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CAUSATION IN INSURANCE CONTRACT LAW

Causation is a crucial and complex matter in ascertaining whether a particular loss or damage is covered in an insurance policy or in a tort claim, and is an issue that cannot be escaped.

Now in its second edition, this unique book assists practitioners in answering one of the most important questions faced in the handling of insurance and tort claims. Through extensive case law analysis, this book scrutinises the causation theory in marine insurance and non-marine insurance law, and provides a comparative study of the causation test in tort law. In addition, the author expertly applies causation questions in concrete scenarios, and ultimately, this book provides a single-volume solution to a very complex but essential question of insurance law and tort law. Thoroughly revised and updated throughout to include the Insurance Act 2015, several landmark cases and potential impacts of the COVID-19 pandemic, the second edition also features an introduction re-written to clarify elementary and central questions of causation in insurance law and tort. Additionally, it also provides three brand new chapters on factual causation and legal causation, causation and interpretation, and causation and measure of losses to provide a deeper and more thorough analysis, comparing academic approaches and juridical approaches to addressing causation issues in insurance claims.

This book is an invaluable and unique guide for insurance industry professionals, as well as legal practitioners, academics and students in the fields of insurance and tort law.

Meixian Song is Associate Professor at Dalian Maritime University and editor of Lloyd’s Shipping and Trade Law. Meixian was lecturer at the University of Exeter, then joined the University of Southampton. Meixian’s research interest lies in maritime law and commercial law. Her recent research articles were published in Legal Studies, Lloyd’s Maritime and Commercial Law Quarterly and the JournalofBusiness Law.

CONTEMPORARY COMMERCIAL LAW

Maritime Law in China

Emerging Issues and Future Developments

Editedby Johanna Hjalmarsson andJenny Jingbo Zhang

Illegality in Marine Insurance Law

Feng Wang

Insurance Law Implications of Delay in Maritime Transport

AyşegülBuğra

Online Arbitration

Faye FangfeiWang

Double Insurance and Contribution

Nisha Mohamed

The Law and Autonomous Vehicles

Matthew Channon, Lucy McCormickandKyriakiNoussia

FIDIC Yellow Book

A Commentary

Ben Beaumont

The Contract of Carriage

Multimodal Transport and Unimodal Regulation

Paula Bäckdén

FIDIC Red Book

A Commentary

Ben Beaumont

Blockchain Technology and the Law

Opportunities and Risks

Muharem Kianieff

Third Party Protection in Shipping

Carlo Corcione

Multi-sided Music Platforms and the Law

Copyright, Law and Policy in Africa

Chijioke Ifeoma Okorie

Comparative Analysis of Interim Measures

Interim Remedies (England & Wales) v Preservation Measures (China)

VivekJain, Thomas Macey-DareQCandShengnan Jia

Knock-for-Knock Indemnities and the Law

Contractual Limitation and Delictual Liability

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Managing International Trade Risk

Customs, Revenue and VAT Compliance

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Company Directors' Liability and the Protection of Creditors

Andrew Kaey

For more information about this series, please visit: www.routledge.com/Contemporary-Commercial-Law/book-series/CCL

CAUSATION IN INSURANCE CONTRACT LAW

SECOND EDITION

MEIXIAN SONG

Designed cover image: Getty

First published 2024 by Informa Law from Routledge 4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN

and by Informa Law from Routledge 605 Third Avenue, New York, NY 10158

Informa Law from Routledge is an imprintofthe Taylor &Francis Group, an informa business

© 2024 Meixian Song

The right of Meixian Song to be identified as author of this work has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers.

Trademarknotice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe.

BritishLibrary Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library

Library ofCongress Cataloging-in-Publication Data

Names: Song, Meixian, author.

Title: Causation in insurance contract law / Meixian Song.

Description: Second edition. | Abingdon, Oxon [UK] ; New York, NY: Routledge, 2024. | Series: Contemporary commercial law | This was originally based on author’s dissertation (doctoral) -- University of Southhampton, School of Law, 2013, issued under title: Rules of causation under marine insurance law from the perspective of marine risks and losses. | Includes bibliographical references and index.

Identifiers: LCCN 2023041236 (print) | LCCN 2023041237 (ebook) | ISBN 9781032153759 (hardback) | ISBN 9781032153766 (paperback) | ISBN 9781003243847 (ebook)

Subjects: LCSH: Marine insurance law--Law and legislation--England. | Proximate cause (Law)--England.

Classification: LCC KD1845 .S66 2024 (print) | LCC KD1845 (ebook) | DDC 346.42/086--dc23

LC record available at https://lccn.loc.gov/2023041236

LC ebook record available at https://lccn.loc.gov/2023041237

ISBN: 9781032153759 (hbk)

ISBN: 9781032153766 (pbk)

ISBN: 9781003243847 (ebk)

DOI: 10.4324/9781003243847

Typeset in Times New Roman by Deanta Global Publishing Services, Chennai, India

This book is dedicated to my grandparents.

