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Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, aa many frames as required. The following diagrams illustrate the method: Les cartea, planchee. tableaux, etc., peuvent Atre filmte A dee taux de reduction diff Arents. Lorsque le document est trop grand pour Atre reproduit en un seul clichA, 11 est film* A partir de I'angle supArieur gauche, de gauche A droite. et de haut en baa. en prenant le nombre d'images nAcessaire. Les diagrammes suivants illustrent la mAthode. . ■ ! r * [ 3 1 i ; • ! ♦ •: 1 « ' • c u. oVe-N^Vfe ^c\ , Tra^^c \b (rffl); CURATIVE EFFECT OF EXPLORATORY LAPAROTOMY. BY IRANCIS J. SHEPHERD, M.D., CM., Professor of Anatomy, McGill University, Surgeon to the Montreal General Hospital. Reprinted from the Montreal Medical Journal, March, 1894. THE CURATIVE EFFECT OF EXPLORATORY ' LAPAROTOMY.* I By FRANCife J. Shepherd, M.D., CM., Prorcgsorof Anatomy McGill University, Surgeon to the Montreal Qeneral Hospital. It has been known for years that in certain cases the m^e performance ot abdominal incision has some remarkable effects on growths and other conditions of the abdomen. This has been widely recognized especially in cases of tuberculosis of the peritoneum. In 1889, Mr. Lawson Tait (^Edinburgh Medical Jour.'), drew attention to the fact that certain diseases of the abdomen seem to yield to surgical treatment applied to them by accident, and that he had more than once seen tumours, often of large size, disappear after a mere exploratory incision. These cases he reported at the time, but his statements were not believed. The cases in which he had seen tumours disappear in this way were chiefly in connection with the liver, spleen and head of the pancreas. From the number of cases of this kind observed by him, Mr. Tait is satisfied that the disappear- ance is not a mere coincidence, but that the opening of the peritoneal cavity has a direct influence in setting up the process of absorption of the tumour. Every one knows that after the smallest wound of the peritoneum, an intense thirst is set up which lasts for some days, and that this thirst is not set up after . * Read before the Montreal Modico-Chirurgical Society, January 12th, 1894. opening any other serous cavity, or in wounds of the abdomen where there is no injury of the peritoneum. Mr, Tait relates a number of remarkable cases in this paper. One case parti- cularly deserves mention. A lady, aet 54, had an abdominal section performed for supposed gall stones or possibly cancer of the liver. The liver was found covered with large hard ncdules, one of which closely imitated the lump which had led to the diagnosis of distended gall bladder. The case had so much the appearance of malignant disease, that no hopes were given of her recovery. Contrary to expectation, however, the patient completely recovered, and was alive and well several years after. A number of other cases are also given. In no less than three out of four cases of greatly enlarged spleen, the tumour disappeared without more being done than opening the abdomen and examining the growth, and in one case of tumour of head of pancreas, with great emaciation, exploratory incision resulted in entire disappearance of the tumour in five or six weeks, and complete restoration to former health. In the case of supposed cancerous nodules of the liver, the evidence would have been much stronger had Mr. Tait excised a portion for microscopic examination. It is hard to believe that there was malignancy in any of the cases, but the fact remains that the gross clinical appearances were those of malignancy, and that the observers were skilled in recognizing the normal appearance of the organs. It is possible that some of the lesions may have been due to syphilis. In 1891, Dr. J. White, of Philadelphia, published in the Annals of Surgery an interesting and exhaus tive paper on the '• Curative EflTects of Operation per se," and came to the conclusion that epilepsy, certain abdominal tumours, peritoneal effusions, and also tubercle were benefited by these operations, and thought one of the possible factors was anaesthesia, also psychical influence, relief of tension and reflex action may enter into the therapeutics of these cases. He does not think accident or coincidence explains them. Pierre Delbet {Bull, de la Society Alchemique de Paris, Oct. and Nov., 1892) reports the case of a child, oet. 2^ years, whose health had been failing for some months. On examina- ■\ m tion a large smooth, firm tumour was found on the right s'ule of the abdomen, extending from the costal cartilages to the iliac fossa. The diagnosis of sarcoma or carcinoma of liver was made. An exploratory operation was performed, and the tumour was found to be an enlarged right lobe of the liver, pale in colour, with violaceous marblings. Enlarged glands were found in the hepatic omentum. Punctures were made but revealed nothing. The result was immediate and surprising ; in three days the child regained appetite and cheerfulness, the liver rapidly decreased in size and returned to normal in two months. The character of the enlarged liver was revealed later, when syphilitic gummata appeared on forehead and scalp. Dr. Wm. White, in the elaborate article in the Annals of Surgery^ referred to above, cites many cases where exploratory abdominal incision relieved symptoms of pain, vomiting, ^c, and also some cases of tumour, which shrank away after opera- tion, although at the time the operator considered them malignant and gave a hopeless prognosis. Prof. Von Mosetig, of Vienna, in 1888, showed a case where he had performed exploratory laparotomy some time before for a tumour which filled the whole pelvis ; it was quite fixed, and removal was not attempted, so the wound was closed. To his surprise, when examined 14 days later, he found the tumour had shrunk to half its former size, and it continued to diminish, so that when shown to the Imperial Society of Physicians at Vienna, it was no larger than a man's fist. He thought the disappearance might be due to the intense hypersemia observed during the operation ; in the same way sometimes sarcomata may disappear under the influence of severe erysipelas. Cases also occur where, for a time, in malignant cases great improve- ment takes places as the result of exploration, but these cases always relapse and the patient soon succumbs. In this connection I shall now relate a case of which I had personal