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Stohr/Walsh, Corrections: A Text/Reader (Second Edition) Instructor Resources

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1412997178 9781412997171
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Section II:
A History of Corrections
Multiple Choice (36)
1) In 1831, which pair came to America with the intention to study the newly minted prison
system? (c)
a. Bentham and Beccaria
b. Howard and Penn
c. Beaumont and Tocqueville
d. Dix and Maconochie
2) Which of the following was a benefit when examining the extent of punishment among tribal
groups? (e)
a. Gender
b. Wealth
c. Status
d. Both a and c
e. Both b and c
3) What was the first type of correctional facility to develop? (c)
a. Day reporting centers
b. Prisons
c. Jails
d. Bridewells
4) In Ancient Greece and Rome, citizens who broke the law might be subjected to: (e)
a. Fines
b. Exile
c. Imprisonment
d. Death
e. All of the above
5) King Henry II required that gaols be built for the purpose of: (c)
a. Extorting fine money from citizens
b. Removing the poor from the streets
c. Holding the accused for trial
d. All of the above
Stohr/Walsh, Corrections: A Text/Reader (Second Edition) Instructor Resources

6) The Catholic church had their greatest influence on punishment during: (a)
a. The Middle Ages
Stohr/Walsh, Corrections: A Text/Reader (Second Edition) Instructor Resources

b. Elizabethan England
c. The Reform Era
d. None of the above
7) Galley slavery was used more regularly: (b)
Stohr/Walsh, Corrections: A Text/Reader (Second Edition) Instructor Resources

a. By the ancient Greeks and Romans

b. By the late Middle Ages
c. In the American colonies
d. In Norfolk Island, Australia
8) After the disintegration of feudalism, what sparked government entities to increasingly respond
in a more severe fashion in the demand for resources? (c)
a. Crime
b. Prostitution
c. Poverty
d. War
9) Early workhouses were known as: (d)
a. Gaols
b. Reformatories
c. Prisons
d. Bridewells
10) The removal of those deemed as criminal to other locations such as the American colonies or
Australia is known as: (c)
a. The Marks System
b. Galley slavery
c. Transportation
d. Corporal punishment
11) Which of the following is a benefit associated with the practice of transportation? (d)
a. The removal of criminal classes
b. Exploitation of labor to satisfy a growing need
c. Humane treatment of criminals
d. Both a and b
e. Both a and c
12) Which Enlightenment Period influenced reformer personally experienced incarceration while he
was a prisoner of war? (c)
a. Jeremy Bentham
b. Cesare Beccaria
c. John Howard
d. William Penn
13) Which Enlightenment Period influenced reformer wrote in his book On Crimes and Punishment
that “it is essential that [punishment] be public, speedy, necessary, the minimum possible in the
given circumstances, proportionate to the crime, and determined by law”? (b)
a. Jeremy Bentham
b. Cesare Beccaria
c. John Howard
d. William Penn
14) Which Enlightenment Period influenced reformer was the Sheriff of Bedford, in England? (c)
a. Jeremy Bentham
b. Cesare Beccaria
c. John Howard
Stohr/Walsh, Corrections: A Text/Reader (Second Edition) Instructor Resources

d. William Penn
15) Which Enlightenment Period influenced reformer created the panopticon? (a)
a. Jeremy Bentham
b. Cesare Beccaria
c. John Howard
d. William Penn
16) Which Enlightenment Period influenced reformer sought reform in every gaol throughout
England and Europe? (c)
a. Jeremy Bentham
b. Cesare Beccaria
c. John Howard
d. William Penn
17) Which Enlightenment Period influenced reformer was also influenced by his Quaker religious
principles? (d)
a. Jeremy Bentham
b. Cesare Beccaria
c. John Howard
d. William Penn
18) Which Enlightenment Period influenced reformer instituted his Great Law which deemphasized
the use of corporal and capital punishment for all but the most serious crimes? (d)
a. Jeremy Bentham
b. Cesare Beccaria
c. John Howard
d. William Penn
19) Which Enlightenment Period influenced reformer was imprisoned in the Great Tower of London
for his promotion of his religion and defiance of the English Crown? (d)
a. Jeremy Bentham
b. Cesare Beccaria
c. John Howard
d. William Penn
20) The influence of religion on early prison operations in the United States is due primarily to: (b)
a. The Shakers
b. The Quakers
c. Enlightenment thinkers
d. Presbyterians
21) Which of the following is one of the early institutions built in America that followed the Quaker
principles and ideas? (c)
a. Newgate Prison
b. San Quentin
c. Walnut Street Jail
d. All of the above
22) The first jail in America, built around 1606, was located in: (a)
a. Jamestown, Virginia
b. Philadelphia, Pennsylvania
Stohr/Walsh, Corrections: A Text/Reader (Second Edition) Instructor Resources

c. Ossining, New York

d. Barnstable, Massachusetts
23) One of the earliest American makeshift prisons known as Newgate prison in Simsbury,
Connecticut started as a: (d)
a. Well
b. Cave
c. Dungeon
d. Mine
24) In what year did the American Prison Congress convene? (b)
a. 1860
b. 1870
c. 1880
d. 1890
25) The separate system is part of which model? (a)
a. Pennsylvania Prison Model
b. New York Prison Model
c. Walnut Street Jail
d. Western Pennsylvania Prison
26) The congregate system is part of which model? (b)
a. Pennsylvania system
b. New York system
c. Walnut Street Jail
d. Western Pennsylvania Prison
27) Which early prison was built to hold inmates in complete solitary confinement, with no labor,
for the full span of their sentence? (b)
a. Walnut Street Jail
b. Western Pennsylvania Prison
c. Auburn Prison
d. Sing Sing Prison
28) To which early facility did inmates refer to as being sent “up the river”? (d)
a. Walnut Street Jail
b. Eastern Pennsylvania Prison
c. Auburn Prison
d. Sing Sing Prison
29) In Beaumont and Tocqueville’s outline, which prison did they consider to be even worse than
Walnut Street? (c)
a. Auburn
b. Sing Sing
c. Pittsburgh
d. Cherry Hill
Stohr/Walsh, Corrections: A Text/Reader (Second Edition) Instructor Resources

