INFLAMMATION IN THE RIGHT ILIAC FOSSA, ASSOCIATED WITH LESION OF THE CECUM, THE VERMIFORM APPENDIX AND ADJACENT TISSUES.' BY JOHN B. DEAVER, M.D., PROFESSOR OF SURGERY IN THE PHILADELPHIA POLYCLINIC; ASSISTANT PROFESSOR OF APPLIED ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA. FROM THE MEDICAL NEWS, August 6, 1892. [Reprinted from The Medical News, August 6, 1892.] INFLAMMATION IN THE RIGHT ILIAC FOSSA, ASSOCIATED WITH LESION OF THE CECUM, THE VERMIFORM APPENDIX AND ADJACENT TISSUES.1 By JOHN B. DEAVER, M.D., PROFESSOR OF SURGERY IN THE PHILADELPHIA POLYCLINIC ; ASSISTANT PROFESSOR OF APPLIED ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA. It was with no little hesitancy that I selected for the subject of my remarks "Inflammation in the Right Iliac Fossa, Associated with Lesion of the Cecum, the Vermiform Appendix and Adjacent Tis- sues," as I was conscious that the part of the subject coming especially under the head of appendicitis is one upon which much has been written. My apology, therefore, is that I hope to present it in a somewhat different manner than it is usually dealt with, and, to insist upon the importance of the sur- geon being called in counsel earlier than has been the custom. So often have I been impressed with the responsibility of the position of the physician who is called to treat cases of this character and does not seek the advice of the surgeon until the eleventh hour, when, perchance the patient has de- 1 Read at the Twelfth Annual Meeting of the Lehigh Valley Medical Association, held at Bethlehem, Pa., July 7, 1882. 2 DEAVER, veloped a diffuse peritonitis, or is in a state of col- lapse, most commonly caused by the rupture of an abscess, that I feel warranted in offering this sugges- tion. Inflammation in the right iliac fossa, associated with lesion of the cecum, the vermiform appendix and adjacent tissues, can be divided clinically into two classes, namely, intra-peritoneal and extra-peritoneal. The former includes the cases referred to in the text-books as those of appendicitis, typhlitis and peri-typhlitis. I propose the term intra-peritoneal inflammation to include all cases of inflammation in the right iliac fossa having their origin within the peritoneum and associated with lesion of the cecum or the appendix, for the following reasons: i. I believe it impossible to differentiate between appen- dicitis, typhlitis and peri-typhlitis. 2. I believe the terms typhlitis and peri-typhlitis to be mislead- ing, and so long as it is taught that they are dis- tinct affections, independent of trouble with the appendix, will the physician be misled. As a re- sult of this classification, there is delay from day to day, in the hope that the case is one either of typhlitis or peri-typhlitis, and that operation is not so urgently called for as were the case one of appen- dicitis. I consider it nothing more than a mere refinement to divide inflammation of the cecum, as is done, into inflammation of the gut proper and inflammation of its serous covering (peri-typhlitis). I cannot see the practical value of such a division, as both conditions require a common treatment, and further, I do not believe it possible to make the differentiation at the bedside. APPENDICITIS, ETC. 3 It has been my fortune to have seen a large num- ber of cases of inflammation in the right iliac fossa, as well as to have operated on many, and I think I have clearly demonstrated that the best classifica- tion of the three pathologic conditions, appendi- citis, typhlitis and peri-typhlitis, is under the head of intra-peritoneal inflammation in the right iliac fossa. In the greater number of cases of inflamma- tion in the right iliac fossa the vermiform appendix is the organ primarily attacked; yet there are cases, as has been demonstrated post-mortem, in which the cecum alone is the seat of the trouble. Again, I believe, as do most observers, that when post- mortem both the cecum and the appendix are found to have been the seat of inflammation the starting-point has been in the appendix. Granting, then, that there are three pathologic conditions included in intra-peritoneal inflammation in the right iliac fossa, and that it is only in exceptional cases that the diagnosis between typhlitis and peri- typhlitis can be made, is it not safer and more rational to dispose of all three conditions as one ? The differentiation is to be compared with the at- tempt to recognize the different coverings of the strangulated hernia: while anatomically there are several coverings, these are practically indistinguish- able. The differentiation between typhlitis and peri-typhlitis, I think, requires an astuteness greater than we are willing to concede even to the most expert. Extra-peritoneal inflammation in the right iliac fossa includes the class of cases in which the tissues adjacent to the cecum and the appendix are in- 4 DEAVER, volved and constitutes para-typhlitis. While I do believe that there are cases of extra-peritoneal in- flammation (para-typhlitis) that originate independ- ently of any trouble in the appendix, and involve simply the connective tissue adjacent to the cecum, I do not deny that the starting-point of such an in- flammation may not be in the appendix. The latter condition