experience. It is as follows : — In October, 1891, 1 was consulted by Mrs. E., a nurse, aet. 28, spare in habit and of a sanguine temperament, for a tumour she bad recentiy felt in the neighbourhood of the umbilicus. She had always been healthy had been married and vras the mother of one child aet. 8 years. Never had any miscarriage and no history of syphilis. No tuberculosis in family, never had any jaundice nor had she ever had anything like severe colic. For some time has not been feelin;^ well and not up to her work ; has frequent elevations of temperature and occasional sweats ; her appetite good and there are no symptoms pointing to any affection of the stomach, no vomiting or dyspeptic symptoms. Notes of Examination. — Oh examining her in the recumbent position a tumour the size of an orange is felt to the right and a little above the umbilicus. This tumour is smooth, very tender to the touch and moves with the respirations. It can be pushed to the left side, under left costal cartilage, and to the right apparently under the edge of the liver. In fact the tumour is very freely movable. Occasionally the tua?our is very painful and it is always tender to the touch. I did not examine her again until Dec. 20th, as she had in the meantime gone about her nursing duties in the hospital, bujt these she soon found too much for her and she was compelled to take to her bed. Her temperature was carefully registered and she was closely observed. Her temperature was always 101° at night and 100* in the morning. Every other day she had a severe sweat. She said she felt more comfortable up than in bed, for then she had »her corsets on, and these when tightly laced, kept the movable tumor in its place. On examining her waist a well marked line of constriction was iseen to pass imme- diately above the tumour when it was in its normal position. It was thought that the tumour was caused by a lacing lobe of the liver, with probably an enlarged gall bladder beneath. Not getting any better, and being anxious to have something done, she consented to an exploratory incision. Operation^ Dec. 23r(£, 1891. — An incision was made in the median line above the umbilicus, and the left lobe of the liver was immediately come down upon. On examination a portion of this lobe was seen to be quite abnormal in appearance and very definitely marked off from the healthy part by a distinct line. This abnormal portion of the liver commenced at the great fissure where the round ligament entered, and extended upwards to a furrow, corresponding to a lacing furrow, and to the left it reached to the edge of the left lobe, where the lateral ligament leaves the liver. This portion was thick, somewhat puckered on its surface as if from cicatricial contraction. It was of a deeper color than the rest of the liver. A needle entered into the cicatrical part with difficulty, but in other parts no resistance was offered to the entrance of the needle. On holding the lobe between the finger and thumb well marked nodules, like masses of uew growths, were felt. Adherent to this part of the liver were some portions of omentum. On removing these, the liver bled freely and haemorrhage could only be stopped by application of the cautery, indeed this abnormal portion differed from the ordinary cirrhotic lacing lobe in that it was exceedingly vascular. There was some intention of removing this diseased portion of the liver, but it was decided not to do so, because the pedicle was so broad and the parts were so vascular, so the wound was closed. The patient after operation had some pain for 24 hours and distension, but went on to an uneventful recovery. After the exploratory incision she had no more tenderness, and after the first day no more pain. Her sweating ceased and her tem- perature became absolutely normal. On examining her a few weeks after operation the tumour could still be felt, but it was immovable. She soon returned to her work and complained no more, in fact she was perfectly cured, and when last heard from, some short time ago, she was in perfect health and able to perform all her duties as superintendent of a hospital. The tumour disappeared within a year of the operation— or at least could not be felt. Thinking the case might be of specific origin, I put her on Potassium Iodide for som,e time, which may have had something to do with the disappearance of the tumour. No doubt the benefit derived from simple incision, without any other procedure, is due in many cases to the moral effect of the operation itself, or expectation, as in metallic therapy, 8 and this accountj for the tnarvellous cures reported as following the application cf the new and extraordinary methods of treat- ment, such as faith cure, visit j to shrines, laying on of hands, &c. Manj of the diseases 'thus healed being those of the imagination are cured by imagination. Again, certain opera- tions on the eye have relieved nervous symptoms and trephining the skull without further procedure has temporarily cured epilepsy. This would explain the disappearance of pain and tenderness after exploratory incision, but not the disai^pearance of tumours or alterations in temperature, so other causes musl be looked for, such as those suggested by Dr. White, viz., relief of tension, reflex action, &c , or perhaps some causes working in w.^.ys mysterious, and of which we know nothing, but to which we give such names as altered nutrition^ trophic disturbance, nervous influence, &c., &c. No doubt these cases in time will receive suitable explanation, but at present we are in the dark as regards them. In many cases such sympton:3 as pain and tenderness with general discomfort may be due to adhesions which at the time of the operation are releaFed ; for instance in the case I reported above, the omentum was adherent to the liver, and its release may have banished the pain and tender- ness. In many cases of nephralgia exploratory incision has caused relief. I myself have had several such cases, but in every case the kidney was more than usually movable, and now I think the explanation is generally accepted that in cases of nephralgia, where no calcutus is found, the cause of the pain is due to twisting of the ureter of a more than usually movable kidney, and that operation tends to fix the kidney in place. No doubt many of you here will be ablp to add to the cases I have narrated, and perhaps some of you may be able to explain them more satisfactorily than the reader of the paper.