Beauty & Rage (Broken Crowns Book 1)

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 Copyright
Beauty & Rage by Natalie Bennett
© 2022 by Natalie Bennett. All rights reserved.
No part of this book may be reproduced in any written, electronic, recording, or
photocopying without written permission of the publisher or author. The exception would be
in the case of brief quotations embodied in the critical articles or reviews and pages where
the publisher or author specifically grant permission.
This is a work of fiction. Names, characters, businesses, places, events, and incidents
are either the products of the author’s imagination or used in a fictitious manner. Any
resemblance to actual persons living or dead, or actual events is purely coincidental.
Cover Design: Maria Spada
Editing by: Pinpoint Editing
 AUTHOR’S NOTE
If you picked this up looking for a feel-good paranormal romance, this story will not
appeal to you. However, if you have a thing for insanely possessive twisted antiheros,
questions not easily answered, mystery, violence (it gets progressively worse), and explicit
steam, then keep turning the pages!
These characters will fall deeply into hate before they come even close to love. This
may not end with a traditional HEA, but their story does wrap up exactly as it needs to.
I hope you enjoy it!
Table of Contents
Copyright
AUTHOR’S NOTE
BLURB
Playlist
Glossary
EPIGRAPH
CHAPTER ONE
CHAPTER TWO
CHAPTER THREE
CHAPTER FOUR
CHAPTER FIVE
CHAPTER SIX
CHAPTER SEVEN
CHAPTER EIGHT
CHAPTER NINE
CHAPTER TEN
CHAPTER ELEVEN
CHAPTER TWELVE
CHAPTER THIRTEEN
CHAPTER FOURTEEN
CHAPTER FIFTEEN
CHAPTER SIXTEEN
CHAPTER SEVENTEEN
CHAPTER EIGHTEEN
BROKEN CROWNS
DEMONIO
OTHER BOOKS
THE SECT
NEFARIOUS
SOCIALS
 BLURB
Crumbled castles. Napalm skies.
Ancient oaths and exiled royals.
Nowhere to run from this. No way to forget.
All the king's horses and all the king's men couldn't put her back together again....
Reyes Straykova is an abomination.
Born of death and madness, he’s only satisfied by bloodshed and destruction.
His tyrannical uprising has cloaked the sun in an impenetrable darkness. The savage and corrupt pledge loyalty to his
rule, causing more blood to spill whilst striking fear in the masses.
Duvessa Vasiel wasn’t ready to be a queen.
Her crown’s been snatched away and replaced with another—along with her freedom.
Claimed by the volatile and ruthless beast responsible for bringing the world to its knees, she becomes ensnared in a
court of hellish nightmares.
Sleeping with the enemy takes on a whole new meaning when her life is held within their treacherous hands.
As Reyes immerses her in endless obscenity and wickedness, something slumbering deep within begins to wake.
Lines are blurred and truths become questioned.
When every word and action could bring about her demise, how can she ever reclaim what was stolen?
Murder. Betrayal. Sinister schemes.
Bow to the King and watch chaos reign.
 Playlist
(SPOTIFY)
Imagine Dragons—Dream
Unions—Afraid of the Dark
BANKS—Contaminated
Breaking Benjamin—What Lies Beneath
Lana Del Rey—Change
We Came As Romans—Learning To Survive
Digital Daggers—Paper Bag Princess
The Plot In You—Feel Nothing
Evanescence—Broken Pieces Shine
Sadistik—Russian Roulette
WENS—Bones
Gin Wigamore—Hallow Fate
Mumford and Sons—Broken Crown
Halsey—Bells in Santa Fe
DeathbyRomy—Time
Sofia Karlberg—Viva La Vida
Ruelle—Slip Away
Creed—Overcome
Jill Andrews—Lost It All
Lumineers—Nightshade
 Glossary
Supe (Sue-pay) — all pureblood supernaturals.
Demi (Dim-E) — all half-breed supernaturals.
Chimera (chee-mare-a)— varying, manmade creatures containing a mixture of
genetically different tissues, formed by processes such as fusion of embryos, grafting, or
mutation.
Smilodon (smi-lo-don)— a genus of saber-toothed cats.
 EPIGRAPH
Those who make no lasting impression in life will surely be forgotten in death.
~Duvessa Vasiel~
 CHAPTER ONE
Can you imagine what it’s like to die almost every time you close your eyes?
There’s a familiar sting of doubled-edged teeth digging into tender flesh, followed by
excruciating pain. Your throat’s viciously torn open, leaving blood to run in thick rivulets over a
naked body, staining the darkened forest floor crimson.
You know this is the end, heart slowing until it ceases to beat in the arms of a faceless killer. No
one comes to your rescue. You die alone without knowing why such a cruel fate was bestowed upon
you, wondering what you did to deserve this.
I awoke as I usually did with perspiration coating my skin, fingers grasping at my neck as if I
could fix what had been shredded.
Off and on for the past six months, I’d been having this same dream. I never saw my murderer’s
face, and my brain still hadn’t caught on to the fact that it was merely a dream.
None of it was real, yet terror and a deep sense of sadness always remained in the hollows of my
chest long after I woke up.
Swiping strands of midnight hued hair from my sweaty forehead, I clumsily reached for the cup
of water I kept on my nightstand, sighing the second the cool glass touched my fingertips. I’d barely
lifted it when a bang on the other side of my door made me jump, sending it straight to the floor where
it shattered.
Another bang—more forceful—and someone yelling my name cleared away all lingering
drowsiness.
The hands of time came to a near stand-still and reality slowly began to seep in.
Something was burning.
And it was too quiet.
While not unusual for such an hour, it wasn’t the kind of quiet that came on the heels of peaceful
slumber. It was unnerving, the type of silence that sent blind panic and blood-curdling dread to the pit
of one’s stomach.
That’s what ultimately sent me stumbling from my bed, feet sliding into silk slippers, just missing
the shards of glass scattered across the wine-colored marble.
I undid the heavy lock barring me in and everyone else out and pulled the door open.
