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 in highly populated countries like India and China 6)

7) If all resources were unlimited and wants were 7)

limited:
A) the problem of choice would not exist
B) everyone would have to work much harder
C) the economy would experience severe
unemployment
D) the economy would experience inflation

8) The need to choose among alternatives is a direct result of: 8)

A) limited wants B) greed C) habit D)
scarcity

2
 9) We can eliminate the problem of scarcity 9)
by:
A) encouraging everyone to work twice as
hard
B) producing goods and services at a lower
cost
C) increasing our natural resources
D) none of the above

10) Economics is important to individuals because it: 10)

A) gives personal satisfaction B) sharpens their common
sense
C) helps them to make rational choices D) all of the above

11) Choice is a direct result of: 11)

A) scarcity B) freedom C) abundance D)
luxury

12) Which of the following is correct? 12)

A) Individuals have to make choices but society as a whole does not have to make
choices
B) Individuals as well as society must make choices
C) Society does not have to give up anything to get something else
D) Society is not confronted with scarcity because society owns all the resources

13) Economics is: 13)

A) the study of human beings interacting with one another in groups
B) the science that studies how people use scarce resources to satisfy their unlimited
wants
C) the discipline that explains how the human mind works
D) the science that is concerned with voting behaviour and international relations

14) Economics deals, to a large extent, with: 14)

A) how societies and governed B) political relations among countries
C) scarcity and choice D) the social aspects of human
behaviour

15) Economists concern themselves with: 15)

A) abnormal behaviour of human beings
B) the behaviour of people engaged in the activity of using scarce resources to satisfy
their
wants
C) the organization, functions, and operations of the state, and with voting behaviour
D) all of the above

16) Economics is concerned with the fact that: 16)

A) resources are limited while wants are unlimited
B) resources are plentiful but the members of society are
wasteful
C) wants and resources are both limited
D) people are just never satisfied with what they have

17) Social science includes all of the following except:

3
 A) biology B) economics 17)
C) psychology D) political
science

18) Things used to produce goods and services are called: 18)
A) commodities B) outputs C) resources D)
amenities

4
19) Examples of resources are: 19)
A) hydro-electricity plants B) roads and
waterways
C) trees and paper D) All of the above

20) Which of the following statements about resources is 20)

incorrect?
A) They can never be used to produce other resources
B) They are used to produce goods and services
C) They are generally scarce
D) They are also called factors of production

21) The main difference between goods and services is 21)

that:
A) services give satisfaction while goods do not
B) goods give satisfaction while services do not
C) services are tangible while goods are intangible
D) goods are tangible while services are intangible

22) Items such as garbage and pollution that are unwanted and do not give any satisfaction are 22)
called:
A) bads B) unwantables C) discards D)
wastes

23) Which of the following statements is true? 23)

A) Human activity often results in the production of bads
B) Bads are produced only by evil people
C) Bads are items like cigarettes and alcohol that are known to harm
people
D) In a modern, civilized society, bads are produced only by accident

24) Which of the following is not a scarce resource in Canada? 24)

A) Forests B) Machinery in a manufacturing
plant
C) Water that runs from the tap in a house D) Sunlight

25) Which of the following is classified as land? 25)

A) Natural waterfalls B) Oxygen in the
air
C) Minerals embedded in the earth D) All of the
above

26) The difference between land and capital is that: 26)

A) land is manufactured while capital is a natural
resource
B) land is natural while capital is manufactured
C) land is abundant while capital is scarce
D) land is scarce while capital is abundant

27) Examples of capital goods are: C)

A) wildlife and rivers B) the efforts of truck drivers natur
al
5
 forests D) buildings, roads, machinery and tools 27)

28) Which of the following is not real capital, according to economists? 28)
A) An airport B) A computer in an
office
C) The furniture in a school D) Money in a bank
account

29) Which of the following groups provides labour services? 29)

A) Lawyers B) Engineers
C) Farmers D) All of the
above

6
30) A mining company owns a coal mine. It hires miners to mine the coal with shovels, load it 30)
on a truck and take it to the coal market where it is sold. In this scenario:
A) The mine is land, the coal in it is capital because it can be sold for money, and the miners
are labour
B) The mine and the coal in it are land, and the shovels are capital
C) the owner of the company makes all the important decisions and is a good example of
labour
services
D) the mine, the shovels and the truck are all capital because they cost money

31) Which of the following statement is correct? 31)

A) Labour services generate a kind of income called profit
B) Entrepreneurship generates a kind of income called
profit
C) Capital generates a kind of income called profit
D) Land generates a kind of income called interest

32) Ken owns an apartment building. The money that he collects from his tenants is 32)
technically
classified as:
A) Wages and salaries B) Profits
C) Interest and dividends D) Rent

33) Jennifer Lo owns a small lake which she hires out on week-ends to campers. The income that 33)
she derives from her lake is classified as:
A) Profit B) Rent
C) Wages and salaries D) Interest

34) Jennifer Lo owns a small lake which she hires out on week-ends to campers. The workers 34)
that
Jennifer hires to work for her receive a type of income called:
A) Profit B) Rent C) Wages D)
Interest

35) If R denotes rent; W denotes wages and salaries; i denotes interest and dividends; and π 35)
denotes
profits, then the equation for total income can be written as:
A) total income = W - i + R + π B) total income = π - W - R + i
C) total income = W + R + i - π D) total income = i + W + π + R

36) Economics is: 36)

A) a social science because it uses graphs and mathematical
equations
B) an exact science because economists make accurate predictions
C) an exact science because economists use models
D) none of the above

37) The scientific approach involves: 37)

A) the formulation of hypotheses B) the testing of
hypotheses
C) observation and measurement D) all of the above

7
38) The scientific approach refers to: 38)
A) the systematic investigation and observation of phenomena, and the formulation of
general
laws after testing and verifying
hypotheses
B) any method that involves the use of mathematical formulae
C) experiments in laboratories only
D) the use of graphs to help clarify explanations

8
39) The empirical aspect of science is: 39)
A) the development of relevant and useful
assumptions
B) the measurement and recording of facts
C) the use of models
D) the formulation of hypotheses

40) Scientific inquiry differs from other types of inquiry in that scientific inquiry: 40)
A) relates questions to evidence B) is necessarily more lengthy
C) always results in absolute truth D) relies solely on the use of
mathematics

41) Which of the following is an example of a hypothesis? 41)

A) Students who understood graphs did much better in their examinations than those who
did
not understand
graphs
B) If you understand graphs, you will get a better grade in your examination
C) It snowed heavily yesterday
D) Seventy per cent of students passed their economics examination last year

42) A model is: 42)

A) a theory that has been tested and found to lack realism and
precision
B) a faithful and complete reproduction of reality
C) a means of making reality more scientific and complex
D) a simplification of, or an abstraction from, reality