30) Beaumont and Toqueville attributed the first ideas of American prison reform to ?
(a)
a. Pennsylvania
b. New York
c. Ohio
d. Massachusetts
31) The Eastern State Penitentiary had what before the White House? (c)
a. Security guards
b. On site garden
c. Central Air
d. None of the Above
32) What scandal(s) did Cherry Hill face 5 years after its construction? (d)
a. Prisoner communication
b. Double occupancy
c. Prisoner labor
d. All of the above
33) Who led the movement to establish separate prisons for women? (a)
a. Women
b. Men
c. Wardens
d. The Quakers
34) What was missing from the first confinement of women in penitentiaries? (d)
a. Matrons
b. Discipline
c. Solitary
d. All of the Above

True/False (26)
1) True or False? Beaumont and Tocqueville came to the United States but did not observe
anything wrong with the systems that they studied. (F)
2) True or False? One of the constant themes in corrections is that money, or a lack thereof is a
factor that exerts over virtually all correctional policy decisions. (T)
3) True or False? Prisons and other such institutions serve as a social control mechanism. (T)
4) True or False? Religious influence is not one of the themes that are apparent in corrections
history. (F)
5) True or False? Among tribal groups, the wealthy and poor were treated equally under the eyes
of punishment. (F)
6) True or False? The use of imprisonment can be traced back to the Old Testament in the Bible. (T)
7) True or False? The Protestant church had its greatest influence on punishment in the Middle
Ages. (F)
Stohr/Walsh, Corrections: A Text/Reader (Second Edition) Instructor Resources

8) True or False? Galley Slavery was only used to get the poor off the streets. (F)
9) True or False? Under 18th century England, a person could receive the death penalty for rioting
over wages or food. (T)
10) True or False? Brideswells provided a location to send poor people in order to remove them
from the streets. (T)
11) True or False? The practice of transportation was short-lived in the correctional system. (F)
12) True or False? Americans continued to transport their prisoners well after the Revolutionary
War. (F)
13) True or False? Historically, prison labor was considered part of an inmate’s punishment, rather
than solely a means of revenue. (T)
14) True or False? The Progressive period was the era that spelled out major changes incorrectional
reform and gave rise to such great thinkers as Cesare Beccaria. (F)
15) True or False? John Howard believed that English gaols treated inmates inhumanely and needed
to be reformed. (T)
16) True or False? William Penn is credited with creating the panopticon, which was the first prison
ever to be constructed. (F)
17) True or False? William Penn proposed the Great Law, which deemphasized the use of corporal
punishment and capital punishment for all crimes, but the most serious. (T)
18) True or False? One of the oldest American prisons was a copper mine. (T)
19) True or False? The first jail built in America was in Philadelphia Pennsylvania in 1790. (F)
20) True or False? Dorothea Dix was the first warden of the Elmira Reformatory. (F)
21) True or False? The state of Ohio shocked Beaumont and Tocqueville by the barbarous state of
its prisons compared to its mildness of its penal code. (T)
22) True or False? Beaumont and Toqueville extensively covered the Southern states in their
outline of American prisons. (F)
23) True or False? In the reading Norman Johnston proclaimed Cherry Hill as “the most influential
prison ever built.” (T)
24) The architect of the “most influential prison ever built” was Samuel Wood. (F)
25) The first penitentiary conditions for women were “worse than death”. (T)
26) Mount Pleasant was the first state penitentiary to include a nursery. (T)

Short Answer (10)

1) What are constant themes that have been seen throughout the history of corrections? (p. 15-
16)
2) According to the text, prior to their widespread use in England, where could early versions of
gaols be found? (p. 16-17)
3) According to the text the Riot Act, created during 18th century England, allowed the use of
capital punishment for what behavior? (p. 18)
4) Where did Brideswells get their name? (p. 18)
5) Why did transportation from England to the American colonies end? (p. 18-19)
6) John Howard’s genius was his main insight regarding corrections. What was this insight? (p. 19-
20)
Stohr/Walsh, Corrections: A Text/Reader (Second Edition) Instructor Resources

7) Though they created separate deterrence theories, on what specifics did both Bentham and
Beccaria agree? (p. 20-21)
8) Bentham believed that his creation, the panopticon, would greatly enhancing supervision of
inmates by melding which two ideas? (p. 20-21)
9) What did William Penn’s Great law seek to achieve? (p. 21)
10) Why were Southern prisons little used prior to the Civil War? (p. 30-31)

Essay (8)
1) What key events as described in the text facilitated the widespread use of gaols in England? (p.
16-17)
2) Discuss the history of gallery slavery from its first uses to its end as well as the rationale behind
it. (p. 17)
3) Compare and contrast the separation (classification) of inmates from early Brideswells with
those of the early European and British Prisons. (p. 18)
4) Discuss the history of transportation from its first uses to its end, as well as the rationale behind
it. (p. 18-19)
5) What was the significance of the enlightenment on correctional thinking? (p. 19)
6) Pick one of the four Enlightenment Period reformers discussed in detail from the text. What did
they believe in regards to reforming corrections? How did they propose to promote such
reform? (p. 19-21)
7) Discuss the Pennsylvania and New York Systems. Which do you believe was better from
inception? Why? (p. 24-27)
8) What is the Declaration of Principles? Do you think they should be applied to our system today
(in part or in whole)? Why or why not? (p. 28-29)

Reader Questions (12)

1) Compare and contrast the two conflicting penitentiary systems written about by De Beaumont
and De Tocqueville. (p. 36-43)
2) List the names and locations of four of the prisons studied by Beaumont and Tocqueville. (p. 3-
43)
3) Which two cities did Beaumont and Tocqueville describe as having horrible prison situations? (p.
42)
4) What was the conclusion of Beaumont and Tocqueville at the end of the reading? (p. 43)
5) What is name of “The world’s most influential Prison” from your second reading and why was it
built? (p. 44-49)
6) Discuss some of the technology implemented in the construction of “The world’s most
influential prison”. (p. 47-48)
7) What were some of the scandals involved with the operation of “The world’s most influential
prison? (p. 48)
8) Discuss “The world’s most influential prison’s” fall from grace. (p. 50)
9) What is main theme of “Much and Unfortunately Neglected” your third reading? (p. 54-55)
Stohr/Walsh, Corrections: A Text/Reader (Second Edition) Instructor Resources