may arise when the appendix is an extra- peritoneal organ, as when it lies posteriorly to the cecum and the ascending colon. When the ap- pendix is post-cecal, as well as post-colic, and is the seat of ulcerative inflammation, it is readily under- stood how, by extension by continuity of tissue, the inflammatory process may involve the connective tissue adjacent to the appendix, and thus occasion a so-called para-typhlitis. This anomalous position of the appendix, when the seat of perforative appen- dicitis, further accounts for extra-peritoneal collec- tions of pus in the right iliac fossa due to appendi- citis and not (in every instance) consequent solely upon inflammation of the connective tissue in the neighborhood of the cecum. It likewise explains why abscess, the result of an appendicitis, does not always point internally to the anterior superior spine of the ilium, but may from its position simulate peri-nephric or lumbar abscess. An intra-perito- neal inflammation starting as an appendicitis and forming a circumscribed swelling, shutting itself off from the general peritoneal cavity by the formation of adhesions, may go on to pus-formation and even rupture into the peri-cecal and peri-colic tissues. With a knowledge that all inflammations in the right iliac fossa associated with lesion of the cecum, APPENDICITIS, ETC. 5 the vermiform appendix and the adjacent connective tissue are divisible into intra-peritoneal and extra- peritoneal, our first duty is to distinguish between them. This we will do under the following heads : 1. History. 2. Symptoms. 3. Physical Examination. History. Extra-peritoneal Inflammation. Usually constipation. Very slow onset, particularly if not caused by injury inflicted from without. Intra-peritoneal Inflammation. Constipation the exception rather than the rule. Onset sudden. There may have been one or more attacks before. Likely to follow a very heavy meal, eaten in a hurry, or the ingestion of indigestible food. Symptoms. Pain confined in great measure to the outer part of the iliac fossa in the line of the loin. Con- stitutional disturbance not at all pronounced early. Disposition, when standing, to incline to the right side, soon followed, if the trouble does not abate, by flexion of the thigh upon the abdomen. Numbness and pain in the right leg frequently com- plained of. When the inflam- matory deposit is great enough to exert pressure upon the right iliac vein there will be edema of the right leg. In most cases, pain at first re- ferred to the umbilical and epi- gastric regions, but later to the right iliac fossa. Nausea early and very often vomiting, which becomes uncontrollable if the case does not yield to active treatment. Thirst, which may be extreme. Furred tongue. Bowels usually confined, but there may be a slight tendency to diarrhea. The temperature ranges from ioi° to 103°, or higher, with a rapid pulse-rate. Here, too, there may be a dis- position on the part of the pa- tient to incline the body to the affected side, as well as to flex the limb upon the abdomen. Very often, frequency of urina- tion. 6 DEAVER, Physical Examination. Extra-peritoneal Inflammation. Tenderness above the crest and externally to the anterior superior spine of the ilium and in the line of the loin. Dulness followed by flatness, at first upon deep percussion, and later upon superficial per- cussion in the line of the crest of the ilium. If the case steadily pro- gresses, a mass corresponding in position with the area of dul- ness will be detected. Digital examination through the rectum yields negative in- Intra-peritoneal Inflammation. General tenderness over the right iliac region is very marked. In the majority of cases I have not found the greatest amount of tenderness at any one point in the fossa, as has been described by McBurney. Yet, in a few cases, I have seen it most pro- nounced at the so-called Mc- Burney point.1 Superficial percussion in the very early part of the case yields negative information, while deep percussion will reveal dul- ness, and later flatness, as the case steadily advances. Palpation detects very de- cided resistance offered by the abdominal muscles of the af- fected side.2 In many cases an indurated mass is detected by palpation of the abdominal wall, which, in many instances, is circum- scribed, while in others it be- comes rapidly diffused, particu- larly in the direction of the linea alba and of the pelvis. Deep rectal, as well as vagi- nal, examination3 I do not re- 1 This point I regard as more useful in approximately locating the site of the base of the appendix than as a diagnostic sign. If the inflammation is most intense in the terminal portion of the appendix, as well as in the class of cases in which the appendix is anomalously located, of what value can this so-called point be ? I consider it of no significance whatever in helping to arrive at a correct conclusion as to the nature of a given case. 2 This I regard as an important sign to be considered in the diagnosis. 