“ On entering the peritoneal cavity, the surgeon introduces his hand, and proceeds to ascertain the nature of any morbid condition that he sees or feels, or he evacuates any free fluid, blood, or pus which may be present. Occasionally he finds that attempts to remove a tumour would be futile or end in immediate disaster to the patient; then he desists and closes the wound, and the procedure is classed as an exploratory cœliotomy. Should a removable tumour, such as an ovarian cyst, an echinococcus colony in the omentum, or the like be found, it is removed. ”

“ Probably no operation in surgery has so many modifications, many of which possess advantages and disadvantages which counterbalance each other so nearly that the individual surgeon must decide for himself which is the most satisfactory to carry out. The opinion of many surgeons, including the author, is that the ideal operation is one which can obtain sight for the patient at one sitting. ”

“ In regard to marital relations in women with a belated ovary, nothing trustworthy is forthcoming, but I believe the retention of an ovary is an additional factor in promoting domestic bliss. The question of nubility is interesting; I am able to state that women who have had subtotal hysterectomy performed, with conservation of one ovary, have married and lived happily with their husbands; and I am of opinion that the preservation of the vaginal segment of the neck of the uterus is an important factor, as it leaves the vagina intact, and though such women are sterile, they are certainly nubile. ”

“ One great danger which attends operations for the removal of cancerous organs is what may be called ‘post-operative cancer-infection’, that is, in the course of the operation tracts of connective tissue are opened up and become soiled with cells, which engraft themselves on this tissue and on the peritoneum, and give rise to extensive masses of cancer which are often described as recurrent cancer. This accident often causes the patient to die quicker than if the primary cancer had been left untouched. ”

“ In a case of prolapse of the ovary, or a gravid tube or ovary in the earliest stages, the operation presents no difficulty and can be carried out with the ease and safety of the simplest ovariotomy; but there are many cases where the tubes and ovaries contain pus and are distended into cysts as big as a fist, or even as large as the patient’s head, which are adherent to bowel, uterus, bladder, indeed everything with which they come in contact; this renders their removal tedious and exacting for the surgeon and dangerous to the patient. ”

“ A good source of illumination is the first necessity for satisfactory operations on the upper air-passages. The natural sources at our disposal are sunlight and diffuse daylight. They have the great advantage of not altering the natural colours of the parts examined. Reflected sunlight forms a perfect illuminant, if we are careful not to bring the rays to an exact focus on the mucous membrane, as this might produce a burn.
Diffuse daylight is too feeble for the examination of the cavities of the nose and larynx, but it can be used for inspecting the mouth, pharynx, and ear. ”

“ TRACHEOTOMY IN DIPHTHERIA
Operation. As local anæsthetics are of little practical value in the case of children, the surgeon must decide whether a general anæsthetic shall be used; for any nervousness on his part increases the danger of death upon the table. A general anæsthetic is not necessary, but undoubtedly has certain advantages: the operation is easier and can be performed more rapidly; the patient is more likely to fall asleep; and any vomiting that occurs is beneficial rather than harmful. On the other hand, children suffering from diphtheria are apt to die suddenly under chloroform ”

“ In order to incise the peritoneum without damaging the tumour, cyst, or intestine, a fold of the membrane is picked up with forceps and cautiously pricked with the point of a scalpel; air rushes in, destroys the vacuum, and generally produces a space between the cyst (or intestines) and the belly-wall; the surgeon then introduces his finger, and divides the peritoneum to an extent equal to the incision in the skin.
It is important to remember that the bladder is sometimes pushed upward by tumours, and lies in the subperitoneal tissue above the pubes; it is then liable to be cut. ”

“ It must, however, be remembered that in many cases a slight discharge may exist for years without giving rise to any complications. If the patient be made aware of the slight danger which exists in every case of middle-ear suppuration, and be in a position to obtain medical attention if retention of pus occurs, then operative measures may be deferred indefinitely. If, on the other hand, the patient intends going to some remote country where medical attendance is impossible, then it is probably wiser to submit to the complete operation rather than risk future trouble. ”

“ When the patient wishes to speak, the upper end of the last-mentioned tube is either placed in the angle of the mouth or passed through the nose to the back of the pharynx, and the air which has been made to vibrate in the inner tube is thus carried to the mouth. This instrument is easy to adjust and clean, produces remarkable phonetic effects, and is much the most ingenious and serviceable device that has so far been invented. In some cases, however, a patient can make himself understood without an instrument of any kind. ”

“ I shall attempt to show that thyrotomy is the best operation for early malignant disease, whether carcinoma or sarcoma, so long as it remains intrinsic. No attempt will be made to separate the different forms of these diseases. ”

