Compliments of the Author. INAUGURAL ADDRESS ON SlO BY WILLIAM B. VAN LENNEP, A.M., M.D. Reprinted from the Hahnemannian Monthly, July, 1893. SHERMAN &. (Jo. PRS. PHIIA INAUGURAL ADDRESS ON SURGERY. BY WILLIAM B. VAN LENNEP, A.M., M.D., (Chairman of the Surgical Section of the World's Congress of Homceopathic Physicians and Surgeons.) The instructions of the Executive Committee were that the chairmen should give a review of the literature of their respective departments for the past year or two. Such a review of the surgical work, if any justice were done to the subject, would require more time than the utmost limits of courtesy could accord even a chair- man. We were also instructed to give the utmost possible latitude to the discussion of the various papers, and, as far as possible, to have the latter of such a character as to invite comment. The es- says were, therefore, to deal with live subjects, to be suggestive, and not too exhaustive. To further this end a number of gentlemen have prepared themselves to discuss or, better, to enlarge the scope covered by the different essays. In this way, practically two or three papers are assured on each subject, which is viewed from as many different standpoints. Surgery in general will be the theme of an address to the Congress by our eminent colleague, Dr. Hel- muth, who will undoubtedly handle it as he only can. Again, the essays presented by the bureau cover a number of the most im- portant divisions of the domain of surgery-anaesthesia, shock, the brain, the thorax, the bladder. Each of them will necessarily re- view the literature more or less completely. It has, therefore, been deemed advisable by your chairman, for the sake of brevity, and particularly with a view of eliciting dis- cussion, to confine himself to a subject that has not been touched upon by the members of the bureau-a review of the work done in the surgery of the intestines during the past year. The aids to intestinal suture inaugurated by the work of Senn have been extensively used and modified in this country. In Eng- land, the decalcified bone plates were popularized mainly by the work of Jessett, but on the Continent, and particularly in Germany, these 2 devices were looked upon with suspicion, and, after considerable discussion and experience, there seems to be a revulsion of feeling, until the ideal method is getting to be one that depends on the un- aided suture. This is particularly true of lateral anastomosis, which has come to stay apparently, the great drawback to plates and rings of any kind being the small communicating opening, which in time contracts to a dangerous extent. To avoid this a four-inch anasto- motic opening seems indispensable, and the technique is as follows: The intestinal surfaces are united by two parallel rows of con- tinuous Lembert sutures, a quarter of an inch apart and an inch longer than the proposed opening. The ends of the threads are left attached to their needles. The bowel is opened to the extent of four inches, a quarter inch from the two rows of sutures. Bleeding points are clamped until caught up by a whip stitch running around the opening and including all the intestinal coats. The two rows of continuous sutures first applied are then carried around this and the union is complete (Abbe). Weir and Markoe report successful cases by this method. To avoid the danger of infection from opening the gut an anas- tomosis in two tempos has been proposed, the second, however, being carried out by nature. While intended particularly for gastro- enterostomy, the principle is applicable to any portion of the intes- tinal canal. The serous surfaces being united by a linear suture, an oval piece is cut out from each intestine, a quarter of an inch from the suture, leaving the mucosa intact. The free edges of this opening are united on one side, the bulging mucous membranes are drawn out, and a ligature tied tightly around them. The remaining free edges of the opening are then stitched, and the field of operation enclosed by a continuation of the first serous suture. By sloughing of the ligated mucous membrane the anastomosis is completed by the third or fourth day (Postnikow). The importance of the firm fibrous submucosa as an anchoring ground for any suture is to be particularly borne in mind, and prac- tice will teach the surgeon to recognize the resistance that shows it has been entered. While it is indispensable to the firmness of a suture that it should include a few fibres of this coat, great care must also be exercised not to perforate it and enter the intestinal lumen, as fatal leakage would result (Halstead). Another valuable principle, which has a great range of applica- bility, e.g., pyloric excisions, gastro-enterostomy, intussusception, end-to-end union, high rectal excisions, etc., consists of tacking to- 3 gether the lumina to be united by two stitches, one being applied at the mesenteric junction when that is to be included. An opening is made in the bowel a short distance from the ends to be united, which are then invaginated and drawn out of this