43) An economic model: 43)

A) does not require assumptions B) is necessarily mathematical
C) may be expressed verbally D) must employ a graphical
procedure

44) Which of the following is not a necessary component of a 44)

model?
A) One or more hypotheses
B) A set of mathematical equations or graphs
C) A set of assumptions
D) A set of definitions

45) Definitions are useful in model building 45)

because:
A) they eliminate objectivity from models
B) they identify variables so that measurement can be
facilitated
C) they replace hypotheses
D) they avoid the use of assumptions

46) Assumptions: D)
A) are statements about the conditions under which a model are
operates speci
B) are statements that can never be proved or disproved al
C) express reality exactly types

9
 of hypotheses 46)

47) The “ceteris paribus” assumption: 47)

A) allows the analyst to isolate the effects of certain
variables
B) makes economics a science
C) is a good example of a hypothesis in economics
D) really complicates economic analysis

10
48) The ceteris paribus (other things being equal) assumption allows one 48)
to: A) isolate the effects of certain variables
B) distinguish between stocks and flows
C) interchange endogenous and exogenous variables
D) none of the above

49) By assuming “other things equal”, economists can: 49)

A) examine the effects of all variables simultaneously
B) examine the effects of one variable while holding others
constant
C) make economics an exact science
D) none of the above

50) Ceteris paribus means: 50)

A) “after all changes have been made” B) “other things being
equal”
C) “after this therefore because of this” D) none of the above

51) Which of the following is an economic prediction? 51)

A) If the price of oil rises, interest rates will also rise
B) The growth rate of total output will be 3.8% in 2010
C) The unemployment rate will fall to 4.2% by the end of the year
D) The price of oil will reach a peak of $100 a barrel by the end of the
year

52) Which of the following is an example of an economic forecast? 52)

A) A fall in the rate of interest will cause an increase in the level of investment
B) The value of the Canadian dollar will be US$1.08 by the end of June next year
C) A reduction in personal income taxes in Canada will lead to an increase in imports of
goods
and services into Canada
D) If the money supply increases, the rate of interest will fall

53) The goodness of a model depends on: 53)

A) how widely it is used
B) the extent to which it employs
mathematics
C) the realism of its assumptions
D) how well it predicts and explains reality

54) The branch of economics that deals with the use of statistical methods to test economic 54)
theories is
called:
A) econostats B) metroconomics
C) econometrics D) none of the above

55) A positive statement 55)

is:
A) a statement with no scientific basis
B) an opinion
C) a statement about some fact that can be verified or
disproved
D) a statement that is true
11
56) A normative statement: 56)
A) cannot be verified by examining the facts B) is a value
judgement
C) deals with what ought to be D) all of the above

12
57) Which of the following is a positive statement? 57)
A) Canada produced $700 billion worth of goods and services last year
B) Every university or college student ought to take at least one course in economics
C) The government should reduce the debt by at least 20% annually over the next few
years
D) All of the above

58) Which of the following is a normative statement? 58)

A) Over 70% of the students in this class will obtain a final grade of at least
70%
B) Canada has the second highest output per capita in the world
C) Economics is more important than either mathematics or history
D) High interest rates cause unemployment

59) Economists are more likely to disagree over: 59)

A) the predictions of economic theory than over the theory itself
B) positive economics than normative economics
C) normative economics than positive economics
D) none of the above, because good economists do not disagree over
anything

60) Economists may disagree because: 60)

A) they use different economic models B) they have different
values
C) neither A nor B D) both A and B

61) A variable is: 61)

A) found only in mathematical equations
B) anything used to construct a model
C) anything that can assume different
values
D) anything whose value cannot be found

62) Which of the following statements about endogenous variables is 62)

correct?
A) Their values are pre-determined outside a model
B) They have no place in scientific economics
C) They are always fixed
D) Their values are determined within a model

63) Which of the following statements about exogenous variables is 63)

correct?
A) Their values are determined within a model
B) They have a constant value
C) They have no place in scientific economics
D) Their values are pre-determined, outside a model

64) Exogenous variables: 64)

A) cannot affect the endogenous variables because they are outside the
model
B) may affect the endogenous
variables C) are of no importance to
economists D) none of the above

13
65) It is possible to determine whether a particular variable is endogenous or exogenous 65)
by: A) observing whether the variable affects others
B) examining its value
C) examining the
model D) all of the
above

66) Which of the following statements is incorrect? 66)

A) A flow can affect a stock B) Stocks and flows are both
variables
C) A flow has a time dimension D) A flow changes but a stock does
not

67) Which of the following is an example of a 67)

stock?
A) The balance in an individual’s bank account
B) The annual profits earned by the XYZ Company
C) The amount of goods and services exported in a
year
D) The annual interest payment on a loan

68) Which of the following is an example of a 68)

flow?
A) The annual output of a firm
B) The number of cars on a parking lot
C) The number of students who attended class on May
16
D) The amount of money in your purse or wallet

69) A and B are two variables that are highly correlated. From this, we can safely conclude that: 69)
A) an increase in B causes an increase in A B) an increase in A causes an increase
in B
C) any change in A will cause a change in B D) none of the above

70) The post hoc fallacy refers 70)

to:
A) an error resulting from “ad hoc” analysis
B) the error in concluding that A causes B because A
precedes B
C) an error discovered after examining the facts
D) none of the above

71) Microeconomics is concerned 71)

with:
A) the impact of the money supply on overall economic
activity
B) how specific prices are determined
C) total income and total employment in an economy
D) the overall level of prices

72) A theory explaining how much a firm should produce in order to maximize its C)
profits is: macr
A) microeconomic theory B) income and employment oecon
theory omic
14
 theory D) none of the above 72)

73) Macroeconomics is concerned with: 73)

A) price determination in particular markets
B) fluctuations in general economic activity
C) price and output decisions in individual
firms
D) all of the above

15
 74) Macroeconomics differs from microeconomics in that: 74)
A) macroeconomics is concerned with individual decision making while
microeconomics is
concerned with such variables as total employment and the average level of prices
B) macroeconomics is concerned with the study of broad economic aggregates while
microeconomics is concerned with the study of the units that make up the
aggregates
C) macroeconomics is concerned with the study of the units which make up the
aggregates
while microeconomics is concerned with the study of broad aggregates
D) macroeconomics is complex while microeconomics is simple

TRUE/FALSE. Write ʹTʹ if the statement is true and ʹFʹ if the statement is false.
75) In order to understand world affairs, one must study political science or history because 75)
economics
is not useful in understanding world affairs.