CONTENTS

Foreword

Preface

Table ofcases

Table oflegislation

CHAPTER 1 INTRODUCTION TO THE LAW OF INSURANCE CAUSATION

CHAPTER 2 CAUSATION AND INTERPRETATION

Introduction

2.1 Theoretical accounts of causation in the law

2.1.1 Is there common-sense causation?

2.1.2 Actual causation

2.1.3 The bifurcation of cause-in-fact and causein-law

2.2 Juridical approaches to causation issues

2.2.1 Textual interpretation

2.2.2 Contextual interpretation and commonsense principles

2.3 The relationship between interpretation and causation

Concluding remarks

CHAPTER 3 TESTS OF CAUSATION IN INSURANCE CONTRACT LAW

Introduction

3.1 Nature of insurance and insurance causation

3.2 Historical development of tests of causation in English marine insurance case law

3.2.1 Prior to the Marine Insurance Act 1906

3.2.2 After the Marine Insurance Act 1906

3.3 Causal terminology: shades of semantic difference

3.3.1 Scalarity of causation

3.3.2 Variations of “caused by”

3.3.3 Contractual variations as to “proximately”

3.4 Intervening causes (again)

3.5 Counterfactual dependence in insurance causation

3.6 The inevitable consequence test

CHAPTER 4 BUT-FOR TEST IN TORT

Introduction

4.1 How does the basic but-for test operate?

4.1.1 One tort

4.1.2 Successive torts

4.2 When the but-for test fails

4.2.1 Material contribution to injury

4.2.2 Material increase to risk

4.2.3 Loss of chance

4.3 Tort and liability insurance

4.4 Foreseeability: ending a causal chain

CHAPTER 5 CONCURRENT CAUSES

Introduction

5.1 Room for concurrent causes

5.2 Definitions of concurrent cause

5.2.1 Some baselines

5.2.2 Two independent perils of equal efficiency?

5.2.3 Cumulative damage

5.3 Rules established by case law

5.3.1 Insured peril concurrent with uninsured peril

5.3.2 Insured peril and excluded peril

5.3.3 Internal causes and external causes

5.4 Insurance recovery of concurrent causes

5.4.1 All or nothing

5.4.2 Proportionate remedy

5.4.3 Anti-concurrent causes clause

CHAPTER 6 DEFINING AND INTERPRETING THE CAUSE OF LOSS

Introduction

6.1 All-risk insurance

6.2 Marine risks

6.2.1 Maritime perils

6.2.2 Perils of the sea

6.2.3 The Inchmaree Clause – “due diligence proviso”

6.2.4 Unseaworthiness as a cause of loss

6.3 Non-marine risks

6.3.1 Life cover: accidents

6.3.2 Liability insurance: fault or negligence of the assureds

6.3.3 Business interruption cover: the FCA test case and subsequent decisions

6.3.4 Reinsurance: an occurrence

6.4 Common exclusions

6.4.1 Wilful misconduct of the assureds

6.4.2 Delay

6.4.3 Nature of the subject matter insured

6.5 Apprehension of peril and mitigation measures

CHAPTER 7 CAUSATION AND MACHINERY FOR QUALIFYING LOSSES

Introduction

7.1 The machinery of calculating losses

7.2 Aggregation of losses

7.3 Assessment of quantum in the cases of COVID19-related BI cover

CHAPTER 8 BURDEN AND STANDARD OF PROOF

8.1 Balance of probabilities in insurance causation

8.2 Burden of proof on assured

8.3 Burden of proof on insurers

8.4 Generic perils: all-risk

8.5 Unexplainable losses

8.5.1 Unexplainability

8.5.2 Presumptions as to burden of proof in unexplainable losses

8.5.3 Mysterious disappearance clauses

CHAPTER 9 CAUSAL NOTIONS UNDER INSURANCE

ACT 2015: BEYOND THE PROXIMATE CAUSE OF LOSS

Introduction

9.1 Breaching terms of insurance contracts

9.2 Assured’s duty of fair presentation

9.3 Fraudulent claims vs collateral lies

Index

FOREWORD

The first edition of Dr Meixian Song’s Causation in Insurance Contract Law was rightly greeted with critical acclaim. Although there have been numerous books on causation in the common law, as well as detailed philosophical analyses of causation, Meixian’s book was the first comprehensive treatise on causation as it operates in the law of insurance.

The requirement that the assured must demonstrate that the loss was proximately caused by an insured peril is inherent in any insurance claim and is at root in most cases a simple question of fact. That said, there have always been underpinning policy issues. The courts in early marine cases had to decide whether insurers should be held responsible where the crew of a wooden ship chose to try to keep warm by starting a small fire, or where the crew responded to a collision, grounding or threatened taking at sea was itself the reason for the loss. All of this led to a less than satisfactory codification in the Marine Insurance Act 1906, the draftsman of which somehow managed to convert a causation question into a duty to mitigate loss and thereby to create confusion for over a century. Subsequently, the courts had to deal with the problem of death or personal injury resulting from a variety of unfortunate conjunctions of natural causes and unexpected occurrences, and produced a series of conflicting decisions some of which displayed clear sympathy with the bereaved.

In recent years the context has changed. Man-made and natural catastrophes have required further policy determinations. How was the law to deal with the horrible and negligently-inflicted disease of

mesothelioma when pinning liability on a single culprit was in many cases beyond the capabilities of science? The decision in Fairchild to impose liability in tort without proof of causation led to two decades of insurance – and, inevitably, then reinsurance – litigation to determine how the liabilities should be treated under employers’ liability policies not designed to deal with long-tail illnesses and operative in different years for different potential defendants.

Perhaps the greatest challenge was posed by the COVID-19 pandemic, and a mass of ongoing case law to try to fit the business interruption losses from a worldwide disaster into policies designed exclusively to respond to local events. The answer was, controversially, to be found in causation, leading to the conclusion that a single case of infection on or near the insured premises was in causation terms as weighty as the millions of infections elsewhere. Questions of concurrent causes were thus brought into sharp focus, raising in particular the “but for” problem that even if there had not been an insured peril there would still have been a loss: that caused two members of the Supreme Court in the Arch decision to admit the error of their ways a decade earlier when as arbitrator and judge they decided in the context of the New Orleans hurricanes that there should be no cover in such circumstances. As in Fairchild, the equally important “law of unintended consequences” was triggered: if there is pandemic cover, what is the response of causation to losses occurring after the expiry of the contractual indemnity period that can be traced back to losses within it? We are awaiting an appellate answer to that question.

The point, then, is that causation cannot be analysed simply by a case-by-case analysis of individual rulings. Some of course are discrete: for example, Meixian discusses the question of whether a bomb dropped on Exeter in 1942 can be the proximate cause of damage to the university and other buildings after its discovery and controlled detonation 80 years later. But for others, there are complex underlying policy issues with wide-ranging consequences. The complexities of causation led the draftsman of Section 11 of the Insurance Act 2015 to bow to pressure from the insurance industry and to seek to devise a means other than via the mechanism of

causation to allow an assured to recover under the policy despite being in breach of a clear policy obligation. Nobody disputes that an assured who has failed to install adequate locks should be precluded from recovery if the building is hit by a falling plane. But should that also apply where inadequate locks are not picked but instead subjected to the overzealous treatment afforded to the “bloody doors” by Michael Caine’s crew in The Italian Job?

All of this and more is analysed, thoroughly, deeply and clearly in Meixian’s second edition. The book is a thought-provoking treatment of all aspects of causation in insurance law. There is no shying away from recognising policy issues and tackling them head-on. The book is a delight to read, full of insights. Forewords often say that a book should be found on the shelves of libraries, practitioners and academics. That can be said about Meixian’s book without a shred of hyperbole. Causation in Insurance Contract Law cannot be recommended highly enough.

RobMerkin 15August 2023

PREFACE

The primary purpose of a causation enquiry in insurance cases is to determine whether and if so to what extent insurers are liable under contracts of insurance. The works of Hart and Honoré and many other scholars including Stapleton have contributed to unpacking legal elements of causal notions in general, and in tort in particular. Although insurance notoriously investigates the “proximate” cause of loss in order to determine whether insurers are to be liable for certain losses, the decisions made by English courts are far from reconcilable. Sir Chalmers, the codifier of the Marine Insurance Act 1906, had suggested that the problem lies in the inference of matters of fact, and that consequently causal connection is perceived as a complex and uncertain issue.

In the earlier edition, we considered how The Cendor MOPU [2011] UKSC 5 placed the spotlight on the causation question in insurance law. It illustrates the significance of dealing with incoherency and uncertainty in the law. In the past decade, several further landmark cases have been decided by the Supreme Court, including The Brillante Virtuoso, The B Atlantic and The FCA test case. As will be seen in the discussion of these decisions in the following, causation remains a complex issue.

Considering the significant developments in case law during the decade since the first edition of this work was published, the second edition provides a more careful account of academic and judicial approaches to causation issues in insurance claims. This book highlights that English courts have identified contractual limitations and causal requirements as decisive components of an insurer’s

liability. This book examines the extent to which the judicial approaches should draw a clearer line between contract interpretation and causation issues in insurance contract law. This argument is informed by academic discussion, in which Hart and Honoré suggested that causal issues should be kept separate from issues of legal policy such as legal policies concerning the optimal allocation of social risks, the scope of rules of law and the impact of fairness between the parties in the particular case. Scholars including Stapleton and Wright go further, claiming that there is a significant and sharp separation between causal enquiry and noncausal normative assessment. The value judgement embedded in legal causation would require a book of its own. This book aims to unpack the relationships between interpretation and the causation to the determination of insurance indemnity. In this second edition, there are major updates in the chapter entitled Concurrent Causes, and three new chapters entitled “Causation and interpretation,” “Causation and machinery for qualifying losses” and “Causal notions under Insurance Act 2015: beyond the proximate cause of loss.”

Another aim of the second edition is to provide a more detailed account of the comparison of causation theories in tort law and insurance law. Such a comparison has been the subject of judicial scrutiny in the UK Supreme Court decision of the FCA test case. Causation and the allocation of liability have traditionally been viewed as different in insurance law compared to criminal or the law of tort. Through the comparison, this book highlights that it is not necessary to isolate causation in insurance contracts from the central debate surrounding the common question regarding the roles of causation in ascertaining and truncating legal liability.

I must express my thanks here to Professor Robert Merkin KC and Dr Johanna Hjalmarsson for the invaluable support on this edition and guidance on the first edition.