10) Discuss some of the negative observations of the Ohio prison in “Much and Unfortunately
Neglected”. What were the causes? (p. 56-57)
11) Who led the reform on segregation near the end of the nineteenth century in “Much and
Unfortunately Neglected” and what grudging changes proceeded it? (p. 60-62)
12) Where was Mount Pleasant constructed? Why was it significant for its time? (p. 62-65)
Another random document with
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 The nature of the bacterial invasion is of more interest to the
pathologist than to the surgeon as such. In general, however, it may
be said that, in addition to the ordinary pyogenic organisms, the
colon bacilli are perhaps the most frequently to blame, while the
more putrid types are the result of actual escape of bacteria from the
intestine, as through a perforated appendix, and the addition of a
mixed type to one which began perhaps as a simple one. Thus in the
so-called putrid forms multiple bacterial contamination is usually
discovered upon making cultures. The pneumococcus, the capsule
bacillus, and the gonococcus are also not infrequently found, in
cases of peritonitis whose nature and origin will be suggested by the
discovery of the particular germ involved in each case.
Symptoms.—While varying much in time and intensity, and even
completely changing their type during the successive
stages of the disease, there are, nevertheless, certain cardinal
symptoms which are universally recognized in cases of surgical
peritonitis. These include vomiting, pain, tenderness, with more or
less shock, followed sooner or later by abdominal spasm and
distention, while to these symptoms there is sure to be added bowel
obstruction of some type which becomes, toward the end, perhaps
the most profound feature, and which may even mask the
significance of other symptoms. According as the lesion is localized
or generalized pain may be referred to a particular area or may be
general and intense. Local pain, with tenderness, usually implies, at
least at first, a localized lesion, and is not so likely to be
accompanied by vomiting as the more diffuse form. Depression is
found to correspond largely to the type and degree of sepsis, while
collapse is a prominent feature in the more severe cases. The pain,
which is sometimes intense, subsides, and it should be emphasized
that a speedy subsidence is not necessarily a favorable symptom. It
too often marks the transition of an ordinarily acute case into one of
intensely septic or even putrid type. Tenderness may be acute and
localized, or diffuse and only evoked on deep pressure. One of the
most significant symptoms is abdominal rigidity, which persists
throughout the active state of the disease, and which, when followed
or accompanied by meteorism, may to some extent mask and
obscure all conditions within. If the patient be not seen until this
stage is reached diagnosis can be made only by history and
conjecture, for it is almost impossible to determine anything by
palpation.
Temperature is an uncertain factor. It sometimes rises high at first,
and then falls, while if it fall too low the prognosis is serious. The
pulse also shows very irregular variations, usually rising, however, as
the disease becomes more severe, and being often almost
uncountable at the end. A combination of rising pulse and falling
temperature is of serious import.
In addition to the vomiting, which is a pronounced early feature of
the disease, we have, as bowel obstruction comes on, an added
fecal character to the vomitus, which sometimes is most
characteristic of complete obstruction. This obstruction is due in part
to toxic paralysis of the muscular coat of the bowels, and in part to
the result of adhesions or fixations by which bowel motility is
completely prevented. Thus in many instances of peritonitis following
acute appendicitis there are loops of intestine glued together by
exudate in such a way as to practically occlude or disable them.
The depression, shock, and final collapse of the disease are
characteristic, as is also the facial appearance, the cheeks becoming
discolored and the orbits hollowed out, so that the eyes early sink
back. Other expressions of diminished blood pressure are not
lacking—coldness of the extremities; cold, clammy perspiration;
lividity of the skin, and the like.
While this is a picture of the most common expressions of acute
septic or surgical peritonitis, it is occasionally found that conditions
equally serious arise without such marked symptoms, and that the
patients become rapidly worse, finally dying, who neither vomit
continuously nor show extreme meteorism nor abdominal rigidity.
Such cases are thereby stamped as those of more extreme toxicity,
where systemic reaction is paralyzed almost from the outset, and are
accordingly the more hopeless on that account.
Ordinarily it is not difficult to recognize the onset and the course of
peritonitis in surgical cases. The condition may be confounded with
one of septic intoxication from some focus which has not involved
the peritoneum; otherwise differentiation is rarely difficult. The
occurrence of such a condition does not necessarily indicate faulty
technique on the part of an operator, as the condition is too often
present when the surgeon begins his work. On the other hand, it too
often follows faulty technique and constitutes the strongest argument
for vigilance both in preparation, performance, and after-treatment.
Treatment.—But little will be said here about non-operative
treatment, although first it should be emphasized that
treatment in the past was too often of the non-operative type. Many
cases of peritonitis could be saved by operation were it performed
while the infection is still localized, but this is at a period when they
too rarely reach the surgeon’s hands, he being called in as such
when the inefficacy of drug treatment has been already
demonstrated. Without denying that the surgeon is not blameless in
all these respects, blame should, nevertheless, be placed where it
properly belongs, at the door of the man who fails to recognize and
carry out plain surgical principles.
The opium treatment for peritonitis, with which the name of Clark
will always be associated, was introduced at a time when many
things were considered as peritonitis which were not necessarily
such. It was furthermore an advance on previous methods and gave
better results. That, however, is no excuse for adhering to it when
better means are at hand. On the other hand it must not be denied
that much can be done medicinally to give comfort and meet certain
indications. In spite of the many disadvantages attaching to the use
of opiates it seems unnatural to let patients suffer as they would
without them. It is justifiable, then, to use them in cases which are
hopeless, or in those which refuse operation; but given
indiscriminately and early they often mask symptoms which, if
properly appreciated, would lead to early diagnosis, and, it is to be
hoped, early operative relief. Views also differ regarding catharsis. It
is a great disadvantage to permit the intestines to retain fecal matter
for days and add a consequent copremia to the other features of the
disease. On the other hand, intestinal activity tends to disseminate
infection, and is, consequently, most undesirable. If at the outset the
intestinal canal could be emptied and then left at rest it would best
meet the somewhat contrary indications.
Ordinarily, however, it is of small advantage to keep bombarding
the stomach with repeated doses of laxatives which are more often
rejected than retained, and which have little effect.
One of the most distressing features is vomiting, and here it is well
to follow Berg’s suggestion and test the vomitus with litmus paper. If
it be found alkaline small doses of morphine should be given, each
with a drop or two of aromatic sulphuric acid, in a little chopped ice. If
it be found acid small doses of milk of magnesia are advised or
some such preparation, with minute doses of morphine, frequently
repeated. The greatest relief in these cases, where the upper bowel
is emptying itself into the stomach, will be obtained from lavage. In
the same way tympanites and meteorism are best treated by passing
a rectal tube high, leaving it in place, and utilizing it for lavage of the
bowel, using warm water with a little sodium salicylate. Not the least
distressing feature of such a case is the reflex hiccough which is
produced by diaphragmatic spasm, since the phrenic nerve
distributes sensitive fibers as well to the peritoneum. For this there is
no really effective remedy. Small doses of Siberian musk, with or
without morphine, beneath the skin will sometimes quickly relieve it.
Depression and lowered blood pressure are best treated by
adrenalin and digitalis, rather than by strychnine, which stimulates
peristalsis. Fever, when high, should be treated by cold sponging
rather than by antipyretics. The kidneys should be kept active, if
necessary by hypodermoclysis, and the skin equally so by hot-air
baths, as through both of these emunctories much elimination may
be effected. The question of catharsis comes up again in considering
what can be done to improve elimination of ptomains by watery
stools, but these are hard to secure; it is, after all, questionable
whether their effectiveness in this regard has not been greatly over-
rated. Richardson, for instance, is inclined to believe that cases
reported as cured by free catharsis would, in all probability, have
recovered without it, it being doubtful whether the really infectious
element be present.
Surgical treatment of peritonitis includes a recognition of the
