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PALGRAVE CLOSE READINGS
IN FILM AND TELEVISION
Ambiguity and
Film Criticism
Reasonable Doubt
Hoi Lun Law
Palgrave Close Readings in Film and Television
Series Editors
John Gibbs
Department of Film, Theatre & Television
University of Reading
Reading, UK
Doug Pye
Department of Film, Theatre & Television
University of Reading
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belief that, while a scrupulous attention to the texture of film and television
programmes requires the focus of concept and theory, the discoveries that
such attention produces become vital in questioning and re-formulating
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Hoi Lun Law
Ambiguity and Film

Criticism
Reasonable Doubt
Hoi Lun Law
Bristol, UK
ISSN 2634-6133 ISSN 2634-6141 (electronic)

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Acknowledgements
Looking back at the path I’ve travelled, I appreciate all the help and kind-
ness I encountered along the way. My special thanks go to Alex Clayton,
who has patiently guided me to rediscover and reflect on what I mean by
what I say during my doctoral research. I was told “Alex can teach you
things” before commencing the degree. What I learned over the years
working with him has made this book possible. My ongoing conversations
with Dominic Lash have not only informed the arguments of this volume
but also enriched my understanding of film and film aesthetics. Most
importantly, we share the acquired taste in sour beers! Catherine Grant has
been a great mentor and (later also) a dear friend ever since I came to her
office to discuss film theory in late 2010. Her generosity is legendary. And
surely, I am not the only one who thinks Katie is a magnificent human
being as well as a wonderful educator. Adrian Martin has been extremely
supportive of this project since the early stage. Pointing out a notable
omission in my arguments, his erudite comments helped refine my claims.
Andrew Klevan (who, by the way, made the aforementioned remark about
Alex) gave an unpolished draft of Chap. 2 the kind of sustained critical
engagement (and critique) that I’ve always wanted for my work. Part of
Chap. 6 was presented as a paper at Screen conference 2016 and benefited
from Chris Keathley’s keen eye (in this specific case, ear) for detail. Jacob
Leigh and Kristian Moen were attentive and discerning as the examiners
of my doctoral thesis. Pete Falconer (half-jokingly?) said his role as my
second PhD supervisor was to not get in my way. But I knew very well—
and he made sure of it—that he was available if I ever needed his aid.
v
vi ACKNOWLEDGEMENTS
Whenever I talk to James MacDowell, not least about ambiguity, I profit

from his lucidity of thought. Elliott Logan and Murray Pomerance prof-
fered heartfelt words of encouragement when they were most needed,
during that exhilarating yet trying final stretch of writing. I am glad to
have John Gibbs and Doug Pye, who are sympathetic to my critical
approach and temperament, as the series editors of this title. At Palgrave
Macmillan, Emily Wood had provided excellent editorial assistance. It is
my pleasure to be friends with Hanna Kubicka (with whom I enjoyed
many intellectual and not-so-intellectual conservations), Ali Rasooli-Nejad
(whose enthusiasm about “movie masterpieces” is galvanising), and
Jordan Schonig (whose perceptiveness never fails to bring clarity and
rigour to a discussion). Thank you to Lara Perski for being my travel com-
panion throughout this difficult but rewarding path. I will always remem-
ber the time when we had walked such a path and found ourselves “stuck”
on a hilltop. The trail down was steep and narrow, frighteningly treacher-
ous. What to do? We braved the adverse uncertainty together. My greatest
gratitude goes to my parents and my sister, who are always there for me.
This book is for those who are attuned to the teachings of doubt.
Contents
1 Introduction: Why Is It as It Is? 1
Part I Pursuits of Reasons 23
2 Difficulty of Reading 25
3 Perplexity of Style 49
4 Depth of Suggestion 87
Part II Drama of Doubt 113
5 Uncertainty of Viewpoint115
6 Threat of Insignificance149
7 Concluding Remarks: Reasonable Doubt175
Index183
vii
List of Figures
Fig. 2.1 Late Spring (Yasujirō Ozu, 1949) 26