Meixian Song July 2023

TABLE OF CASES

(bold= main textualref; roman = footnoted)

A/BKarlshamns Oljefabriker v MonarchSteamship Co. Ltd(1948–1949) 82 LlL Rep. 137

Ace European Group v Chartis Insurance UKLtd[2013] EWCA Civ 224; [2012] EWHC 1245

Adelaide Steamship Co Ltdv Crown (1923) 14 LlL Rep. 341

AIGEurope Ltdv Woodman [2017] UKSC 18

AioiNissay Dowa Insurance Co. Ltd(formerly Chiyoda Fire and Marine Insurance Co. Ltd)v Heraldglen Ltd[2013] EWHC 154 (Comm); [2013] Lloyd’s Rep IR 281

Ajum Goolam Hossen &Co. v Union Marine Insurance Company [1901] AC 362

Alexander John Dudgeon v E. Pembroke 1874 LR 9 QB 581; (1876–1877) LR 2 App Cas 284; (1877) 2 AC 284

Aliza Glacial[2002] 2 Lloyd’s Rep 421

Allianz Insuranceplc v The University ofExeter [2023] EWHC 630 (TCC)

AlliedMaples Group Ltdv Simmons &Simmons [1995] 1 WLR 1602 CA

AlphacellLtdv Woodward[1972] AC 824

Alstom Ltdv Liberty MutualInsurance Co. [2013] FCA 116

American CentennialInsurance Co v INSCOLtd[1996] LRLR 407

AMIInsurance Ltdv Ross John Legg andothers [2017] NZCA 321

Andersen v Marten [1907] 2 K.B. 248; [1908] 1 KB 601 [1908] AC 334

Anderson v Minneapolis (1920) 146 Minn. 430, 179 NW 45

Anderson v Morice (1874–1875) LR 10 CP 58

Antaios Cia Naviera SAv Salen Rederierna AB[1985] AC 191

Anthony Gibson v RobertSmallandOthers (1853) 4 HL Cas 353

Arnoldv Britton [2015] AC 1619

AssicurazioniGeneraliSpAv ARIG[2003] Lloyd’s Rep IR 131

AssociatedMetals &Minerals Corp. v M/VOLYMPICMENTOR1997

AMC 1140

AtlantikConfidence [2016] 2 Lloyd’s Rep 525

Axa Reinsurance(UK)plc v. Field[1996] 2 Lloyd’s Rep. 233

Axa Versicherung AGv ArabInsurance Group [2017] EWCA Civ 96

AXLResources Ltdv Antares Underwriting Services Ltd[2010] EWHC 3244 (Comm)

AXN&Ors v Worboys &Ors [2012] EWHC 1730

Bailey v Ministry ofDefence [2008] EWCA Civ 883

Baines v Dixon Coles &Gill[2021] EWCA Civ 1211

Baker v Willoughby [1970] AC 467

BankofNova Scotia v Hellenic War Risks Association(Bermuda) Ltd(The GoodLuck)[1992] 1 AC 233 (HL)

BankofQueenslandLtdv AIGAustralia Ltd[2018] NSWSC 1689

Banque Bruxelles LambertS.A. v Eagle Star Insurance Co. Ltd [1995] QB 375

Barker v Corus UKLtd[2006] UKHL 20

Barnett v Chelsea &Kensington Hospital[1969] 1 QB 428

Beazley Underwriting Ltdv The Travelers Companies Incorporated [2011]EWHC1520(Comm)

Becker, Gray v London Insurance Corporation [1918] AC 101

Bellv Lothiansure Ltd1993 SLT 421

Betty v LiverpoolandLondon Globe Ins Co Ltd(1962) 310 F 2d 308 (US CA 4th Circ)

Bird’s Cigarette Manufacturing Co. Ltdv Rouse [1924] 19 LlL Rep. 301

Blackenhagen v The London Assurance Company 170 ER 1019

Blower v The Great Western Railway Company (1871–1872) LR 7 CP 655

BoardofTrade v Hain Steamship Co. Ltd[1929] AC 531

BondAir Services v Hill[1955] 2 QB 417

Bonnington Castings Ltdv Wardlaw [1956] AC 613

Borealis ABv Geogas Trading SA[2011] 1 Lloyd’s Rep 482

Boydv Dubois [1811] 3 Campbell 133, 170 ER 1331

Brian Leighton(Garages)Ltdv Allianz Insurance Plc [2023] EWCA Civ 8

Bridgeman v AlliedMutualInsurance Limited(1999) 10 ANZ Insurance Cases 61-448

Britestone Pte Ltdv Smith&Associates Far East, Ltd

British&Foreign Marine Insurance Co v SamuelSanday &Co [1916] 1 AC 650

British&Foreign Marine Insurance Co. Ltdv Gaunt [1921] 2 AC 41

BritishandForeign Marine Insurance Company Ltdv Gaunt [1923] 16 LlL Rep. 129

BritishWaterways v Royal&Sun Alliance Insurance Plc [2012] EWHC 460 (Comm)

Brotherton v Aseguradora Colseguros SA(No. 2)[2003] 2 CLC 629

Brownsville Holdings Ltdv Adamjee Insurance Co Ltd(The Milasan)[2000] 2 Lloyd’s Rep 458

BrushfieldLtd(t/a The Clarence Hotel)v Arachas Corporate Brokers Ltd[2021] IEHC 263; [2022] Lloyd’s Rep IR Plus 18

Butler v Wildman (1820) 3 B&Ald 398; 106 ER 708

Canada Rice Mills Ltdv Union Marine &GeneralInsurance Co. Ltd [1941] AC 55

Canada Rice Mills Ltdv Union Marine andGeneralInsurance Co. Ltd(1940) 67 LlL Rep. 549

Canadian Indemnity Company v Walkem Machinery &Equipment Ltd1975 CanLII 141 (SCC), [1976] 1 SCR 309

Caribbean Sea [1980] 1 Lloyd’s Rep 338

CarrollvQBEInsurance(Europe)Ltdandothers [2020] EWHC 153

Casalino v Insurance Australian Ltd[2007] ACTSC 25

Caudle &Ors v Sharp [1995] CLC 642

Cehave v Bremer [1976] Q.B. 44

Chaplin v Hicks [1911] 2 KB

ChartbrookLtdv Persimmon Homes Ltd[2009] 1 AC 11

Chester v Afshar [2005] 1 AC 134

ChubbInsurance Singapore Ltdv Sizer Metals Pte Ltd[2023]

SGHC(A) 17

Clothing Management Technology Ltdv Beazley Solutions Ltd(t/a Beazley Marine UK)[2012] EWHC 727

Compania Maritima San Basilio SAv Oceanus MutualUnderwriting Association(Bermuda)Ltd(The Eurysthenes)[1977] QB 49

Compania Naviera Martiartu v RoyalExchange Assurance Corporation (1924) 19 LlLRep 95

Compania Naviera SantiS.A.v Indemnity Marine Assurance Co. Ltd[1960] 2 Lloyd’s Rep 469

Compania Naviera Vascongada v British&Foreign Maritime Insurance Co. Ltd(1936) 54 LlL Rep 35

ContinentalIllinois NationalBank&TrustCo ofChicago and Xenofon Maritime SAv Alliance Assurance Co Ltd(The Captain Panagos DP)[1989] 1 Lloyd’s Rep 33

Cookv Lewis [1952] 1 DLR 1

Coxe v Employers Liability Assurance Corp Ltd[1916] 2 KB 629

CTBowring &Co. Ltdv Amsterdam London Insurance Co Ltd(1930) 36 LlL Rep. 309

Cullen v Butler (1816) 5 M&S 461

CulturalFoundation &Anor v Beazley Furlonge Ltd&Ors [2019] Lloyd’s Rep IR 12

CVStealth(No. 2)[2017] EWHC 2808 (Comm)

Davidson v Burnand(1868–1869) LR 4 CP 117

Delphine [2001] 2 Lloyd’s Rep 542

De Souza v Home &Overseas Insurance Co. Ltd[1995] LRLR 45

Derksen v 539938Ontario Ltd[2001] SCC 72

Dhakv Insurance Co. ofNorthAmerica(UK)Ltd[1996] 1 WLR 936

Dixon v Sadler (1839) 5 M&W

Dunthorne v Bentley [1999] Lloyd’s Rep IR 560

Durham v BAI(Run Off)Ltd. [2012] UKSC 14; [2012] 1 WLR 867

E. D. Sassoon &Co. v Western Assurance Co. [1912]

AC 561

E.D. Sassoon &Co. Ltdv Yorkshire Insurance Company [1923] 16

LlL Rep. 129

Elfie A.Issaias v Marine Insurance Co., LTD. (1922) 13 LlL Rep 381

EnvironmentAgency v Empress Car Co. (Abertillery)Ltd[1998] UKHL 5, [1999] 2 AC 22

