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Tuberculous peritonitis generally occurs in the young, principally in women, although it may affect either sex. After considerable experience with abdominal operations, I have found that tuberculous peritonitis is usually cured by a celiotomy. The simple opening of the abdomen without anything else being done, nothing being removed and no irrigation being instituted, has sometimes resulted in a cure. At other times, complications have been found which had to be remedied. Often the operation was performed for pus tubes, which were very properly removed on account of mixed infection. It has become a custom with some surgeons when operating for tuberculous peritonitis to remove the tubes whether there was mixed infection or not, simply in order to close an avenue for the entrance of tubercle bacilli, which were supposed to be poured out from the end of the tube into the peritoneal cavity. I have protested against this practice for

The terms adynamic ileus and paralytic ileus are used to designate a condition characterized by distention and relative inactivity of the bowel. As implied by the latter term, there prevails an opinion that the condition is the result of paralysis of the bowel. This is implied also in much that has been written, and there have been statements from sources of authority that intestinal motor activity is totally or virtually suspended for many hours or even days after abdominal operations. These opinions, as will be shown, are not supported by factual evidence, either clinical or experimental. As to clinical evidence, our interest in the subject was aroused by experiences with the Miller-Abbott tube. It was observed that this tube traveled down the small bowel as readily and rapidly in the patient with so-called paralytic ileus as in the patient with normal intestinal function. Obviously, for a state of paralysis this

The object of this paper is not to enlarge upon a great variety of procedures which have become or seem destined to become obsolete, but rather to present briefly the more useful operations for the treatment of fibro-myomata of the uterus. The subject will be divided as follows: 1, palliative operations. 2, radical vaginal operations. 3, radical abdominal operations. I. PALLIATIVE OPERATIONS. The palliative operations are, a , curettage, b , electrolysis, c , ligature of the uterine arteries and broad ligaments, d , removal of the uterine appendages. a. Curettage. —The irritating presence of the tumor often gives rise to hemorrhagic endometritis. Curettage is therefore indicated precisely as it would be in hemorrhagic endometritis from any other cause. The operation is generally followed by a degree of relief from the menorrhagia, is seldom permanent in its results and must usually therefore be repeated again and again. It is especially useful in connection with

In 1909 and again in 1913 I1published two papers on the subject of acute intestinal obstruction. Since that time I have been keenly interested in the clinical phase of this subject as it has arisen in patients coming under my own observation, and also in the voluminous published reports on this subject. In reviewing the literature, one is amazed at the conflicting reports pertaining to the fatal factor in acute intestinal obstruction. This is strikingly illustrated in the extensive review by Ellis.2 Nesbitt,3in 1899, in a study of the content above the occlusion, found that food rich in lecithin resulted in cholin and neurin, and he believed that neurin was the responsible fatal factor in acute intestinal obstruction. Buchbinder,4in 1900, showed that the intestinal wall is not permeable to bacteria until a severe degree of gangrene develops, or until injury is produced in

There is no doubt that the number of cesarean sections being done in this country today is on the increase. The indications for the operation have been widened, and this situation is leaving us with many women who are forced to look forward to abdominal operations in the future if they are to increase their family. It is no part of this paper to discuss whether or not this widening of the indications for cesarean sections is wise. Nor shall I consider whether or not the dictum, "Once a cesarean, always a cesarean," should be followed, although I feel that this is a generally accepted theory. This paper is to consider whether the obstetrician has any responsibility toward his cesarean patient other than that of trying to return her to normal health as rapidly as possible, and with a living child. Is it a part of his duty to consider

Thrombosis may occur in any part of the vascular system but is most frequently encountered in the pelvic veins and in the veins of the lower extremities. It occurs during the course of the puerperium and in the convalescent period following abdominal operations. There is usually a systemic elevation of temperature of from 1 to 3 degrees fahrenheit associated with local pain and tenderness along the course of the vein involved, followed by swelling and cyanosis of the extremity involved. Thrombosis is much less common in the upper extremities, and primary thrombosis of the axillary vein is relatively rare. Cadenat,1in 1920, and Lohr,2in 1929, both give Schrotter credit for first describing this clinical syndrome in 1884. Cadenat reviewed twenty-four cases from the literature. The right arm was involved in twenty-one cases and the left arm in three. More than fifty cases have been reported. Gould and