76) Economics helps us to understand the economy but it does not help us to understand society. 76)

77) Economic analysis is an exercise in logic and thus helps to improve oneʹs common sense. 77)

78) Even though Canada has large supplies of various resources, it still faces scarcity. 78)

79) All resources are scarce in Canada. 79)

80) If scarcity did not exist, we would still have to make choices. 80)

81) Because of scarcity, individuals have to make choice, but society as a whole does not. 81)
82) Economics can be defined as the study of how people cope with the ever present 82)
problem of
scarcity.

83) Economics is a social science because it deals with human behaviour. 83)

84) Economics is an exact science because economists use mathematical models. 84)
85) A resource is not scarce, in an economic sense, if large quantities of the resource are 85)
readily
available.

86) The main difference between goods and services is that goods are tangible while services 86)
are
intangible.

87) Bads give satisfaction and are wanted even though they may be harmful. 87)
88) The Canadian economy is so modern and technologically advanced that it can now avoid 88)
the
production of bads.

16
89) Examples of bads are cigarettes, alcohol, illicit drugs, and guns because they are 89)
harmful to
individuals and society.

90) We know that a resource is scarce if it has a price. 90)

17
 91) In economics, resources such as forests, wildlife, rivers, and oceans, are classified as land. 91)
92) The services of professionals such as doctors, lawyers, professors, and consultants 92)
cannot be
classified as labour because they do not exert much physical effort.

93) Real capital refers to money because the only purpose of other types of capital is to make money. 93)
94) Owners of apartment buildings collect rent from their tenants; therefore apartment 94)
buildings are
classified as land.

95) The scientific procedure involves observation and measurement, the formulation of 95)
hypotheses,
and the testing of hypotheses.

96) The descriptive or empirical aspect of science involves observation and measurement. 96)

97) Hypotheses are statements about the conditions under which a model operates. 97)
98) Economists follow the scientific approach by conducting controlled laboratory experiments. 98)
That’s
why economics is a science.

99) Economists gather information, analyze it, and formulate and test hypotheses and thus 99)
arrive at
general statements or laws concerning economic phenomena. That’s why economics is a
science.

100) An economic model must replicate economic reality in every detail. 100)
101) An economic model differs from an economic theory in that a model is more complicated 101)
than a
theory.

102) An economic model comprises definitions, assumptions, and hypotheses. 102)

103) To be scientific, an economic model must be expressed in fairly advanced mathematics. 103)

104) Assumptions are statements about the conditions under which a model operates. 104)
105) Because economics is not an exact science, economists need not formulate their hypotheses 105)
in a
testable manner.

106) By assuming ceteris paribus, economists make sure that economics can never be a science. 106)
107) The ceteris paribus assumption allows us to keep other factors constant while we examine 107)
the
effects of the factor that is of current interest to us.

18
108) An economic forecast is a statement about the general direction of events resulting from 108)
the
fulfilment of certain conditions.

109) The statement that an increase in the price of a product will cause people to buy less of 109)
that
product is an example of an economic prediction.

19
110) The statement that in a year from now, the rate of inflation will be 8.5% is an example 110)
of an economic prediction.

111) The goodness of a model depends on the extent to which it follows scientific procedures, and 111)
not on its predictive capacity.

112) Mathematical models always have greater predictive powers than non -mathematical models. 112)

113) The branch of economics that deals with the use of statistical tools and methods to test 113)
economic theories is called econometrics.

114) Positive economic statements are factual and can never be wrong. 114)

115) Positive statements are statements about facts expressed in a verifiable manner. 115)

116) Normative economics makes statements about how the economy ought to operate. 116)

117) The statement that regular class attendance has a negative effect on students’ grades is an 117)
example of a positive statement.

118) A study explaining the effects of an increase in income on consumer spending is an 118)
example of positive economics.

119) Normative and positive issues are totally unrelated and have totally different orientations. 119)

120) Competent economists never disagree because economics is a science. 120)

121) Economists are in general agreement about the normative aspects of economics, but they 121)
disagree generally about the positive aspects.

122) As long as economists use the same economic models, there can never be any 122)
disagreements among them.

123) Disagreement among economists over normative economics can generally be settled by 123)
observing the facts.

124) Those variables whose values are determined within the model are called endogenous 124)
variables.
125) In any economic model, the level of income will be an exogenous variable. 125)

126) Exogenous variables are so called because they have no effect on the endogenous variables 126)
of the model.

127) A model is not necessary in order to determine whether a variable is endogenous or exogenous. 127)

128) Examples of economic flow variables are income, investment, and consumption. 128)

129) Flow variables have no time dimension; stock variables do have time dimensions. 129)

20
130) The number of students currently in your economics class is an example of a flow. 130)

131) One way of distinguishing stocks from flows is to recognize that stocks are constants while 131)
flows are variable.

132) A high correlation between two variables does not establish a cause -effect relationship 132)
betwee them.

133) The post hoc fallacy refers to the error in concluding that A causes B because A precedes B. 133)

134) The two main branches into which economics is divided are paraeconomics and minieconomics. 134)

135) Microeconomics is the branch of economics that examines the behaviour of individual 135)
economic units.

136) Macroeconomics concerns itself with the behaviour of economic aggregates such as 136)
total employment and the average level of prices.

137) A study of the effects of an increase in the money supply on the rate of interest and the 137)
level of income in an economy would fall under microeconomics.

138) An investigation into the pricing policies of college bookstores with regard to all textbook 138)
prices would fall under microeconomics.

21
Answer Key
Testname: UNTITLED1

1) D
Skill: Applied
2) D
Skill: Recall
3) D
Skill: Recall
4) C
Skill: Recall
5) C
Skill: Recall
6) B
Skill: Recall
7) A
Skill: Applied
8) D
Skill: Applied
9) C
Skill: Applied
10) D
Skill: Recall
11) A
Skill: Recall
12) B
Skill: Applied
13) B
Skill: Recall
14) D
Skill: Recall
15) B
Skill: Recall
16) A
Skill: Recall
17) A
Skill: Recall
18) C
Skill: Recall
19) D
Skill: Recall
20) A
Skill: Recall
21) D
Skill: Recall
22) A
Skill: Recall
23) A
Skill: Recall

22
Answer Key
Testname: UNTITLED1

24) D
Skill: Recall
25) D
Skill: Recall
26) B
Skill: Recall
27) D
Skill: Recall
28) D
Skill: Recall
29) D
Skill: Recall
30) B
Skill: Applied
31) B
Skill: Recall
32) C
Skill: Applied
33) B
Skill: Applied
34) C
Skill: Applied
35) D
Skill: Applied
36) D
Skill: Recall
37) D
Skill: Recall
38) A
Skill: Recall
39) B
Skill: Applied
40) A
Skill: Applied
41) B
Skill: Applied
42) D
Skill: Recall
43) C
Skill: Applied
44) B
Skill: Applied
45) B
Skill: Applied
46) A
Skill: Recall