Fig. 3.1 Ten (Abbas Kiarostami, 2002) 61
Fig. 4.1 In a Lonely Place (Nicholas Ray, 1950) 89
Fig. 5.1 Force Majeure (Ruben Östlund, 2014) 120
Fig. 6.1 Beyond a Reasonable Doubt (Fritz Lang, 1956) 150
ix
CHAPTER 1
Introduction: Why Is It as It Is?
In spite of its wide currency in film scholarship, criticism, and everyday

conversation, ambiguity has not been systematically developed as an aes-
thetic concept for the medium of film. It has received considerable atten-
tion in discussions of “art cinema” and “modern cinema”, which often
assert the significance of ambiguity in these modes of filmmaking without
unpacking its implications (see Armes 1976; Bordwell 2008; Self 1979).
And when the concept is studied in detail, it is typically in reference to
André Bazin’s phenomenological understanding of cinematic realism (see
Andrew 1973; Carruthers 2017). As a result, there is room in critical lit-
erature for an exploration of ambiguity across diverse film styles. What
would such an account involve? A main task of this book is to offer a useful
framework to appreciate the variegated manifestations of ambiguity
in movies.
What Makes Ambiguity Ambiguous?

Perhaps one reason why ambiguity is understudied, habitually taken for
granted, has to do with its ironically unambiguous standard definition.
Dictionaries define ambiguity as the characteristic of what bears multiple
meanings. This is arguably how the term is ordinarily understood too. The
straightforward definition seems sufficient in itself, not only detailed
enough as a description of what ambiguity entails but also capable of
© The Author(s), under exclusive license to Springer Nature 1

Switzerland AG 2021
H. L. Law, Ambiguity and Film Criticism, Palgrave Close Readings
in Film and Television,
https://doi.org/10.1007/978-3-030-62945-8_1
2 H. L. LAW
covering a variety of instances and situations. It particularly speaks to a

kind of ambiguity that prevails in everyday life—the ambiguity of lan-
guage, meaning that words can possess more than one semantic connota-
tion. The linguistic view has a great purchase on how ambiguity is perceived
in the realm of the arts. A Glossary of Literary Terms, for example, refers to
ambiguity as “the use of a single word or expression to signify two or more
distinct references, or to express two or more diverse attitudes or feelings”
(Abrams and Harpham 2009, 12). And a similar assumption of ambiguity
as a matter of sign and signification prompts David Bordwell to proclaim
“[w]hat was ‘ambiguity’ in New Criticism could become ‘polysemy’”
(1989, 99). It is evident that something is missing, if not amiss, in these
views; it feels flattening and schematic to equate ambiguity to the plurality
of suggestions. Such an understanding, we want to say, fails to appreciate
what makes ambiguity ambiguous.
This issue is touched upon in William Empson’s Seven Types of Ambiguity
(1961 [1930]), a seminal work of New Criticism that is also the most
influential account of ambiguity as an aesthetic concept (specifically in
poetry). In his preface to the second edition of the book, Empson sug-
gests that puns would not be typically considered ambiguous, even though
they manage to say two things simultaneously, “because there is no room
for puzzling”. Instead, they result in “conciseness” (x). Throughout Seven
Types, the feeling of puzzlement is frequently cited as something like ambi-
guity’s defining effect. This crucial point, insisted by Empson, allows us to
see why the semiotic notion of polysemy, as “literally, many ‘semes’ or
meanings” (Stam et al. 1992, 30), should not be taken as synonymous to
ambiguity. In fact, polysemy cannot be more different from how New
Critics, especially Empson, understand ambiguity. Not necessarily puz-
zling, the polysemic harbours aesthetic possibilities that are dissimilar from
that of ambiguity. Most importantly, to call something polysemic does not
entail an act of evaluation like calling something ambiguous often feels to
involve. Indeed, the legacy of Seven Types lies less in the categories it pro-
poses—which are almost impossible to memorise and liable to be mecha-
nistically applied—but in its establishment of ambiguity as a value (as
opposed to an “objective” condition). It has become difficult nowadays to
talk about ambiguity without also evoking a sense of aesthetic judgement.
For Empson, what makes ambiguity ambiguous—what activates our
puzzlement—is the relationship between the different interpretations. His
typology of ambiguity is a typology of such relationships, which include,
for example, conflation (the second type), confusion (the fifth type), and
1 INTRODUCTION: WHY IS IT AS IT IS? 3
contradiction (the seventh type). He likens these diverse relationships