Equitas Insurance Ltdv MunicipalMutualInsurance Ltd[2019] EWCA Civ 718

EUILtdv BristolAlliance LtdPartnership [2012] EWCA Civ 1267

European Group v Chartis [2012] EWHC 1245 (QB); (Comm)

Eurus [1998] 1 Lloyd’s Rep. 351

F . W. Berk&Co. Ltdv Style [1955] 2 Lloyd’s Rep 382

Fairchildv Glenhaven FuneralServices Ltd(2002) UKHL 22; [2003] 1 AC 32

Fawcus v Sarefield(1856) 6 E&B 192

FCAv Arch[2021] UKSC 1

Fenton v Thorley &Co Ltd(1903) AC 443

,

Fidelity andCasualty Company ofNew Yorkv Mitchell[1917] AC 592

FinancialConduct Authority(Appellant)v ArchInsurance(UK)Ltd andothers(Respondents)[2021] UKSC 1

3, 56, 103, 114, 170, 194,

FinancialConduct Authority v Arch Insurance(UK)LimitedandOthers [2020] EWHC 2448 (Comm)

Fooks v Smith[1924] 2 KB 508

,

Galloway v Guardian RoyalExchange(UK)Ltd[1999] Lloyd’s Rep IR 209

Galoo Ltd(in liquidation)andOthers v BrightGrahame Murray(a firm)andAnother [1994] 1 WLR 1360

Garvey etal. v State Farm Fire andCasualty Company, 48 Cal 3d 395

George Cohen Sons &Co. v StandardMarine Insurance Co. Ltd (1925) 21 LlL Rep 30

Gibbs v Mercantile MutualInsurance [2003] HCA 39

GlobalProcess Systems Inc v Syarikat TakafulMalaysia Bhd(The Cendor Mopu)[2011] UKSC 5; [2011] 1 All ER 869; [2011] 1

Lloyd’s Rep. 560

3–4, 18, 36, 48, 61, 104, 109–110, 113, 121, 129, 131–134, 135, 139, 144, 151–154, 162, 164, 174, 180–181, 185–186, 188, 215, 216

Gl owrange Ltdv CGUInsurance Plc

Gordon v Rimmington (1807) 1 Camp 123

GovernmentOffice ofNew SouthWales v RJGreen &LloydPty Ltd[1966] HCA 6

Grant v Sun Shipping Co [1948] AC 549

Grant, SmithandCompany andMcDonnellv Seattle Construction andDry DockCompany [1920] AC 162

Gray v Barr [1971] 2 Lloyd’s Rep 1; [1971] 2 QB 554

Green v Brown (1743) 2 Str 1199

Gregg v Scott [2005] 2 WLR 268 HL

16, 37, 69, 70,

,

Greggsplc v ZurichInsuranceplc [2022] EWHC 2545 (Comm)

Guaranty NationalInsurance Co v NorthRiver Insurance Co 909 F.2d 133 (5th Cir. 1990)

Hadkinson v Robinson (1803) 3 B&P 388

Hagedorn v Whitemore 1816, 1 stark, 157

Hamilton, Fraser &Co. v Pandorf&Co. 12 App Cas 518

Hamlyn v The Crown AccidentalInsurance Company [1893] 1 QB 750

Harrisons v Shipping Controller(The Inkonka)[1921] 1 K.B. 122

Helicopter Resources Pty Ltd&VowellAir Services(Helicopters) Pty Ltdv Sun Alliance Australia Unreported, Supreme Court of Victoria, Ormiston J, 26 March 1991

HIHCasualty &GeneralIns Ltdv New Hampshire Ins Co [2001] EWCA Civ 735

Hodge v Anglo-American OilCo. (1922) 12 L1LRep. 183

Hogan v BentinckWest Hartley Collieries [1949] 1 All ER 588

Home Office v Dorset YachtCo Ltd[1970] AC 1004

Hornalv Neuberger Products Ltd[1957] 1 Q.B. 247

Hotson v East Berkshire HealthAuthority [1987] AC 750 HL; [1987] 2 All ER 909

Houghton(RA)andMancon Ltdv SunderlandMarine Mutual Insurance Co. Ltd(The Ny-Eeasteyr)[1988] 1 Lloyd’s Rep 60

Humber OilTerminalTrustee Ltdv Owners ofthe Sivand[1998] 2 Lloyd’s Rep 97

Hutchinson v Epson &St Helier NHSTrust [2002] EWHC 2363

Hyper Trust Ltdv FBDInsuranceplc [2020] EWHC 2448 (Comm); [2020] Lloyd’s Rep IR 527

IAGNew ZealandLtdv Jackson [2014] Lloyd’s Rep IR 97

Ide v ATBSales Ltd[2008] EWCA Civ 424

Impress(Worcester)Ltdv Rees [1971] 2 All ER 357

InternationalEnergy Group Ltdv ZurichInsurance Plc UK[2013] EWCA Civ 39

Investors Compensation Scheme Ltdv West BromwichBuilding Society [1998] 1 WLR 896

Ionides v The UniversalMarine Insurance Company (1863) 14 CB (NS) 259

,

Issaias v Marine Insurance Co. Ltd. (1923) 15 LlLEep 186

,

,

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hours, according to the amount of discharge, which when collected with a syringe should be carefully estimated. Any cavity which is not filled at a rate faster than 2 or 3 Cm. in an hour may be regarded as capable of disposing of all the fluid which may collect within it, and every tube which is no longer needed is an irritating foreign body, whose lower end may press upon intestine, and even produce ulceration if allowed to make pressure too long. Appendicular abscesses usually require to drain from two to three or four days; gall-bladders and hepatic abscesses for a much longer time. In nearly all instances it may be expected that within from forty-eight to sixty hours after the establishment of drainage a natural passage will be formed, by exudate appearing first around the drain, and remaining after its removal, which should serve drainage purposes as would a canal. Sometimes the outer end of such a canal tends to close too quickly, and then with accumulation in the deeper part there may come retention, with later spontaneous escape, or possibly rupture into the abdominal depths, which may be serious. In nearly every instance, however, a large drain may be substituted within a short time by a smaller one and final removal be thus accomplished. Any localized cavity whose discharges are offensive or putrefactive should be cleansed each day, either with hydrogen peroxide or by gentle irrigation, or with a reasonably strong antiseptic solution—iodine, silver nitrate, etc. While no such cavity will close until all such material has escaped, it nevertheless is well to keep the external opening wide open, in order to hasten the whole process. This may be accomplished by gauze packing or the insertion of a short tube.

Cavities which persist, with apparently permanent fistulas, require more radical treatment, which will consist at least of a thorough curetting and considerable enlargement of the fistulous opening, in order to permit of this. Such a cavity, then, may be comfortably packed with gauze for a few days.

The use of massive tampons and the introduction of large-sized pieces of gauze into the abdominal cavity have been generally discontinued, largely through the writings of Morris, who stigmatized such practice as “committing taxidermy upon patients.”

Abdominal drainage may be favored by one other expedient—i. e., position. The peritoneum possesses unusual powers of absorption and is capable of taking care of morbid material up to a certain point. It has been shown that the peritoneum of the upper abdomen especially, even that lining the diaphragm, is particularly potent in this direction—next to it perhaps that of the pelvic cavity. Septic processes in the upper abdomen are then sometimes advantageously dealt with by placing the patient in bed in a position with the pelvis considerably elevated and the head dependent. This is the more valuable after irrigation has been practised, where there may be considerable fluid which may thus gravitate. On the contrary, in serious septic pelvic infections it is often good practice to keep the patient in the semisitting posture, so soon as sufficiently recovered from the anesthetic. (Fowler.) These expedients are perhaps the more valuable when provision is made in either one of the dependent portions for drainage, gravity thus favoring the accumulation of fluid where it can be best cared for.