opening by traction on the two sutures above mentioned. By passing a dozen or more in- terrupted stitches through the tube that is thus drawn out, pick- ing them up in the middle and dividing and tying them, the in- testinal edges may be united at twice as many points. The sutured gut is then drawn back and the temporary opening closed. In this manner all the sutures are passed from the inside (Maunsell). A case of intussusception with carcinoma has been successfully treated by this method (Hartley). A somewhat similar procedure has been practiced for irreducible intussusceptions. The intussusceptum and intussuscipiens are united at a point where the former enters the latter, by a fine silk suture which includes the mesentery. The intussuscipiens is opened two inches below this point, and the intussusceptum amputated. The stump is sewed with a whip stitch, arresting all bleeding, and the opening closed (Barker). Another modification consists of amputation of the intussusceptum in the same manner, ligature en masse of the stump, and an anasto- mosis between the intestine above and the opening made to get at the intussusceptum (Bier). The principle of the Heineke-Miculicz method of pyloroplasty has been extended to intestinal constrictions of a cicatrical nature in which resection is not deemed necessary (Pean, Hacker). The danger of leakage after intestinal perforation or suture has been shown, experimentally, to be obviated by closing the opening or protecting the suture, by covering it with a neighboring loop of intestine or omentum. This has been found safer, and, of course, of wider applicability than the omental grafts so extensively used of late (Chaput). The same writer closed openings made in the intes- tines of dogs with five or six thicknesses of iodoform gauze in the shape of pads, the edges of which were stitched around the orifice. The gauze acted temporarily, working its way gradually into the bowel, the opening being closed by adhesions to neighboring coils of intestine or omentum. He also found that strips of iodoform gauze were an efficient protective to any intestinal suture. It has also been shown, experimentally, that a part of the small intestine could be transplanted between two ends of the colon and replace the latter when extensive resections of it have been made 4 (Micholi, Robinson). These experiments have led to a novel proposition for the treatment of the hitherto rebellious cicatricial strictures of the rectum. The patient is placed in the Trendelenburg position and the abdomen opened. A loop of small intestine lying near the rectum is removed, care being taken that a large nutrient artery supplies each extremity of the piece to be transplanted. The ends are anastomosed with the rectum, forming a new channel around the stricture. The serous surfaces are scarified and sutured together. Subsequently this line of union is divided by compression forceps from the anus, cutting through one-half of the stricture, and making the two lumina into one (Bacon). In resections for malignant disease, while one of several cases may be cited, in which the caecum, ascending colon, and several inches of the ileum were successfully removed (Lowson), the tendency is toward an operation in several stages: 1. The growth is first isolated by resection, the two ends of the intestine being drawn out of the wound. 2. The continuity of the intestinal canal is established by anastomosis or end-to-end union. 3. The isolated growth is excised (Bloch, Hochenegg). This method can often be practised when hitherto we only had physiological exclusion by anastomosis at our disposal; it is a curative instead of a mere palliative measure, where primary excision is unsafe. Among the substitutes for the bone plates may be mentioned plates of raw potatoes (Dawbarn) and raw Swedish turnip (Von Baracz). They have the advantage of being obtainable in emergen- cies, and can be cut to any size desired, so as to insure a large anas- tomotic opening. The sutures are fastened by being drawn through rubber tabs cut from drainage-tubing, much as carpet tacks are armed or protected (J. E. James). Another device, which has excited considerable comment, consists of two metallic buttons or cup-shaped discs from the middle of which protrude hollow cylinders. One cylinder can be pushed into the other, but has to be unscrewed when withdrawn. The intestinal openings are drawn over the edges of the discs by a puckering con- tinuous suture, and are firmly held together by them until union takes place (Murphy). Their sphere appears to be particularly end-to- end union, for, when used in a case of ileo-colostomy, the anastomotic opening closed to a dangerous extent in a few weeks (Keen). The stomach has received considerable attention. Gastrostomy appears to be particularly indicated in cicatrical narrowing of the oesophagus, when tubage fails, as it offers a curative inducement in 5 the shape of retrograde dilatation. For malignant disease it is dan- gerous and prolongs life but a short time (Senn). The rectus muscle and the eighth intercostal space