The ovaria become enlarged by degeneration of their structure and the addition of solid matter in great abundance. The consistence and structure of such tumours are very various; they are sometimes, though rarely, medullary, often fibrous, with or without cysts, sometimes melanotic. In the majority there are cysts, varying in size, number, and contents; sometimes the bag contains hydatids, or it is filled with curdy matter, sometimes with glairy colourless fluid, sometimes with a turbid and flaky serum, sometimes with blood; and in them, as well as in the enlargement from accumulated fluid, though perhaps more rarely, are occasionally found teeth, hair, and membranous looking matter; some are intermixed with bone, cartilage, and fat.
The situation and attachments of such tumours cannot be correctly ascertained by examination during life, far less can their internal structure and dispositions be arrived at. Indeed an accurate diagnosis is exceedingly difficult, if not impossible. Innumerable mistakes have been made, which have led to most unjustifiable proceedings. In one case, the abdomen was, after two or three dry tappings, opened by an incision from the ensiform cartilage to the pubes; the viscera were turned over and over, but no tumour could be discovered. The woman was sewed up, and did not die. The following was a still more complete failure in diagnosis. In a case of large tumour of the belly, many persons accustomed to manipulate abdominal swellings considered that extra-uterine conception had taken place; and that the child had come to maturity and perished. The history of the case countenanced the supposition; the symptoms had been such as indicate impregnation. The woman, to avoid exposure, went to a distance to be relieved of her burden, which was becoming more and more troublesome and bulky. The usual period passed over. It was thought that the head and thorax of an infant could then be felt readily through the parietes, and perhaps some one might have been found heroic enough to have divided them and explored the tumour. The young woman, however, was in the last stage of phthisis, and soon died. A wonderfully tuberculated omentum, a very small portion of which is here represented, filled the peritoneal cavity; the uterus and its appendages were quite healthy.
Operation has also been proposed, when, on dissection, the liver was found to compose the abdominal swelling. Such cases, a long list of which might be given, render the prudent surgeon very cautious in his diagnosis of abdominal tumours, and chary of operative interference with them. The abdomen has been opened, as already stated, and the result has been such as to render the perpetrator indictable for culpable homicide, and to qualify him for such punishment as his rash and reckless conduct richly deserved. A less severe censure might have sufficed, had not the example been followed by similar proceedings, and equally direful results; and these have been such as to render any condemnatory remarks not only justifiable but absolutely necessary. A great many unfortunate women have, I am afraid, been sacrificed to a desire for false reputation. The attempts to remove abdominal tumours by incision of the parietes were some time ago very numerous; and, as might have been expected, the issues were highly unsatisfactory to those concerned. Such doings, however, were recorded in print, represented in plates, and moreover puffed and placarded ad nauseam. The majority of those who were thus “dissected, to see what part was disaffected,” perished within forty-eight hours. One woman survived for some time, after having been subjected to this operation, improperly so termed. In her there was a tumour, but of such a size, and so connected, that it could not be removed. A second survived the extirpation of one ovarium; and the other, also diseased, was left for a further exhibition of daring intrepidity. It is not easy to conceive how the proposal could have been seriously entertained by any sane individual, far less put in practice and persevered in, when disaster after disaster crowned every attempt. It is my opinion, and I believe that I express the sentiments of a very large portion of the profession, that the repetition of any such incisions and gropings would be unpardonable.—1. On account of the difficulty, nay, impossibility, of forming a correct diagnosis; of ascertaining with certainty what organ is involved; of ascertaining the structure and disposition of the tumour, if any, and to what parts it is adherent. 2. Because the ovarian disease, in general, even though extensive, does not threaten imminently a fatal termination, being slow in its progress, and the greater number of the swellings being not of a malignant nature. The solid tumours are sometimes of a bad kind, as already stated; but enlargement by fluid is much more frequent in the ovaria than that by solid and new matter. 3. If the tumour be malignant, it will be impossible to ascertain to what extent the parts are involved by the diseased action, or whether the lymphatics are affected or not. There is a strong probability of the lymphatic system being involved, even at a very early period; and then the extirpation of the tumour—supposing the mass to be so situated as to admit of removal without difficulty or danger—cannot be attended with any advantage; in every point of view, therefore, interference is unadvisable. 4. The operative attempt is attended with imminent danger. There is almost a certainty of the patient being almost instantly destroyed by it, as shown by the sad experience of the past. “We are not the arbiters of life and death of those who apply to us for relief. If people die in consequence of disease, it cannot be helped. They submit to it because they know it is inevitable. But we had better refrain from making such experiments as may probably destroy them, and bring disgrace upon the profession.”
Bruises of the abdomen are apt to be followed by inflammation of the contained parts, particularly of the serous membrane. Occasionally lacerations of the viscera, both solid and floating, but more frequently of the former, are produced by bruising or squeezing of the abdomen, as by a blow, or by a heavy body passing over; they may also follow a violent concussion of the parts by falling from a height. The liver is the organ most frequently torn, and death is commonly the result, rapid, and principally from hemorrhage. The laceration is generally on the convex surface; extravasation takes place under the peritoneal covering; or this is torn, and the effusion is into the abdominal cavity. When the quantity of blood is not so great as to cause speedy dissolution, the patient may survive for some time, and even ultimately recover. Reaction is slow, the patient continuing a long time pale, exhausted, and almost pulseless; there is tenderness in the hypogastric region, with swelling. The spleen is liable to similar injury, and pours out a large quantity of blood.