cause, and, if possible, its removal. Richardson has grouped in the
following suggestive manner the indications for operative
intervention in the early stages, when cases are not without hope:
General pain, becoming local; or local, becoming general,
according to cause;
 Tenderness, showing the same indications;
Abdominal rigidity;
Green vomitus;
Rising pulse and temperature;
Diminished peristalsis without too much shock.
On the other hand, in cases of fully developed peritonitis, where
the surgeon may still consider the possibility of intervention, but
where prognosis is far less favorable, the conditions include:
Lessening or vanishing pain;
More general tenderness;
Great distention, replacing rigidity;
Excessive dark or fecal vomitus;
Obstipation;
Rapid and feeble pulse;
Pain extremely severe;
Low temperature and the ordinary evidences of reduced blood
pressure.
In such cases the decision rests largely upon the degree of
collapse. To operate upon a moribund patient is hopeless and brings
discredit upon surgery. Before operating upon any serious case of
this kind the circumstances should be fully explained to those
concerned, and they should be impressed with the fact that should
the patient die he dies not in consequence of the operation but in
spite of it.
The operation itself will in a large measure depend upon what can
be learned of the etiology of the disease and the diffuseness of the
resulting infection. To reach a localized focus the incision may be
made at any point which will best afford access; but in dealing with a
generalized process the middle line, and an extensive incision, will
ordinarily afford the best opportunity for doing whatever is necessary.
The preliminary incision may be made short, as for exploratory
purposes. Unless a loop of distended bowel be at once blown into
the opening there will be prompt escape of fluid, whose character will
reveal much of what has gone wrong within. If reasonably clear the
operator is fortunate. If it be purulent he has to combat a most
serious condition; if it be offensive, it is probably due to
contamination from a septic abscess or from intestinal gases, while if
the fluid be nondescript and contain floating particles of fecal matter
there is an intestinal or gastric perforation. So soon as one comes
upon fixation or adhesion of viscera he will find lymph, in condition of
greater or less organization. Inside the masses thus bound together
he will probably find the greatest centre of pernicious activity.
The more one sees of these intra-abdominal conditions the more
respect he, as a surgeon, feels for the omentum. Only recently have
surgeons learned to appreciate the kindly activities of this duplicature
of the peritoneum, with its slight or heavy load of contained fat. It
manifests a tendency which may be almost regarded as a sagacity
or instinct for shifting itself toward a local focus of infection, and there
throwing out lymph by which it becomes attached and helps to form
a protective barrier that often is most effective. Were it not for this
tendency many cases of acute appendicitis, for instance, which now
recover would be lost during the early days of the attack, in
consequence of a quickly disseminated infection. Thus a
gangrenous appendix, or hernia, or gall-bladder, is frequently so
wrapped up in a protective layer of omentum that the operator has
first to detach this, or go through it, before he comes upon the actual
site of the trouble. Some such disposition of the omentum, then, may
be easily discovered during the earliest moments of his exploration,
and if later he conclude to remove a portion of it, because of actual
or impending gangrene, he nevertheless sacrifices it with a feeling of
regret because of the good it has already done.
The further treatment of these cases is essentially a matter of what
can be done to remove the exciting cause. Questions of gravest
import, and often difficult of immediate decision, will present in nearly
every case; as, for instance, whether to resect a portion of intestine,
to remove a gall-bladder, to hunt for an appendix when embarrassed
with the difficulty of the effort and necessity for widely separating
intestinal coils, or of the treatment of distended bowel, which it may
perhaps be impossible to restore to place, of extensive and complete
flushing of the abdominal cavity, or of mere local cleanliness. And
after these questions have been decided, and action taken, there
comes still the question of drainage, with the wisdom of or necessity
for counteropening, as in the loin or in the cul-de-sac, and the
character of drain to be used. As to what should be attempted in
general there will rarely be much room for doubt. As to how best to
accomplish it should be decided according to the training, the
experience, and the opportunities of the operator, and the nature of
the environment. When the entire peritoneal cavity is invaded, and
flooded with more or less infectious material the more thoroughly it
can be washed out the better. At the same time to do this with any
degree of even apparent thoroughness requires practical
evisceration of the patient, and an amount of time spent and shock
produced by handling the viscera, which are exceedingly depressing
and may of themselves be more than can be borne. The meteorism,
which is so conspicuous a feature of most of these cases, means the
distention of the bowel to such a degree that when once the
intestines lie upon the surface of the body they can usually be
restored with the greatest difficulty; and this would raise the question
of the desirability of either one or more punctures, through which gas
should be allowed to escape, or a sufficiently wide opening, with the
introduction of a Monk tube, and the complete emptying both of gas
and putrefying fecal matter. The latter is certainly in theory the much
more desirable measure, if the patient’s condition will only justify it.
Probably after pelvic drainage the Fowler semi-sitting posture in bed
would be desirable, while after high drainage the Trendelenburg
position, with the pelvis higher than the thorax, would be preferable.
If free abdominal irrigation is to be practised a large quantity of
warm sterile saline solution should be used, to which may be added
perhaps a small proportion of acetozone or of mercury bichloride.
The silver salts also make equally effective and less irritating fluid,
the nitrate being used in the proportion of 1 to 10,000, or the citrate
or lactate in proportion of 1 to 500 or 1 to 1000. These metallic salts
will coagulate the albuminoid fluids and give to the peritoneum an
opaque appearance, which, however, need cause no alarm.
Another question of importance is that of enterostomy. In some of
these cases the acute bowel obstruction is the most predominating
and distressing late feature, and an enterostomy may be attempted,
even though it be known it will serve but a temporary purpose, in
order to relieve distress. There never can be more than sentimental
objection to it, in such cases, with the possibility of something more
than mere temporary relief. It can be effected under local cocaine
anesthesia, by attaching to the parietal peritoneum the first loop of
distended small intestine that presents, and, after firmly fixing it in
place, making a small opening, and then preferably inserting a glass
or other tube for better drainage purposes.
These constitute the precautions to be followed and the advice to
be given in cases of septic or surgical peritonitis. How successful
they may be, or how satisfactory the termination of the case, cannot
be foretold by statistics nor by reports of cases in the hands of
others. Success will depend in large measure upon the early or late
period at which the case is thus treated, and upon the general
surgical discretion and experience of the operator. It is probable that
disappointment will result more often than success. Nevertheless
every life thus saved is one snatched from a certainly fatal
termination without it, and if successful but once in ten times one life
has thereby been saved that may be worth saving, without saving
the other nine. While I would advise to make the attempt in any case
which offers a reasonable prospect of success, caution should be
used against doing it without a full understanding with those
concerned that it is an effort in the right direction, concerning which
no promise can be made; death results not from the operation so
much as in spite of it.
Summarizing, briefly, the best methods of treating a diffuse septic
peritonitis we may agree with Le Conte,[53] that they consist of the
following measures: The least possible handling of peritoneal
contents, the elimination of time-consuming procedures, most
perfect drainage of the pelvis by a special suprapubic opening, as
well as free drainage through the operative incision, the semi-sitting
posture of the patient after its conclusion, the prevention of peristaltic
movements by withholding all fluids by the mouth, and perhaps by
small amounts of opium, and the absorption of large quantities of
water through the rectum, by which there may be produced a
reversal of the current in the lymphatics of the peritoneum, making it
a secreting rather than an absorbing surface and increasing urinary
secretion. It is inexpedient to waste time sponging peritoneal
surfaces or wiping away lymph, for danger of septic absorption is
increased rather than diminished. Patients with diffuse septic
peritonitis bear brief operations fairly well, but prolonged ones badly;
therefore a minimum amount of work should be done.
[53] Annals of Surgery, February, 1906.