are the points of election for the fistula. In the former location leakage is prevented by a sphincter- like action (Allingham). Leakage may also be avoided by the use of two inflatable rubber bags, one inside and one outside, connected by a rubber tube. The operation is done in two tempos. It is claimed that the movements of the stomach are seriously interfered with, and considerable stagnation occurs; also, in all probability, the hepatic function is impaired if not destroyed, nutrition being carried on by the intestine (Ewald). Gastro-enterostomy has been quite extensively practiced, with not altogether satisfactory results. It is, after all, but a palliative meas- sure, and owes its popularity largely to the dangers of pylorectomy. With a view to lessen these, it has been combined with excision and closure of the openings in the stomach and duodenum. Another palliative plan has been suggested, i.e., jejunostomy. The jejunum, a short distance below the duodenum, is drawn out and divided, and the distal end sewed into the wound, while the proximal end is implanted into the distal intestine, a few inches from the fistula, to allow the pancreatic juice and bile to flow into the intestine. (Maydl). Digital divulsion (Loreta) has resulted fatally from rupture, al- though not carried to the extent recommended by its originator (Swain). Pyloroplasty (Heineke-Mictilicz) has been successfully practiced a number of times for cicatricial pyloric stenosis (Page, Koehler, etc.). A novel plan has been followed for the relief of dilatation of the stomach, i.e., folding or plaiting its walls by rows of sutures which do not include the mucous membrane (Weir). It is a generally acknowledged fact, that an operation for bowel obstruction is not completed until the intestinal paresis is relieved by puncture of the distended intestine. As a substitute for this, lavage of the stomach is proposed, and has been successfully used. (Lund). Post-operative obstructions have been, in several instances, suc- cessfully operated by section and separation of adhesions (Lucas- Championiere). From the fact that these are soft, and easily sep- arated within the first few days, the attempt has been made to break them up, by first washing out the stomach, and then pouring into the tube a half-ounce of castor-oil. Flatus and copious stools were 6 passed (Klotz). Both lavage and opium are looked upon as dan- gerous from their masking effects in intestinal obstruction, although the former is of value immediately before an operation to relieve re- versed peristalsis, and prevent actual "drowning" of the patient (C. M. Thomas). Early operations or exploratory section, as soon as the diagnosis of obstruction is made, have been, more than ever, emphasized. The term " exploratory " is used because the pathognomonic symptom being faecal vomiting, this should not be waited for, but the section made "on suspicion." Every condition, aside from faecal impaction, which can produce the clinical picture, calls for a like treatment. In cases where the cause of the obstruction is hard to find, a short circuit by lateral anastomosis has given gratifying results (Atkin- son). Unnecessary, and often fatal delay and handling of the intes- tine is avoided in this manner. Nelaton's enterostomy has also been resorted to in desperate cases. A rapid method of forming the artificial anus consists of attach- ing the intestine to the parietal peritonaeum by eight or ten haemo- stats, which are removed in twenty-four hours, when adhesions will have formed (Chaput). In spite of the fact that the respective advocates of the clamp and cautery, and those of the ligature, in the treatment of haemorrhoids, have partly ceased their invective against the more surgical methods of excision (Pratt and Whitehead), and directed their abuse to those who dare suggest any but the operation they have recently learned, colotomy, nevertheless, the excisions of malignant rectal neoplasm have increased their hold on the profession. And justly, too, for every physician should strive after curative rather than palliative measures. The plan proposed by Kraske has, with certain modifi- cations, been extensively and successfully practiced and advocated (McCosh). The results are as satisfactory as could be expected with cancerous disease. The sphere of the operation has been extended to attack the uterine adnexa (Montgomery) and the terminal por- tion of the ureter (Cabotj. In consequence of the incontinence frequently resulting, to allow of more extensive enucleation, and to insure an asepsis of the wound, the writer has successfully practiced the followed method : 1. The formation of a permanent anus by inguinal colotomy, the intestine being drawn well down to leave an abundance of sigmoid flexure below, and to prevent prolapse. 2. Complete and thorough extirpation through the anus, through the sacrum, or by opening the 7 peritonaeum and drawing down the gut. Usually two or all three of these steps have been combined. 