23
Answer Key
Testname: UNTITLED1

47) A
Skill: Applied
48) A
Skill: Applied
49) B
Skill: Applied
50) B
Skill: Recall
51) A
Skill: Applied
52) B
Skill: Applied
53) D
Skill: Applied
54) C
Skill: Recall
55) C
Skill: Recall
56) D
Skill: Recall
57) A
Skill: Applied
58) C
Skill: Applied
59) C
Skill: Applied
60) D
Skill: Applied
61) C
Skill: Recall
62) D
Skill: Recall
63) D
Skill: Recall
64) B
Skill: Applied
65) C
Skill: Applied
66) D
Skill: Recall
67) A
Skill: Applied
68) A
Skill: Applied
69) D
Skill: Applied

24
Answer Key
Testname: UNTITLED1

70) B
Skill: Recall
71) B
Skill: Recall
72) C
Skill: Applied
73) B
Skill: Applied
74) B
Skill: Recall
75) FALSE
Skill: Recall
76) FALSE
Skill: Recall
77) TRUE
Skill: Recall
78) TRUE
Skill: Applied
79) FALSE
Skill: Recall
80) FALSE
Skill: Applied
81) FALSE
Skill: Recall
82) TRUE
Skill: Applied
83) TRUE
Skill: Applied
84) FALSE
Skill: Recall
85) FALSE
Skill: Recall
86) TRUE
Skill: Recall
87) FALSE
Skill: Recall
88) FALSE
Skill: Recall
89) FALSE
Skill: Applied
90) TRUE
Skill: Applied
91) TRUE
Skill: Applied
92) FALSE
Skill: Recall

25
Answer Key
Testname: UNTITLED1

93) FALSE
Skill: Recall
94) FALSE
Skill: Applied
95) TRUE
Skill: Recall
96) TRUE
Skill: Recall
97) FALSE
Skill: Recall
98) FALSE
Skill: Recall
99) TRUE
Skill: Applied
100) FALSE
Skill: Applied
101) FALSE
Skill: Applied
102) TRUE
Skill: Recall
103) FALSE
Skill: Applied
104) TRUE
Skill: Recall
105) FALSE
Skill: Applied
106) FALSE
Skill: Applied
107) TRUE
Skill: Applied
108) FALSE
Skill: Recall
109) TRUE
Skill: Applied
110) FALSE
Skill: Applied
111) FALSE
Skill: Recall
112) FALSE
Skill: Applied
113) TRUE
Skill: Recall
114) FALSE
Skill: Applied
115) TRUE
Skill: Recall

26
Answer Key
Testname: UNTITLED1

116) TRUE
Skill: Recall
117) TRUE
Skill: Applied
118) TRUE
Skill: Applied
119) FALSE
Skill: Applied
120) FALSE
Skill: Recall
121) FALSE
Skill: Applied
122) FALSE
Skill: Recall
123) FALSE
Skill: Applied
124) TRUE
Skill: Recall
125) FALSE
Skill: Applied
126) FALSE
Skill: Applied
127) FALSE
Skill: Applied
128) TRUE
Skill: Applied
129) FALSE
Skill: Recall
130) FALSE
Skill: Applied
131) FALSE
Skill: Applied
132) TRUE
Skill: Applied
133) TRUE
Skill: Recall
134) FALSE
Skill: Recall
135) TRUE
Skill: Recall
136) TRUE
Skill: Recall
137) FALSE
Skill: Applied
138) TRUE
Skill: Applied

27
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Fig. 628
 General scheme of cholecystectomy; detachment of gall-bladder and duct from
their investments; ligation of cystic duct and arteries. (After Kehr.)

Cholecystendysis.—The term cholecystendysis, now almost

obsolete, implies practically a cholecystotomy
with drainage, the gall-bladder having been opened for the purpose
of removal of one stone or more and then united to the abdominal
wound.
Of the operations upon the ducts there is something to be said in
addition to the directions already given. Inasmuch as they lie more
deeply they are more difficult of access, and variously shaped
retractors, with walling off the cavity with gauze, are more often
required, while in proportion as deep adhesions have enwrapped the
structures they are made more difficult of exposure. At present
surgeons have less hesitation in leaving duct incisions unclosed than
was formerly felt. It was formerly held that every incision into a duct
should be closed with sutures. It has been later found that
satisfactory results ensue when the end of the drainage tube is left
resting, or even fastened, within the duct opening, the operation
being thus made shorter and simpler and the difficulties of deep
suture thus obviated. As elsewhere noted the common duct may
become enormously dilated, and may be almost mistaken for the
small intestine. The passage-way between this duct and the gall-
bladder may be so obstructed that double drainage will be of
advantage, or this may be a case where partial removal of the gall-
bladder may be effected, with drainage of the common duct. Such
cases should be judged upon their merits. The more infectious the
existing condition the more is free drainage demanded. When a
stone is impacted in the ampulla of Vater there should be no
hesitation in dividing the walls of the duodenum in order to extract it.
In such a case the duodenum is sutured, but the duct or the gall-
bladder must be drained (Fig. 629).
These deep operations require free incision, several inches in
length, and it will astonish the beginner to see how the liver may be
delivered from the abdominal cavity through such an opening. Much
assistance will here be gained by a large pillow or sandbag placed
beneath the back. Bleeding vessels need to be secured, at least
temporarily, with forceps, and usually with sutures or ligatures en
masse. The exposed or torn surfaces of the liver will ooze freely at
first, but bleeding usually ceases with the pressure of a gauze
tampon. From the uninflamed gall-bladder the peritoneum is usually
easily separated, with but trifling hemorrhage. For deep work traction
on the middle portion of the duodenum makes more prominent the
junction of this part of the bowel with the gastrohepatic omentum, at
which point the peritoneum may be incised and separated along the
free border of the duodenum until this portion is free from external
peritoneal covering. There will be exposed here the second portion
of the common duct where it lies upon the pancreas, it being more or
less embedded in the latter further along. When it is necessary to cut
away more tissue it is better to sacrifice a portion of pancreas rather
than of duodenum itself. Blunt dissection alone should be made
here. When it is necessary to cut it will be better to use the
thermocautery.
 Fig. 629

Removal of gallstone entangled at the papilla. Kocher’s method of displacing the

duodenum: a, incision in the paraduodenal peritoneum; b, pancreas; c, location of
the stone; d, duodenum; e, sutures used either for retracting or closing opening in
the common duct; f, retroduodenal venous plexus. (Kehr.)