between meanings to different “forces” that “hold together a variety of
ideas” (1961, 235).1 If the standard definition of ambiguity stresses its
condition of multiple readings (as in Abrams and Harpham), Empson
reminds us that these readings, however incompatible or clear-cut they
may seem, are by definition connected, in the sense that they stem from
the same origin; that is, however we define it, ambiguity concerns the pos-
sibilities of the many in what is one. To show the nature of an ambiguity,
Empson suggests, it is not enough to simply unpack its “ideas”, we further
have to work out the relations between these ideas, showing “the nature
of the forces which are adequate to hold it together” (ibid.).
This study explores ambiguity as an aesthetic concept for film by
rethinking its standard definition, seeing it as more than the availability of
multiple meanings. Like Empson, I do so by paying attention to the
“forces” that hold an ambiguity together, observing what is ambiguous as
an interlacing weave of suggestions. But this book will not “translate” his
understandings into the context of cinema. Nor am I interested in cate-
gorising ambiguity. On the contrary, it is my aim to engage with ambigu-
ity in its specific instances, exploring their singularities. And that should in
turn allow me to identify some key or recurring characteristics of the con-
cept. One such important feature, as Empson helpfully points out, is the
aesthetic reaction of puzzlement. Throughout this book, I will typically
refer to this reaction as uncertainty or doubt, for they better capture the
sense of interpretative suspense that my account pivots upon. We shall see
how uncertainty and doubt are integral to the aesthetics of ambiguity.
Two Senses of Ambiguity

This study is entitled Ambiguity and Film Criticism not because it charts
the development of the concept in film criticism. Rather, it probes the
relationship between the concept and criticism, exploring the possibilities
of ambiguity by examining the challenges it poses to film analysis. As a
result, readers will not find an interdisciplinary approach to the concept in
the following pages, yet discussions of ambiguity (and its attendant ideas)
in other arts will be cited when appropriate (ambiguity in art and photog-
raphy is discussed in, for example, Elkins 1999; Franklin 2020; and
Gamboni 2002). However, my distinct focus is not an assertion of medium
specificity. It is instead an effort to flesh out several productive ways of
addressing and appreciating ambiguity that are already available in film
4 H. L. LAW
criticism, worthy of highlighting or rediscovering, even though they may

