Speaking English as a Second

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Speaking English as
a Second Language
Learners‘ Problems
and Coping Strategies
Edited by
Alireza Jamshidnejad
Speaking English as a Second Language
 Alireza Jamshidnejad
Editor

Speaking English
as a Second
Language
Learners’ Problems and Coping
Strategies
Editor
Alireza Jamshidnejad
Department of English Language
College of Education
University of Technology and Applied Sciences
Rustaq, Oman

ISBN 978-3-030-55056-1 ISBN 978-3-030-55057-8 (eBook)

https://doi.org/10.1007/978-3-030-55057-8

© The Editor(s) (if applicable) and The Author(s) 2020

This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specifically the rights of translation, reprinting,
reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical
way, and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are exempt
from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this
book are believed to be true and accurate at the date of publication. Neither the publisher nor the
authors or the editors give a warranty, expressed or implied, with respect to the material contained
herein or for any errors or omissions that may have been made. The publisher remains neutral with
regard to jurisdictional claims in published maps and institutional affiliations.

This Palgrave Macmillan imprint is published by the registered company Springer Nature Switzerland
AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
 Contents

1 Introduction: Challenges of L2 Oral Communication

in EFL Contexts 1
Alireza Jamshidnejad

Part I Approaches to the Nature of L2 Oral

Communication

2 L2 Communication as a Social Action: Silence

in Oral Communication 33
Yamin Qian

3 Pragmatic Nature of L2 Communication: Spoken

Grammar in Native and EFL Speakers 51
Yen-Liang Lin

4 An Ecological Perspective on EFL Learners’ Oral

Communication 75
Ruiying Niu

v
vi Contents

5 Cultural Challenges for L2 Communication Among

Persian Migrants in Australia 103
Hossein Shokouhi

6 Approaches to Research on L2 Oral Communication 129

Alireza Jamshidnejad, Reza Falahati, and Etske Ooijevaar

Part II The Nature and Typology of Learners’ Problems

in L2 Oral Communication

7 The Construction of Problems in L2 Oral

Communication 165
Alireza Jamshidnejad

8 The Construction of Problems in L2 Oral

Communication 195
Alireza Jamshidnejad

Part III Communication Strategies and Their Functions

in L2 Oral Communication

9 The Nature and Functions of Communication

Strategies in L2 Oral Communication 229
Alireza Jamshidnejad

10 Language-Oriented Functions of Strategies 253

Alireza Jamshidnejad

11 Context Oriented Functions of Strategies 287

Alireza Jamshidnejad
 Contents vii

12 Communicators-Oriented Functions of Strategies 313

Alireza Jamshidnejad

13 Conclusion and Implications for Future Research 329

Alireza Jamshidnejad

Index 339
 Notes on Contributors

Reza Falahati is a lecturer of academic and professional English at

Leiden University and Amsterdam University of Applied Sciences. He
has taught a wide range of English, and (Applied) Linguistics courses in
different universities located in Canada, Iran, and The Netherlands. His
research interests are mainly L2 speech acquisition, academic writing, and
discourse analysis. He is currently interested in the application of ultra-
sound in teaching pronunciation. His research is published by Routledge
and in journals such as ESP across Cultures and Journal of the Cana-
dian Acoustical Association. His master’s thesis from the University of
Victoria received the 2005–2006 ISG/SUTA Outstanding Thesis Award
by MIT & Sharif University. He holds an M.A. in education (University
of Tehran), an M.A. in (applied) linguistics (University of Victoria), and
a Ph.D. in linguistics (University of Ottawa). He also has the experience
of working as a postdoctoral research fellow in Italy, SNS, for two years.
Dr. Alireza Jamshidnejad is an associate professor of English language
studies at the University of Technology and Applied Sciences in Oman,
and has over twenty years of experience teaching and researching TEFL
and Applied Linguistics. He obtained his first Ph.D. in Education, but
shifted his research interest to EFL oral communication and foreign

ix
x Notes on Contributors

language teaching in his second Ph.D. from the UK. Most of his recent
publications focus on language learners’ interaction in EFL contexts, and
his unique approach to functions of communication strategies is very well
known. After years of teaching, researching and publishing papers in the
field of oral communication in EFL contexts, he has innovated a research-
based model to understand the nature of and classify the problems and
strategies of L2 oral communication.
Yen-Liang Lin is currently an Associate Professor in the Department of
English, also serving as the Director of Media and Language Teaching
Center, at National Taipei University of Technology, Taiwan. He received
his Ph.D. in Applied Linguistics in 2013 from the University of
Nottingham, UK. He has taught EFL at secondary and university levels
for 15 years. His research interests include corpus linguistics, discourse
analysis, speech and gesture, and language teaching research.
Ruiying Niu is professor of English at Guangdong University of
Foreign Studies, China. Her research interests include Sociocultural
Theory, language production, interaction, writing feedback, and second
language acquisition.
Etske Ooijevaar is a Ph.D. candidate in Linguistics at Meertens Insti-
tuut in The Netherlands. She is writing her dissertation about the
acoustics and articulation (with Ultrasound Tongue Imaging) of liquids
in Dutch dialects. Her research interests are phonetics, phonology,
and language variation and change. She has worked as a statisti-
cian/methodologist at Meertens Instituut. She holds an M.A. in Linguis-
tics and a B.A. in French Language and Culture, both from the Univer-
sity of Amsterdam in The Netherlands.
Dr. Yamin Qian is currently an Associate Professor at School of English
Education, Guangdong University of Foreign Studies in China. She has
been an English as a Foreign Language (EFL) teacher in Higher Educa-
tion for more than 20 years. Her major fields of interests include, not
limited to, Sociology of Education, second language education, and
Sociolinguistics.
 Notes on Contributors xi

Dr. Hossein Shokouhi currently a Senior Lecture at Deakin Univer-

sity, Australia, has co-authored two books, has published in various jour-
nals including Lingua, Discourse Studies, Australian Journal of Linguis-
tics, book chapters with John Benjamins, Routledge, and Springer, has
taken 7 Ph.D. students to completion, and has been external exam-
iner for a number of Ph.D. theses. He has taught various subjects of
Linguistics, Applied Linguistics, and TESOL in Australia and overseas,
and has been a visiting scholar at Potsdam University, Germany, Deusto
University, Spain, as well as La Trobe University, Australia, where he
received his Ph.D. He has been a keynote speaker at several International
Conferences. His current research is on language, culture, and critical
thinking.
 List of Figures