It has been said that as long as surgery remains an art sponges will be overlooked and unintentionally left in the abdominal cavity. Yet I believe the day is coming when we will not place a sponge, clamp or any other instrument wholly within the abdomen. The ablest surgeons the world has known have had the misfortune to have left a sponge, a drainage tube or an instrument in some cavity of the body. The possibility of leaving a sponge in the abdominal cavity has been a source of anxiety to every surgeon, and although we have devised numerous methods to avoid this accident, the human element is always present, and must be reckoned with, and alas, too often this unfortunate accident takes place. The man who has to bear the stress of the unexpected calamities that occur in surgery realizes how easy it is to leave a foreign body

The purpose of this study was to determine the relative incidence of infections of the respiratory tract after inhalation anesthesia and after spinal anesthesia in patients who had not had preoperative infections of the respiratory tract and who had undergone the same types of abdominal operations. Since 1901 a copious literature has accumulated concerning postoperative complications involving the respiratory tract. An examination of this literature revealed that there was no previous report comparing the rates of occurrence of such complications in controlled groups of patients who had been subjected to the same abdominal operative procedures under ether, cyclopropane and spinal anesthesia. MATERIAL AND METHOD The material consisted of 631 cases in which abdominal operations were performed in the surgical service at Duke Hospital between the years 1930 and 1941. The operations included 245 appendectomies, 216 inguinal herniorrhaphies and 170 operations on the biliary tract, of which 166 were cholecystectomies. The

When one contemplates the marvelous change in the past twenty years in our knowledge of the diseases of the digestive apparatus and honestly tries to analyze what has been the fundamental cause of this change— this metamorphosis from poverty of method and uncertainty of result to our present wealth of diagnostic data and successful therapy—I feel that we must admit that it is to the surgeon and to the physiologist that this great change is mainly due. The use of the stomach tube has been an aid, and the more refined and newer methods of studying gastric and intestinal secretions have proved of interest; but an attempt to evolve a gastro-intestinal pathology fundamentally on the basis of secretory variations is to lean on a frail reed—and in the stomach the secretory findings must be regarded as but general indexes of the tendency of the functional digestive act rather than as

INTRODUCTION Gaseous distention of the intestine is one of the most frequent complications following the trauma of abdominal operations, peritonitis or other type of injury to the abdominal viscera. It always entails discomfort to the patient and is sometimes a grave danger. The methods advocated in different clinics for its prevention and treatment are so varied in character and often in such striking contradiction to each other that one is forced to the conclusion that there is no general agreement as to the underlying physiologic processes. These processes are complex, and the amount of experimental work bearing directly on them is small. Some of the more fundamental features of the problem are undoubtedly concerned with the disturbances of motor activity of the gastro-intestinal tract, following injury. A clinical classification and discussion of the different types of injury will be found in articles by Murphy, 1 Rost 2 and others. The

More than a decade has elapsed since the late Mr. Greig Smith of Bristol fixed the surgeon's standard of attainments for abdominal and pelvic operations in these words: "To be prepared, at the appearance of any complication, to apply the best-known surgical technics; to do what is wanted, and no more than is wanted; to have the manner and method of each procedure mentally laid down in clear and definite lines; and generally to perform the operation in a steady, straightforward, workmanlike manner through the endless complications that may arise, is no trifling call on the capacities of a human being. Much of it may be learned by intelligent practice at the expense of the patients; much may be learned by careful study and practice on the dead body; but most of all will the young surgeon derive information from a close and

The following is a record of the results of screen examination of the chests, particularly with regard to the excursion of the diaphragm, in thirty consecutive post-operative cases. All the cases were after operation for hernia or appendicitis, and were investigated in an effort to throw light on the occurrence of minor chest complications following herniotomy. The herniotomies were almost all MacArthur fascial repairs, and the anaesthetics used were gas-oxygen-ether, spinal, or continuous drip Pentothal.

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MULLER et al 1 and others have observed that diaphragmatic excursions are decreased after abdominal operations. While this is now a well-recognized occurrence, little information is actually available in the literature about changes in pattern of breathing immediately following operations. Our purpose is to describe this in detail and to discuss it in relation to other events which may occur at the same time. Materials and Methods The apparatus used in the main part of this study was a gage which in principle was the same as that described by Whitney 2 in 1949 as a mercury-in-rubber strain gage. A piece of commercially available latex tubing 29 cm in length with an inner diameter of 3.185 mm and an outer diameter of 4.761 mm was filled with an electrolyte cream used in clinical electrocardiography. The ends of the tubing were sealed with metal plugs which were inserted into the electrolyte