“Dove!” Toby’s wide blue eyes and worried face showed fleeting relief before a rushed, “We
need to go,” flew from his mouth and his hand shot out to grab my wrist. I was pulled into an empty
hall. Two guards should have been stationed at either end while I slept, but both were missing.
“What’s on fire?” I asked, settling into a speedy jog to match his pace.
 The further we went from my bedroom, the stronger the acidic stench in the air became.
“Everything but this castle. For now.”
“Everything?” I struggled to keep my voice level. “Where is my father?”
He stopped abruptly at the end of the hall, using a gentle hand to prevent me from slamming into
his broad back. His head turned to the left and then to the right before he looked at me with a somber
expression, unmistakable pity in his eyes.
“We no longer have a king. We have only you now, my queen.”
“What do you mean…?” I trailed off as he pulled me forward again, blinking dumbly at the back
of his curly blonde head. Realization hit me like an arrow to the chest. My stomach plummeted, heart
splitting right down the center.
I didn’t ask for further clarification or elaboration. I knew exactly what he meant.
For us to be without a king meant my father was dead. As his only child and sole heir, I was the
one meant to ascend the throne. I’d been raised, educated, and sculpted to be a queen by every means,
but it wasn’t supposed to happen like this.
I wasn’t ready.
I staved off the overwhelming urge to fall apart. I couldn’t become deadweight for Toby. As
terrible and painful as this news was, I had neither the luxury nor the time to grieve. Whatever was
going on, the situation was urgent.
“The other supes and demis?”
“Scattered or dead.”
That had me drawing up short, pulling my wrist free from his grasp. “You need to tell me what’s
going on.”
“I will tell you everything the moment you’re safe. Princess Jacinda and Princess Scarlett have
already been escorted away from the palace. The longer we stay here, the more danger you’re in.”
Away from the palace.
Those words looped through my head twice. He wanted us to flee.
I dodged his attempt to grab me again and took a step back, and, as I did, the smell of smoke and
fire intensified.
“You wish for me to run? You’re telling me to abdicate?”
A tic in his rounded jaw was the only sign of his growing frustration. His duty was to protect me,
but mine was to protect this palace and all those loyal to the Vasiel crown. Even if it was burning to a
crisp, a captain never abandoned their ship.
“If you stay, there will be nothing left for you to abdicate from. And nothing left of you, either.”
He stepped forward and offered his hand this time. “Please. The princesses will not go any further
without you, and the same fate awaits them.”
Indecision warred within me for a matter of seconds. He had me. Catching myself before I
reacted uncouthly, I nodded as if the predicament regarding my two closest friends didn’t mean more
to me than the wellbeing of my newly acquired kingdom.
I didn’t like the idea of fleeing. It went against everything I’d been taught, but I knew Toby was
right. He was also fiercely loyal and risking his life to save mine.
“Then let’s go.” I took his hand, allowing him to lead me once more.
Wordlessly, he set off at a rapid pace.
“How are we able to move so freely?”
“The very reason the palace is near empty. Your father’s last order was to protect you by all and
any means necessary. Your subjects took it upon themselves to serve as a… distraction. The ones that
haven’t fled, that is.”
Fled where? I wanted to ask, but I knew my energy needed to be solely focused on escaping. My
silken slippers fell into rhythm with Toby’s boots. We took three sharp turns before coming to the hall
in the very back of the palace. An ornate side table was affixed to the rear wall; moving it revealed a
small indention that served as a mechanism to open a secret door.
Father had planned for it to be used in a situation such as this one, although he’d never wanted
that plan to come to fruition.
Toby led me through the passage with ease, ensuring the door closed behind us so no one could
follow.
We rapidly navigated the narrow passage set between moss-covered walls, lit by flickering
candles.
When we finally emerged, it was directly into the woodland a little way behind the palace. The
moment we stepped outside, I sensed an immeasurable amount of death. It crawled over my skin and
poured into my lungs. The stench of burning bodies clung to the air, along with the sound of my
subjects losing a battle.
Again, I was troubled with my decision.
Leaving like this felt wrong, regardless of my station, but I would do them no good dead, and,
though I could fight well enough, I knew I was no match for whomever was behind this all by my
lonesome.
I stepped deeper into the trees with no idea where I was going, staggering as the weight of what
was now lost truly began to sink in.
One final glance back and my splintered heart shattered into pieces. We may have been escaping,
but it was not unscathed.
My life as I knew it was over.
My home.
My family.
It was all gone.
 CHAPTER TWO
Not all crowns come with wealth and power. Not all fiefs were made up of generous land,
boasting prestige.
That wasn’t the case for the kingdom of Vita.
My father could be called nothing less than a great ruler. His devout dedication to his kingdom
and the subjects that dwelled within it was evident even to those who wished to see his head mounted
on a pike. A man so great his enemies marveled at his excellency.
It left the maddening question of who would do this, and for what purpose. If someone were after
his position or the fief, they wouldn’t have brought down the castle and turned a utopia into this
dystopian hell. I would never have made it out intact, for as long as I lived, the Vita was mine by right
and by blood.
A kingdom of anguish and suffering. That’s what I had inherited.