CLOSURE OF ABDOMINAL INCISIONS.

In what may be termed a clean abdominal operation it is seldom that drainage is provided. Such cases are expected to heal promptly and the wound to close immediately and without pus formation. It is only in cases where drainage has been necessitated that there is a really legitimate excuse for subsequent yielding of the scar, and the production of postoperative ventral hernia. These at least are the ideal and theoretically correct notions, although it should be acknowledged that in the practice of even the most competent such undesirable sequels as ventral hernia do sometimes occur. Foreseeing the possibility of their occurrence and realizing the conditions which permit the same, every known precaution should be taken. The question then of the method of closure of even a small abdominal wound is one of great importance, which has long engaged the attention of the most experienced operators, who have not yet united upon what all consider the ideal or perfect method. In general it may be said that suture of each separate tissue layer comes nearest to this ideal, along with the employment of a suture

material which should serve its purpose sufficiently long, and yet not remain as a possible future irritant. When time is afforded, and there are no contra-indications, the following may be given as the best directions in this regard: A suture of the peritoneal edges, with or without the deep fascia. In or near the middle line the posterior sheath of the rectus may also be included in this row. These sutures should be inserted with extreme care so as not to include any peritoneum of the bowel surfaces. Then the muscle edges are brought together by a second row, over which the deep aponeurosis is covered and brought together with a third row Rather than fail in accurate approximation of this third row it would be better to overlap the edges and fasten them together in this position. These sutures should be made with hardened catgut, of whose sterility and durability there is no question. It should have been so treated that reliance may be placed on its remaining for at least twenty days. The method with the balance of the wound may depend to some degree upon its thickness. In individuals with fat abdominal walls it is better, in order to avoid dead spaces, to insert one or two rows of buried sutures, by which the fatty surfaces are brought into contact. Finally the skin margins may be approximated, either with a subcutaneous chromic or silkworm suture, or by the ordinary continuous or interrupted suture, which may be made, according to choice, of celluloid thread (Pagenstecher’s linen thread soaked in a celluloid solution and thus made non-absorbent), sterile silk, or fine wire.

The nature and the location of the incision and the thickness of the tissues, along with the degree of tension which may be made upon them, will to some extent determine how the more superficial stitches may be placed. The depressing effect of postoperative vomiting may be forestalled by placing another set of three or four mattress or quilted sutures, which may be brought out at a distance of two or three inches from the incision and guarded with shot, plates, or rolls of gauze. These sutures have a tendency to take off tension from those immediately closing the wound and are a valuable means of securing primary union.

Ordinarily, as stated above, one never drains the abdominal wound proper. Nevertheless if it has been infected by contact with gangrenous or infectious material it is better to leave some opening

for escape, or else, as a final precaution, to trim the surfaces which have been exposed and bring into contact only those which are absolutely fresh and uncontaminated. In gunshot wounds, for example, unless the track of the missile has been cleanly excised some provision should be made for drainage thereof.

A further protection should be, however, afforded in the dressings, by strips of plaster placed over the deeper dressings, by which again tension is taken off the wound, and still further by such snug bandaging and arrangement of compresses and dressings as shall complete this protection.

There are occasions when this procedure, which necessarily consumes a little time, cannot be completely carried out, and when there must be haste in order to get the patient off the table in suitable condition. In such cases the operator usually contents himself with the application of silkworm-gut sutures, which include the whole thickness of the abdominal wall, or the use of secondary sutures, which can be tightened and utilized later. As Binnie has said: “Inexperienced surgeons, after completing a prolonged operation on an exhausted individual, sometimes forget that it is better to have a postoperative hernia in a living patient than a perfectly closed wound in a corpse.”

AFTER-TREATMENT OF ABDOMINAL OPERATIONS.

While in the general principles regarding the after-treatment of abdominal cases practitioners are well agreed, the world over, they differ so in regard to minor points that it is difficult to give explicit directions which shall be acceptable to all. Much will depend upon whether the patient has had suitable preliminary preparation. If, for instance, the bowels have been thoroughly emptied there need be no haste to administer laxatives, as though this had not been the case. In many instances where this precaution has been neglected catharsis is, after operation, the most important consideration, and yet this may be difficult to secure, the difficulty being enhanced by the fact that an individual just operated on and extremely tender finds it difficult to give natural assistance to the process of defecation. The matter is particularly complicated by the difficulty of

selecting an active cathartic which may be retained by a sensitive stomach. One of the greatest needs of the surgeon, as well as of the physician, is a suitable medicament of active cathartic properties which can be satisfactorily administered with a hypodermic syringe. Nothing of this kind is as yet known.

It is good practice in many cases to throw into the intestine, through a fine needle connected with a large syringe, a considerable quantity of saturated solution of Epsom salt before closing the abdomen. This places it where it will not be rejected by an irritable stomach, and where it must have the desired effect. The needle so used should be carefully introduced, in a very oblique direction; while should the minute puncture bleed or seem to leak it may be included in a suture or ligature loop, which should take up the peritoneal coat only. In addition to this, an occasional expedient, the writer usually administers, before the patient leaves the table, a subcutaneous injection of ¹⁄₅₀ Gr. of eserine sulphate, the active principle of Calabar bean, this being a powerful stimulant to the muscular coat of the intestine. The bowels should be thoroughly emptied in the easiest manner after every operation.

The next question is one of pain. Patients should not be allowed to suffer when morphine is at hand, and this would always be true were it not that morphine has, at times, undesirable effects, both in checking intestinal activity and in “locking up the secretions.” Moreover, it frequently nauseates. On the other hand, patients who have undergone serious operations need to be kept absolutely quiet, and to be prevented from tossing and moving themselves in bed. Some expedient then is called for in many cases, and one may, if he choose, begin with the milder of these—such, for example, as the administration of 2 Gm. each of chloral and sodium bromide, with or without chloretone, in a little saline solution or sterile water, thrown high in the rectum. When pain is not severe this is frequently sufficient to soothe and allay, and often to produce sleep. It reduces or prevents the nausea with which many patients suffer. This, too, may be given before the patient leaves the table. Such an enema, with or without asafetida or other soothing drugs, may be repeated as often as indicated, and does much to quiet a rebellious stomach.

It is assumed here that the reader is already familiar with the precautions advised before the administration of anesthetics and that it is now simply a question of after-treatment. (See Chapter XX.) My own advice is not to withhold morphine in those cases which seem to require it, remembering, at the same time, that suitable management of the stomach is required. It is inadvisable to permit the patient to take any fluid in the stomach for several hours, for even plain water will upset a stomach which has seemed to be perfectly calm and controllable. According to the degree of nausea and discomfort should the stomach be used, the patient’s need for fluids being supplied by more or less copious saline enemas. So soon as the stomach becomes quiet ice pellets or small quantities of water, as hot as can be borne, may be used, the latter frequently proving the more acceptable.

Until the bowels are freely moved whatever food may be administered should be fluid, and, under most circumstances, not more than forty-eight hours should elapse after any operation before the intestinal canal is emptied. Milder degrees of nausea may be treated by the use of milk of magnesia, of small doses of orthoform, or by a mixture which the writer is fond of using, in each dose of which the patient receives 0.02 of cocaine, one minim of carbolic acid, and one or two minims of dilute hydrocyanic acid, in a small amount of water. I have found this in many instances very soothing.