3 When I speak of deep rectal examination, I mean introduction of the finger alone, and not the introduction of the hand, as has been suggested. The latter I consider a most deplorable measure. APPENDICITIS, ETC. 7 formation. Vaginal examina- tion may be of some value, and should at least be made. If suppuration takes place, it is usually first manifested by edema of the abdominal walls overlying the mass. Fluctua- tion is more readily made out than in intra-peritoneal inflam- mation. gard of much diagnostic impor- tance, early in the case at least. In those cases in which the ap- pendix holds its third position, I regard it of value. Suppuration is not so readily dectected in this as in the extra- peritoneal form, as fluctuation is more difficult to elicit. Yet I have seen it moderately well pronounced many times. If the mass can be felt through the rectum or the vagina it is well to palpate the abdominal walls at the same time, and in this way elicit fluc- tuation. Edema of the overlying abdo- minal walls I have not found present as often in the intra- peritoneal inflammation as in the extra-peritoneal. If asso- ciated with the presence of a mass in either variety of inflam- mation there are decided chills and sweats, it would be very evident that pus is present. Case I.-W. R., thirty-eight years old, seen in consultation, presented a swelling in the right iliac fossa, extending backward in the line of the loin; edema of overlying abdominal walls; a rather sharply defined mass. The thigh was flexed on the abdomen. The temperature had been fluctuating for several days, and there had been chills and sweats. The history was one of slow onset, with pain in the right iliac fossa, extending to the loin. A diagnosis of extra-peritoneal inflammation was made, and operation advised. An incision was made in the right semi-lunar line down to the trans- versalis fascia, which was opened, and the sub- peritoneal fat exposed, when, after a little dissection, carried backward in the direction of the loin, a large quantity of pus was evacuated. The cavity was 8 DEAVER, washed out, drained, and packed with iodoform- gauze. Palpation of the peritoneum, which was clearly exposed, over the site of the appendix, yielded negative information. Recovery was complete and uneventful. Case II.-R. B., twenty-two years old, was ad- mitted to the German Hospital for acute abdominal trouble. The temperature was 102° ; the pulse-rate 112. The woman had been sick for three days. There was abdominal pain, most intense in the region of the umbilicus; and diarrhea, followed by constipation. The greatest amount of pain was now referred to the right iliac fossa. Examination of the abdomen elicited tenderness, especially pro- nounced over the right iliac fossa, with the presence of a distinct mass a little above and to the inner side of the anterior superior spine of the ilium. Deep vaginal examination detected a painful mass. Rectal examination was not satisfactory. Operation was advised. An incision was made in the right semi- lunar line, exposing the peritoneum, which on pal- pation presented the presence of an unquestionable mass. The peritoneum was incised, an abscess-cavity containing the vermiform appendix opened, and the appendix removed. The cavity was washed out, a glass drainage-tube introduced, and the wound packed with iodoform-gauze. Either end of the incision was closed with two sutures. Some days later, this cavity still containing a small amount of pus, a counter-opening was made through the loin into the cavity, and thorough drainage established. Recovery soon followed. Case III.-M. H., nineteen years old, was seen in consultation. The woman gave a history of having been taken suddenly ill five days previously, with nausea, severe pain in the right iliac fossa, accompanied by constipation. A tumor rapidly APPENDICITIS, ETC. 9 developed in the right iliac fossa, which, within thirty-six hours, extended in the line of the linea alba and of the pelvis. At the time of my visit the patient was vomiting almost incessantly, the stomach being practically non-retentive. The abdominal walls were decidedly rigid over the right iliac fossa, with very slight edema, and a diffused mass pre- senting questionable fluctuation. Rectal and va- ginal examination yielded negative results. A diagnosis of intra-peritoneal inflammation was made. An incision was made in the right semi-lunar line down to the peritoneum, which bulged into the wound, and upon palpation presented a fluctuating mass. The peritoneum was opened, and found to be adherent to the great omentum, which was dis- tributed over the most prominent part of the mass. The incision was carried carefully through the omentum. In attempting to examine the under- lying mass with the finger a large abscess-cavity was ruptured, giving exit to a quantity of fecal-smelling pus. The cavity was washed out with warm dis- tilled water, and further examination made with the finger, when the cavity was found to be shut off from the peritoneal cavity by a limiting wall. The appendix could be neither seen nor felt. The cavity was drained by glass and rubber, and packed with iodoform-gauze. Recovery was uninterrupted. Case IV.