3. Closure of the resulting wound by granulation aided by suture. In cases where the growth is not readily accessible from the abdo- men or through the sacrum, Maunsell suggests the use of the prin- ciple already referred to: the abdomen is opened and the peritonaeum around the bowel incised. The growth is then drawn out of the dilated or incised anus by invaginating the gut. It is excised by amputating the intussuseptnm and the stump sutured in the manner already described. The intestine is drawn back into the abdomen, and the peritoneal incision closed. Inguinal colotomy or colostomy or sigmoidostomy is the operation of election and has been very extensively used to the exclusion of the lumbar, the well-known methods of suspension with a rod or suture, together with previous drawing down of the intestine being followed. When no time is to be lost the gut has been simply sus- pended with a rod, the wound being stuffed with gauze (Reeves after Maydl). When immediate opening is necessary a tube has been introduced and the bowel tied around it (Jones), or the intestine has been punctured with a trocar and a rubber drain attached to the ca- nula to carry off the discharges (Robson). In this way contamina- tion is prevented until safe adhesions take place. The subject of appendicitis has naturally received considerable attention. While but little that is new has been published, what is already known has been emphasized, and, better still, the profession generally have been aroused to realize the importance of this affec- tion. The impossibility of an idiopathic peritonitis, the frequency of appendical trouble, its fatality, and the importance of a study of each case from its incipiency, by the surgeon as well as the physi- cian, are becoming pretty generally realized. It was a healthy sign of the times to the writer when he offended the physician and disap- pointed the family by advising against an operation between attacks in a recent case. The advisability of such operations between at- tacks has been very strongly emphasized, and the cases, which were but few and far between when the writer gave his experience on the subject at the last congress, have been indefinitely multiplied, and have shown most satisfactory results (Morris and others). The in- dications are frequency of recurrence, increasing severity of attacks, and, particularly, continuance of pain and tumor between attacks. Persistent colicky pains, with tenderness in the region of the appen- dix, have been relieved by excision of the organ, which was found 8 to be moderately diseased. Distinct attacks were absent (Hoch- steter). The writer has opened three such eases, and has been sur- prised at (1) the slight changes in the appendix; (2) the suffering resulting from such lesions, amounting at times to complete invali- dism ; (3) the complete and permanent relief following excision. Such cases have led to the use of the term "appendicular colic" (Bin- 11 ie, Kammerer), which probably applies to the majority that get well, the pain being due, it is said, to expulsive efforts on the part of the organ to get rid of concretions, or to overcome stricture or twists. The indications for operation are the same, however, as when marked pathological changes are present, so that the distinc- tion has but little clinical value. While almost every case of so-called typhlitis is dependent upon a diseased appendix, an occasional report is published of lesions in the caecum, which produce much the same phenomena and results. In one instance a circumscribed faecal abscess was found to- be due to a perforating caecal ulcer. The onset of the trouble was more insidious, diarrhoea having preceded it and being present; the ini- tial vomiting was also absent; the appendix was normal (Hartley). As to the pathology of appendical disease, catarrh beginning at the caecal junction is still considered the usual cause. This is fol- lowed by the well-known changes: thickening, stricture, ulceration, perforation, or the formation of faecal concretions (Kiimmel). For- eign bodies are rare, although occasionally met with (Pinnock). Tubercular disease has also been known to be a not infrequent cause of this affection (Delorme), and actinomycosis may also affect the organ (Lang). The importance of early operating has received due attention, some going so far as to recommend it as soon as a diagnosis in made (Hurd, Marshall). Persistence or aggravation of the symptoms after twenty-four hours, and particularly, the characteristic signs of peritoneal infection are the indications mainly relied on. An occa- sional cure after septic peritonitis has been lighted up, gives en- couragement to try to save life even in this desperate condition. Cocaine as an anaesthetic (Tachard), and rectal puncture without anaesthesia have been resorted to in very weak patients (Rich- ardson). That attacks which subside should be watched with care and sus- picion is shown by a case of the writer's: a young man got over a severe attack so completely that he was allowed to go about the house. A little exertion was followel by dangerous constitutional 9 symptoms and the rapid development of a large tumor. A