One of the most valuable procedures in carrying out the above

advice is Murphy’s method of slowly introducing large quantities of
water into the rectum. The rectal tube used for the purpose ends with
a sort of nozzle containing three or four openings, and the reservoir
containing the solution is elevated but a few inches above the level
of the bed, the intent being that it shall simply trickle into the bowel
no faster than absorption can occur. In this way from a pint to a quart
may be absorbed each hour, the pressure being continuous, and the
flow so regulated that no accumulation of fluid takes place in the
bowel. Murphy claims that by this method the lymph current in the
peritoneal lymphatics is so reversed that the peritoneum is bathed
with free discharge and that this should be afforded escape by
suitable drainage methods, coupled with Fowler’s (the sitting)
posture.

TUBERCULOUS PERITONITIS.
Acute or chronic tuberculosis of the peritoneum assumes usually,
first, the miliary form, after which, in the slow cases, infiltration and
great thickening occur to such an extent as to alter the appearance,
texture, and behavior of the peritoneum itself. It is rarely a primary
condition, but is usually secondary to some other tuberculous focus,
which may be one or more of the mesenteric nodes, these being
involved in consequence of infection from the alimentary canal; or
the peritoneum may be easily infected either from the genito-urinary
tract or directly from the intestine. In children, the most common path
of infection is through the mesenteric nodes; in females, through the
Fallopian tubes, and in males, either through the intestine or the
kidneys or ureters. The peritoneum, under these circumstances,
behaves very much as does the pleura, in the presence of acute or
chronic tuberculous lesions which extend to and involve it. Thus it
may become so thickened, and even “leathery,” as to have lost all its
original characteristics, and to appear more like a dense, firm
membrane than in its original semblance.
Peritoneal tuberculosis appears in three different types: A
fibrinoplastic type, characterized especially by adhesions; an
ulcerative and sometimes absolutely suppurative form, marked
always by the presence of pus and pyoid; and an ascitic type,
characterized by leakage of increasing amounts of serum and the
development of well-marked ascites.
The first, or fibrinoplastic, is a localized lesion, and leads to the
formation of dense adhesions, as, for instance, between a Fallopian
tube and the pelvic walls or the other viscera. As the disease
spreads all the tissues become matted together in a mass which
renders them almost indistinguishable, frequently much resembling
malignant disease. In some instances it may be possible to remove
the entire affected area. At other times it is best to let it alone.
The ulcerative form is characterized by more general symptoms of
conspicuous febrile type. It produces rapid loss of strength and
weight, frequently attended with evidences of intestinal ulceration
and with abdominal tenderness and pain. A certain proportion of
these cases justify exploration, though but few of them will be found
favorably disposed for radical surgical measures.
The ascitic type is characterized by rapid accumulation of fluid,
with accompanying malaise and debility. As the abdomen distends
and the diaphragm is pushed upward respiration becomes more
difficult and rapid. A certain protrusion of the umbilicus also
characterizes many of these cases. Their course is not so febrile, but
it may be possible, especially in the early stages, to make out some
enlargement of mesenteric nodes, or involvement of the viscera,
which will aid in diagnosis. It is most common in children, but it may
be met with at any age. In general such a collection of fluid, which
cannot be accounted for by recognizable disease of the heart, liver,
or kidneys may be suspected to be tuberculous.
Treatment.—Treatment of tuberculous peritonitis should be
surgical when possible. This statement is based partly
upon the fact that it is so commonly a secondary condition. Such
treatment will depend, in large measure, upon the extent to which it
may be possible to remove any exciting foci of the disease; but
experience shows that even this is not always necessary to bring
about a cure, as in those cases of the ascitic type where it is
desirable only to wash out the abdominal cavity and close it again,
this simple procedure seeming to suffice.
It is the cases of the ascitic type which seem most benefited by
incision and irrigation, usually without drainage, and it is these which
are perhaps as hopeless as any under non-operative treatment. It
was Van de Warker, of Syracuse, who, in 1883, first recognized the
value of simple irrigation in these cases, and while at present we find
it impossible to explain the benefit which so often and so rapidly
accrues, the measure is universally recognized as that offering the
most hope. This, like every other surgical procedure, should be
practised early rather than late, preferably so soon as diagnosis is
made, or, when this is difficult, it should be made a part of an
exploratory operation intended partly for diagnostic purposes. The
measure itself is simple. A small opening in the middle line, between
the pubis and the umbilicus, permits free escape of all contained
fluid, which should be facilitated by changing the position of the
patient, thus preventing plugging of the opening by presenting bowel.
Every drop which can escape having been removed, the abdomen is
then flushed repeatedly with either warm saline solution or a plain
watery solution of acetozone, 1 to 1000, or silver lactate or citrate, in
the same proportion or a little stronger. My own preference has
always been for the latter, and with a silver solution I have obtained a
large degree of success. There is no objection to leaving a small