-H. J., thirty-two years old, after eating a large quantity of peanuts, was seized dur- ing the night with violent paroxysms of pain in the right iliac fossa. Medication was resorted to for a few days without producing any good effect. When I first saw him the abdomen was tympanitic, the walls of the right iliac fossa tense, but not pitting on pressure, and an indistinct mass was discovered. The family strongly objected to operation. On the following morning the patient being worse, with 10 DEAVER, persistent vomiting, I was hastily summoned. A diagnosis of intra-peritoneal inflammation was made, and operation advised. An incision was made in the right semi-lunar line, down to the peritoneum, through which a small tumor could be distinctly seen. The peritoneum over-lying the tumor was incised. The mass was opened, and about one ounce of pus escaped. The abscess-cavity was washed out, when by touch it was found to contain the appendix. The appendix was ligated, and was found to be perforated, as well as containing a small piece of a peanut. The cavity was packed with iodoform-gauze. Recovery ensued. Case V.-A. M., twelve years old. History of pain in the umbilical region. A tumor was found in the right iliac fossa, extending back into the loin. Resistance was offered by the overlying abdominal muscles. The temperature ranged from ioo° to 102.0 The patient was seen twelve days after the onset of the trouble with the attending physician, Dr. Stephen R. Ketcham, who told me that, until within a few days at least, he regarded the case as one of appendicitis, of which it had presented all the symptoms. The pain was now referred to the right costo-iliac space, which, when compared with the the opposite side, was found to be bulging, with edema of the overlying integument. Examination further revealed an unquestionable collection in the loin-space. The patient was removed to the Ger- man Hospital, where an incision was made in the loin, and a large quantity of fecal-smelling pus evacuated. The cavity was washed out and packed. Two days later the appendix was cast off through the wound with a quantity of fecal matter. A fecal fistula resulted, but spontaneous recovery ultimately ensued. This was in all probability a case of inflammation of an anomalously-placed appendix, APPENDICITIS, ETC. 11 resulting in an extra-peritoneal collection of pus, simulating a peri-nephric abscess. Case VI.-Mr. S., eighteen years old, became uddenly ill, with pain in the right iliac fossa, adiatingto the region of the umbilicus. A day later he pain was much more severe, with distention of he abdomen and nausea. The temperature ranged between ioi° and 102.5°. The pulse-rate increased correspondingly. The bowels were moved by Rochelle salts. A mass about the size of an orange was now to be felt in the right iliac fossa. The pain becoming much more severe, and the abdomen enlarging, I was asked to see the case. I found the patient considerably better, the pain much less, the abdomen smaller, the mass less apparent. The man had gotten out of bed, when his bowels were copi- ously moved; the dejecta, it was stated, contained milk. With this history, I believed an intra-peri- toneal abscess of the right iliac fossa to have rup- tured into the cecum. Operation not advised. Recovery ensued. The use of the exploring or the hypodermatic needle, to determine the presence of pus, I do not think wise or judicious, and I believe it to be capa- ble of doing much harm. It will be inferred that it is difficult to say when a case of inflammation in the right iliac fossa, associated with a lesion of the cecum, vermiform appendix, or the adjacent tissue, demands operation. The decision will be governed by the local as well as the general condition of the patient, and the result obtained by well-directed medical means. If the recently accepted treatment by means of mild purgation with salines, or calomel if the stomach rebels against salines, and the very moderate use of opium if necessary, fails to render 12 DEAVER, the patient comfortable, to allay vomiting, to pre- vent abdominal distention, to produce liquid evacu- ations, the temperature remaining high or tending to rise, and the local trouble becoming more pro- nounced, with increase of abdominal resistance, tenderness, and induration, I at once and un- hesitatingly advise operation. Constant retching, increasing abdominal distention, and obstinate constipation, are three conditions that, when asso- ciated, warrant immediate interference, granting that the patient's general condition does not contra- indicate interference. There is, I think, already a sufficient number of fatal cases on record in which treatment by opium alone in gradually increasing doses has been adopted in preference to operation, to disabuse the minds of both physicians and sur- geons of the fallacy of such a course. After refus- ing to operate on many cases brought into the hos- pital in approaching collapse, with a diagnosis of peritonitis consequent upon an obstruction of the bowels, with hugely distended belly, incessant retching, with a history of the bowels not having been moved for four or five days, and death follow- ing in from eight to twelve hours, the autopsy show- ing the abdominal cavity flooded with pus, the vermiform appendix perforated if not gangrenous, the coils of small intestines greatly distended and matted together with layers of fibrinous lymph, I cannot conscientiously form any other opinion than that the attending medical man did not believe in opera- tive treatment, or deferred calling