small, well-encysted abscess had ruptured, and the whole right side of the abdomen was filled with a stinking fluid only feebly protected by adhesions. But for these adhesions he would have quickly died of fulminating septic peritonitis. As to the technique, iodoform gauze to protect the general ab- dominal cavity, together with a light pack of the same and a drain for the abscess, are universally used. The appendix unless readily accessible is usually left alone in these abscesses. Occasional cases of peritoneal infection have been met with in which the appendix was not perforated or gangrenous (Poncet). Operations for the radical cure of hernia have been performed frequently, and on the whole, with improved results, but the ten- dency is a revolution from the enthusiasm that has led to indis- criminate operating and early reports of so-called cures by new methods. The ultimate results of a number of procedures have been reported, which show the failures, particularly after the method that claims to substitute a cicatrix for a truss (McBurney), and which has been extensively practiced (Bull). The tendency now seems to be toward a restoration of the normal relations of the tissues as laid down in the method of Bassini. The principles of this procedure are, excision of the sac with obliteration of the peritoneal dimple, closure of the internal and external rings, and narrowing the canal, which has been split, by a close approxi- mation of the different muscles and fascia. The narrowing of the external ring has been still further completed by chiselling a groove in the public bone, laying the cord in this, and covering it with periosteum which has been preserved (Frank). The presence of the cord as an invitation to recurrence has been studied too. Its removal to prevent relapse once led to such a uni- versal practice of castration as to call for special legislation. The sac being excised and sutured or tied, the ends of the ligature are passed through the muscles above the internal ring to draw up and smooth the peritonaeum. (In this connection it is worthy to note that Tait's proposition, to reduce the hernia and close the sac and ring from the inside through an abdominal incision, has been prac- tised occasionally.) The cord is hooked up while the muscles and fascia are closely united, obliterating the inguinal canal ; by fasten- ing the cord in the outer angle of the wound, its direction of exit is changed from that of the inguinal canal to directly forward, or for- ward and outward. It is then laid outside the muscles, and the skin and fat closed over it (Halstead). By carrying an incision up- 10 ward from the internal ring the direction of the cord may also be changed to an upward one, whence it comes down into the scrotum as above (Fowler). To lessen the size of the opening all but one or two of the spermatic veins, which are apt to be enlarged, are excised (Halstead). As aids to closure of the opening decalcified bone has been used: also the outer pillar of the external ring has been detached, to- gether with a bit of bone forming its insertion, carried across to the inner pillar and nailed to the symphysis. In this way the open- ing is reduced to a mere slit (Landerer). The sac has also been used as an external plug in contradistinction to Macewen's internal pad; after being isolated it is drawn out of an opening opposite or external to the inner ring thus changing its direction. It is then twisted to obliterate the peritoneal dimple (after Ball), and fastened outside of the aponeurosis of the external oblique (Kocher). Following the observation that the mesentery of the protruded gut is usually lengthened in hernia, and that the presence of this condition invites recurrence, it has been proposed that it be short- ened by folding and suture (Shimwell). To avoid infection of the wound, particularly in children, the urine has been diverted through a peritoneal opening (Gerster). The treatment of femoral hernia, hitherto either entirely ignored or relegated to a hurried postcript after an elaborate description of a new method for the cure of inguinal hernia, has received more attention. The stump of the sac may be tacked well up inside the abdominal wall through which the suture ends are passed, or the isolated sac may be drawn through an opening above Poupart's ligament, twisted and incorporated in the lower wound, serving in this way as a plug to fill the femoral canal (Kocher). The need of such a plug or bar- rier has led to the turning up of a piece of the fascia of the pecti- neus muscle where it is thick and tough (Salzer), or the fascia and a flap of this muscle itself (Cheyne). In this manner the femoral canal is completely closed. As the results of operations for the cure of inguinal hernia have been far superior to those for the femoral variety, an attempt has been made to transform the latter into the former. The tumor is incised and the sac freed; the inguinal canal is split and its posterior wall divided ; the sac is drawn into this opening, tied off, and both wounds accurately sutured (Ruggi). The