The after-management of many of these cases includes also the treatment of shock and collapse, which have been considered in a previous chapter. It should include, also, suitable attention to the bladder, and a catheter should be used within the first ten or twelve hours if no urine be passed, and as often thereafter as may be necessary. Catheterization should be conducted with the same precautions as indicated at any other time. Other details of aftertreatment, such as the removal of drainage materials, change in position of the patient, etc., have been discussed. Stitches of chromic catgut need no further attention, while those of silk or thread will need removal. It is to be emphasized that the great danger of the so-called stitch-hole abscesses comes not so much from the material first employed as from failure to protect it and guard it against the possibility of subsequent infection. Non-absorbable

sutures in the abdominal wall are usually allowed to remain from ten to twelve days, but any stitch which is seen to fail in accomplishment of its purposes should be immediately removed, as should also stitches around which a drop of pus is seen to be escaping.

Certain abdominal wounds, especially in fleshy individuals, seem to heal perfectly, then part a little and give vent to material which is hardly pus, but appears more like liquefied or altered fat. Such, in effect, it often is, and the condition implies a necrosis of a certain amount of fatty tissue, with its liquefaction and escape instead of absorption. In this way a small cavity will be left which should heal by granulation, and this may be hastened by the use of mild nitrate of silver solution.

A patient having been removed from the operating table in a satisfactory condition the principal danger is that of internal hemorrhage, which, though fortunately rare, is disturbing when it does occur. In fact, severe abdominal hemorrhage is one of the most serious of surgical accidents, either primary or secondary. It may occur from wounds of all descriptions, as the result of erosion, perhaps of a foreign body, even of a drainage tube, from the slipping of a ligature, from reaction after shock, the heart recovering its vigor and pumping blood out from the vessels which had not previously oozed. In other instances, of course, it may be the result of rupture of an abdominal aneurysm or the twisting of the pedicle of an abdominal tumor. Constitutional causes which contribute toward it are jaundice, both with or without accompanying cholemia (mentioned more particularly in the section on the Biliary Passages), hemophilia, scurvy, and that form of myelogenous leukemia for which splenectomy has been occasionally performed. In all these cases the patients are abnormally prone to bleed freely. When this condition is suspected it is well to determine the coagulation time of the blood. If this be over six minutes the calcium salts, with iron and fruit acids, should be administered some time previous to operation.

The most important symptoms of postoperative or internal abdominal hemorrhages are rising pulse, with fall in temperature, pallor, and that marked reduction of blood pressure which gives rise to the ordinary symptoms of shock or collapse, along with extreme restlessness and disturbance of vision or almost complete blindness.

When there has been any notable collection of blood within the abdomen there may be found dulness on percussion over the flanks. Richardson has spoken of the nurse’s duty and the surgeon’s duty under these conditions, the former being to recognize the indications of increasing shock and alteration in pulse rate, the latter being to adopt every expedient for the checking of hemorrhage, including, in many cases, prompt re-opening of the abdomen. The more promptly this measure is instituted when demanded the greater the probability of saving the patient.

The principal danger after all abdominal operations, next to the possibility of hemorrhage, which rarely occurs, is that of peritonitis, a danger so imminent in the pre-antiseptic era as to have made the abdomen an almost sacred cavity, but one which is now almost abolished by perfection of aseptic technique, yet calling for neverending care and attention to detail, and occurring occasionally in spite of all the precautions which the most experienced and conscientious operator can take. This condition is to be feared when vomiting continues or comes on afresh, and in the presence of tympanites, with a steadily rising pulse. The first appearance of these threatening signs will be always a warning, although not invariably an indication of danger, since the condition producing them may be averted by catharsis or by meeting some special indication. Septic peritonitis, the great dread of the abdominal surgeon, and practically the only form with which he as such has to deal, will be considered by itself a little later. Yet it is always a question whether it is advisable, even in these cases, to administer powerful cathartics which provoke undue intestinal motion and favor the distribution of infection. While it is true that opium masks symptoms and leads to erroneous conclusions the same is frequently true of cathartics. From them a really obstructed or really paralyzed bowel suffers harm rather than good. They are too sparingly absorbed, and if absorbed their effect is bad. It is much better in these cases to wash out the stomach with a weak soda solution, and then keep it empty, emptying the lower bowel by the same means, and thus placing as much as possible of the intestinal tube at rest. With from 1000 to 2000 Cc. saline solution introduced beneath the skin each twenty-four hours patients can be kept from

starving for a sufficient length of time to permit of other treatment for the condition.

INJURIES OF THE ABDOMINAL WALL.

Contusions.

—Contusions of the abdominal wall may be followed by serious consequences, even though they have the appearance of being trifling. The injury that may be done implicates not alone the abdominal wall proper, but the viscera beneath. A blow upon the abdomen, followed by immediate collapse of temporary character (as the history of many a prize fight has shown), indicates a sudden reduction of blood pressure, the nausea and other features being due to the mechanism of the semilunar ganglia and the sympathetic nerves.

Contusions of the abdominal walls alone are serious largely in proportion as they are followed by extravasation or hematoma, since from failure of absorption of the latter there may result a cyst, or possibly an abscess should local infection occur. In either event evacuation and suitable local treatment are demanded. But any blow, even without penetration, may give rise to serious disturbances within the abdomen. Thus, as Richardson has said, the hollow viscera are liable to rupture, with extravasation, the solid to fracture with hemorrhage, while lacerations of the omentum or mesentery may produce immediate hemorrhage and subsequent possibility of intestinal obstruction. When extravasation has occurred distention and the ordinary evidences of peritonitis supervene. When the spleen or liver has been torn or crushed there will be obtained evidences of extensive internal hemorrhage.

Of the hollow viscera much will depend upon the degree of their fulness—especially with fluid. In a small tear there may be eversion of the mucosa, which may hinder or even prevent extravasation. Escape of infectious material into the cavity of the lesser omentum may produce local peritonitis, with subsequent development of what is practically a subphrenic abscess. When the patient vomits blood it shows that there has been rupture of the gastric mucosa. Intestinal rupture will be made known by rapid distention and the ordinary evidences of acute peritonitis. These injuries rarely lead to vomiting

of blood, but when occurring low in the bowel may lead to the occurrence of bloody stools. Rupture of the spleen or pancreas is rarely diagnosticated previous to exploration, save as a severe abdominal injury. It is not so likely to lead to rapid peritonitis. Rupture of the liver permits of more or less escape of bile, as well as of blood, and rupture of the gall-bladder permits the free emptying of bile into the upper abdomen. As this is usually harmless, in otherwise healthy individuals, the injury is not necessarily so serious as might appear. In such a case the resulting peritonitis will probably be local rather than general.

In this connection may be considered ruptures of the kidney, which are produced by similar injuries to those under consideration, and which may permit escape of urine or blood into the abdominal cavity, as well as the appearance of blood in the urine. While these will be considered in another place the possibility of their complicating abdominal injuries cannot be overlooked.

Considerable laceration will predispose to subsequent hernias, either direct or indirect, in the latter case by absorption following injury. The more serious consequences of abdominal contusions— i. e., the deep hemorrhages and lacerations of viscera—may then include all degrees of such injury, from trifling subperitoneal ecchymosis to extensive ruptures of such organs as the kidney or liver, or perhaps multiple perforations of stomach and bowel. These deep injuries will be considered by themselves when dealing with special organs. It is sufficient here to indicate their possibility and to warn that every severe contusion of the abdomen which is followed by local symptoms, or those which are grave and progressive, may at any time demand exploratory section, which should be made early rather than late. It is advisable to pass a catheter to make sure that there is no blood mixed with the urine, and to make a rectal examination in order to discover blood should it have escaped.

Penetrating wounds of all descriptions, punctured, incised, and gunshot, are again of importance largely in proportion to the damage done to intestines and great vessels. Some of these injuries are so evidently superficial that exploration may be abstained from, but every penetrating wound which has truly penetrated is to be treated either as they are treated on the battle-field, by mere inspection and

occlusion, or by careful exploration under all aseptic precautions. What the operator would do deliberately may not be what he can do in an emergency, but if he cannot reach one extreme he would best be content with the other.