These various cutting operations have superseded the previous

methods of endeavoring to crush stones within the duct and force
the fragments along by pressure. The Mayos have recommended
the use of two fine parallel sutures, introduced longitudinally into the
duct, between which the incision should be made, and which may be
used as tractors, or subsequently for purposes of closure.
Practically every gall-duct case should be drained with a tube
extending down to the deepest portion of the site of the operation.
This may be done with what has been called a “dressed tube,” made
by surrounding an ordinary rubber drain with a few layers of gauze
and covering this with oiled silk. The lower end of the tube is then
bevelled or trimmed in fish-tail fashion. This may be passed into the
depths, or it may be used for gall-bladder drainage as well.
 Of the anastomotic operations there is less heard now than a few
years ago. There are now considered to be but a few conditions
which are not better dealt with by biliary drainage as made above
than by any other method. Occasionally, as, for instance, when the
common duct is strictured or involved in pancreatitis or cancerous
deposit, and bile is backing up into the gall-bladder, it may be of
great advantage to effect an anastomosis between the latter and the
bowel. At one time the colon was used for the purpose, but this
prevented the utilization of the bile in the upper bowel, where it is
most needed. Consequently it should always be made into the upper
portion of the bowel, the duodenum, or one of the upper loops of the
jejunum. For this purpose a small Murphy button is probably still the
speediest and best expedient. This is true also when it seems
necessary to drain the common duct into the bowel, since the field of
operation in most cases lies too deeply to permit of accurate and
satisfactory suturing. A further and more difficult as well as later
application of this principle has been suggested for certain cases of
permanent obstruction of the common and main hepatic ducts.
Under these circumstances the operation last mentioned would be
useless and a cholangiostomy would be objectionable, as it would
constitute a permanent fistula. As practised by Kehr and others this
hepato-cholango-enterostomy is performed by removing from the
lower surface of the liver a strip of its tissue about 7 Cm. long and
2.5 Cm. wide. The hemorrhage is checked with the thermocautery,
and with it an opening is made into the liver, of such a depth that
several of the bile ducts are thus divided and opened. The
uppermost loop of bowel which then can be utilized without tension
is opened and sutured to the margins of liver wound. The method is
still on trial, and yet in at least one successful case it was shown that
the liver tissue tolerated this unavoidable contact with the contents of
the upper abdomen (Fig. 630).
 Fig. 630

Demonstrating the technique of anastomosis between the gall-bladder and the

jejunum. (Cordier.)

After-management.—What to do with these cases of biliary

drainage after it has been effected is
sometimes a serious problem. No hard-and-fast rules can be laid
down regarding the length of time during which drainage should be
maintained. In instances where the gall-bladder has been removed
the drain should be taken out within thirty-six hours, but in those
cases where a tube has been fastened into the gall-bladder for so-
called permanent drainage the term “permanent” may be regarded
as elastic, and covering a period of from ten days to perhaps ten
weeks. In the majority of instances three weeks or so of such
drainage suffice to meet the original indication. In cases, however, of
chronic pancreatitis a long period of easy outflow will be demanded,
while in rare cases of cancer drainage once thus made cannot be
abandoned.
When the gall-bladder has not been fastened nor allowed to
adhere to the skin, but only to the peritoneum, the fistulas thus made
will usually close and rarely need stimulation. Should, however, the
granulation process by which closure is effected be too sluggish it
may be stimulated by the application of nitrate of silver, either in
solution upon a swab, or in solid form, as when melted into a bead
upon the end of a suitable probe. Firm pressure will also assist in
final closure.
It is not reasonable to expect that after so much intervention,
within the rudely triangular potential cavity occupied by the gall-
bladder and the ducts, adhesions will not form as a part of the
reparative process. In fact it may rather be expected that as it
becomes obliterated adhesion must necessarily follow. In
consequence there may result an agglutination around the gall tract,
and into a common mass, of the liver, the colon, and the pyloric end
of the stomach. In spite of these adhesions bad symptoms rarely
ensue, and when discomfort persists it is usually in those cases in
which no stone was found or those in which stones have been
overlooked. Andrews regards such postoperative adhesions as
unavoidable and even desirable, and, having no faith in any
measures to prevent their formation, differs from Morris in regard to
the technique of their subsequent removal. It appearing from
observation and experience that the stomach is the organ which
suffers most by extensive adhesion to the liver, he has proposed to
substitute the colon for the stomach in this necessary union of
surfaces, and would even practise it in old cases after separation of
old adhesions.
The operation suggested by Andrews, and which he calls
cholehepatopexy, or colon substitution, is made with an incision
through the middle line of the right rectus, avoiding any old scar, long
enough to afford plenty of room. The stomach is then carefully
separated from the liver, tearing liver tissue rather than that of the
former, if something must be torn, and checking bleeding by hot
sponges. The pylorus having been exposed the stomach is
invaginated into it in order to demonstrate its patency. The freshly
separated viscera will now fall again into immediate contact unless
the transverse colon be pulled up and held in place between the liver
and the pylorus, this not being so much of a displacement as would
appear, as the bowel is not rotated and does not cross over the
stomach. The colon is held in its new relation by attaching its
omentum to the gastrohepatic ligament, to the liver surface, or to
remnants of old adhesions in the angle between the pylorus and the
liver. The looser the omentum and the more easily it can be
interposed in this way the better. Andrews’ conclusions are that gall-
tract adhesions are unavoidable, both in disease and after operation,
that they are harmless except in a very few cases, and often
beneficial, and that in the few cases where they do harm this comes
from malposition rather than from adhesions per se. He even
believes that certain vague gastric adhesions which might have been
benefited by this operation have been previously treated by gastro-
enterostomy.
 CHAPTER LIII.
THE OMENTUM, THE MESENTERY, THE SPLEEN,
THE PANCREAS.