the surgeon until the golden opportunity was a thing of the past. Under circumstances like these, the argument, Why APPENDICITIS, ETC. 13 not operate, if the patient is sure to die any way? is often brought forward. In answer to this, all that I can say is that it often requires better judgment to decide when not to than when to operate. The conscientious surgeon should always be willing to take desperate chances if there is the slightest indi- cation of benefit to his patient, but certainly not otherwise. In cases in which the symptoms and the local conditions are relieved by the treatment I have sug- gested, surgical interference should certainly not be considered. I recently operated upon a case of extra-peritoneal inflammation, with suppuration, re- ferred to me by my friend, Dr. Charles Styer. Fluctuation being most pronounced in the loin, I carried my incision through this part and evacu- ated a considerable quantity of fecal-smelling pus. As the case was originally believed to be one of in- flammation of the appendix, I exposed the appendix by an incision in the right linea semilunaris, when both appendix and cecum were found to be per- fectly normal. This case, as well as others upon which I have operated, demonstrates beyond doubt, to my mind at least, that we meet with cases of extra-peritoneal inflammation associated with the bowel, arising independently, and not caused by intra-peritoneal irritation. This being so, is it not unwise to argue that every case of inflammation in the right iliac fossa arising in connection with the bowel, and going on to pus-formation, should be subjected to laparotomy? I am, therefore, forced to believe that the operative technique, as I have described it, is the safer procedure in dealing with inflammation of the fossa when it is impossible to 14 DEAVER, say whether it is intra-peritoneal or extra-peritoneal, as is so often the case. The operative technique for the relief of inflam- mation in the right iliac fossa associated with lesion of the cecum, vermiform appendix and adjacent connective tissue consists in exposing, first, the transversalis fascia and the sub - peritoneal fat, through the right linea semilunaris by a vertical incision of from four to six inches in length, the middle of which should correspond with the point at which a line drawn from the anterior superior spine of the ilium to the umbilicus intersects the semilunar line. The transversalis fascia and the sub-peritoneal fat having been exposed, if the in- flammation be of the extra-peritoneal variety, and if pus be present, the fluid is very readily evacuated, while, at the same time, if the surgeon prefer, a counter-opening can be made well back in the flank, through which a drainage-tube can be intro- duced and the cavity thus drained to the best pos- sible advantage, or the operation may be terminated after the manner of Parker. If the inflammation be of the intra-peritoneal variety, the peritoneum is taken up between a pair of hemostatic forceps and incised, when, if an abscess exists, it is evacuated, and the appendix removed, as the case may be. The abscess having been evacuated and thoroughly washed out, the appendix is sought for, care being taken not to break through the limiting wall of the abscess-cavity, granting that it is shut off by such a wall from the general peritoneal cavity. If the appendix is not to be seen or located, I at once complete the operation by either intro- ducing a glass and a rubber drainage-tube to the APPENDICITIS, ETC. 15 bottom of the cavity, around which I pack iodo- form-gauze, or simply pack the cavity with gauze, not using any drainage-tube. In the cases not under my care after operation I prefer to use the drainage-tube, and have it irrigated twice daily with Thiersch's solution, which when thrown into the rubber drainage-tube will escape through the glass tube, and vice versa. The case progressing favorably, the gauze need not be removed for two or three days. When suppuration has decidedly lessened, the tubes are removed, the cavity washed out and packed with gauze, and healing by granu- lation promoted. In the class of cases in which the general peri- toneal cavity is involved, I make further search for the appendix if it is not to be seen or felt at the bottom of the wound, keeping in mind its three relations. Most commonly the appendix lies be- hind the terminal part of the mesentery, pointing in the direction of the spleen. The second most common position of the appendix is directly behind the ascending colon ; in the third it dips down into the pelvis. To ascertain if it occupies the first posi- tion, it is necessary to lift up the cecum and the terminal portion of the ileum, when the retro-mesen- teric space will be exposed. When it occupies the second position, it becomes necessary to lift up the cecum and probably the commencement of the ascending colon as well; this may necessitate divid- ing the external layer of the ascending meso-colon, which is selected in preference to the internal layer, as the bloodvessels that supply this portion of the gut are in relation with the latter. When the ap- pendix holds the third position, it is more readily 16 DEAVER, exposed, and in the female it is not uncommon to find it attached