The gall-bladder has sometimes been torn, as also portions of the small intestines, by a blow or kick, or by a heavy body passing over the abdomen, as the wheel of a loaded wagon. The escape of the contents is followed by sickness, rigour, quick, weak, and indistinct pulse, most excruciating pain, a sense of heat diffused all over the abdomen, and rapid sinking of the powers of life; a fatal termination generally occurs within twelve hours. The same train of symptoms supervene when the contents of the intestinal canal have been effused into the peritoneal cavity, through an opening in the stomach or bowel, caused either by slow destruction of the coats, the peritoneum giving way last, or by a rapid ulceration or sloughing process, as in hernia. The patient may live in agony for a day or two, but death generally takes place much within twenty-four hours. The same may be said of the rupture of the bladder, from external violence, with effusion of urine into the peritoneal sac. No treatment is of any avail; venesection hastens the sinking. Fomentation over the abdomen, and sedatives either by the mouth or by the anus, soothe the patient, and render his last moments more calm.
Penetrating wounds of the peritoneal cavity, if they reach the solid viscera and large vessels connected with them, are attended with effusion of blood externally and internally, in quantities proportioned to the size of the external aperture, the importance of the vessels concerned, and the vascularity of the part. The patient may perish from the bleeding, either instantly or after some time; or inflammation and its consequences supervene in the violent form, and destroy him at a more remote period. The mere opening of the peritoneal cavity, and to a very slight extent, without the slightest injury of the contained parts, is often attended with a great shock to the system, and is followed by inflammatory action, which may run on to a fatal issue, in spite of the most active and judicious management. The inflammatory symptoms are to be combated by free abstraction of blood; in short, the utmost endeavours must be made to keep the action within bounds. When the intestines are wounded, the injured part may protrude; or the relative size of the openings through the parietes and bowel may be such, that the intestinal contents do not escape into the peritoneal bag. A natural cure sometimes takes place by adhesion of the surface of the bowel to the lining of the parietes round the wound, feculent matter continuing to be discharged externally; after a time the opening may contract, and the discharge diminish and ultimately cease; or an artificial anus may be permanently established, and this is not so easily cured as that following upon hernia. Wounds of the intestines, whether transverse or longitudinal, attended with feculent escape into the peritoneal cavity, are not uniformly fatal. Effusion of lymph takes place around, gluing the wounded bowel to the peritoneal surface of a neighbouring fold, or forming a sort of pouch within which the extravasation is limited. The treatment consists in absolute rest, and most rigid antiphlogistic regimen; manual interference with the wounded part is not generally advisable.[46]
Lumbar Abscess is generally chronic; the collection of matter is gradual and slow. Sometimes it is acute, and rather rapid in its appearance. It may originate in the sheath either of the psoas or of the iliacus muscle; more frequently it seems to form behind these, and is connected with diseased bone. The precursory symptoms are often not particularly attended to; these are rigors and pain of the loins. As the disease advances, the patient feels great pain in the erect position, and in general the pain is aggravated by extending the thigh. Thickening and slight glandular enlargement takes place in the groin; there is an evident fulness there; and then swelling appears on the inner side of the femoral vessels, beneath the pubal portion of the fascia lata. This swelling is more prominent in the erect position, and is also increased by exertion of the abdominal muscles; an impulse is given to it on coughing. As it advances, and comes more to the surface, fluctuation is perceived. This is the most common site in which the abscess presents itself; but it is not unfrequently met with on the outside of the vessels, either lower or higher in the thigh, above Poupart’s ligament, in the loins over the crest of the ilium, and occasionally the matter is insinuated under the pelvic fascia and appears by the side of the anus. Large and neglected collections may work their way to the surface in two or three of these situations at the same time.
The disease is often attributable to a sprain or wrench of the loins, or to exposure to cold and over-fatigue. Occasionally the mischief is confined entirely to the soft parts; the vertebræ, a portion of the os innominatum, or the sacrum, may be denuded and of irregular surface, but this is evidently the result of the pressure of the abscess. A striking example of this, and of the extensive destruction of parts which this affection sometimes produces, may be shortly stated.—A very large lumbar abscess formed within a few weeks, in consequence of great and continued fatigue and exposure to bad weather. At first it had been trifled with. At last it was opened in the usual situation in the thigh, and a vast quantity of matter evacuated. Thirty-six hours afterwards, the patient was suddenly suffocated by a flow of purulent matter into and through the air passages. On dissection, the cavity of the abscess was found to be immense, opening through the diaphragm into the lung which was adherent, and communicating with the bronchi. The forepart of the lumbar vertebræ was exposed, and in some parts stripped of the theca; but there were no cavities in the bone, and no disease of the interposed cartilages. Such cases are now and then met with, of abscess in the loins not originating in any vice either of the bones or of any other part of the apparatus of the spinal column. Most frequently, however, the collections have their foundation in ulceration of the bodies of the vertebræ. The patient has had tenderness in the part, weakness of the back and of the lower limbs, and increase of pain on pressing or striking some particular spinous processes—perhaps slight excurvation. Then pain in extending the thigh supervenes, followed by swelling and other signs of abscess. This is preceded generally by deposit of tubercular matter in their cancellated texture. Sometimes the disease seems to originate in the ligaments and articulating surfaces; occasionally portions of the bone perish,