CHAPTER I.

THE OPERATION.

The cavity of the abdomen, may be opened without disturbing that of the chest. An incision from sternum to pubes, down the central line, and through the superficial structures, should be followed by a careful division of the tendinous portions of the muscles and peritoneum, for a sufficient space to admit two fingers, when, by introducing the same, the remaining portion may be divided without risk of injury to the intestines. A cross incision having been made at the umbilicus, the angular flaps may be turned aside, fully exposing the abdominal contents. Where the chest is opened at the same time, the transverse incision will not be required. The peritoneum, with any serous or other contents having been examined, the attention may be given to any special organ or part that may be involved, or each may be taken up seriatim.

In many instances there will be no occasion for removing any of the viscera, while in others, one or all of the organs may require so careful an examination, as to necessitate an entire removal from the body.

The _small intestines_ may be removed _en masse_, or in sections. After applying double ligatures at the lower end of the ileum, and just below the duodenum, the bowel may be divided between these, when, by dividing the mesentery near its intestinal border, with either the knife or scissors, the whole mass may be removed. By means of the _enterotome_, they may now be rapidly laid open through their entire length, the contents removed, and the surface cleansed if desired for more careful inspection. Occasionally, portions only of the small intestines will require examination. By applying double ligatures, above and below the portion to be examined, the removal is effected without escape of the contents into the abdominal cavity.

In the removal of the _colon_, either in sections, or as a whole, the same care should be observed in the application of the ligatures. The rectum having been divided, it may be lifted and rendered tense, its attachments, with those of the ascending transverse and descending colon, being successively divided with the knife, and thus the whole gut removed and afterwards split open with the enterotome.

The removal of the _rectum_, for the examination of its whole length, will usually require the removal of the other pelvic viscera, directions for which will be given further on.

In all cases where the _stomach_ is to be examined, it will be better first to remove it from the body. To accomplish this, both omenta should be detached from the curves of the stomach, which may be done either with the fingers or scissors. The hand may now be carried down to the cardiac end of the stomach and the fingers forced around the œsophagus without the use of the knife, and a ligature placed upon that tube. A ligature should also be placed just below the pyloric orifice, and another an inch below this. The knife or scissors may be used to divide the œsophagus close to the diaphragm, and the duodenum between the two ligatures; the stomach may then be lifted from its position without loss of any of its contents.

If the object is merely to make a chemical analysis of the contents, the stomach should be placed immediately in the vessel prepared for its reception, and carefully sealed and labelled. If, on the other hand, we may wish to examine the inner surface of the organ, it may be freely opened along one of the curves with the scissors, the contents removed, and the mucous surface cleansed with a stream of water, for more satisfactory inspection. Both the contents and the stomach, may still be preserved for chemical examination, should the circumstances of the case seem to require it.

From the manner in which the _duodenum_ is bound down to the posterior abdominal walls by the peritoneum, some little care will be required in its removal. Ligatures should be applied for retaining the contents, as directed with the stomach.

_The kidneys_, with the suprarenal capsules, may be reached by lifting the intestines, and tearing open the peritoneum with the fingers. The gland may then be readily lifted from its position, and the vessels divided with the knife. To examine the interior, the gland may be split open longitudinally along its convex border, which will give a view of the cortical and pyramidal portions, with the interior of the sinus and pelvis. For microscopic examination, portions should be hardened in alcohol or solution of bichromite of potassa.

_The spleen_ may be easily removed from its position, by dragging it from its bed, in the left hypochondriac region, and dividing its vessels and omental attachments to the stomach.

_The pancreas_ may be brought into view, by tearing open the great omentum just beneath the stomach, when the gland may be seen behind the peritoneum, extending transversely across in front of the aorta. To remove it from its position will require some care, owing to its being bound down to the posterior walls by the peritoneum, and closely attached to the duodenum by its right extremity or head.