Chapter 1
Fig. 1 Ogden and Richards’ triangle of meaning 7
Fig. 2 A systematic approach to oral communication 9

Chapter 4
Fig. 1 Hierarchical connection of the four layers of the ecosystem 94

Chapter 7
Fig. 1 The initial position of participants’ characteristics and their
performances in the investigation on L2 communication
(Arrows show  A is investigated to inform B ) 169
Fig. 2 The revised version of the interaction between investigated
areas in L2 communication research 169

Chapter 8
Fig. 1 Context-oriented problems in L2 oral communication 214

xiii
xiv List of Figures

Fig. 2 The sources of problems in L2 oral communication 215

Fig. 3 The process of problem construction in L2 oral
communication in EFL contexts 219
 List of Tables

Chapter 3
Table 1 Elements of ellipsis in BATTICC 60
Table 2 Number of vague expressions 61
Table 3 Number of headers and tails 64
Table 4 Number of unfilled and filled pausing 67

Chapter 4
Table 1 Factors affecting participants’ oral language learning 84

Chapter 9
Table 1 The general description of strategies introduced in
Dörnyei and Scott’s inventory (1997) 240
Table 2 The functions and priority use of CSs by EFL learners 245

Chapter 13
Table 1 Learners’ problems and their corresponding strategies in
L2 communication 334

xv
 1
Introduction: Challenges of L2 Oral
Communication in EFL Contexts
Alireza Jamshidnejad

1 Introduction
Becoming a fluent speaker of a new language is the main dream
that motivates a large percentage of learners to take language courses.
Still, many language learners perceive communicating skills such as
speaking the most challenging skills to master (Khan & Pinyana,
2004; Lafford, 2004; Pinter, 2006; Somsai & Intaraprasert, 2011).
This even becomes worse since oral skills are usually employed as the
first criterion for assessing the effectiveness of second/foreign language
education programmes. Students in second/foreign language education
programmes are considered successful if they can communicate effec-
tively in that language (Richards & Rodgers, 2014; Riggenbach &
Lazaraton, 1991).

A. Jamshidnejad (B)
Department of English Language, College of Education,
University of Technology and Applied Sciences, Rustaq, Oman
e-mail: alirezanejad.rus@cas.edu.om

© The Author(s) 2020 1

A. Jamshidnejad (ed.), Speaking English as a Second Language,
https://doi.org/10.1007/978-3-030-55057-8_1
2 A. Jamshidnejad

Indeed, communicating in a language other than ones’ mother tongue

can constitute a real challenge for most language learners. Mastering oral
skills in a new language, particularly in an environment where there is
not enough input of the target language (L2), would take probably a
decade or so (Khan, 2010; Kongsom, 2009; Teng, 2012). Even after
years of developing their semantic and syntactic competences, language
learners often become frustrated and reluctant to participate effectively
in L2 oral communication. They frequently complain about the lack
of opportunities and resources that would enable them to learn how
to communicate their message or intended meaning. Even advanced
language learners can suffer from a lack of sufficient preparation to
communicate beyond the classroom. Consequently, they prefer to keep
silent whenever they are not sure whether they can manage the commu-
nication successfully. Others may decide to moderate or replace what
they ‘want to say’ with what they ‘can say’ (Ervin, 1979, p. 359).
As speaking is essentially a communicative act, study the nature
of L2 oral communication is very crucial in understanding the causes
of the problems mentioned above. Communication in a target language
is a highly complex, demanding and multi-faceted skill that involves
different competencies and mechanisms (Bygate, 2001; Kormos, 2006;
Levelt, Roelofs, & Meyer, 2000). It is also a skill that cannot be
transferred automatically from the speaker’s first language into their
second (Thornbury, 2007). Moreover, speaking is an activity generally
performed in real-time but learned in the classroom where there are
insufficient opportunities for practising command of English skills for
real-world communication (for example see Choomthong, 2014; Karn-
nawakul, 2004; Kimsuvan, 2004). There are also different factors influ-
encing the learners’ spoken performance in a communicative event, from
individual (i.e. age, gender, L2 proficiency level, personality) to psycho-
logical (i.e. anxiety, confidence, motivation, stress, fears of mistakes) and
social factors (i.e. face-threatening, the power relationship between inter-
locutors, educational context, task types) (see Chapter 12). This poses
considerable pressure on L2 communicators and forces them to spend a
great deal of time and effort struggling to construct tangible utterances
for transferring their message in L2 oral interactions. Not being able to
compensate for their L2 deficiencies, language learners may give up, keep
 1 Introduction: Challenges of L2 Oral … 3

silent, speak with numerous pauses or trembling voices or even switch

to their first language (L1) in their L2 oral interactions. Unwillingness
to communicate, lack of confidence, anxiety, apprehension, nervousness
and stress are feelings commonly reported by EFL language learners in
L2 oral communication (Jackson, 2002; Tanveer, 2007; Tuan & Mai,
2015).
However, some successful L2 speakers, despite their limited knowl-
edge of the target language, can communicate effectively in a foreign
language. They rely entirely on their available resources to communi-
cate within restrictions by using coping strategies. The effective use of
a target language to construct L2 communication in situations where
there is communicative deficiency involves the effective use of commu-
nication strategies (hereafter CSs). This makes it urgent to explore oral
communication as an independent skill to understand better the nature
and causes of the difficulties participants face in their L2 speaking
and the functions of strategies to cope with them. Due to the multi-
facet nature of L2 speaking, scholars from different branches of applied
Linguistics are required to be involved in studying the problem construc-
tion in L2 oral communication. The following fields have significant
contributions on what we know today about speaking (Khan, 2010):
SLA (second language acquisition), first language acquisition, cogni-
tive psychology (Khan, 2010), speech processing (Dell, 1986; Levelt,
1989, 1999), interaction (Gass, 2002; Long, 1985; Pica & Doughty,
1988; Swain, 1985), discourse analysis (Kasper, 1985; Tarone, 1981),
language learner strategies (LLS) (Cohen, Weaver, & Li, 1996; Nakatani,
2006; O’Malley, Chamot, Stewner-Manzanares, Kupper, & Russo, 1985;
Oxford, 1990), communication strategies (CS) (Dörnyei & Scott, 1997;
Færch & Kasper, 1983; Poulisse, 1990; Tarone, 1981), task-based
research (Bygate, Skehan, & Swain, 2001; García Mayo, 2007; Gilabert,
2004, 2007; Robinson, 1995) and oral proficiency testing (Lumley &
O’Sullivan, 2006; O’Sullivan, 2000; Purpura, 1999; Swain, Huang,
Barkaoui, Brooks, & Lapkin, 2009).
Although L2 oral communication has been attractive to a big group
of senior and junior researchers around the world, to my knowledge,
there is no published book focusing primarily on nature and construc-
tion process of problems in EFL oral communication. The main goal
of this book is to bring together several lines of isolated research and
4 A. Jamshidnejad