amount of either of these fluids in the abdominal cavity—i. e., no
more than an ordinary effort to empty it before closing the wound. An
incision one inch long, made for this purpose, will serve nearly every
indication. Through it the parietal peritoneum, as well as that
covering numerous loops of intestine, can be inspected, and through
it also a finger may be inserted for exploratory purposes, for the
detection of mesenteric nodular disease or of any other focus.
Should any serious local condition be revealed which might be
benefited by radical measures, this would be the time to practise
them.
Before closing the wound margins it would be well to thoroughly
disinfect them, for over them has flowed infected fluid, and we
sometimes see tuberculous foci develop at this point. This fact
explains also the disadvantage obtaining in these cases of making
drainage openings. They serve their purpose admirably for a short
time, but, becoming thus infected, lead to the establishment of
tuberculous fistulas and sinuses, which may call for subsequent
operation. Fecal fistula may even be a more remote consequence.
As the peritoneum is approached it will be found more or less
altered, and there may even be observed bowel or omentum
adherent behind it; therefore caution must be observed.
A final caution should also be given in order that we may avoid
mistaking that form of ascites which is frequently seen in connection
with cancer of the abdominal viscera extended to the peritoneum,
and particularly that form spoken of as miliary carcinosis or miliary
sarcomatosis, for a tuberculous collection. While surgeons are
occasionally deceived, one will usually find much in the history of the
case, and in the results of local examination, which may save
making this error, if it be so regarded; but, in effect, the opening and
the evacuation will give relief, even though this character of the
disease makes it less amenable to help from any such source.
 C H A P T E R X LV I I .
INJURIES AND SURGICAL DISEASES OF THE
STOMACH.

CONGENITAL MALFORMATIONS OF THE STOMACH.

These malformations are quite rare, at least those raising the
question of possible surgical remedy. Transposition does not require
relief, nor does a stomach abnormally small allow it. More or less
stenosis of the pylorus as a congenital defect has been observed,
but it is extremely rare. Along with it is often associated a certain
hypertrophy of the stomach muscle. Hour-glass deformity may be of
congenital or acquired origin. The latter two conditions permit of easy
surgical remedy. Pyloric stenosis may be atoned for by gastro-
enterostomy or treated directly by a plastic operation, while the hour-
glass stomach permits of an anastomotic rearrangement, either of its
dilated portions with each other or with the bowel below.
The acquired malformations are connected with the consequences
of ulceration and stricture. They include more or less complete
stenosis, either cicatricial or malignant, various forms and types of
gastroptosis and gastric dilatation, in which sometimes enormous
degrees of distention are produced, with disturbed or practically
destroyed stomach digestion. These cases will be considered by
themselves a little later, along with their surgical relief.
The anatomical relations of the nerves supplying the stomach are
worthy of the surgeon’s especial consideration. Its sympathetic nerve
supply is in particular and intimate relation with the seventh, eighth,
and ninth spinal roots, by which we account for the tenderness of the
overlying surface in ulcer of the stomach, and the pain which is often
referred to the region of the left shoulder-blade. When the stomach is
adherent to the gall-bladder, in cases of biliary calculi, the pain is
often referred to the right shoulder, but so soon as the pylorus
becomes entangled and bound down pain is referred also to the left
side as well.
 HOUR-GLASS STOMACH.
Hour-glass stomach is now more common, and is to be attributed
more to results of pathological conditions than to any congenital
anomaly, it being now well established that it is usually the result of
perigastric adhesions of chronic ulceration, with cicatricial
constriction, as well perhaps of subsequent malignant implantation.
Cancerous infiltration may produce the so-called “leather-bottle”
stomach. Moynihan suggests, among other methods of diagnosis,
the passage of a stomach tube and lavage with a quantity of fluid. If
there be loss of a certain amount of this, when it is returned, it will
indicate that a portion has escaped into the distal sac of the
stomach. Again if the stomach be washed until the fluid returns clear,
and then if there suddenly comes an amount of offensive fluid, or if
the stomach be washed clean, the tube withdrawn and passed again
a few moments later, and if then offensive fluid escape, the facts can
be best explained on the hypothesis of an hour-glass constriction.
“Paradoxical dilatation” may also be noted, i. e., the fact that
palpation will still elicit a splashing sound after a stomach tube has
been passed and while the organ is apparently empty.
Moynihan has suggested still another method of recognition. The
area of stomach resonance being outlined, a Seidlitz powder in two
halves is then administered. After about twenty or thirty seconds
great increase in resonance of the upper part of the stomach will be
found, while the lower part remains unaltered. If now a bulky pouch
can be felt or outlined the diagnosis is determined, as the increase in
resonance occurs in the distended cardiac segment.
The method of treating an hour-glass stomach will consist either,
in selected cases, of a plastic operation by which an incision made in
one direction is closed in the opposite, i. e., a measure like that
practised at the pylorus for benign stricture, or else the separate
sacs of the stomach must be united by an anastomotic opening and
a gastrogastrostomy thus performed.