_The liver_ may be generally examined _in situ_. The condition and contents of the gall-bladder, the size, color, density, etc., of the gland, may all be noted without removal. Where, however, we may desire to ascertain the weight of the gland, or to examine its posterior and upper surface, its removal will be required. Where the chest has previously been opened, this will not be a difficult operation. In other cases, the cartilages and ribs, forming the lower boundary of the chest, should be strongly elevated by an assistant; the operator then, by dragging down the liver, having first divided the suspensory ligament, may expose the coronary and lateral ligaments, which will require care in their division, to avoid opening through the diaphragm into the chest. The fingers should be now freely used, to peel the gland from the diaphragm. From the close connection of the liver to the ascending vena cava, this vessel will require to be divided at the upper border of the liver, close to the diaphragm, and again, after the gland has been rolled from its bed, at its lower border, with also the portal vessels, hepatic artery and duct, which reach the transverse fissure through the border of the lesser omentum.

The liver may now be lifted from the body, and placed in any convenient vessel for a more detailed inspection.

The Pelvic Viscera.

The whole _pelvic viscera_, with the external organs of generation, in either the male or female, may be removed together, in the following manner:—Apply a double ligature to the upper portion of the rectum, and divide the gut between. The peritoneum may now be divided around the border of the pelvis, in the female, at the same time, cutting across the round and broad ligaments of the uterus, when, with the hand, the bladder may be stripped down from the inner side of the pubes, the rectum torn from the hollow of the sacrum, and in the same manner the parts torn off from the sides of the pelvis, using the knife only for dividing the more closely adhering points.

Now, after flexing the thighs upon the abdomen, an incision may be made through the skin of the mons veneris just over the anterior commissure of the vulva of the female, and over the penis of the male, and then carried back upon either side of the genital organs, meeting behind the anus, near the point of the coccyx. This incision may be carried through the superficial tissues, down to the pubic arch, when the crura of the penis, or clitoris, may be detached from the rami of the pubes, by carrying the knife close to the bone. The finger may now—after a slight use of the knife—be pushed beneath the arch of the pubis, and made to appear in the pelvis. Taking this as a guide, the knife may be introduced at this opening, and carried deeply along the ramus of the ischium and pubis of either side, dividing the levator ani muscle and pelvic fascia. The bladder may now be drawn forward beneath the arch, this followed by the rectum, deep incisions being carried back to the tuberosities of the ischia and point of coccyx, and thus the whole mass removed entire.

The external parts may afterwards be so drawn together by stitches, as to make the absence of the external organs scarcely noticeable, while a bundle of rags crowded into the pelvis from above, will prevent the possible escape of any of the abdominal contents.

Where the _internal organs_ only, are required to be removed; after they have been detached upon all sides as before directed, the knife may be carried down beneath the pubic arch, and the urethra divided, in the male, just in advance of the prostate. Incisions may now be carried back upon either side of the bladder and rectum, dividing the levator ani muscle, when, by drawing upwards upon the mass, the rectum, and in the female, the rectum and vagina, may be divided near their lower ends, and the whole removed together.

In many cases it may be desired to remove the uterus of the female alone. This may be done by dividing the broad and round ligaments upon either side, when, by dragging the uterus forcibly upwards, the vagina may be cut across about an inch below the cervix, and thus the organ removed. In all cases, a few rags should be crowded into the pelvis for the purpose of preventing the escape of any fluids.

In hospital cases, where parts are to be exhibited to a class, and especially if several organs are involved in the disease, the whole thoracic and abdominal viscera may be removed together and brought before the class on a large tray. This may be effected in the following manner:—A single incision may be carried from the upper end of the sternum to the pubes, and the sternum removed in the usual manner. The trachea and œsophagus, with the large vessels of the arch of the aorta, may now be divided at the root of the neck. Grasping the arch of the aorta and the trachea, the whole thoracic contents may be stripped from the spinal column. The diaphragm being now separated from its attachment to the ribs on either side and the spinal column, the whole abdominal contents may, in the same manner, be dragged from above downwards, the rectum tied and divided, and the contents of the two great cavities removed entire and with little disturbance of the relation of parts.

In closing up the cavity after the examination is completed, the viscera having been replaced, a sufficient quantity of wheaten bran or clean sawdust should be thrown in to absorb any remaining fluids, thus preventing their escape after the sewing up of the incisions.