provide a comprehensive overview of the various kinds of problems in

oral communication, the ways they are constructed, and the strategies
which can be used to deal with these problems in EFL (English as a
foreign language) contexts. By the EFL context, we mean those contexts
in which learners’ learn English in a situation/locality where it is not
spoken/used in the community. A foreign language is mainly learned to
be used in another country and usually has no communicative function
outside the classes. Both L2 ‘oral communication’ and ‘speaking’ refer to
learners’ ability to communicate in English fluently and effectively.
The main framework of this book has been taken from the chief
editor’s qualitative studies on oral communication in EFL contexts
(Jamshidnejad, 2010). Using these studies, interpersonal communica-
tion theories and models, this book then offers a systematic framework
to achieve a coherent process-oriented description and a deeper under-
standing of the complex and multidimensional nature of EFL oral
interaction problems and then classifies them into different categories.
This book not only stimulates learners’ problem construction process in
EFL interactional discourse but also contains a practical typology and
strategies which will be invaluable to both new and advanced language
users.

2 The Nature of Communication

Communication is the main concept in the term ‘L2 oral commu-
nication’. Communication, as a concept, originally comes from the
Latin word ‘communicare’ meaning ‘to share’ or ‘establish common-
ness’. Although there is not a single, universally accepted definition of
communication used by scholars (Trenholm and Jensen [2004] referred
to Dance and Larson [1972] who found 126 definitions of communica-
tion), ‘sharing’ a ‘message’ between two individuals or more is a ‘common
part’ of all kinds of human communication. Social scientists use the term
‘dyadic communication’ to describe the interaction between two people
(dyad) and interpersonal communication for interaction between two
or more individuals. Small group communication, public communica-
tion and mass communication are other kinds of human communication
 1 Introduction: Challenges of L2 Oral … 5

(Adler & Rodman, 2006, p. 6). By living in a society, people have spent
a major part of their waking hours in some form of communication,
whether they want to or not.
Beck et al. (2004) and Adler and Rodman’s (2006) define communi-
cation as:

a social systematic process of creating symbolic meaning and responding

between communicators.

The ‘social ’ characteristic covers the interaction among ‘communica-

tors’ as human beings. Because of the social nature of communication,
scholars believe ‘we cannot not communicate’ (Watzlawick, Beavin, &
Jackson, 1967; Rosengren, 2000, p. 38). ‘Systematic ’ introduces the
multidimensional nature of communication involving different interre-
lated subsystems. In the above definition, ‘communicators’, ‘symbolic
meaning’ and ‘context’ can be introduced as the main subsystems of
communication. Each communicator, as one of the main subsystems,
needs ‘input ’ (past and present stimuli that give the communicator
his/her information about the world) to participate in the process of
communication (Tubbs & Moss, 1994, p. 8). According to Adler and
Rodman (2006) communicators’ personal and social background, their
perceptions of ‘self ’ and ‘others’ and their verbal and non-verbal language
skills are some of the inputs influencing the process of communica-
tion. Communicators’ perception and image of themselves is called
‘self-concept’, containing an important element; ‘self-esteem’ [‘our evalu-
ation of self-worth’ (ibid.: 48)]. The ‘self-concept’ is shaped by significant
others’ evaluation of our ‘personality’ as well as by cultural factors (i.e.
stereotyping) (Adler & Rodman, 2006, p. 69). Thus, feedback and
the level of self-esteem have a direct relationship: positive feedback
enhances your performance and improves your self-confidence, and
negative feedback can cause a break- down in conversation (Tubbs &
Moss, 1994).
‘Perception of others’, as another input, is shaped by communica-
tors’ past experiences and expectations about communication, their social
roles, and relationship, their knowledge of the interlocutor, the degree of
involvement with others in communication and cultural factors (Adler &
6 A. Jamshidnejad

Rodman, 2006). Self-concept, self-esteem and the perception of others

in communication are the factors to which I think previous studies have
paid little or no attention. This book intends to consider them and to
discuss to what extent learners’ oral problem and their use of coping
strategies might be influenced by the communicator’s perception of self
and others (see Chapters 7 and 12).
Language skills in both verbal and non-verbal forms can also influ-
ence the communication process. Language is a collection of symbols
managed by a set of rules (both linguistic and social rules) and is used
to convey meaning between people (Adler & Rodman, 2006). Skills
are goal-oriented activities or a series of actions that can be learned.
Language skill, defined as knowledge and the ability to use this knowl-
edge in communicative situations, has been the focus of most language
studies, and they have highlighted the lack of language skills as the main
source of problems in L2 communication.
‘The process of creating symbolic meaning and responding ’ is another
main subsystem of communication, consisting of three themes: symbols,
meaning and the process of creating and responding (Wood, 2004;
Verderber & Verderber, 2003). ‘Process’ defines communication as
ongoing, continuous, always in movement and motion and continuously
changing; ‘creating and responding ’ involves creating a relationship by
simultaneously sending, decoding and receiving messages, intentionally
and unintentionally; ‘Symbolic ’ refers to symbols or signs as abstrac-
tions, arbitrary and ambiguous representations of things, process, ideas or
events and ‘meaning ’ in Verderber & Verderber’s (2003) words, consists
of ideas and feelings which communicators use as symbols to create
meaning. Symbols are words, sounds and actions communicators use to
present their meanings. Symbols are ‘arbitrary constructions that repre-
sent a communicator’s thoughts’ (Adler & Rodman, 2006). Due to their
‘abstract’ and ‘arbitrary’ nature, symbols are not concrete and tangible
phenomena and do not have an intrinsic, natural relation to things to
which they refer. Thus, the meaning of symbols depends on how people
use them in the process of interaction. Adler and Rodman (2006) also
described meanings as ‘social constructions’ and explained them by using
Ogden and Richard’s ‘triangle of meaning’ (Fig. 1). The assumption of
meaning as a social construction can shed light on the analysis of the
 1 Introduction: Challenges of L2 Oral … 7

User

Thing Words
(Referent) (Symbols)