Abdominal contusion has been found by Makin to be the cause of about 70 per cent. of the cases of intestinal rupture which have followed sudden or sharp blows, while the other 30 per cent. have been due to the passage over the abdomen of heavy objects. Le Conte has well summed it up in the following words: “If the force be circumscribed, and of high velocity and of small inertia, such as a kick or blow from some rapidly moving object, crushing of the intestine is more likely to occur; while if the force be diffuse, as from a slowly moving, ponderous object of considerable inertia (e. g., a wagon wheel), the belly is more apt to be torn at one of its fixed points or the mesentery injured. Thus out of 61 cases of horse-kicks of the abdomen in 59 intestinal rupture occurred. When the abdominal muscles have been braced in expectation of a blow less harm results than when it has been suddenly inflicted upon a relaxed musculature.” Crile has shown that the more specialized and abundant the nerve supply to a given viscus the more will it contribute to the production of shock when injured.

Pain is not always an immediate symptom. It may be delayed for hours, or possibly even for days. When intestinal rupture has occurred pain is most often referred to the central portion of the abdomen. In rupture of the spleen it is complained of in the left side, while when the kidneys have been ruptured pain follows the course of the ureters to the genitals and there is usually retraction of the testicle.

Muscle rigidity is a sign of equal diagnostic value with pain, and immobilization of the abdominal wall nearly always indicates intestinal rupture. The facial expression is also of importance, it being in the more severe cases almost distinctive. A steadily rising pulse is always a bad sign, usually indicating a developing peritonitis. Vomiting, if long continued, after a patient has rallied from the immediate shock, is considered of itself to justify operation. The same is true of paralysis of peristalsis.

Such injuries to the abdominal walls proper may divide important vessels, such as the epigastric, and give rise to hemorrhage which may be internal rather than external. The first and most important danger of hemorrhage having been passed or being avoided, the next and always urgent risk is of infection. This may come from nonpenetrating injuries, as well as those which open a wide path into the interior, and it is sometimes the small punctures which prove most disastrous.

From any wounded abdomen there may protrude omentum, intestine, or portions of some other abdominal viscus, while extensive abdominal incisions permit more or less evisceration. There are cases on record of pregnant women being injured by the horn of an infuriated animal and having the entire abdomen, as well as the pregnant uterus, ripped open, everything thus escaping. The omentum is the most likely to escape through small openings of all the abdominal contents, and this is fortunate for the patient for reasons to be mentioned in connection with the omentum and the peritoneum.

When the nature or the appearance of the wound make a complete perforation of the abdominal wall probable it will always be safer to be satisfied regarding deeper conditions. The parts having been thoroughly sterilized the ordinary probe is rarely sufficient, the best method of orientation being the sterile finger. Its use may require enlargement of the incision, and this should always be made. Such an opening being made and proving insufficient should be enlarged to any desired extent. Possibly a deep condition will be thereby revealed, which will make it expedient to open the abdomen freely in the middle line, and to deliberately practise one of the many expedients called for in such an emergency, such as ligation of vessels, intestinal suture, removal of a foreign body, and the like. The indication once met the incisions are closed, an infected wound being suitably drained.

In general it may be said that laparotomy is the wiser course in nearly every instance, and that it should be done when the surgeon is in actual doubt as to its necessity, it being better to give the patient the benefit of the doubt and operate. In all cases with serious symptoms it is certainly safer than to wait for further symptoms. This

will appear advisable in view of Curtis’ collection of 116 cases of intestinal rupture which were left unoperated, all of which died.

Gunshot Wounds. Foreign Bodies.

—In regard to gunshot wounds the principles of treatment in civil life are different from those obtained in an active military campaign. In the former the patient is usually given the best chance by an early exploratory section, with thorough examination of the abdominal contents, done with every aseptic precaution and every means for correct work. This is not possible upon the battle-field.

—Foreign bodies are occasionally met with in the abdominal wall. These may be introduced from without by accident or design, such as needles or splinters, or may result from the escape by slow process of some foreign body from within, such as a fish-bone, a needle, and the like. Thus in an abscess of the abdominal wall I once found a stick-pin over five inches long with a large glass head. This had been swallowed by an insane patient, who, subsequently recovering from her mania, went home and developed this disturbance a year or so after her release from the asylum.

PHLEGMONS AND OTHER SEPTIC INVASIONS OF THE ABDOMINAL WALL.

Abscesses may develop within the abdominal wall, without reference to deeper phlegmonous processes within. Thus they are occasionally seen after typhoid and the exanthemas, appearing perhaps as often in the rectus as anywhere. They may at any time result from superficial abrasions and travelling infections. They may occur sometimes as the extension of suppurating bubo, especially after phagedenic chancroid. They are recognized by signs which are usually unequivocal, and when once detected should promptly be evacuated.

Gummas, both tuberculous and syphilitic, frequently break down and form abscesses of mixed type. These may burrow deeply behind fascial planes, and require one or more counteropenings. As the result of a particularly virulent infection with the specific organisms that produce it one sees, rarely, about the abdomen expressions of

gangrenous cellulitis or malignant edema, which may spread here from some adjoining part and involve wide areas. Abscesses also result from infection of hematomatous or other cysts, while collections of pus arising in the chest, travelling far, may spread downward along the subperitoneal connective tissue and appear even low within the abdomen or externally upon it. Acute osteomyelitis of the bones of the pelvis, or acute suppurative spondylitis, may produce abscesses which will also involve the abdominal wall, while it frequently suffers in the effort of pus to burrow toward the surface, as in large perinephritic collections and the like.

Erysipelas not infrequently involves the abdominal surface, and, spreading deeply, may produce suppuration or a virulent type of peritonitis. The latter is more likely to occur in connection with wounds and other injuries.

Aside from burns of the minor type, which may involve large areas, there may be seen, especially upon the abdomen, extensive and distressing expressions of x-ray dermatitis, so called, followed by ulcerations, perhaps with the later development of epithelioma. These results of injudicious exposure to the cathode rays are always of the most painful and erethistic type, and most difficult to heal. Resistant cases are probably best treated by complete destruction of the surface with knife or spoon and skin grafting.

Upon the abdominal surface are seen some of the characteristic expressions of the ulcerative syphilide and of tuberculosis of the skin. The former will require active antispecific medication and the latter call for the curette or complete excision. In either case radical treatment is usually promptly successful.

Actinomycotic lesions are also seen, perhaps as often about the abdomen as anywhere. They are likely to be mistaken at first for tuberculous or syphilitic disease, but may be differentiated by appearances elsewhere noted. They require active eradication, combined with the local and general use of iodine and copper sulphate.

TUMORS OF THE ABDOMINAL WALL.

The abdominal walls are not exempt from tumors which involve similar textures in other parts of the body. About the ordinary hernial outlets it is advisable to proceed cautiously with any tumor, lest it may prove to contain or to be combined with a true hernia in disguise. This is especially true at the umbilicus. Congenital cysts in the walls are usually met with along the middle line, and will prove to be remnants of embryonic cysts, vitello-intestinal, urachal, echinococcus, or dermoid. Cysts should be distinguished from fatty tumors and sometimes from hernias or from cold abscesses.

Fatty tumors are common in all shapes, locations, and sizes. Among the benign tumors frequently observed are the fibromas, especially those of the type spoken of in Chapter XXVI as desmoids —i. e., those arising from the dense, fibrous, aponeurotic tissues, growing slowly, being exceedingly firm and hard in character, intimately connected with the fascia or aponeurosis, but not with the overlying skin nor with the viscera beneath. They are practically painless, may attain great size, and should always be removed while yet small, in order that the abdominal wall may not be weakened more than necessary by taking away the fibrous structures which especially give it strength.

The vascular tumors which call for surgery are uncommon. Pigmented nevi, however, are occasionally met, and these should always be promptly removed lest they degenerate into melanosarcomas. Varices and venous angiomas, sometimes of extensive dimensions, are also not infrequently found here. Extensive varicosities may have a congenital cause, the deep venous channels being insufficient, or they may be due to thrombotic occlusion of the abdominal veins following typhoid, puerperal fever, or injury.