“ The instrument, which measured 5 inches long and 21⁄2 across the handles, was lying point downwards in the pelvis, and the ring handles could be felt through the belly-wall before the operation: it had made its way into the small intestine.
The tendency for a foreign body, whether hard like forceps, or soft like gauze pads, to erode its way into the intestine is very remarkable. Thus Gifford operated on a patient with intestinal obstruction; an impacted mass was felt in the ileum, it was extracted through an incision in the gut and proved to be a pad of cotton-wool enveloped in gauze. ”

“ Although the employment of buried sutures has made abdominal incisions more secure in the process of healing, and renders them firmer after union, and thus reduces the chances of a yielding scar, and saves the patient the inconvenience of an abdominal hernia or the annoyance of wearing an abdominal belt, it renders the patient liable to another discomfort, namely, stitch-abscess. This complication arises from a variety of causes—for example, imperfect sterilization of the suture material, or of the patient’s skin preceding the operation. ”

“ An incomplete ovariotomy is a very different condition to an enucleation. The cavity left after enucleation closes completely, but when the wall of an ovarian cyst or adenoma is left the tumour gradually grows again, or it may suppurate so profusely that the patient slowly dies exhausted. There are few things sadder in surgery than the slow, miserable ending of an individual who has been subjected to an incomplete ovariotomy. ”

“ The surgeon may start on an operation and, after opening the abdomen, may find many adhesions, yet he feels that the removal of the tumour is possible. He sets to work and overcomes many of the difficulties, but finds at last such extensive pelvic adhesions that it is imprudent to proceed further. In such cases he evacuates the contents of the cyst and stitches the edges of the opening in the cyst to the margins of the abdominal wound, and drains the cavity. This mode of dealing with a cyst is usually termed ‘incomplete ovariotomy’. ”

“ A hernia may or may not form immediately. If no hernia takes place, it is wiser to do nothing further; that is, provided sufficient bone and dura mater have been removed to reach the limits of the infected area. Some authorities, however, consider that the necrosed portion of the brain should be curetted out. Although in other parts of the body the removal of necrosed tissue is a proper procedure, yet in the case of the brain there is considerable risk of setting up further œdema or septic cerebritis, the progress of which may have become arrested at the time of the operation. ”

“ The action of the heart is feeble, rapid, or intermittent; no nourishment can be swallowed. It is always difficult to determine how much of this collapse is due to toxin; but by relieving the obstruction the most distressing feature of the disease is removed, better aeration of the blood is obtained, and the heart is relieved from strain. The operation also drains the trachea, and the amount of poison absorbed is thus diminished. There is abundant evidence to show that the best results are obtained by early operation, especially in young children, in whom the larynx is comparatively small. ”

“ Cœliotomy is a useful expression, because many abnormal conditions arise in the abdomen which require treatment through an incision in its walls which do not lend themselves to an expressive term, for example, the removal of omental cysts, the evacuation of pus, blood, or the removal of foreign bodies, &c. It is true that a cœliotomy performed on an uncertain diagnosis may become a colectomy, ovariotomy, hysterectomy, &c., and the preliminary step to the performance of the operations to be described in this section is an abdominal incision, or cœliotomy. ”

“ In a typical case, when the peritoneum is opened the surgeon at once recognizes the bluish-grey glistening surface of the ovarian cyst, and gently sweeps his hand over it in order to ascertain its relations and to learn whether the cyst wall be free from adhesions. It is of the utmost importance to be satisfied as to the nature of the tumour, especially when the operator follows the unsatisfactory practice of tapping, for if he plunge a trocar into a uterine tumour, or into a pregnant uterus, he will involve himself in anxious difficulty. ”

“ Swallowing after laryngectomy is satisfactory, and the general health in many cases improves. The mental condition of the patient is often disappointing. ‘Even in favourable cases, when the tumour does not recur after laryngectomy, the patient finds himself in such a condition of inferiority to his fellows, that he may, with some reason, ask himself (at least in certain cases) whether death would not have been preferable to such an existence as is left to him’ (Moure23) . With recurrence of the disease the patient’s life is terribly sad. ”

“ Disease in the nose involves both medical and surgical treatment. The general progress of surgery, improved technique, local anæsthesia, and the control of hæmorrhage we now possess, have all tended to replace local medication by surgical measures. But in many affections of the nose—such as syphilis, or diphtheria—surgical relief is quite secondary to medical treatment. In any case the surgeon cannot dispense with a knowledge of suitable topical applications and the principles on which they are founded. ”

“ Occasionally very serious consequences follow simple perforations by dilators and curettes; this has induced some gynæcologists to urge that if, in the course of dilatation and curettage of the uterus, a rupture or perforation of the uterine wall occurs, it is better to perform a cœliotomy and assure oneself of the safety of the patient than to hope that no untoward result will ensue.
This advice is too sweeping. When the perforating instrument is clean, and there is little or no bleeding, the case may be left to itself; if untoward signs arise, cœliotomy should be performed. ”