Fig. 1 Ogden and Richards’ triangle of meaning

nature and function of one of the main sources of misunderstanding and

problematic communication.
Figure 1 presents L1 communication as having a triangular rela-
tionship between symbols, things (an indirect relationship) and the
user. So, people’s interpretation of symbols, and not symbols (words),
creates meaning in the interaction. As a complete understanding requires
complete agreement on the meaning of symbols among different users, it
is not unusual if we experience misunderstanding in communication. For
L2 communication, in which people are using L2 symbols with different
perceptions, the problems are more serious.
Context is the third concept in the definition of communication. In
the transactional model, instead of a static environment, communica-
tors are surrounded with a fluid context which is created and changes
from moment-to-moment depending on contextual variables. Verderber
& Verderber (2003) classified communication context into the following
settings: physical, social, historical, psychological and cultural. With
this classification, language researchers are afforded a more compre-
hensive perspective providing five different aspects of the context in
communication which potentially could be used in their investigation.
Similarly, Thompson (2003) summarised the following variables as
major parts of context in interpersonal communication:
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they nor vessels be cut across transversely. There is also need for
complete drainage, and several tubes may be used for this purpose,
being passed completely across or beneath the breast.
Chronic Mastitis.—Chronic mastitis may be the termination of a
partially resolved acute process, or of injury, or
of apparently unknown causes, being in these instances of
apparently spontaneous origin. Pathologically it comprises
induration, with more or less infiltration of the interacinous and
interlobular tissue, and with some infiltration of the other structures of
the breast, by which fixation, retraction of the nipple, or condensation
of the surrounding structures and adhesion of the overlying skin are
produced. The result may be to produce either an enlargement or
diminution in size of the breast. One or both glands may be involved.
It is a disease usually of late adult life.
Breasts thus affected are often tender and painful, especially
during menstruation, and upon palpation are found to be irregular in
shape, more or less nodulated, extremely firm in some cases and
places, and perhaps so infiltrated as to strongly simulate cancer. The
changes which are thus produced are slow, and it is important to
note that the lymphatics are usually not enlarged, and that after
attaining a certain degree the diseased condition becomes
stationary. The general health usually does not suffer beyond a
certain point; at least even in the more chronic cases there is no
characteristic cachexia. While the condition is more frequent in
women who have nursed it may be met in those who have never
borne children nor have been married.
Suitable examination of all these cases can only be made with the
upper portion of the patient stripped, the body in the horizontal
position, and both breasts compared and examined, first with the flat
hand in order that differences of shape, size, mobility, and fixation
may be determined. Subsequently the patient should be raised to the
sitting position, the surgeon standing behind to examine each breast
with one hand and simultaneously, in order that differences may be
more accurately noted. Any tumor present will be more easily
discovered with the flat hand than with the finger-tip, while chronic
induration will not give the sensation given by neoplasms. The axillæ
should also be carefully examined, as well as the supraclavicular
regions, for evidences of lymphatic involvement. When the entire
breast is involved diagnosis is less difficult than when one or more
lobules alone are concerned. These constitute the painful nodular
conditions to which so many names have been given by different
writers.
Significant features in their differentiation from cancer are the
disproportionate pain and tenderness, their diffuse leathery
hardness, and the fact that both breasts are usually similarly
involved, though perhaps not to the same extent. Cancer is, on the
other hand, somewhat dense and confined to one breast, and
affords a sensation of infiltration of the surrounding tissues, with the
peculiar “saddle-skin” retraction or adhesion of the overhang skin
and nipple. Moreover, the growth is more rapid and localized, and
the lymphatics are involved in nearly every instance. Some of these
cases are so obscure that diagnosis previous to operation is
impossible, while innocent lesions may gradually merge into
malignant, and no one can say when the transition begins or has
begun.
Treatment.—The milder forms of chronic mastitis gradually improve
under the influence of local applications such as the ichthyol-
mercurial ointment, to which menthol may be added for its soothing
effect. Pendulous or painful breasts should be supported as much as
possible. Otherwise these cases are best let alone—i. e., they
should not be rubbed or massaged. There is usually a constitutional
condition which is closely related, and in nearly every instance there
is more or less failure of elimination. These features should be
studied and treated as they are identified. Finally there are some
intractable forms of innocently indurated breast which give so much
trouble that it is best to remove them as though they were
cancerous.

NEURALGIA OF THE BREAST; MASTODYNIA.

Many women suffer from annoying and painful affections of the
breast for which no sufficient excuse is found, while others who have
small fibrous nodules or innocent lobular tumors will suffer an
amount of pain which is disproportionate, and in instances of either
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case and to say that it must be, at least to a certain extent, neurotic.
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neurotic women, often of the more impressionable type, it is
generally proper to consider them as to some extent hysterical, while
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account for neuralgic breasts, because of the well-known intimate
relations between the pelvic organs and these glands. In some
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innocent character. In other cases there are hypersensitive areas of
entire breasts, to a degree where the patient cannot stand the
slightest handling. These cases are hyperesthetic, even if not
hysterical, and some are unsatisfactory to treat. The pains are more
or less periodical, and often radiate down the arm or the side of the
thorax; this may be explained through the intercostohumeral and
other nerve connections.
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constitutional, local, and moral measures, but of these
the local are the least important. The excision of painful nodules is
often disappointing, the remaining scars becoming even more
sensitive than the original lesions. Women who under these
circumstances have insisted upon the removal of an entire breast
have still suffered from intercostal neuralgia or other remaining
painful conditions, so that their ultimate condition has not been much
improved. Each case should be studied upon its merits, and while
one may be benefited by some pelvic operation, or another by
Turkish baths and improvement of elimination, others are best let
alone, or given a minimum of drugs with a maximum of general and
sexual hygiene.

TUBERCULOSIS OF THE BREAST.