THE OMENTUM.
The omentum is something more than what it generally appears,
i. e., a more or less thick and extensive apron of fat, hanging down in
front of the small intestines, although in this respect alone it serves
as a sort of reservoir or storehouse for fat, which is always drawn
upon as the needs of the system may require. The omentum varies
within wide limits from being the flimsiest veil of peritoneum, whose
four original layers have become so blended as to be lost to
recognition, and which may even be perforated in places with
openings through which strangulation of the bowel is possible, to the
thickest and grossest mass of fat found in the human body,
resembling a coarse mat rather than any finer texture, and having a
thickness, in obese individuals, of two to four inches. Under these
circumstances it makes a formidable obstacle to nearly all abdominal
operations. The thickness of the omentum sustains usually a pretty
constant proportion to the amount of adipose between the skin and
the abdominal muscles. In certain enormously fat individuals one has
then to go through from four to six inches of tissue, mostly adipose,
before reaching the rest of the abdominal contents. This
necessitates a longer incision and is always a disadvantage and
impediment. To the operating surgeon, then, the omentum
sometimes appears a nuisance.
It does not deserve, however, to be so regarded, and when
properly viewed the omentum will frequently appear in the role of the
surgeon’s as well as the patient’s best friend. This is due to its power
of shifting itself, and, as it were, enclosing actively dangerous foci
due to any variety of infection, the natural intent being, as it were, to
wrap itself around and thus completely imprison the source of the
trouble, a fact which is often actually accomplished, and by which
life-saving protection is frequently afforded. This is true of the
omentum whether thick or thin. By virtue of the adhesions which
often annoy the surgeon, and which necessitate separation and
perhaps considerable work before the actual trouble is exposed, a
protective barrier is formed and the greater portion of the abdominal
cavity shut off from danger of spreading infection. Moreover, that the
omentum has a really valuable purpose appears from the fact that its
removal from young animals seems to cause retardation of
development, and from adult animals a diminution of resistance to
the action of poisons introduced into the peritoneum. It is the
omentum which, to a large extent, absorbs foreign corpuscles, such
as those from extravasated blood. It helps, moreover, to dissolve
blood clots and to facilitate their disappearance, and after the
removal of the spleen it would appear to vicariously perform at least
some of its duties. Thus when the complete blood supply of the
spleen is cut off the organ almost completely disappears as the
result of its absorption by the omentum. (This at least in
experimental animals.)
The omentum serves further useful purpose by plugging various
openings and wounds in the abdominal walls, and thus affording at
least a temporary protection, just as the mucosa sometimes acts in
reference to the stomach. Moreover, it is so vascular, so flexible, and
so available that it may be used for plastic purposes in covering
weak spots, lines of sutures, and the like, in the small intestine or
even elsewhere. These same physical qualities make it extremely
prone to escape through the natural outlets. Hence the frequency of
epiplocele or omental hernia (q. v.). By a species of such hernial
protrusion it has saved many a life after bursting open or re-opening
of recent abdominal wounds. Sometimes it will escape after removal
of a gauze drain which has not been judiciously placed and
protected, this accident then constituting one variety of postoperative
or traumatic hernia.
By virtue of its adhesions, which at first are short and flat, but
which later become stretched into bands, obstruction of the bowels
may be produced, or by atrophic or absorptive processes openings
or windows may occur in it with the same result. When participating
in septic processes it becomes infiltrated, is often covered to a large
extent with breaking-down lymph, and may become gangrenous. All
portions thus compromised are best tied off and removed when
exposed during operation. Nevertheless the omentum should be
gently handled, because its venous walls are thin and liable to
rupture, and its bleeding points should be carefully secured,
especially after separation of adhesions.

INJURIES TO THE OMENTUM.

By contusions, lacerations, and punctures various injuries to the
omentum may be inflicted, naturally more commonly when it is the
anterior abdominal wall which has sustained the traumatism. As
result of lacerations, hemorrhages or strangulations may occur. The
immediate danger is, then, from hemorrhage. Indications of such
lesions of the omentum are not specific, but grave symptoms after
any abdominal injury require exploration, and that minute punctures
or lacerations should be repaired, while other injuries should be
treated according to obvious indications.

TORSION OF THE GREAT OMENTUM.

Torsion of the great omentum was first described by Oberst, in
1882, as a condition found in the sac of a large irreducible hernia. As
a distinct and serious condition it has been reported in about sixty
instances. The condition occurs within the abdomen as simple
torsion, also within hernial sacs, or in both, where the torsion is not
limited to the sac, but extends upward into the abdomen. It is more
frequent in males, and its onset is usually sudden. Of all its
symptoms pain is the most constant and the earliest. This is usually
acute and persistent, and in a large proportion of cases is referred to
the right iliac fossa. Vomiting is not constant; bowel conditions are
not significant. Absolute obstruction is usually rarely noted. In most
of the recorded cases some tumor can be felt on examination, which
is hard, tender, dull to light percussion, and irregular in shape.
Meteorism is not common. Death has occurred in about 15 per cent.
of known cases. Diagnosis previous to exploration can be inferential
only, but such symptoms as above noted should lead to exploratory
laparotomy.

TUMORS OF THE OMENTUM.

The most common of the omental tumors are cysts of
inflammatory origin, such as may, for instance, be formed by
inclusion between surrounding adhesions or by previous
hemorrhage; lymph cysts, often large and multiple, and sometimes
of congenital but often of lymphatic origin, are also occasionally
seen. The so-called omental dermoids are usually ovarian products.
Hydatid cysts have been found in the omentum, but only as
secondary products. Omental cysts are difficult or almost impossible
of diagnosis previous to operation, which latter should always be
performed, and without previous aspiration, as the presence alone of
any such tumor requires removal. If large they are most likely to be
confused with ovarian cysts. Those which may prove not to be
removable should be drained, after being fastened to the abdominal
wall—that is, marsupialized. Angioma in the omentum is rare, but
has been recorded by Homans and others. Fatty or other benign
tumors are also rare. Primary sarcoma is rarely seen here, but most
of the sarcomas, and all of the carcinomas which never arise here
primarily, but are often seen, are either metastases or direct
extensions. In these forms cancer of the omentum is common.
With extensive involvement of the omentum radical operations in
these cases are seldom advisable. A circumscribed involvement
may, however, be removed, while such operations as anastomoses,
enterostomies, and the like are often necessitated.
Omental tumors are difficult of diagnosis, although they are usually
superficial and overlie the intestines. They are not affected by
respiration. They move laterally and upward, but not downward. If
confined to the omentum proper they cause no functional but only
mechanical disturbances. Obviously in the presence of extensive
adhesions every distinctive feature may be confused.