“ Time and experience have considerably modified surgical opinion in regard to oöphorectomy. Removal of the ovaries is no longer practised for the relief of hæmorrhage due to fibroids: it is easier, safer, and affords greater relief to the patient to remove the uterus (see p. 36) . When dysmenorrhœa is so severe as to need radical operation, hysterectomy is the only certain method, with conservation of at least one ovary. The removal of both ovaries in certain forms of insanity is now abandoned, and this is true of bilateral oöphorectomy for the relief of mammary cancer. ”

“ Intravenous injection is the best method of treating patients when the loss of blood has been great. It is unwise to transfuse more than three pints into the veins, or the lungs will become waterlogged and the patient will be later in great peril. When the loss is moderate in amount and the patient is not greatly enfeebled, a pint or more of saline solution may be poured into the abdomen before closing the incision, and this may be supplemented by the administration of six or more ounces of the solution by the anus at two-hourly intervals until the force of the circulation is restored. ”

“ Unless coated with solid accretions there is never any need to break up a foreign body; anything small enough to slip into the nose is small enough to be extracted entire. If it should be found impossible to remove the body through the anterior nares, it may be pushed backwards into the post-nasal space, where the forefinger of the left hand is in readiness to prevent its falling into the gullet or larynx.
The usual warm alkaline lotion may be used to clear the nose, but liquid should never be forcibly injected into the nostril with the idea of thus expelling the foreign body. ”

“ If consciousness returns, the patient begins to cough and mucus or membrane is expelled from the air-passages. On the other hand, it is useless to continue artificial respiration if the obstruction is not relieved; aspiration must be employed if special instruments are at hand. The fact that a number of surgeons have lost their lives as the result of sucking through a catheter in the attempt to save the child is sufficient to condemn this practice; but good results have been obtained by passing a catheter low down into the trachea and blowing through it with a syringe or even with the mouth. ”

“ Hastings also states that in a patient who died from pulmonary embolism, after an operation, a thrombus occupied the right cardiac ventricle, and he thought it possible that this intraventricular clot furnished the embolus (Fig. 25) .
We must bear in mind that individuals apparently in good health die suddenly in the street, in the armchair, in a bath, or even during sleep: it is a fair assumption that some of the instances of sudden death occurring during convalescence from surgical operations may be due to failure of the heart absolutely unconnected with the operation. ”

“ In cases where the enucleation of adherent and inflamed tubes leaves large raw and slightly oozing surfaces in the pelvis, drainage is a wise precaution. After a trial of a variety of measures for this purpose I find the simplest to be a narrow rubber drainage tube reaching to the bottom of the pelvis and emerging at the lower extremity of the abdominal incision. It is rarely required for more than forty-eight hours. Some surgeons are opposed to drainage, and one writer compares it to ‘defending oneself against the sparks of Vulcan with an umbrella’; his mortality is high. ”

“ Although he may begin the operation under the impression that he has to deal with an ovarian tumour, it may turn out to be a fibroid, a tumour of the pelvic wall, a misplaced spleen or kidney, a tubal pregnancy, a sequestered extra-uterine fœtus (lithopædion) , or a calcified hydatid cyst. Thus an expected ovariotomy may terminate as a Cæsarean section, or as a hysterectomy. In many cases the surgeon must rely on his own judgment and experience, but it may be useful to furnish some directions which may help him. ”

“ In explanation of these facts it appears probable that after five years of age the larynx and trachea are increased in size, so that obstruction is only met with where there is a large amount of membrane, namely, in the worst cases; in patients over ten, the age which marks the change to the adult type of larynx, the air-passages become so large that obstruction seldom occurs even when much membrane is present; dyspnœa, in these cases, points to extension of the disease to the smaller tubes, and tracheotomy is unable to give the same relief. ”

“ Every case must be judged on its own merits according to the extent and severity of the disease. In a few cases in which the incarceration of the capsule in the wound leads to a very chronic cyclitis, its division with a cutting needle will sometimes lead to subsidence of the inflammation. It is most important that every eye that has been operated on should be examined for the presence of keratitis punctata, especially before allowing the patient to use the eye or before another operation is performed on it. ”

“ The ‘radical abdominal operation’ enables the operator not only to remove the uterus and its neck, but the broad ligament, the ovaries, Fallopian tubes, infected lymph glands, and the infected para-uterine connective tissue, and by affording the operator free access to the floor of the pelvis the proceedings may be carried out with a free exposure of the operating field, thus allowing important structures like the ureters to be dissected out of implicated tissue. ”