not explicitly concern the concept. One purpose of this book is to re-
evaluate what film criticism has taught us about how to think and write
about ambiguity. (It is worth pointing out that the general framework I
develop here—based on the dynamic of “question-and-answer”, as we will
see later—can be in fact revised to explore ambiguity in other artistic
mediums.) Now, it is useful to survey two prominent senses in which
ambiguity is typically understood in relation to film.
Interpretative “Freedom”
Given ambiguity’s connotations of multiplicity and uncertainty, it seems
intuitive to speak of it as a feature of reality. It is therefore not surprising
that the concept has been taken as a hallmark of cinematic realism. And
this particular view of realist aesthetics is the critical legacy of André Bazin.
Situating the critic in his contemporary intellectual milieu, Dudley Andrew
takes note of the influence of phenomenology on Bazin’s thoughts:
Bazin would be obliged to say that the real exists only as perceived, that situ-
ations can be said to exist only when a consciousness is engaged with some-
thing other than itself. In this view reality is not a completed sphere the
mind encounters, but an “emerging-something” which the mind essentially
participates in. Here the notion of ambiguity is a central attribute of the real.
(1973, 64)
For Bazin, as Andrew points out, our perception interacts with and com-
pletes the world. Ambiguity, therefore, also needs to be understood in
light of this situation. Specifically, it means that ambiguity is not an “objec-
tive” feature but an attribute of our negotiation with what we perceive as
reality. Reality is ambiguous not because it is inherently plural in meaning
but because its meaning is equally like an “emerging-something”, only
made available through our ongoing exchange with the world. This is also
why each of us sees reality differently. We can say that ambiguity is the
condition that enables our distinctive understandings.
Rather than the recording of unadorned reality, Bazin’s realism involves
the reproduction of the condition of ambiguity in movies. And this condi-
tion, in the medium of film, becomes an insistence on the viewer’s “auton-
omy” of reading. This is put into sharp relief by Bazin’s provocative claim:
“[e]diting, by its very nature, is fundamentally opposed to ambiguity”
(2009, 101). Note that by “editing”, Bazin means specifically analytical

editing such as the conventions of the shot/reverse-shot and the point-of-
view shot.2 Dissecting a scene into dramatic units and reassembling them
into a chain of actions, this type of edits imposes a specific course of under-
standing. As a result, there is little leeway for the audience’s perceptual and
interpretive exploration.
In this way, analytical editing is the opposite of deep focus cinematog-
raphy, a technique that Bazin famously champions because it “re-introduces
ambiguity into the structure of the image, if not as a necessity […] at least
as a possibility” (21). Unlike analytical editing, the use of depth-of-field,
by withholding visual emphasis and dramatic priority in a scene, requires
us to work out what is significant, to perform our own reading, exercising
our prerogative of interpretation. The device is capable of reproducing an
involved experience not unlike our perceptual entanglement with reality.
And this achieves what the critic considers “a sound definition of realism
in art: to force the mind to draw its own conclusions about people and
events, instead of manipulating it into accepting someone else’s interpre-
tation” (1997, 123).3 For Bazin, the reproduction of ambiguity is what
allows film to fulfil its promises as a realist medium.4
This study does not intend to pursue a realist account of ambiguity or
explore further Bazin’s phenomenological understanding. But the interac-
tion between screen and spectator that undergirds the critic’s understand-
ing remains a productive way to think of the concept. And this conception
is echoed by other film critics. For example, André S. Labarthe suggests:
Traditional cinema had managed to do away with any possibility of ambigu-

ity by building into every scene and shot what the spectator was meant to
think of it: i.e. its meaning. Taken to its extreme, this kind of cinema did not
need the spectator since he [sic] was already included in the film. (1986, 55)
The remark complements Bazin’s claim about analytical editing, though

also pushing it too far: It is doubtful that a total control of meaning, of the
viewer’s reading, is achievable in film. Interestingly, while Labarthe’s state-
ment shares Bazin’s assumptions about ambiguity, these assumptions are
used against the kind of cinema that the critic argues to be capable of (re)
creating ambiguity—it is in the “tradition cinema” of Orson Welles and
William Wyler that Bazin discovers illuminating uses of depth-of-field.
Labarthe’s remark speaks to ambiguity’s common association with what is
“modern” or “unorthodox” (made clear by book titles such as The
6 H. L. LAW
Ambiguous Image: Narrative Style in Modern European Cinema and