With a sigh, I poked at the fire one last time and slowly rose, keeping a tight hold on the worn
fleece throw I’d wrapped around my shoulders. This was the sixth dwelling we’d moved to in a span
of two months.
Staying in one place for long periods of time was not a feasible option, and while this was not as
bad as some of the other places we’d sheltered, it gave the impression that it would crumble and
crush us if the wind blew hard enough. I didn’t dare complain. Not when so many lay rotting on once
pristine cobblestone roads now dull from old blood, those who once knew them picking flesh from
their maggot-infested bodies in a desperate attempt to prolong starvation.
I turned towards the warped piece of wood that served as a front door, watching Toby and Victor
enter, a dark, flurried sky overcast behind them.
They brought in nothing but chilled air and tangible anger.
Their sour moods could have been caused by a sleuth of things, but I knew the bold red flyer
crushed in Toby’s right hand had a lot to do with it.
“Is that old or new?”
“Who knows? There’s even more today. So many I can’t remember all the places I’ve already
torn them down from!”
“Quiet,” I hushed him gently, casting a glance to where Jacinda and Scarlett were sleeping.
“Give it to me.”
I held out my hand, and he begrudgingly passed me the flyer. I carried it to the rickety table in the
far corner and smoothed it out. I’d seen many of these since the night everything went up in flames. It
Another random document with
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Fig. 628
 General scheme of cholecystectomy; detachment of gall-bladder and duct from
their investments; ligation of cystic duct and arteries. (After Kehr.)

Cholecystendysis.—The term cholecystendysis, now almost

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

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

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

These various cutting operations have superseded the previous

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

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

jejunum. (Cordier.)

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

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

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

INJURIES TO THE OMENTUM.

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

TORSION OF THE GREAT OMENTUM.

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

TUMORS OF THE OMENTUM.

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

OMENTOPEXY; OMENTOSPLENOPEXY; TALMA’S OR

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

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

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

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

INJURIES OF THE MESENTERY.

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

THROMBOSIS AND EMBOLISM IN THE MESENTERIC VESSELS.

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

ABSCESS OF THE MESENTERY.

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

TUBERCULOSIS OF THE MESENTERY.

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

CANCER OF THE MESENTERY.

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

CYSTS OF THE MESENTERY.

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