I cannot agree with writers like Fowler, who claim that tuberculosis
of the mammary gland is extremely rare. I think it not infrequent. In
the breast may be noted the presence of lesions, either separate or
coalescing, and gummas as such, or breaking down into caseous
masses or into cold abscesses. In connection with the local lesions
there may be more or less involvement, even to ulceration, of the
overlying skin, with the formation of lupoid ulcers, while the axillary
lymphatics will be nearly always involved. In some instances the
disease may have gone on to suppuration and burrowing of pus, with
its discharge, and the existence of tuberculous sinuses; or in others
may be seen results of a secondary infection of the remains of
multiple mammary abscess. The condition is most often met with in
the young and fair, but may be seen in elderly women. Around the
distinctly tuberculous lesions there may be considerable tissue
sclerosis. The actual proportion of cases is about one of this
condition to fifty of cancer. Lesions are more frequent in the outer
quadrant of the breast than the inner, and they occasionally produce
retraction of the nipple or adhesion of the skin, above described,
before its distinct involvement.
In any of these circumstances secondary purulent infection may
occur, and an acute phlegmonous process may seriously complicate
the previous chronic condition.
Treatment.—There is but one satisfactory method of dealing with
tuberculous disease of the breast—i. e., its extirpation.
The entire breast, or so much of it as may be distinctly involved,
should be extirpated as though it were cancerous, while the axilla
should be opened and its contents cleared out, if it appear in the
slightest degree involved. Moreover, every other tuberculous lesion
in the neighborhood should be eradicated, either with the knife, the
scissors, or the sharp spoon. After such radical treatment results are
usually satisfactory.

ACTINOMYCOSIS; SYPHILIS OF THE BREAST.

Actinomycosis is not common in this location; nevertheless tissue
conditions are such that it would furnish accessible and
diagnosticable features which would be distinctive, at least until
some secondary infection had occurred.
Syphilis appears in this location in many of its protean
manifestations. Chancres about the nipples and on the surface of the
breast are not uncommon, the disease being often conveyed from
syphilitic infants through cracked nipples, while many other methods
of contamination have been reported. Near the nipple the chancre
may not have those characteristics which usually distinguish it upon
the genitals, but may appear rather as an indurated, intractable ulcer,
with firm base, accompanied by distinct involvement of the axillary
and supraclavicular nodes, and unless early recognized and
promptly treated as such will so endure until the occurrence of the
first significant secondary eruption, whose appearance should dispel
doubt and lead to radical treatment.
There is difficulty, sometimes, in distinguishing between
tuberculous and syphilitic skin lesions upon the breast, especially
near the nipple. When other methods fail the therapeutic test will
nearly always clear up the difficulty. All truly syphilitic lesions here, as
well as elsewhere, yield promptly to well-directed treatment.

TUMORS OF THE BREAST.

The mammary gland is a frequent site for tumors, although
neoplasms of embryonic origin are not as frequent here as might
perhaps be expected. Nearly one-fifth of all tumors occurring in the
body will be found in this location, while the larger proportion of
breast tumors are malignant.
Cysts abound in this locality, occurring in one or both breasts, and
singly or in exceedingly multiple form, the latter being small and
containing but a few drops of fluid. Their cystic contents are colorless
and of a serous consistency, sometimes thick and mucous,
occasionally discolored, and in rare instances almost like unchanged
milk. In the latter case the condition is known as galactocele.
In an organ so thoroughly provided with ducts it is easy to
understand how retention cysts may readily occur from plugging of
some duct and the accumulation of secretion behind it. Should it
occur at a time when milk is forming galactocele may be readily
explained. At other times it is in every respect an abnormal
development. This occlusion of the ducts may be the result of
disease or of injury, and is not always complete, for it often happens
that from a distended duct more or less accumulated material may
be expressed by gentle pressure. In this case it will be found thick
and loaded with the epithelial cells which line the passages. These
retention cysts are spoken of as serous, mucous, or sanguinolent
(blood cysts), according to their contents, while the lacteal contain
material more or less resembling butter. True galactocele seems to
be rare. While the original contents are milky it is claimed that
through changes taking place in the neighborhood induration and
proliferation in the surrounding membrane may result, or that
mammary tissue may soften and break down into pulpy detritus.
Cystic tumors in the breast may be of innocent character, or may
assume all degrees of malignancy. A cyst whose lining membrane is
smooth, without reduplications or irregularities, may be regarded as
innocent, while the complete extirpation of its walls will be all that is
required. This may be made more complete after injecting it and
staining it with methyl blue, or filling it with melted paraffin in order to
occupy the place of the fluid, which should have been drawn off. On
the other hand, every cyst whose interior is roughened, or presents
the slightest papillomatous appearance, or which is unduly adherent,
or has about it any mark of infiltration, calls not only for its own
eradication, but for practically the complete removal of the breast.
The signs of cystic tumor in the breast are essentially those of any
other neoplasm, except that it is frequently possible to recognize its
cystic character by fluctuation. A cyst ordinarily presents as a distinct
tumor, and when innocent is circumscribed and non-adherent,
lacking the clinical evidences of malignancy. Pain is an uncertain
feature. Most cysts develop slowly, but a cyst developing suddenly
after parturition or during lactation, without previous local
inflammatory changes, is probably a galactocele. The small multiple
form of cyst, with which one or both breasts may be studded, is
frequently confused with chronic mastitis, from which it is difficult to
separate it. The escape of sebaceous material or of milky fluid from
the nipple, or the possibility of making it appear by gentle pressure,
will probably afford the best indication. If along with this possibility
the nipple be found ulcerated, or if the extruded fluid be bloody,
complete extirpation of the breast would be the only suitable
measure.
Treatment.—The general treatment of cyst has been indicated. It
is a question simply of how extensively the eradication
should be made. The advice of the older text-books is misleading,
and it is the studies of very recent years which have shown how
early the lining membrane of apparently innocent cysts may undergo
malignant changes, by which the breast is soon compromised and
which necessitate its entire removal.[52]
[52] It will be a safe rule to follow if it be assumed that every cyst whose
contents are bloody, unless this can be traced to recent accident, and
especially every cyst whose interior is papillomatous, is on the border-land
of malignancy, if not malignant in character. All such tumors then should be
extirpated. If they occur in the breast a complete operation, as for cancer,
should be done.