Potential Images: Ambiguity and Indeterminacy in Modern Art). This
brings us to the second typical understanding of ambiguity.
Analytical Challenge
In critical literature, ambiguity often stands for what is unconventional
and challenging. And this is reflected by its long-established link to “art
cinema”, ever since the emergence of the genre. In an early conceptualisa-
tion of ambiguity in film scholarship, which is also one of the first system-
atic discussions of “art cinema”, David Bordwell (2008 [1979]) defines
the genre by its aesthetic deviations from Classical Hollywood Cinema.
The unfamiliar stylistic devices and the loose narrative causality in “art
films”, Bordwell observes, may be challenging to the viewer, but these
anomalies can be understood in reference to the twin poles of “realism”
and “authorial expressivity”:
Whenever confronted with a problem in causation, temporality, or spatiality,

we first seek realistic motivation. (Is a character’s mental state causing the
uncertainty? Is life just leaving loose ends?) If we’re thwarted, we next seek
authorial motivation. (What is being “said” here? What significance justifies
the violation of the norm?) Ideally, the film hesitates, suggesting character
subjectivity, life’s untidiness, and author’s vision. Whatever is excessive in
one category must belong to another. Uncertainties persist but are under-
stood as such, as obvious uncertainties, so to speak. Put crudely, the slogan
of the art cinema might be, “When in doubt, read for maximum ambigu-
ity”. (156)
In Bordwell’s account, ambiguity seems to mean the uncertainty between

the two types of motivations. And the “ideal” scenario is where this uncer-
tainty is irresolvable, that the detail or device in question is both driven by
artistic and realistic concerns (Chap. 2 will look closely at why explaining
ambiguity in terms of motivation is unproductive). On this view, ambigu-
ity is not what calls for analysis and appreciation in “art films”. Instead, as
the advised strategy of “read[ing] for maximum ambiguity” implies, it is
the “explanation” of “art cinema”. And positing “ambiguity” as the
“goal” of analysis, Bordwell’s “reading procedure” amounts to little more
than flagging up and re-stating a film’s difficulties. This seems to me not
only an unsatisfying account of ambiguity and “art cinema”5 but also an
unhelpful way to construe an analytical approach to ambiguity. In particu-

lar, I maintain that ambiguity is in fact an invitation to our critical account,
which further calls for certain appropriate ways of accounting. We read to
neither “maximise” nor nullify ambiguity but to come to terms with it,
exploring why something is ambiguous in detail and in depth.
Other early literature on “art cinema” liken the films to “puzzles”. For
Robert Self, “[t]he texts of the art cinema exist quite explicitly as puzzles to
be solved by the viewer, but puzzles also constructed to prevent easy solu-
tion” (1979, 77). Writing on what would later become the canon of “art
cinema”, Norman N. Holland sees it as innovative that these “puzzling
movies” “bus[y] us with solving the riddle” (1963, 19). Recently, this film-
as-puzzle analogy is revived by the emerging scholarly interest in “contem-
porary puzzle film”. Mostly consisting of popular and independent movies
from the 1990s, the genre is characterised by its “complex storytelling”,
which usually serves as an expressive means to articulate its themes of con-
fusion or serious philosophical concerns such as schizophrenia and episte-
mological doubt. These films advance an entangled plot that is difficult to
understand and sort out (see Buckland 2009, 2014; Kiss and Willemsen
2017). To call films puzzles is to foreground their analytical difficulties.
If ambiguity marks what is difficult, then it is not only possible but also
productive to explore the concept beyond the genres of “art cinema” and
“puzzle film”, and in relation to narrative fiction movies in general, includ-
ing what Labarthe calls “traditional cinema”, especially due to its exclu-
sion from prevalent considerations of the concept. Attractive as a way of
picturing ambiguity, the “puzzle analogy”, however, seems to me prob-
lematic as a conceptualisation of its difficult nature. In particular, the anal-
ogy envisions the task of criticism, suggested by Self’s and Holland’s
remarks, as one that of “solving” a film’s meaning, as though to reassem-
ble and recover a definitive understanding. According to this view, what is
difficult, as it were, is not a part of the movie’s expression but a hindrance
in need of elimination. A film is ambiguous only because, and as long as,
we haven’t found the solution to it.
It is questionable that there exists an “ultimate solution” to any film.
Moreover, if we are interested in ambiguity as an aesthetic concept, we
would want to investigate its possibility as an achievement, and not con-
ceive it merely as an interpretative complication to be overcome. I take the
dubious premise of the “puzzle analogy” as symptomatic of an unproduc-
tive critical stance that is not uncommon—unfortunately, as we have
seen—in both scholarship and criticism. (Just to be clear: my reservation
8 H. L. LAW
concerns this specific premise and not the phenomenon of the puzzle film,
nor is it directed towards any particular study on the subject.) A chief con-
cern of this book is therefore meta-critical (made explicit by the chosen
title Ambiguity and Film Criticism, instead of what is expected of a project
of this kind: Ambiguity in Film). Throughout the chapters, not only will I
explore prominent features of the concept but I will also examine some
unhelpful assumptions or approaches with regard to the analysis of ambi-
guity. These include the Neoformalist category of “motivation”, the criti-
cal anxiety about “over-interpretation”, and the much-debated divide
between “surface” and “deeper” meanings. Literature on ambiguous
movies is abundant (e.g., there is a plethora of anthologies and journal
articles on “puzzle films” and those who made them). This is time we
attend to our critical practices and methodological procedures. Rising to
this challenge, this book reflects on how we could appropriately under-
stand and assess what is ambiguous. And by doing so, I argue, we further
gain general insights into the nature and operation of film criticism.
Question and Answer