FOREIGN BODIES IN THE STOMACH.

 These are most commonly those which have been swallowed,
either by design or through inadvertence, and may consist of almost
all imaginable substances. In those animals that have the constant
habit of licking their own fur or that of others, and thus scraping off a
quantity of hair, hair-balls in the stomach are frequently formed, and,
as may be seen in museums, these sometimes obtain relatively
enormous size—a foot or more in diameter. Hair-balls in the human
being are of rare occurrence, and are the result of the habit of
chewing the hair, observed in some hysterical or insane patients.
There are several instances now on record of successful removal of
such hair-balls from human stomachs. Artificial dentures, partial or
complete, are not infrequently passed into the stomach, sometimes
during sleep. In dealing with a case of this character extreme caution
should be exercised, because many individuals have deceived
themselves, or have been deceived, and the missing teeth supposed
to have been swallowed have been found in some place where they
have been mislaid and forgotten. Children have a habit of swallowing
almost anything left loose in the mouth, and all sorts of toys and
small playthings have disappeared into their stomachs, sometimes
causing death, and occasionally passing through the alimentary
canal. The insane sometimes show a maniacal tendency to swallow
foreign bodies, such as nails or anything else which they can get into
the mouth. Hysterical patients and museum freaks evince the same
habit, and it is wonderful how tolerant the stomach becomes in some
of these individuals, and what objects seem to pass the pylorus and
escape externally without doing serious harm. Still, sooner or later
nearly every one of these individuals comes to grief. Thus from one
patient at the Erie County Hospital, in Buffalo, Gaylord removed an
astonishing amount of junk, including nails, screws, pieces of glass,
knife-blades, and the like. As a general rule, any reasonably smooth
object which can pass through the esophagus may also pass
through the pylorus.
Symptoms.—The symptoms produced by these foreign bodies
will vary according to their size, number, and
character. A hair-ball may lie for a long time within the stomach,
producing few symptoms, and none by which it may be recognized.
So long as no perforation of the entire thickness of the stomach walls
occur, nor any infection which may produce a local peritonitis, the
disturbances they set up may be limited to those included under the
name “dyspepsia.” So soon, however, as pain, tenderness, or septic
indications, or those of local peritonitis supervene, the abdomen
should be promptly opened. Today we have the cathode rays as an
aid in diagnosis, which will clear up doubt in most instances, and
afford a definite indication for operation. Nevertheless a negative
result does not necessarily imply that no foreign body is present.
Treatment.—The operation indicated is gastrotomy, i. e., opening
of the stomach at a suitable or convenient point,
removal of the foreign body or bodies, and the complete closure of
the wound as well as of the abdominal incision, without drainage. If
due care be maintained throughout, and the element of previous
infection be excluded, prognosis is good. When perforation with local
peritonitis, and perhaps abscess, has already occurred, there is a
local indication as to exactly where to open; one should then
complete the operation with the establishment of suitable drainage.

WOUNDS OF THE STOMACH, INCLUDING RUPTURE.

As already indicated, the stomach maybe ruptured, especially if
weakened by previous disease, by severe abdominal contusion. It is
subject to all possible wounds by perforation, either gunshot or by
puncture. As it is more protected than the bowel below it is less liable
to perforating injuries. Much will depend upon the nature and the
extent of the injury. A small perforation may be protected by prolapse
of the mucosa in such a way that little escape of contents takes
place. On the other hand it may be extensive, and nearly the entire
gastric contents may be poured out into the upper abdomen. The
location of the stomach lesion by no means necessarily corresponds
to that of the abdominal wall, this being particularly true in gunshot
cases. Extravasation depends in amount and rapidity upon the
stomach contents and their fluidity. If the posterior wall alone be
injured it will empty rather into the cavity of the lesser omentum.
Stomach injury may always be diagnosticated if, after abdominal
injury, the vomited matter contains blood. The pain is usually severe
and involves generally the entire upper abdomen. In proportion as
the lesion lies near the diaphragm the breathing may be affected.
Collapse is usually prompt and may be due to hemorrhage from a
vessel of considerable size. Pain, collapse, and hematemesis
constitute indications for the promptest possible opening of the
abdomen and investigation, with suitable suture of the stomach
wound, toilet of the peritoneal cavity, and drainage, which should be
posterior as well as anterior. Every ragged or compromised margin
of a stomach wound, especially gunshot, should be neatly excised,
and sutures applied in such a way as to only bring clean and fresh
surfaces together. An external opening of sufficient length should be
made to permit easy and complete withdrawal of the entire stomach,
and a complete search over both its surfaces in order that no lesion
may escape detection. If the opening made into the stomach be
sufficiently large to permit, it would be best to thoroughly empty its
contents and gently wipe it out, in order that it may be left not only
empty but clean. Should the puncture be very small it would be well
to pass a stomach tube from above and wash out the stomach,
protecting the opening by pads and pressure, and thus preventing
contamination of the peritoneum.
While apparently spontaneous rupture, i. e., without previous ulcer
or disease, is most rare, there are a few cases on record where
patients have been seized with intense paroxysmal pain and have
died more or less quickly, and where the condition has been found
with little or nothing to explain it. Immediate operation might possibly
have saved some of these had the possibility of its occurrence been
recognized. Perforation from within may also occur, as it is known to
have happened in the cases of sword or knife swallowers.
Suture of the stomach is practised in exactly the same way in
these cases as for other purposes and the method will be described
later, along with the other operations upon this viscus.