At the St. Paul session of the American Medical Association we presented a paper 1 on "The Practical Application in Abdominal Surgery of Scientific Investigations Concerning the Function, Anatomy and Pathology of the Peritoneum 1 in which the employment of infusions of normal saline solution into the peritoneal cavity after all abdominal operations was advocated. The theory as to its value was based on the proved physiologic fact that there are well-defined currents which waft minute bodies from the lower or more dependent part of the peritoneal cavity toward the diaphragm, through which they gain entrance into the retroperitoneal lymph channels, and thence into the general blood channels. Our experimental work, at that time, had been confined solely to tracing the course of minute innocuous granules, such as India ink and carmine, from the peritoneal cavity into their more remote places of lodgment. This series of experiments unquestionably demonstrated that any foreign

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In a consideration of the more common complications which occur after abdominal operations it is evident that none is more serious than peritonitis and none more deserving of careful study from the standpoint of both prevention and cure. While the incidence of postoperative peritonitis has gradually and steadily declined during the past several decades, the possibility of its occurrence remains one of the chief hazards of operations on the lower part of the intestinal tract, and this is particularly true when resections or anastomoses which involve the large bowel are performed. The general decrease in the occurrence of postoperative peritonitis has been the result of (1) improvements and standardization in operative technic; (2) perfection in anesthesia, and (3) a greater realization of the importance of a proper period of meticulous preoperative care. During this period (seven to ten days or more) the fluid and electrolyte balances are restored and nutritional

It is hoped that it will not be considered impertinent to offer a few suggestions upon this subject, apparently so simple, before a body composed so largely of abdominal surgeons, or surgeons who are familiar with abdominal operations, as is this section. The fact has been impressed upon my mind not only by my own experience, but by observation of the work of others, and a search of a considerable portion of the literature of abdominal surgery,that the subject in question has not received the attention which it deserves, and that it is by no means a matter of insignificance. This statement will be the more readily accepted if one remembers that the essential portion of the omentum (the greater omentum alone is referred to in this paper) consists of peritoneum, and that its function, by virtue of the abundance of fat which forms one of its constituent elements

A RECENT survey of over 500 certified surgeons in this country revealed that only about 26% are employing transverse or muscle-splitting abdominal incisions for the common types of abdominal operations.1It appears therefore that the majority of surgeons and most of the other physicians performing surgery are using midline or paramedian incisions. It seems inconceivable that adherence to these standard incisions by so many still exists, in view of the many unfavorable reports concerning the significantly high incidence of wound dehiscence and herniation which follows these incisions. These complications have been reported to occur in 2 to 10% of abdominal operations in which the midline or paramedian vertical incisions were employed,2whereas the reports of many surgeons using a muscle-splitting or transverse incision indicate that these two complications are rare, occuring in less than 1% of all cases.3 Whitaker and his associates2hreported nine cases, 0.9%

Thrombosis of veins is common in the pelvic region and in the lower extremities. It may follow abdominal operations or develop during the puerperium. Thrombus formation in the veins of the upper extremities, secondary to such conditions, is not common, and thrombosis of the axillary vein caused by effort is comparatively rare. As a clinical entity the condition was first described by Von Schrotter in 1884. Cadenat1in 1920 reviewed twenty-four cases from the literature. Paggi2in 1933 collected reports of seventy-four cases from medical writings. Matas3in 1934 reported one case and reviewed the literature of approximately 100 cases. Since then about twenty additional cases have been described by various observers, but great numbers have not been observed by any one person. A review of the cases by the various authors showed that the patients were young, in good health and engaged in work. Although males

To the Editor:— InThe Journal, July 25, pages 267-269, in an article entitled "Hyperventilation in Abdominal Surgery," Dr. T. J. Ryan concludes that "carbon dioxide is of no value in the prevention of postoperative pneumonia." This conclusion is drawn from a group of 135 cases in which, at the close of abdominal operations, carbon dioxide was administered only once, for about three minutes, and a control group of 276 in which carbon dioxide was not administered. The morbidity is reported as 2.2 per cent for those who received the inhalation and 1.4 per cent for those who did not, and the mortality as 0.74 per cent for those treated and 0.36 per cent for those who were not. Obviously, if these figures are significant they indicate, not merely that carbon dioxide is without value in the prevention of postoperative pneumonia, but rather that this treatment tends to increase the

If the short paper which I present to you to-day is productive of any good results, personally, I look for them not so much from the paper itself as from the discussion which I hope it will inaugurate—"many men, many minds." I do not expect that all my hearers will agree with the opinions which I have formed after some years' experience, and I trust that to-day the views of not a few will be freely expressed in order that the subject may be thoroughly thrashed out. In short it would seem advisable for us to hold what may be termed an "experience meeting" and my remarks may simply be looked upon as prefatory to what I hope may be a full and fruitful discussion. I shall speak briefly of work done by others and by myself sometime ago, and shall supplement this by my own experience in two series