The “puzzle analogy” may be misleading but it has arguably captured an
intuitive way to think about ambiguity. This explains its pervasiveness.
Specifically, ambiguity seems challenging sometimes indeed because we are
not sure how to “answer” it, that its “answer” is unobvious or complex.6
Accordingly, and equally intuitively, we can think of ambiguity as a difficult
or demanding question. There is a sense that ambiguity is what invites our
questions and answers; it sustains both the acts of questioning and answering.
It is not uncommon in everyday life to speak of a film posing questions
or providing answers. And a number of critics have further recognised the
possibility of the question-and-answer structure as a narrative model, such
as Roland Barthes’s theorisation of the “hermeneutic code” (1974) and
Noël Carroll’s account of narrative closure (2007).7 My concern here is
not to explain how the medium of film is capable of articulating questions
and answers (this is, however, a worthy theoretical pursuit).8 Instead, I am
interested in the erotetic structure as an exchange between screen and
viewer. It is worth noting that however questions and answers are expressed
in a movie, they are expressed in ways that are different from how they are
conveyed in language. Of course, there are instances where a character
appears to expressly say what a film means. But the work’s effective mean-
ing, in the final analysis, pivots upon its organisation of sights and sounds,
so accordingly, its questions and answers are suggested by these means.9
They need to be interpreted. In other words, the erotetic dynamic is a