OMENTOPEXY; OMENTOSPLENOPEXY; TALMA’S OR

MORRISON’S OPERATION.
 The effect of stasis in the portal circulation is to produce outpour of
varying amounts of serous fluid into the pleural cavity. This condition,
long known as ascites (dropsy), is the most distressing terminal
feature of such diseases as cirrhosis of the liver, cancer, and the like.
The osmotic direction of fluid seems to be reversed, and
transudation tends to go on until intra-abdominal pressure equals
that within the vessels. Absorption is always impeded and finally
prevented. Reflecting on the biophysics of this condition Talma and
Morrison, independently, and at about the same time, suggested an
expedient by which a portion at least of this fluid might be brought
back into the general venous circulation. The plan was to attach the
epiploön (the omentum) to the peritoneum of the anterior abdominal
wall in such a way and over such an area that, by virtue of the
adhesions thus produced and the new vascular anastomosis thus
established, a new line of vascular connections should be formed, so
that fluid not returnable to the vena cava by the usual route should
be given a new and artificial direction. To this fundamental
proposition much detail has been added.
Thus Schiassi has shown that, so far as the supply of toxins which
shall pass through the liver is concerned, there are really two portal
veins—the superior mesenteric and the splenic—or he would call
what we usually name the portal system the splenoportal.
Consequently he would include the spleen in the above mechanical
procedure, especially in those cases where it participates in the
morbid process—e. g., in the hepatosplenic or pre-ascitic form of
Banti’s disease, and the splenomegalic cirrhosis described by
Gilbert. In 1904 this problem was studied from its surgical aspects by
Monprofit (French Congress of Surgeons), who collected 224
operated cases. Of these 84 died, 129 recovered from the operation,
and 11 could not be traced. In 25 cases relapse occurred, in 26 there
was improvement, while in 70 there was claimed complete
recovery.[64] In other words about one-third of the cases thus
reported have recovered. He insists, as would every other surgeon,
that with this showing the results would be far better were cases
seen and operated earlier. His statistics are not widely variant from
those of Zesas, who found that out of 254 cases which he collected
67 recovered and 82 died, while 42 were greatly improved.
 [64] It is but fair to add that, at the same time, Delagenière maintained
that since, in his opinion, cirrhotic processes in the liver are due to intestinal
infection, the treatment should consist of combating this and its possible
consequences, to which end he would make a temporary cholecystostomy,
having found it of benefit even in the atrophic, but mostly in the
hypertrophic, forms of disease. Thus in two cases of this procedure,
combined with hepatopexy, the patients survived eight and two years
respectively. Nevertheless he acknowledged that the best results would
probably be secured from combination of cholecystostomy, hepatopexy, and
omentopexy.

In brief, we may hold, with Rolleston and Turner, that it is no longer

advisable to treat ascites by repeated tappings, when the patient is
otherwise in fairly good general condition, for numerous surgeons
have warned against repeated punctures. When liver cirrhosis can
be diagnosticated with fair certainty in the pre-ascitic stage, and
when there is evidence of splenic enlargement or hematemesis,
operative intervention would probably succeed far better than in the
later stages. So far as special indications for operation are
concerned they may perhaps be listed as follows:
1. Thrombosis of the portal vein or its compression by
inflammatory products or by tumor;
2. Cirrhosis of cardiac origin, of the ordinary hypertrophic or
even atrophic types, as well as that due to syphilis or
malarial disease;
3. Pseudoliver cirrhosis of pericardial origin;
4. Diabetes of hepatic origin;
5. Splenomegaly combined with hepatic cirrhosis.
If these indications be met by reasonably early omental fixation
there would seem to be a well-marked place for the procedure, while
they cannot give rise to any worse results than the repeated
puncture methods of old.
Among contra-indications to such operations may be mentioned
the presence of much biliary pigment in the urine, its absence from
the feces, jaundice, or marked pigmentation of the skin, while distinct
renal insufficiency would also make any surgical procedure
hazardous.
The operation itself, done according to the simpler and earlier
recommendations of Morrison and Talma, consists in median
abdominal section, withdrawal of all ascitic fluid, and the deliberate
provocation of adhesions between the diaphragm and the upper
surfaces of the liver and the spleen. This is produced by vigorous
swabbing to a degree sufficient to cause a little oozing from the
surfaces attacked. The margin of the liver may then be fastened to
the costal border. After this the anterior surface of the omentum is
also scarified or swabbed and affixed to the anterior abdominal wall,
which has been similarly treated over as large an area as possible,
by means of catgut sutures placed to the best possible advantage for
the purpose. Some operators have preferred to close the abdomen
without drainage, some to insert a tube in the lower margin of the
wound for a day or two, and others to drain the lower abdominal
cavity through a small, distinct opening above the pubes.
Theoretically much advantage attaches to permitting no immediate
re-accumulation of fluid. Practically, however, danger also attaches
to it, i. e., from the difficulty of so managing the dressings as to avoid
infection.
Schiassi has modified the above procedure and has made an
omentosplenopexy of it as follows: He makes a right-angled incision
across the median line and then another several inches downward
along the left semilunar. The tissues down to the peritoneum are
reflected toward the umbilicus, and a transverse deep opening is
made just below the horizontal skin incision. Through this the
omentum is drawn upward and spread over the right portion of the
exposed peritoneum, where it is sutured in place. Through another
vertical opening in the peritoneum, near the vertical skin incision, the
spleen is then exposed, a piece of gauze is placed under each pole
of that organ, and, while thus lifted, by means of a long curved
needle three to six catgut sutures are passed through it, including
also the peritoneum and all the superficial structures except the skin,
this being closed later and separately.
Finally, whatever operative method be selected it is important that
it be done early rather than late, bearing in mind that “the resources
of surgery are rarely successful when practised on the dying.”

THE MESENTERY.
 No one has done more to forcibly place before the surgical
profession those anatomical features of the mesentery which most
concern them than Monks, who, for instance, has demonstrated the
fact that the mesentery is practically an enormous fan, composed of
two layers of peritoneum, between which are spread out the vascular
structures and more or less fat, and whose border contains the
intestinal tube. This fan at its base is but a few (six) inches in length,
while along its outer border, when completely unfolded, one may
measure a distance of twenty-one to twenty-three feet. Not one of
the structures contained between its layers can be regarded as a
negligible quantity. The arterial distribution in the mesentery is
terminal in the same sense that it is in the brain. Consequently
dependence can be placed only on a sufficient blood supply for any
given portion of the intestinal tube when its mesentery is intact. If
necessary to sacrifice a portion of the mesentery it is requisite to
resect that portion of the bowel which is dependent upon it for blood.
This will explain the reason why thrombosis or embolism of the
mesenteric vessels so quickly determines the death of that portion of
bowel supplied by the occluded branches, this being equally true of
the tiny fragment known as the appendix or of the entire bowel.
The root of the mesentery is placed obliquely across the spinal
column, arising from the left side above and crossing obliquely to the
right side below. Monks has shown how easily we may make
practical application of this fact in determining approximately to what
part of the bowel tube a given loop may belong, since it is necessary
only to follow it down to the mesenteric insertion, and from this
estimate what proportion of the entire distance is represented.

INJURIES OF THE MESENTERY.

Obviously the mesentery may be injured in the same way as any
other of the abdominal viscera, either by contusions, lacerations,
punctures, or otherwise. Here the immediate danger is from
hemorrhage, while a more remote but quite possible danger is that of
thrombosis of some of the vessels and its consequences in the
direction of necrosis.
 Erdmann has recently reported two cases of complete
detachment, for several inches, of the mesentery at the intestinal
border, as well as a case of multiple lacerations in the peritoneal coat
of the mesentery with hematoma. While the latter might not be so
serious, the former will almost invariably determine gangrene of
bowel from lack of blood supply; all of which shows the difficulty of
diagnosis, and furnishes a further argument for intervention when,
after an abdominal contusion, the patient has abdominal rigidity or
pain, with or without evidences of hemorrhage, either from the
stomach, rectum, or bladder. These features are sufficient without
the addition of those by which a more certain or minute diagnosis
can be made.

