plugged up the drainage tube. 
Septic fever set in on the third day; on the fourth day I re- 
opened the abdomen and washed out clots and pus, but this 
did not prevent a fatal result. The child breathed and lived for 
half an hour. 
Manifestly the peritoneal cavity became infected, else the case 
would probably have recovered. 
The only antiseptic used has been the hydronaphthol, and I 
am still of the opinion that it is a good agent and it has some 
decided advantages. Notably it is inodorous, not poisonous, 
does not injure instruments or the skin of the operator's hands. 
A saturated solution in hot water is the strength used, and the 
peritoneal cavity can be filled with this solution repeatedly with 
perfect impunity. 
The less opium a patient gets after an abdominal section the 
better, and much the larger proportion of my patients get no 
anodynes whatever. The pain from the operation gradually 
subsides; the patient is turned on either side from time to time 
to rest them; and no food is allowed until peristalsis has com- 
menced sufficiently to expel flatus from the anus. This is often 
much aided by a rectal injection of a teaspoonful of oil and 
turpentine in a quart of hot water and repeated in a few hours 
if needed.