matter of reading. The questions and answers of a movie are also our criti-
cal questions and answers. And this makes the structure useful in develop-
ing the established idea of ambiguity as a negotiation between an artwork
and its audience (besides Bazin, see also Elkins 1999; Gamboni 2002).
Why Is It as It Is?
Ambiguity in film, this book proposes, is an invitation to inquire into “why
is it as it is”. And this involves elaborating the questions in response to a
specific movie, as well as exploring satisfying ways of answering them.
“Nothing could be commoner among critics of art”, Stanley Cavell
observes, “than to ask why the thing is as it is” (2002, 182). In fact, the
“why” question is so prevalent that it arguably captures, in one fundamen-
tal sense, the reason we are interested in artworks. But ambiguity, this study
suggests, because of its “room for puzzling” and analytical challenges,
heightens the urgency of this inquiry, insistently soliciting our answers. In
other words, our experience of ambiguity intensifies our critical practice.
As Cavell points out, the investigation of “why” “directs [us] into the
work” (227). Each individual chapter of this book will delve into one
movie or dwell upon some remarkable moments in a film. These close
readings will detail, as carefully as possible, the “why” questions that these
works invite us to consider.10 By doing so, I also wish to demonstrate that
what is ambiguous requires to be understood in its own terms, under its
specific contexts, as a special manifestation of the concept. That is, each
instance of ambiguity is ambiguous in a distinctive way. This is not to say
the concept cannot or should not be systematically categorised like
Empson does. Only that this study aims for a more practical understand-
ing; it seeks to inform the practice of criticism. The “why” inquiry not
only means to offer a coherent way to conceptualise ambiguity but also to
serve as a cogent framework under which to explore its variegated
instances. Ambiguity, this study maintains, is something to be clarified and
illuminated by reading; it calls for our critical effort, requiring to be
accounted for.
This point is worth stressing because there is a sense that the word
“ambiguity” is prone to be used in advance of reading or as a substitute
for critical engagement. As we have seen earlier in the text, ambiguity is a
multifarious concept which has been taken to mean, at least, analytical dif-
ficulty and interpretative “freedom”. The multiplicity of the term can be
10 H. L. LAW
useful in criticism; it may be employed to eloquently communicate the

complex effects of a movie. But that also abets the possibilities of impre-
cise and uncritical uses. Or worse still, the term could be abused as a con-
venient way out for analysis, that is, as an empty expression of puzzlement,
ignoring the potent call for reading. All this points to an unreflective reli-
ance on the concept, which expects it to do the work for us, whereas
ambiguity, as my account suggests, should be what launches and sustains
the work of criticism. This book insists on our critical responsibility to
work out what is ambiguous. And by working out the “why” questions in
relation to a range of movies, it also delineates a set of characteristics of
ambiguity, which in turn complements the framework of “why is it as it
is”. Our understanding of the concept is then gradually accrued. Instead
of a definitive conception, this study offers the readers a framework to
engage with movies that are beyond the scope of the chapters, inviting
them to continue the investigation of this book.
But what does a specific “why” question typically look like? For instance,
it could be most straightforwardly “why is the character upset at this
moment?” to the more advanced “why does the camera zoom into her
when she is upset?” A few things are already made clear by the sample
enquiries. In a narrative movie, it is common that the “why” question
takes interest in characters and the dramatic scenario, but it may further
comprehend matters of form and style. And it is especially when it does, as
in the second example, that the intertwinement of the two aspects is fore-
grounded. In other words, we cannot productively examine issues of nar-
rative without some consideration of the film’s presentation, and vice
versa. The “why” inquiry can be deceptively simple. An account of it usu-
ally requires a holistic understanding of a whole host of narrative and sty-
listic elements.
This brings us to an even more important issue: what are we inquiring
into when we ask the “why” question? That is, what kind of answer we are
looking for? Throughout the book, I will focus on one type of desirable
answer which I call aesthetic reason. This term is inspired by Ludwig
Wittgenstein’s series of lectures on aesthetic appreciation, a subject whose
central aim, he claims, is to come to terms with the “aesthetic puzzle-
ments” that works of art have upon us (1972, 28–9). Our aesthetic
response then involves, he notes, “giv[ing] reasons, e.g. For having this
word rather than that in a particular place in a poem, or for having this
musical phrase rather than that in a particular place in a piece of music”
(Moore 1955, 19). What Wittgenstein advocates here is indeed what the
“why” question seeks to probe: the reason for a specific artistic choice.
When we ask “why” about an artwork, we want to know what is achieved
by this choice instead of otherwise. Aesthetic reason concerns
particularities.11
Chapters 2 and 3 will explore in greater detail what aesthetic reason
means in the criticism of film. But as the earlier remark on the sample
“why” enquiries suggest, the kind of reason we take interest in is the kind
that can be discerned or deduced from the work itself. And it broadly con-
cerns the meaning and significance of artistic choices. This concern is par-
ticularly instructive towards the appreciation of ambiguity because, as
V.F. Perkin observes, it is often by “project[ing] ourselves into the position
of the artist and think through the problems which he [sic] confronts in his
search for order and meaning” that we become cognisant of how a film
“absorbs its tensions” (1993, 131). Note that this critical projection is not
the same as the uncovering of the filmmaker’s premeditated aesthetic con-
ception. Instead, it is something like a re-imagination of the process of
filmmaking, of the conditions under which one can better contemplate the
reasons for, as Wittgenstein would put it, making this choice rather than
that in a particular place in a movie. The exploration of ambiguity as an
artistic expression—and not an obstacle to meaning as the “puzzle anal-
ogy” has it—can similarly benefit from this practice of critical re-imagina-
tion. (This practice is a good use of what James Grant [2013] calls
“imaginativeness” in criticism, a topic to which I will return in Chap. 3.)
What my discussion has been highlighting so far is ambiguity’s intimate
link to criticism. It is the principal argument of this study that an account
of ambiguity as an aesthetic concept is also an account of its criticism.
Indeed, seeing ambiguity as a dynamic process of reading points to a
potent way of conceiving its analysis. Particularly, it enables the recogni-
tion that our critical task is not only to probe aesthetic reasons but also to
acknowledge our uncertainty. A satisfying account of ambiguity success-
fully engages with both reason and doubt. The search for such an account
is the main concern of my close readings of film.
Reason and Doubt