Of the benign tumors lipomas in the substance of the gland are

rare, while they may frequently develop in its fatty surroundings.
Adenoma and fibroma, with their various combinations, are the most
common of the innocent tumors, and they constitute single or
multiple nodules, located in the substance of the gland, or in evident
communication with it, constituting masses of well-marked density,
slow growth, nearly always mobile and non-adherent to the skin,
causing neither retraction of the nipple nor lymphatic involvement,
and being frequently accompanied by a very disproportionate
amount of pain and tenderness, some of them being, in fact,
exquisitely sensitive. While these growths are rare previous to
puberty they are frequently met in girls and young women, and,
occurring in these neurotic subjects, they cause considerable mental
as well as physical trouble. In these patients there may be found
coincident pelvic disorder. The removal of these sensitive masses,
which seems to be plainly indicated, is often disappointing, as the
remaining scar may retain the original hypersensitiveness, and
patients often suffer as much as before the operation.
The enlargement of the breast, which normally prepares it for
lactation, is to be regarded as the development of a normal or
physiological adenoma. Anything which simulates this under other
conditions is abnormal, and any overdevelopment of true mammary
gland tissue, when localized and circumscribed, should be referred
to as adenoma. In such tumors cystic changes often occur, as well a
later transformation into adenocarcinoma, something always to be
dreaded. These changes are more likely to take place during
lactation, at which time the blood supply to the breast is more free.
The development, then, of an adenoma in the breast of a nursing
woman should be regarded with suspicion, and unless benign it
should be regarded as demanding removal of the entire organ.
These tumors also are non-adherent and lack the ordinary signs of
malignancy.
Cancer of the Breast.—Cancer occurs in the breast more often
than anywhere else, and carcinoma
constitutes about 85 per cent. of these malignant tumors, the
balance being mostly sarcomas, the remaining small number being
made up of endotheliomas and the other rare forms. The most
common type of carcinoma is the so-called scirrhus, in which there is
a large amount of dense stroma, and which forms a strong contrast
with the rare forms of rapidly growing, true soft cancer—i. e., the
encephaloid or medullary as they used to be called—in which the
cancer cells proliferate with greater rapidity and in which there is a
small amount of stroma, so that in consequence the tumor itself is
soft or almost gelatinous.
Sarcoma of the breast may assume either of its well-known types,
and is a tumor seen in the earlier rather than in the later years of life.
It sometimes grows rapidly and attains large size, seeming to
approach the surface more rapidly and readily than ordinary forms of
carcinoma. In consequence it may be mistaken for abscess. As a
rule, however, the skin is not so likely to be adherent to the tumor as
in carcinoma, and the lymph nodes are not so early involved, while in
a cut section of the tumor the fat is not so disposed as in carcinoma,
where it may be seen in layers, while in the former case it has been
transformed into malignant tissue.
The two principal forms of carcinoma are the acinous and the
tubular, in the former the cells being packed into the alveoli and
surrounded with a firm and adventitious stroma, while in the latter the
primary development seems to be within the milk ducts, which being
first involved cause a more multiple minute invasion and a less
distended tumor formation.
The general indications of cancer in the breast are as follows:
The presence of tumor, sometimes of regular and definite outline,
sometimes diffuse and not easily outlined.
 Fixation of this tumor in the surrounding tissues in such a way that
it cannot be moved without disturbing them.
Fixation of the general area, either to the skin above or to the
pectoral fascia below, or both. This gives to the part an immobility in
contrast with normal conditions.
Retraction of the nipple, when the growth is large or located near
it. This is a feature perhaps not noticeable in the primary stages
when it is so important to recognize the disease if present.
Retraction of the overlying skin, at points if not over a considerable
area, giving it a peculiar “saddle-skin” or “pig-skin” appearance. This
indication of itself is always suspicious and one which should be
noted if present.
In addition to the local evidences in the breast the involvement of
the nodes in the axilla and of the lymph vessels leading up toward it.
These should be carefully studied, the patient’s arm being held
loosely away from the body, and somewhat to the front, in order to
relax the pectoral muscle. In fleshy subjects it may not be possible to
discover them even if present. The supraclavicular region should
also be examined, and enlargements may be felt here or along the
cervical chain.
In addition to the above features others which are more indicative,
because they point to advanced disease, are the appearance in the
skin or just beneath it of shot-like nodules, more or less red, or of
any mass which causes the skin to protrude and to have an
unnatural appearance, usually one of lividity or threatening
ulceration. Pain is an uncertain and variable feature, upon which little
stress should be laid. The laity have incorrect notions about the
constancy and significance of pain, and many a woman has deluded
herself into the notion that she had no cancer because her tumor
was not painful. Pain is sometimes pronounced and severe, even
radiating down the arm; at other times it is absent until almost the
terminal stage.
Any tumor in the breast which presents any one of the above
characteristics is to be regarded as at least suspicious, while the
occurrence of two or more of the above features should stamp it as
malignant, and consequently condemn it. This is equally true of the
cancers which rarely appear in the male breast.
 Cancer is supposed to be a disease of middle and usually of
advanced life. This, again, is an error. To be sure, carcinoma is rare
below the age of thirty, and yet one sees it not infrequently in women
much younger than that. One of the saddest cases I have ever
known was one of carcinoma of both breasts in a young mother of
twenty-two, advanced to hopeless condition because her physician
had held that it could not be cancer at her age, and because she had
coincided with his belief, since she had not suffered pain.
The course of a cancer in the breast depends on several factors.
There is a rapidly growing type which tends to kill within a few
months, this occurring usually in younger patients. On the other hand
there is a slowly growing type which may last over a period of years.
This is the so-called atrophic cancer, and its slow growth is due to
the perfection of the protection afforded around the cancerous
masses by the density of the stroma. Occurring in a fatty breast it
leads to a diminution of its total mass, even though the cancerous
features themselves be advancing, and this makes it sometimes
hard to convince patients that a breast which is actually diminishing
in size is becoming more and more seriously involved. Cancer tends
ever to advance, and sometimes, as it were, by leaps, the method of
invasion being usually one of steady progress and infection of the
adjoining tissues; while metastases are to be expected as the case
goes on, and occur sometimes in unexpected forms. Thus in cancer
of the breast there is a well-known metastatic invasion of the bones,
even of the extremities, with the consequent liability to so-called
spontaneous fracture. In cases of the latter the former condition
should always be suspected. There is a possibility always of invasion
of the sternum and the ribs by continuity. It has been shown that
invasion of the pectoral muscle, and even of the firm pectoral fascia,
was a common result, and this demonstration has led to the adoption
of the more recent radical methods of removing both of these
structures along with the involved breast. In rare instances both
sarcoma and carcinoma assume the miliary type, and evince it by a
miliary invasion of the skin of the thorax which becomes gradually
infiltrated, softened, and perhaps finally ulcerated, the involved skin
thus having the aspect of a corset of diseased tissue, and being
spoken of as “jacket cancer” or “cancer en cuirasse.” Such a
condition may before the patient’s death involve the entire
circumference of the thorax. Any of these miliary expressions of
malignancy stamp a case with a hopeless aspect. General miliary
carcinosis is also known to occur.
Nearly all cancers grow faster in the young. Other things being
equal, there is a somewhat better prognosis for the condition in
elderly people, and this applies equally to prospect of recurrence
after removal.
In regard to the curability of cancer the reader is again referred to
an earlier chapter on the general subject, but doubtless there is a
time when if the growth were recognized and thoroughly removed it
would not recur and the patient might be cured. This time is,
unfortunately, too often past when the case comes under the
observation of one competent to deal with it. This is due partly to fear
and ignorance on the part of the patient, and unfortunately too often
to failure on the part of some practitioner to appreciate the
significance of the early manifestations, i. e., to a failure in early
diagnosis.
Cancer also occasionally occurs in the male breast, and I have
record of a number of fatal instances of this kind. It is, however, quite
rare. It is usually of the scirrhus type, but may be the result of
epithelioma commencing about the nipple and spreading. It cannot
assume marked size without becoming thoroughly distinctive, and
probably ulcerating, and there should be no difficulty in diagnosis. It
demands the same radical operation as cancer in the female (Fig.
525).
Treatment.—In regard to the method of treatment there is but one
which needs to be seriously considered, all others being fallacious
and irrational. It is by operative removal alone that every hopeful
case should be treated at the earliest possible date. Patients may
dread the knife and some men may fear to use it. Nevertheless the
above statement holds true. Even then cure is not obtained unless
the knife be used thoroughly. Treatment by plasters is barbarous and
unscientific, as well as uncertain and absolutely unsurgical. None of
the popular remedies is of the slightest value. Treatment by the
Röntgen rays should be reserved for the hopeless cases or for
postoperative protection. Eradication is, therefore, the only scientific
surgical relief.
Any growing tumor in the breast of a woman which cannot be
clearly recognized as perfectly innocent demands operative removal,
and the operation itself should be made thorough if success is to be
attained. In the presence, then, of lymphatic involvement, of any
adhesion or infiltration of the overlying skin, or of the surrounding
textures, or of retraction of a nipple, or of fixation of the breast upon
its base, operation should be advised without any reference to the
question of pain. Equally important is it to decide when not to
operate. When the condition is disseminated, when the presence of
cancer in any other part of the body can be demonstrated, when the
lymphatics of the neck are notably involved, when the arm is already
swollen from obstruction to the return circulation, when the skin
presents numerous miliary nodules, or when from disturbance of the
heart or of respiration—i. e., chronic cough—it might appear that
there is involvement of the bronchial nodes, with consequent
pneumogastric irritation, then it may be held that the case is so far
advanced that it is useless to subject the patient to the risk entailed
by operation. There are exceptions, however, even to this statement;
such as an evidently hopeless case that has reached the stage of
ulceration, in which discharge is offensive or hemorrhage recurring,
when operation may be done for temporary and with humane
purposes.
 Fig. 525 Fig. 526