to the right uterine appendage. The appendix, having been exposed, is ligated close to the cecum and severed on the distal side of the ligature. It has been suggested to invaginate the stump of the appendix into the cecum, and stitch over it the serous covering of the latter. This pro- cedure I have never had occasion to adopt. In the event of the appendix having been sepa- rated from the cecum by ulceration, leaving an orifice of communication with the latter, I close the opening with two or more Lembert's sutures, if the margin of the opening is not infiltrated to too great a degree to warrant the removal of the diseased portion of the bowel. When the cecum is thus perforated by the separation of the appendix, and its coats are very much diseased, I believe it better practice not to attempt to close the opening, but simply to thoroughly drain the wound. My experi- ence has been that the majority of fecal fistulas of this character close spontaneously. If they do not, subsequent operation can be resorted to. In Case V of the series here reported, a fecal fistula resulted, through which the evacuations continued to pass for some days. It ultimately healed without operative interference. The point to be borne in mind in cases of this character is the establishment of free drainage, thus preventing the passage of fecal matter into the peritoneal cavity. The proba- bilities are that in this class of cases the peritoneal cavity has been shut off from the perforated bowel by inflammatory exudation, thus explaining why recov- ery so often takes place under such circumstances. From what I have said regarding the operative APPENDICITIS, ETC. 17 technique, it will be inferred that I disapprove of meddlesome interference, by which I mean, making a prolonged search for the appendix when it is not readily found. I have seen patients prac- tically disemboweled in an eager search for the appendix, and even then it was not discovered. We know that prolonged exposure of the bowels is attended by profound shock, and is to be avoided if possible. The success of abdominal operations in general depends upon their being done with as much rapidity as possible, granting, of course, that every care is taken in each step of the operation. In work of this character I also disapprove of the introduction of the entire hand into the abdominal cavity, believing that, in the majority of cases at least, two fingers, the index and the middle, with, in some instances, the assistance of one or two fingers of the opposite hand, are sufficient to accomplish all necessary manipulation. We have all seen a suffi- cient number of cases of laparotomy for the removal of diseased uterine appendages, particularly cases of pyosalpinx, to know that the skillful surgeon ac- complishes the removal with but two fingers; this holds good in cases of the character included in the subject of this paper. The after-treatment consists in the administra- tion of occasional doses of salines or calomel, de- pending upon the retentive power of the stomach, in order to have the bowels freely moved two or three times daily, and, if the patient suffers much pain, a small amount of opium. I do not believe in the exclusive use of salines, both before and after operation, in cases in which pain has been an important factor, but I likewise give ano- 2 18 APPENDICITIS, ETC. dynes, being governed by the amount of suffering. On the other hand I very much disapprove of giv- ing enough opium to mask the symptoms of the disease, as I regret to say is so often done. (Para- lytic distention of the bowel, a most unfortunate complication in cases of advancing intra-peritoneal inflammation, is certainly favored by the adminis- tration of opium, when given to the extent of pro- ducing its physiologic effect.) Opium has held very much the same relation to abdominal troubles in the past as has blood-letting in the acute sthenic in- flammatory affections. Both are still useful when properly employed. While I appreciate that opium not administered very cautiously in these cases is harmful, yet I do believe that restlessness and sleep- lessness will be more hurtful to the patient than a judicious dose or two of the drug. On the other hand, active purgation by means of drastic cathar- tics, such as podophyllin and others of its class, I equally disapprove of, as I fl el that the excessive peri- stalsis that is certainly brought about by these agents aggravates the local condition . I have said nothing about suturing the abdominal wound. This I do not approve of, with the exception of one or two sutures at the angles of the wound. In other words, I rely upon healing by granulation. I have found that ventral hernia is not any more likely to follow when the wound is treated in this manner than when it is sutuied. In my earlier operations for the removal of the appendix, in which I closed the wound with sutures, I made a counter-opening in the loin and introduced through drainage. By treating the wound by the open method this is not necessary. The Medical News. Established in 1843. A WEEKLY MEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820 A MONTHLY MEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMUTA TION RA TE, PER ANNUM LEA BROTHERS & CO. PHILADELPHIA.