Primary carcinoma originating within or upon the skin, epithelioma of similar origin, and sarcoma arising from the deeper mesoblastic tissues, may occur as primary tumors of the abdominal wall. We may also have endothelioma springing from the peritoneum, with possible origin elsewhere. Occurring secondarily we may see any of the ordinary metastatic expressions of any of these forms of growth, as well as those spreading by continuity, the most frequent example of

the latter being so-called cancer en cuirasse following cancer of the breast.

Finally, for those enormous overdevelopments of fat and connective tissue which accompany exceedingly pendulous abdomens, such as most commonly follow pregnancy or elephantiasis, the surgeon has occasionally to excise large areas, closing the defects thus made by numerous tiers of buried with strong superficial and retention sutures.

THROMBOSIS AND EMBOLISM FOLLOWING ABDOMINAL OPERATIONS.

It is well known that these conditions occasionally follow parturition and then lead to sudden death. A similar condition is now generally appreciated as occasionally following abdominal operation, and sometimes leading to the same fatal result. It has been said that thrombophlebitis follows about 3 per cent. of abdominal sections. It occurs oftener in the left than in the right leg, and its etiology is obscure. It begins with pain in the calf and groin, the leg rapidly swelling and then becoming edematous. Various writers have called attention to the occurrence of pleurisy and pneumonia during convalescence from appendectomy, and ascribe them to the presence of small emboli detached from the thrombi formed around the immediate site of the operation.

Two rather opposite theories prevail at present regarding the condition—one that it starts as a phlebitis due to infection at the time of the operation, the other that thrombosis is the primary lesion and therefore responsible for the phlebitis. Clark and others have contended that injury to the epigastric veins, by retracting and holding open abdominal incisions during protracted operations, is the cause of the trouble.

It would seem rational to hold that mechanical violence to the vessel walls, at or about the site of the operation, is the actual exciting cause in non-septic cases. On the other hand, the cases of infectious type should be accounted for either by local infection or as an expression of toxemia such as we see when similar

thrombophlebitis occurs during the course of typhoid fevers and the like.

Years ago, Agnew, for instance, stated that after operations in which much blood has been lost there is always more or less tendency to the formation of coagula, but certainly the majority of these operations today are accompanied by very little loss of blood. Embolic pleurisy and pneumonia may appear without preliminary symptoms, while abdominal thrombophlebitis rarely shows itself until at least the end of the first week and sometimes not until the fourth week after operation, and then more often in the left than in the right leg.

In the treatment of these cases palpation and massage are to be strongly avoided, lest thrombi be dislodged and thereby produce pulmonary infarcts. Rest and sorbefacient ointments constitute the best treatment.

C H A P T E R X LV I .

THE PERITONEUM AND ITS DISEASES.

Were the peritoneum spread upon a flat surface it would be found to equal in area that of the skin which covers the body. In man it is a closed sac; in woman it is exposed to exterior contamination through the Fallopian tubes by way of the uterus and vagina. Hence the frequency with which infections of the latter are transmitted to the membrane itself. Thickened in some places, or duplicated, for the purpose of forming ligaments and membranous visceral supports, it is usually thin, connected with the structures which it lines or covers by a more or less delicate, cobweb-like connective tissue. In some of its duplications relatively large amounts of fat may be collected. While freely supplied with bloodvessels it may be regarded as an enormous lymph sac, its capabilities of absorption being relatively immense. It is because of this that human beings escape many of the possibly fatal consequences of infection. Along it infectious processes travel, sometimes with wonderful rapidity, while again it throw’s out exudates and rapidly walls off a serious disturbance, imprisoning it, as it were, and often effectually Fluid may escape from it (fluid exudate) with great rapidity, or it may exude a fluid rich in fibrin which rapidly accumulates and forms a dense, firm exudate that serves to bind surfaces together and is often the surgeon’s best friend. In fact, the surgeon looks for a minimum and desirable amount of this exudate to ensure the result of whatever sutures he may pass through the peritoneum and the tissues which it covers. Thus after an ordinary intestinal suture it is expected that within some six hours the exudate thus formed will be of itself almost sufficient for the purpose of safety

Peritoneum is said to possess the power of absorbing from 4 to 8 per cent. of the weight of the individual within an hour, but this only under normal circumstances, since inflammation or previous lesions delay or interfere with the process. Increased peristalsis hastens it, the reverse being also true. On the other hand, conditions may be

easily reversed, and the presence of sugar or glycerin within the peritoneal cavity causes a diluting fluid to be thrown into it at about the same rate. It is by virtue of a firm, fibrinous exudate that foreign materials, e. g., ligatures, sutures, and even larger substances, are encapsulated, those which are capable of disintegration finally disappearing from within this investment. Occasional instances are on record of instruments, sponges, or pieces of gauze being left within the peritoneal cavity, in consequence of inadvertence during or when concluding an operation. Such bodies as these often encapsulate in this way and have been found years after at postmortem examination, or have been slowly extruded during life by natural processes. Such unfortunate occurrences as the latter afford the greatest reason for care during all such operations.

PERITONITIS.

The term peritonitis has been made to cover so many conditions, of widely differing pathological character, that it is intended here to consider only those which have a practical interest for the surgeon. It is unfair both to terminology and pathology to include under the same name conditions that may be brought about slowly, or without any participation of bacteria, with those which are due solely to bacterial invasion. No attempt will be made here to go into a minute or complete classification of the various conditions included by different writers under this name. For instance, they have spoken of an idiopathic form of peritonitis, thus confessing by use of this adjective ignorance of the etiology of the condition. The surgeon has neither use for such an expression nor belief in such a possibility. The thickening of the peritoneum which may result from the proximity of an old hemorrhage, or the irritation produced by the circulating fluids in cases of Bright’s disease, is for him an entirely different entity, and is neither an idiopathic form nor peritonitis itself. For surgical purposes we mention especially the following forms:

A. Consecutive;

B. Traumatic;

C. Perforative;

D. Tuberculous;

E. Malignant; F. Intra-uterine and infantile.

Forms A, B, and C may merge into one another or be confused from the beginning, or they may themselves be consecutive to D, while E, the malignant form, is hardly a distinct type, but rather a peritoneal expression of a more widespread general condition.

Again writers have endeavored to make distinctions by the use of such terms as “virulent,” “septic,” “putrid,” between which, however, no lines can be clearly drawn nor sharp distinctions made. They depend to some extent on the nature of the bacterial invasion, and again upon the actual virulence of the bacteria involved. The most distinctive type of surgical peritonitis is the tuberculous, which is usually relatively slow and recognizable as such, but as between the cases produced by spreading erysipelas, gonorrhea, intestinal perforation or postoperative infection one can make few, if any, distinctions which are serviceable or useful.

Anatomically considered there are two types of great importance— the circumscribed or local and the general or diffuse—prognosis depending in no small degree upon the extent of limitation of the active process, while at any time the former may merge into the latter. Consecutive peritonitis may include that which is the result of direct extension, as from erysipelas, appendicitis, acute cholecystitis, pyosalpinx, or other acute infections which have spread to and involve this membrane. Under this head also may be included those cases due to thrombosis or embolism, of mesenteric or other vessels, which lead to speedy gangrene of a part or all of the intestine.

Traumatic peritonitis refers rather to those cases where infection has been carried directly inward from the exterior. Traumatic peritonitis may be the result of extension of the same conditions which produce the first, the consecutive form, or only occur more directly, as, for instance, those cases produced by rupture of the stomach or duodenum after ulcerations of the same, or perforation of typhoidal ulcers, actual rupture and escape of the contents of a suppurating gall-bladder, appendix, tube, or any other collection of pus, or perforation due to the gradual extension of tuberculous, syphilitic, or malignant disease, with final rupture of a viscus.