TUBERCULOSIS AND SYPHILIS OF THE STOMACH.

The gastric mucosa presents a remarkable contrast to that of the
intestinal tract, the latter being exceedingly likely to succumb to
tuberculous infection, which is exceedingly rare in the former.
Primary tuberculous ulceration of the stomach, then, is most
unusual. When tuberculous ulcers are found there they are usually
the result of a secondary or perforating process. Such ulcers may
attain great size, as in one case reported by Simmonds where the
ulcerated area measured four by eight inches, yet produced no
symptoms during life. This would correspond almost to a lupus of the
gastric mucosa. Tuberculous gummas are even more rare, and,
occurring in the stomach, are pathological curiosities rather than
surgical possibilities.
Syphilis of the stomach is met with either as gumma or ulcer, the
latter leading almost inevitably to more or less stricture as recovery
follows suitable treatment. Although it is claimed that 10 per cent. of
cases of chronic ulcer of the stomach have suffered from syphilis at
some time, it by no means follows that such ulcers are to be
considered as of genuinely syphilitic origin, as a syphilitic patient is
not exempt from other stomach conditions. However, symptoms of
gastric ulcer, associated with actual manifestations of syphilis, might
well indicate associated syphilitic lesions and would probably yield,
with the others, to suitable treatment.
Lesions of either character, which do not subside under proper
medical treatment, and which require a surgical operation, would be
equally benefited by it whether of one of these types or of the other.

DILATATION OF THE STOMACH.

The acute form of gastric dilatation was described by Fagge in
1872, the chief symptoms being excessive vomiting and anuria, and
the disease proving fatal within three days, the dilatation being
enormous. For a condition occurring as rapidly and progressively as
this does there is as yet no satisfactory explanation, careful autopsy
failing to disclose a sufficient reason. It has been known in at least
twelve instances to follow surgical operation, four only of which were
upon the abdomen, and none of them upon the stomach proper, in
all instances the patients apparently progressing favorably. The
stomach becomes rapidly and enormously distended, and bent upon
itself with a sharp kink in the lesser curvature. Thus it seems to
occupy the entire upper abdomen. Two factors at least seem to
assist in the condition: A paresis of the gastric musculature, and the
fact that as it becomes distended it itself produces obstruction of the
duodenum, and thus aggravates the primary condition.
It has been suggested that these acute cases of postoperative
dilatation are closely connected with certain cases of ileus and
obstruction after abdominal operations, the dilatation once initiated
tending to more and more obstruct the duodenum, as well as cause
upward pressure on the diaphragm and embarrassment of the
heart’s action. Hence the value of the stomach tube in treatment of
such conditions.
Symptoms.—The symptoms are usually sudden and fulminating,
beginning with intense pain, which finally involves the
entire abdomen. Vomiting comes early and persists, the vomited fluid
being greenish in color and large in amount, changing later to a
brownish color and having an offensive odor. The act of vomiting is
passive rather than active or violent. In spite of it the stomach never
seems to empty itself. The outline of the dilated stomach may be
seen through the abdominal wall, bulging being often extreme. With
the passage of the stomach tube there may be escape of a large
amount of gas as well as of fluid. Thirst is intolerable and never
satisfied. The amount of urine is almost always reduced and
sometimes anuria is practically complete.
Treatment.—The treatment is too often ineffectual, since the
condition itself is lethal almost from the beginning.
Early and frequent lavage, or perhaps leaving the stomach tube in
place, would be indicated. It might be practicable to pass a small
tube through the nostril and leave it, as is done with the insane.
Gastrostomy would be theoretically indicated, could it be done
sufficiently early. The same is perhaps true of gastro-enterostomy,
although it has never had a fair trial, these cases coming to the
surgeon too late to permit of much help.
Chronic Dilatation of the Stomach.—Chronic dilatation of the
stomach, often spoken of as
gastrectasis, is a frequent complication of various other conditions,
being essentially a consequence rather than a primary condition. It
may be due to:
1. Pyloric stenosis or its equivalent in the first part of the
duodenum:
 (a) From cicatricial processes following ulcers of the pyloric
region;
(b) From perigastritis with cancer of the stomach;
(c) From pylorospasm and hypertrophy continuing after
recovery from ulcer, and including more or less thickening
of the biliary region;
(d) From neoplasms outside the pylorus proper;
(e) From cancer of the pyloric end of the stomach;
(f) From pressure upon the duodenum by pancreatic lesions;
(g) From the results of gallstones ulcerating and causing great
local disturbances;
(h) From displacement of the pylorus, due either to falling of
the stomach or dragging of an attached but movable right
kidney.
2. A dilatation due to old lesions which have subsided, the atonic
stretching not having been repaired.
It will be seen, then, that the condition may be met as a sequel to
many different pathological processes. As such, therefore, it has no
constant etiology nor necessarily distinctive features. In general it is
recognized by tardiness in escape of gastric contents, associated
with vomiting, the vomitus being distinctive, consisting often of old
and undigested food, or perhaps of food which has rested in the
stomach until putrefaction has occurred. The vomitus also contains
evidences of fermentation, with sarcinæ and yeast cells and much
mucus. In cases of ulcer it is usually very sour, owing to excess of
free hydrochloric acid. When due to cancer the acid is usually due to
excess of lactic acid, while hydrochloric acid may be nearly or totally
absent. Even if vomiting does not occur after ingestion of food,
heaviness and discomfort, with much eructation of gas, are
produced. Constipation and diminished urine secretion are almost
invariable accompaniments. When the obstruction is of the
mechanical type a visible peristaltic wave can often be seen and felt,
and this is a sign which should be regarded as always indicating
operation.
Patients gradually lose flesh and become anemic and run down,
suffering from what has been often vaguely called indigestion, their
lives sometimes being terminated by starvation, occasionally by