These close readings are organised into two sections, which correspond to
the study’s dual concerns of reason and doubt.
Part I is named “Pursuits of Reasons”. Not only does it develop the
idea of aesthetic reason but it also addresses the procedure of our critical
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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

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Ambiguity and Film Criticism:

Reasonable Doubt Hoi Lun Law

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More information about this series at

Ambiguity and Film

ISSN 2634-6133 ISSN 2634-6141 (electronic)

Cover illustration: PictureLux / The Hollywood Archive / Alamy Stock Photo

Whenever I talk to James MacDowell, not least about ambiguity, I profit

1 Introduction: Why Is It as It Is? 1

Part I Pursuits of Reasons 23

Part II Drama of Doubt 113

7 Concluding Remarks: Reasonable Doubt175

Fig. 2.1 Late Spring (Yasujirō Ozu, 1949) 26

Introduction: Why Is It as It Is?

In spite of its wide currency in film scholarship, criticism, and everyday

What Makes Ambiguity Ambiguous?

© The Author(s), under exclusive license to Springer Nature 1

covering a variety of instances and situations. It particularly speaks to a

contradiction (the seventh type). He likens these diverse relationships

Two Senses of Ambiguity

criticism, worthy of highlighting or rediscovering, even though they may

(2009, 101). Note that by “editing”, Bazin means specifically analytical

Traditional cinema had managed to do away with any possibility of ambigu-

The remark complements Bazin’s claim about analytical editing, though

Ambiguous Image: Narrative Style in Modern European Cinema and

Whenever confronted with a problem in causation, temporality, or spatiality,

In Bordwell’s account, ambiguity seems to mean the uncertainty between

unhelpful way to construe an analytical approach to ambiguity. In particu-

Question and Answer

They need to be interpreted. In other words, the erotetic dynamic is a

useful in criticism; it may be employed to eloquently communicate the

Reason and Doubt

One of the most valuable procedures in carrying out the above

CONGENITAL MALFORMATIONS OF THE STOMACH.

FOREIGN BODIES IN THE STOMACH.

WOUNDS OF THE STOMACH, INCLUDING RUPTURE.

TUBERCULOSIS AND SYPHILIS OF THE STOMACH.

DILATATION OF THE STOMACH.

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1 Introduction: Why Is It as It Is? 1

Part I Pursuits of Reasons 23

Part II Drama of Doubt 113

7 Concluding Remarks: Reasonable Doubt175

Fig. 2.1 Late Spring (Yasujirō Ozu, 1949) 26