POSTOPERATIVE synergistic gangrene, a spreading, infectious gangrene of skin and subcutaneous tissues, usually begins around retention sutures after abdominal operations. It is caused by an anhemolytic, microaerophilicStreptococcusin synergism with other organisms. A deep ulcer with gangrenous margins develops and may reach tremendous proportions. Although systemic symptoms tend to be minimal, the ulcer is painful. Even before the introduction of antibiotic therapy, this lesion was unusual. Vier,1in 1940, stated that the average surgeon observed only one or two cases during his lifetime. Although synergistic gangrene was described by several authors2,3before 1956, no publication dealing with this infection was found in the American medical literature from that time to the present (January 1966). The case reported here is significant in that the presence of a microaerophilicStreptococcuscultured from the abdominal wound was not recognized as the primary agent in the infection, and the patient was

The mortality in pelvic operations is definitely lower than it is in other types of abdominal operations when the usual surgical principles and standardized technics are employed; thus, the surgeon may not feel the same degree of hesitancy in undertaking pelvic operations as he does, for instance, in undertaking operations on the upper portion of the abdomen. For these reasons pelvic operations are often performed when there is only the slightest indication for them and at times when there is no real indication at all. It should be remembered that the mortality attending any operation reaches its maximum in the hands of inexpert or insufficiently trained men. Although benign lesions of the uterus rarely are difficult to eradicate, there are conflicting ideas regarding the best procedure to follow. I refer principally to the treatment of myomas, which occupy unusual positions with respect to the uterus. Myomas are most frequently encountered

To the Editor:— In the article by Wakefield, Mayo and Bargen entitled "Ileus Associated With Transient Renal Insufficiency: A True Enterorenal Syndrome" (The Journal, June 22, p. 2235) there appears to be no mention of stethoscopic examination and sounds heard over the abdomen in any one of the ten cases reported. It is very likely that such an examination was performed in each case for audible peristaltic sounds and was very likely absent in all, so that it was omitted in the report. The importance of listening for peristaltic sounds in the differential diagnosis of paralytic and mechanical ileus was deeply impressed on me by Dr. Roger T. Vaughan at the Cook County Hospital whenever the problem presented itself. Especially is this of value when the patient has had one or more previous abdominal operations. Dr. Vaughan insisted, and probably still does, that one listen with the stethoscope over each

Of an extensive literature devoted to the role which constitutional factors play in the development of disease, only a small part deals with the digestive tract. In the discussion of gastro-intestinal diseases the local anatomic aspect dominates the conception of the morbid state. This conception is principally based on the demonstration of anatomic lesions at abdominal operations, which undoubtedly in many instances cleared up the true nature of a formerly obscure process. This applies, however, in particular to acute diseases; we cannot say as unreservedly that the demonstration of anatomic lesions has satisfactorily cleared up the pathogenesis of chronic diseases of the alimentary tract. In most of these chronic diseases anatomic lesions usually are the end-results of a pathologic process, but they do not necessarily indicate its working. For the understanding of its development, pathologic physiology promises better information than anatomic facts. It becomes more and more clear that disturbances

Our purpose is to present observations supporting our belief that intestinal volvulus may be precipitated by plumbism, a sequence of events unmentioned in the literature as far as we can determine. It is well known that in some world areas, such as the Baltic region, volvulus may be a major cause of intestinal obstruction, reaching incidences as high as 50% of all obstructions. 1 Among the natives of the highlands of Peru as seen at this hospital, 2 volvuli also cause about 50% of all obstructions seen. The majority of these are of the sigmoid colon. We have observed repeatedly at autopsies and at abdominal operations that the natives of this area generally possess a long, redundant, mobile megasigmoid, usually with a narrow pedicle-like mesosigmoid predisposed to twist. Of the factors mentioned in the literature as being of import in the development of such anatomically long sigmoids, the two factors

Unexpected and, as a rule, preventable postoperative complications make up a large part of the mortality which follows deliberate operative procedures on persons in good general health and presumed to be reasonable surgical risks. These complications are at least in a considerable measure avoidable and, having arisen, assume serious aspects in proportion to the lateness with which they are discovered and adequately treated. Perhaps the simplest and least fatal but most annoying postoperative complication is wound infection, particularly in the clean undrained wounds. Explanations of postoperative fevers without obvious cause should be first sought in the wound itself, and in a large number of cases will be found to be due to localized accumulations, many of which can be cared for by early drainage without further involvement of the wound. A method which I have successfully employed to discover these small localized inflammatory areas early is, with sterile precautions, to

On the basis of his experiments on animals and observations in humans, the author finds the use of these agents before and especially after abdominal operations very useful for maintaining body temperature and reviving blood circulation.