Cancer of male breast. (Buffalo Clinic.) Recurrent carcinoma eight months

after incomplete operation in a
woman seventy-five years of age,
showing the extensive nodular,
ulcerating surface surrounded by
cancerous masses under the skin.
The edema of the right arm from the
circulatory obstruction occasioned
by metastatic growths about the
axillary vessels is well shown.
(Parker.)

Recurrence is to a large extent inseparably connected with the

matter of both early and thorough removal. Only when this can be
practised should any hope of radical cure be offered. While the
results attained by modern methods are very encouraging, they
nowise contradict this statement. The discreet operator will,
therefore, be guarded in giving a favorable prognosis or making
promises. Fig. 526 illustrates many of the sad features pertaining to
recurrence.

OPERATIONS UPON THE BREAST.

Every precaution having been taken the operator should decide
whether the operation is to be enucleation of the tumor or complete
excision of the breast, with dissection of the axilla. An evidently
innocent tumor of small size may be removed, either through a
straight incision, which should be placed radially, or by raising a flap
with an ovoid incision, by which more perfect dissection is permitted.
Small nodules and superficial growths may be removed under
cocaine anesthesia. The first essential is to leave behind nothing of
the mass which it is desired to remove; the second is exact
hemostasis, and the third is the closure of the wound. It is possible to
remove portions of the gland itself, as well as to enucleate tumors
from within its substance. V-shaped incisions may be coapted with
sutures, by which the size of the gland is reduced, but its general
proportions maintained. Tumors situated posteriorly may be removed
by making an incision beneath the breast, around its border, raising it
from the thorax, and returning it to place after the necessary
excision. It is advisable to provide a small drain for these cases, as
in the more or less loose tissues of the breast blood is likely to
accumulate, and by distending the wound to interfere with its repair.
Operations for cancer of the breast are performed more radically
than a few years ago. This is due to a more thorough knowledge of
the pathology of the disease, and to the better appreciation of the
value of thorough extirpation of all affected tissues, especially if this
can be done early rather than late. Therefore the modern operation
includes not only the removal of the breast and of the axillary nodes,
but of the pectoral fascia and muscle, the fatty tissue in the
neighborhood, and everything in which the disease may lurk.
The essential feature, then, of every case is the removal of all
tissue which may be involved. It is therefore necessary to remove
the skin covering the mamma, as well as the structures above
mentioned. This is done by elliptical or ovoid incisions, the amount
thus included being sufficient to take in every particle of skin which
shows the slightest possibility of infection—i. e., every nodule or
dimple which may be in any way connected with the primary
disease. Inasmuch as only in cases seen early is it at all safe to be
less radical than just mentioned the pectoral fascia and muscle
should be removed. For these purposes large and long incisions are
necessary, extending from the anterior border of the axilla down
toward the costochondral junction, while the lower part of the
opening is divided and the incision made elliptical, in order that the
breast, with its coverings, may be completely removed. The upper
end should follow the lower border of the pectoral tendon, or at least
be placed near it, extending as far as the insertion of this tendon,
since that portion belonging to the muscle excised should be divided
at its insertion and removed with the rest of the mass. The incisions
then are usually carried down first to the deep fascia, and then
through this, in such a way that the underlying muscle may be lifted
from the thorax and detached therefrom. The result is that there is
dissected from the chest wall a total mass of gland, fat, fascia, and
muscle, which is continuous upward and outward toward the axilla,
from which the final dissection is made. Then, commencing on the
outer side of the axilla, so much of the pectoral tendon is divided as
may be necessary; close beneath it will be found the axillary vein,
and this is next to be freed from its cellular and fatty surroundings.
The dissection is now carried toward the deeper part of the axilla,
vessels being secured before division, and the entire contents of the
axilla being carefully removed in one continuous mass. This requires
careful and sometimes tedious dissection, which is made much
easier by exact hemostasis. If the greater part of the great pectoral
muscle be removed, complete exposure of the axilla is easier. When
this is not sufficient, because in the uppermost portion of the axillary
cone may be felt enlarged lymph nodes, at the level of or beneath
the clavicle, then the lesser pectoral should be divided at its middle,
and its ends held apart, this affording a still better exposure of the
axillary depths. By this measure the vessels and plexuses may be
easily followed up to the level of the emergence of the former from
the thorax, especially if the arm be held upward and forward, much
depending upon the position in which the assistant thus holds it.
 Everything which is actually involved should be sacrificed. This
might even apply to the axillary vein, which may be doubly ligated
and exsected. It will occasionally happen that it is cut or torn in some
deep dissection. In this event, before resorting to final double
ligation, an effort should be made to suture the opening with fine silk
sutures passed with a round needle, which may be successfully
done, or to secure a small tear within the jaws of a curved hemostat,
may then be left within the dressings for forty-eight hours or longer;
by this time a clot will have formed which will permit its detachment.
While much work may thus be done upon the axillary vein the writer
nevertheless has the feeling that when a case is advanced to such a
degree as to demand this it is scarcely worth while, because
recurrence is practically sure to follow. Nevertheless in the interest of
general thoroughness, if the work has been begun, it is usually well
to finish it as completely as possible.