THROMBOSIS AND EMBOLISM IN THE MESENTERIC VESSELS.

Mesenteric occlusion was first described by Virchow in 1859.
Whether it involves first the arterial or the venous circulation seems
to matter but little. Of course in one case it is to be regarded as
embolic, in the other as thrombotic. In this location either condition is
harder to explain than in many other places. The mesenteric veins
have no valves and collateral circulation is poor. Mitral stenosis and
arterial sclerosis will often account for the former. For thrombosis
search has to be made for some local infectious process, either in
the veins of the pelvis, the kidney, or the intestines. It seems to occur
least often when it might be most expected, i. e., after typhoid.
The blood supply may be simply shut off from portions supplied by
one of the mesenteric vascular branches, or, should the main
branches be involved, from the entire intestinal tract. I have myself
reported two cases of practically complete rapid gangrene of the
entire alimentary canal, due to lesion of this kind, explanation being
forthcoming in neither case.
Symptoms and Signs.—The more complete the occlusion and
the more extensive the area deprived of
blood the more sudden and overwhelming will be the onset. This is
always sudden and characterized by intense and often paroxysmal
pain, so agonizing, in fact, as scarcely to be quieted even by
morphine. While this is common, instances have been known in
which the disease has run an almost painless course. Diarrhea is
frequently an early symptom, evacuations being profuse and bloody.
Symptoms of obstruction are not uncommon, perhaps followed later
by loose stools. Vomiting occurs usually early and becomes fatal in a
few hours. The general physical signs are intensely acute, with rapid
pulse, subnormal temperature, and meteorism, beginning early and
becoming more pronounced. Abdominal rigidity also constitutes a
distressing feature, which, while indicating the gravity of the
condition, masks its diagnostic features. If the patient live long
enough fluid will accumulate in the peritoneal cavity. The cases
terminate with complete collapse and delirium. When the inferior
mesenteric vessels are involved tenesmus is a more prominent
characteristic than when the lesion is confined to the upper, as the
colon and rectum are supplied from the former.
The surgeon may have to distinguish between the condition just
described and the following: Perforating ulcer of the stomach or
duodenum (which will have a previous history), possibly so-called
phlegmonous gastritis; acute obstruction of the bowel (whose onset
is rarely so acute); pancreatitis, which would, at least at first, produce
almost identical symptoms; acute splenic infarct (when the early
symptoms would probably be referred to the region of the spleen);
acute appendicitis; acute cholecystitis, and that acute peritonitis to
which either of these might lead; a ruptured ectopic pregnancy; and
possibly certain intrathoracic lesions, especially pneumonia in the
lower lobes. Mesenteric occlusion is essentially a fatal condition, at
least when extensive. There have been known cases where so
limited an extent of the bowel and mesentery were involved that an
exsection, made early, has proved successful, but when anything
like the entire alimentary canal or its major portion becomes necrotic
there is no hope for the patient.[65]
[65] Annals of Surgery, April, 1904.

ABSCESS OF THE MESENTERY.

Abscess formation may take place within the mesenteric
structures, as an expression of acute septic infection or of a mixed
infection of old tuberculous foci in the nodes. A careful case history
or some peculiarity of local conditions may occasionally furnish a
clue to the conditions, otherwise it will not be distinctly revealed until
such operation as may be necessitated by unmistakable indications
of the presence of pus or by autopsy. Inasmuch as operation can
scarcely exaggerate the danger of the condition it would be best
attempted when such abscess is suspected. When the meso-
appendix is involved, as is often the case, the trouble may be so
walled off that it is almost a purely local affair.

TUBERCULOSIS OF THE MESENTERY.

Aside from the common miliary expressions of acute tuberculosis
which are seen so frequently dotted all over the bowel surfaces and
the expanse of the mesenteric folds, there is a peculiar form of
involvement of the mesenteric nodes, i. e., those which are
especially clustered along its root. These are always involved in
general tuberculous peritonitis, though but slowly in the absence of
such generalized features. To the slow forms of this condition the
early writers gave the name tabes mesenterica. The more limited the
involvement the greater interest the lesion has for the surgeon, since
it may be so limited to the nodes of a single coil as to justify
extirpation. In fact, if such a focus could be easily and thoroughly
removed without too much disturbance of circulation, tabes might be
remedied by surgery. Not very frequently, however, do the location or
the arrangement of a collection of tabetic nodes permit of their
enucleation. They are usually too numerous, too large, too
degenerated, too adherent, or the patient otherwise too extensively
infected.
The acuter expressions of mesenteric tuberculosis may be
considered as already sufficiently discussed under the caption of
Tuberculous Peritonitis.
Occasionally a localized, slightly mobile tumor, especially in the
ileocecal region, may cause suspicion, or may be correctly
diagnosticated, by taking note of other symptoms, along with a good
case history. Especially is this the case in patients known to be
tuberculous. This is particularly true of the appendix and its
mesentery, where a tuberculous gumma may attain considerable
size before there is any active breakdown. The relation between this
condition and tuberculous ulceration within the bowel will also be
obvious. Moreover, it is of interest to recall that calcification of
mesenteric nodes is not impossible, and that occasionally chalky
tumors in this location may be thus explained.
There is also a possibility of involvement of the mesenteric nodes
in constitutional syphilis and in actinomycosis.
The treatment of mesenteric tuberculosis should consist of
exploration and orientation, followed by whatever procedure the
condition thus revealed may require—e. g., abdominal irrigation, with
or without antiseptics, extirpation, drainage, or even resection of a
portion of the bowel (appendix, cecum, etc.).

CANCER OF THE MESENTERY.

The other condition in which the mesenteric nodes are especially
involved is the cancerous. In this location, as in the omentum,
sarcoma may be primary and endothelioma may occur, but
carcinoma is never primary, although it invariably occurs as an
extension from epithelioma or adenocarcinoma of the bowel.
Otherwise cancer will appear here as an expression of metastasis. In
all primary cancers of the intestine early involvement of the
mesenteric nodes may be looked for, while involvement of everything
in the vicinity, even the aorta or spine, will occur in due time, often
with more or less breaking down. There would be little justification for
attacking any cancerous portion of the mesentery or any cancerous
nodes unless the primary lesion could be radically removed.
Generally speaking, in bowel cancer invasion of the deep-seated
nodes imparts to the case such an unfavorable aspect as to justify
only palliative (anastomotic) rather than radical measures.

CYSTS OF THE MESENTERY.

Cysts of the mesentery are, in the main, similar to those met with
in the omentum (Fig. 631). A peculiar form of mesenteric cyst is
produced by obstruction and consequent dilatation of one or more of
the lacteals, and is known as chyle cyst. It may attain considerable