indications for an attempt at radical cure are (1) ineffectual, partially effectual, or painful trusses; (2) irreducible hernia; (3) occupation tending to force out the rupture; (4) proposed occupation 11 which is precluded by hernia; (5) strangulated hernia, where the local and general condition permit of such an undertaking (Ben- nett). Hernia in women, particularly when young, with the child- bearing age before them, seem to merit a trial of operation (Lucas- Championniere). The treatment of gangrenous or suspicious bowel still calls forth a diversity of opinion. Relief of the constriction, warm applica- tions, or temporary replacement with an anchor thread attached should be tried in all uncertain cases. If a doubt still remains, the intestine is fastened outside the abdomen, dressed warmly and anti- septically, and observed. In a case in which this plan was followed the gut was found normal on the fourth day and successfully re- placed (Rovsing). In similar cases it is suggested that the gut be well drawn out, an anastomosis made above the suspicious area, and, after sloughing has taken place, the two openings be closed and the gut replaced (Helferich). In general, however, primary resection is to be preferred to the formation of an artificial anus, and gives, on the whole, a lower mortality. It is of course understood that the patient's condition and lhe surroundings permit such a procedure, and that the surgeon has the requisite skill. As to the method of uniting the two ends, the weight of opinion seems to be in favor of the end-to-end plan, with or without aids. These artificial aids may be in the shape of rubber rings or splints, or metallic buttons to hold the ends together; a rubber tube or de- calcified bone drains to hold the intestine open and prevent invagi- nation. When the two lumina are unequal, several plans may be followed: lateral anastomosis, lateral implantation (the small end into the side of the large tube), slitting up the smaller tube, or ex- cising a V-shaped piece from the larger on the surface opposite the mesentery until the openings are of equal size, when they are united. The dangers of the persistent use of taxis have received well merited attention (Bennett). Bruising or rupture of the bowel are often produced and much valuable time is lost. These two factors are largely responsible for the mortality of from thirty-two to forty- six per cent, in the large English hospitals (Southam). The local application of ether, followed by gentle and intelligent taxis for not more than five minutes, and that only when a true hernial im- pulse is perceptible, will obviate the above mentioned dangers. Im- mediate recourse to operation after the failure of such procedures cannot be too strongly emphasized. The persistent application of sulphuric ether to strangulated hernia has brought about reduction 12 when taxis, under an anaesthetic, has failed (Finkelstein). Such a procedure would be particularly useful as a preliminary to taxis and operation before the arrival of the surgeon and during the prepara- tions for operation. Although, as a rule, the presence of an undescended testicle in a hernial sac calls for castration, Depage records a case in which it was drawn down into the scrotum and the hernia treated in the ordinary way. Cases of strangulation symptoms from the appendix, omentum, and testicle are also reported. Of the special varieties of hernia, a number have been pub- lished : 1. Littrc's hernia with no tumor, the partial nipping of the bowel in the right femoral ring being found and reduced through a median abdominal incision (Keen). 2. An obturator hernia, strangulated and made out by a tumor, was successfully operated by Wyman. Anderson opened the abdo- men for persistence of obstructive symptoms after an operation for femoral hernia, and. found a knuckle of gut in the left obturator foramen. Examination by the rectum or vagina, as well as the dif- fuse deep swelling and pain, are the diagnostic points (Berger). 3. Ischiatic hernia has also been found : (a) through an abdominal section after persistence of symptoms in spite of a femoral herni- otomy (Garve); (6) on removing a fibro-lipoma, to which two her- nial sacs were found attached (Schwab). 4. Hernia into the foramen of Winslow was made out, but not reduced by abdominal section, recovery following a large enema (Neve). 5. Diaphragmatic hernia has been met with, but only diagnosed after death. 6. Pro-peritoneal hernia has been looked for and found, on account of non-relief of symptoms and difficulty in reduction (Bull and others). 7. The writer has operated two cases of hernia of the urinary bladder recently. Pain was a prominent symptom, but vesical symptoms were absent. No truss could be worn. In one the at- tenuated diverticulum was opened for the sac, the bladder drained, and the wound allowed to heal by granulation. In the other the viscus was recognized and the abdominal wound treated in the ordi- nary way. Both recovered and have not had relapses so far. The subject has received considerable attention (Aue, Lejars).