Fig. 527

Diagram showing skin-incisions: triangular flap of skin, a b c, and triangular flap of

fat. (Halsted.)
 Fig. 528

Breast and pectoral muscle completely separated from thorax; axilla exposed.
(Halsted.)

The operation as thus described has been extended by Halsted to

a degree which requires often much more work, and which has
furnished even better results, since he includes in it, if necessary, the
removal of both pectoral muscles, and even the division of the
clavicle for better exposure of the axillary and lower cervical regions,
and the more thorough extirpation of involved lymphatics. In other
cases he makes a vertical incision along the posterior margin of the
sternomastoid, exposing the junction of the internal jugular and
subclavian veins, and removes the supraclavicular fat by a
downward dissection and the infraclavicular fat by a dissection from
below. This is facilitated by elevating the shoulder, by which the
clavicle can be removed one inch or more from the first rib.
Figs. 527 and 528 illustrate the incision recommended by Halsted
and the general method of attack.
 Throughout these operations the primary question is removal of
disease, the matter of subsequent closure of the wound being a
secondary consideration. Nevertheless the extirpation being
completed, there arises the question of how best to close the
extensive defect thus created. This will depend on its size and upon
the amount of loose skin in the vicinity furnished by the patient’s
general physique. With emaciated patients, whose skin is tightly
drawn, it is not easy to furnish flaps, whereas in those who are fatty,
with flabby flesh and skin, it is easy to rearrange the latter. Beck has
suggested to make quadrilateral instead of elliptical incisions, leaving
a square defect, which can then be closed by sliding flaps from two
directions. The names of Warren and Meyer are also connected with
elaborately described plastic operations. Years before any of these
were published the writer was doing similar sliding of flaps, but never
endeavoring to make them conform to a single pattern, raising
semilunar flaps, or those of any other shape, as might best fill the
demand, and taking them from that portion of the thorax, side, or
even the abdomen, which would seem best to furnish them. There is,
therefore, no one method to be especially recommended, for every
operator of good judgment will be able to secure sufficient
integument from some surrounding location, so that it is rarely
necessary to leave such a wound uncovered. In those cases which
require an amount of dissection not permitting this it is a question if
operation be advisable. Nevertheless should it happen that for some
reason a sufficient skin covering is not thus easily available, Thiersch
skin grafts may be applied to any uncovered area at the time of
terminating the operation or later, and may be nearly always relied
upon for their destined purpose.
At least one opening should be made in the lateral flap in such a
location as to drain the axillary cavity when the patient is lying upon
her back, and through this a drainage tube of sufficient size should
be inserted. This should rarely be left more than forty-eight hours.
Inasmuch as there will sometimes be considerable tension upon
flaps a certain number of strong and reliable sutures (silkworm or
thread) should be used, to prevent parting of the wound margins,
while long retention sutures may be inserted if required. The balance
of the suturing may easily be done with catgut. The intent should be
to leave no dead spaces. Any isolated mass of fat which stands out
by itself after the dissection is complete should be pared down to the
common level, in order that it may not perish from ill-nutrition, nor
disturb the general level of the adjoining surfaces. It is rarely
necessary to keep patients in bed more than two or three days after
even extensive operations of this kind, but it is necessary to ensure
that equable pressure be made with the dressings, and that the
entire arm be bound to the side and immobilized in such a way that
the patient cannot move it nor disturb the dressing.
 C H A P T E R X LV.
THE ABDOMEN AND ABDOMINAL VISCERA.

GENERAL CONSIDERATIONS AND CONDITIONS.

That large portion of the human body which with its contents we
term the abdomen was for a long time terra incognita to the surgeon.
Despite the sporadic success of such men as McDowell and others
there was felt, until the latter part of the last century, a universal and
well-merited fear of intrusion upon the peritoneal cavity, because of
the tremendous probabilities of infection and fatal peritonitis. Until
the memorable researches of Lister and the introduction of an
antiseptic, later of an aseptic technique, there was, therefore, the
best of reason for regarding the abdominal cavity as a sanctum to be
entered only when dire necessity required. In spite of the complexity
of its anatomical arrangements, as well as the peculiar and
widespread ramifications and connections of its vessels and its
sympathetic and spinal nerves, with the almost innumerable
complications thus permitted and favored, and the resulting
uncertainty of symptoms and distant disturbances of function, the
abdominal cavity became, first, a favorite seat for laboratory study
and experiment, and then a fascinating field for surgical endeavor.
Today this region is invaded by the surgeon in a manner and with a
freedom which would have been criminal and unjustifiable when the
writer of these pages was a student; and yet, while we have in the
main lost our fear of the peritoneum and our dread of peritonitis, we
nevertheless see the latter occur now and again, as it were as a
punishment for forgetfulness or inattention, the patient unfortunately
paying the penalty for the errors of which he is not guilty. Abdominal
surgery has now become a specialty which has attracted too many
of those not thoroughly fitted by training and by experience. One
hears today of many, the older practitioners especially, insisting that
the abdomen is too often opened; perhaps it would be more just to
say that it is opened by too many. By this expression is meant simply