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M 3NIDIQ3W dO AavaaiT TVNOIIVN 3NIDIQ3W JO AavaaiT TVNOIIVN 3NIDIQ3W dO AavaaiT TVNOIIVN -a c E NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE •J 3NIDI03W dO AMVUfln TVNOIIVN 3NIDICJ3W dO Aavaflll TVNOIIVN 3NIDIQ3W dO AUVasn 1VNOI1VN E NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE I 3NIDIQ3W dO AHVaaiT TVNOIIVN 3NIDIQ3W dO AavaaiT TVNOIIVN 3NIDIQ3W dO AavaaiT TVNOIIVN \ i k\ 1 a*T lectures on appendicitis and NOTES ON OTHER SUBJECTS ROBERT T. MORRIS, A.M.. M.D. Fellow of the New York Academy of Medicine, American Association of Obstetricians and Gynecologists, American Medical Association ; Member of the New York State and County Medical Societies, Society of Alumni of Bellevlie Hospital, Linnean Society of Natural History, etc. With Illustrations by Henry Macdonald, M.D. G. P. PUTNAM'S SONS NEW YORK LONDON 27 WEST TWENTY-THIRD STREET 24 BEDFORD STREET, STRAND ilbc Juiickerbochcr J)rcss l895 p) YA Y\ -C-- f v/r nrnL Copyright, 1895 BY G. P. PUTNAM'S SONS Zbe Tkmcfcerbocftet press, mew Iftocbelle, %\, kj, PREFACE. Eight years ago, when there was confusion in antiseptic methods of wound treatment, I presented a little book, which was accepted because it told of one way for accomplishing certain ends. At the present time, while there is confusion of ideas on the subject of appendicitis, it is perhaps a favorable time for blazing one clear trail through the subject in a similar way. In the matter of operative procedures, I have due respect for methods which are different from my own, believing that in the art of surgery every surgeon is a law unto himself, and that e knows the factors of his own success. This collection of ectures includes the substance of my teaching on the subject of appendicitis at the Post-Graduate Medical School in New York, and I have added a series of notes on other subjects which have received little attention in literature, but which have interested my class. The terms local leucocytosis and phagocytosis I have used synonymously, pending further investigation. The substance of many of the notes has appeared in various periodicals—e.g., the New York Medical Journal and New York Medical Record, the Annals of Surgery, the New England Medical Monthly, the Post-Graduate, the Transactions of the American Association of Obstetricians and Gynecologists, Transactions of the SoutJiern Surgical and Gyneco- logical Association, Transactions of the American Medical Asso- ciation, Transactions of the International Medical Congress at Berlin, iSpo, Transactions of the Nezv York State Medical Society, Transactions of the Pan-A merican Medical Congress. Aid in research work was given by Dr. Arnold Eiloart and C. N. Haskell, in chemistry; and by Drs. J. C. Smith, H. T. Brooks, and William Vissman, in pathology. Dr. J. C. Smith furnished the photo-micrographs, and the illustrations from my specimens and dissections were made by Dr. Henry Macdonald. iii CONTENTS. CHAPTER I. PAGE Preparation of Surgeon and Patient ...... 1-9 CHAPTER II. The Appendix Vermiformis Ceci ...... 10-15 CHAPTER III. Appendicitis ......■-- 16-48 CHAPTER IV. Surgical Treatment of Appendicitis .... . 49-83 CHAPTER Y. The Action of Various Solvents on Gallstones .... S4-91 The Influence of Remains of the Embryonic Vitelline Duct in the Produc- tion of Moist Navels, and of Eczematoid Inflammation about the Navel 92-93 Malignant Islands at the Navel Occurring Simultaneously with Malignant Disease of the Abdominal or Pelvic Organs A Last Resort Hernia Operation ..... The Experimental Production of Ileal Intussusception with Carbonate o Sodium ......•• The Reason why Patients Recover from Tuberculosis of the Peritoneum The Prevention of Secondary Peritoneal Adhesions by Means of an Aristol Film ...••••• Another Method for Palpation of the Kidney Experiments Germane to the Subject of Abdominal Supporters after Lap arotomy ....■■•• An Addition to McGuire's Operation for a Supra-Pubic Urethra The Drainage Wick .....•• Endoscopic Tubes for Direct Inspection of the Interior of the Bladder and Uterus ......... 117-119 94-97 98-99 IOO-IOI 102-104 105-106 107-108 109-111 112-114 II5-II6 VI Contents. The Action of Trypsin, Pancreatic Extract, and Pepsin, upon Sloughs and Coagula ......... The Removal of Necrotic and Carious Bone with Hydrochloric Acid and Pepsin ........ Is Evolution Trying to Do Away with the Clitoris? . The Mechanism and Anatomy of Subluxation of the Head of the Radius Pott's Fracture, and the Fracture of the Fibula which follows Adduction o the Foot . . . . The Dowel-Pin in Dislocation of the Acromial End of the Clavicle . The Dowel-Pin in Fracture of the Clavicle Mallet-Finger .... Two Cases of Conservative Surgery of the Arm Skin Grafting from Blisters Phelps's Hare-Lip Operation in Two Steps . Distension of Fistulous Pipes with Plaster of Paris to Facilitate thei Removal ........ Prevention of Abortion by Removal of a Uterine Fibroid Reduction of an Inverted Uterus by Incising the Constricting Ring Intra abdominally ....... Hysterectomy for Placenta Previa ..... Ovarian Transplantation ...... INDEX 161-163 LIST OF ILLUSTRATIONS. ' PAGE Culture tube .......... . 6 Portable set of culture tubes .... 7 The appendix vermiformis ceci IO Concretions ....... 13 Section of normal appendix .... 16 Section of infected appendix . . . 16 Section of normal mucosa and lymphoid layer of a Dpenc lix . 18 Section of appendix undergoing destruction . IQ- Acute ulceration of appendix 21 Chronic ulceration of appendix 21 Lymph space infiltration .... 22 Thrombus in mesappendix .... 23 Proliferating endarteritis 24 Round sloughs of appendix .... 25 Round slough of appendix 26 Gangrenous appendix ..... 27 Gangrene of mesappendix .... 28 Perforated appendix..... 29 Multiple perforations of appendix . 29 Appendix living by adhesion circulation 30 Interval cases ...... 31 Adhesion band snaring bowel 32 Rhexis of appendix . . . 34 Tenacula stretching skin • 54 Guy line . ■ • • • 55 Aponeuroses involved in appendix operations 56, 57 Evanescent scar ...-•■ . 61 Embryonic remains at the navel 92, 94 Adeno-carcinoma of navel .... c >5, 96 vii Vlll List of Illustrations. PAGE Bowel fastened at hernial opening ...••■ 99 Ileal intussusception . 101 Supra-pubic urethra 112, 113 Drainage wick .... . Il6 Endoscopic tubes . • H7 Decalcified bone .... 124, 125 Section of normal clitoris . 126 Section of adherent clitoris 127, 128 Orbicular ligament • I32 Dislocation of clavicle . • 139 Dislocation of clavicle reduced . 14c Fracture of clavicle . 142 Mallet-finger ..... i43, 144, 145 Injured and repaired arms 146, 147, 148, 149, 150 Blister graft ..... • 151 Transplanted ovarian tissue . 157, 158 LECTURES ON APPENDICITIS LECTURES ON APPENDICITIS CHAPTER I. PREPARATION OF SURGEON AND PATIENT. General Cleanliness is obtained by washing our hands, and the skin of the patient, at the proposed field of operation, with ordi- nary soap and water, aided by a nail-brush. Special Cleanliness for the surgeon and assistants is gained by immersing the hands in 1:2000 bichloride of mercury solution for five minutes in preparation for ordinary work. Theoretically, this does not completely sterilize the hands, but practically it has been sufficient in my experience. It is difficult to destroy absolutely the spores of some of the bacteria, but if the whole operation is properly conducted, we need hardly fear the few spores which re- sist the action of the bichloride on our hands. After operation upon a distinctively septic case, and before proceeding to the next one, the hands are prepared by immersing them in a solution of permanganate of potassium, one drachm to the pint, until they are deeply stained, and then bleaching them in a solution of oxalic acid, two drachms to the pint, and afterward rinsing in 1:2000 bichloride of mercury solution. Special cleanliness for the skin of the patient is obtained by methods employed for cleansing the hands, but, in addition, the skin is always shaved first, and, if possible, a pad of moist bichlo- ride gauze is kept in contact with the skin at the proposed field of operation for ten hours. Special cleanliness of the alimentary canal of the patient is aimed at by emptying the bowels, and then giving five grains of salol. This is an important measure in abdominal work, because the process of digestion stops when the abdominal sympathetic nerves are shocked, and fermentation ensues, poisoning the patient with saprophytic products. Salol lessens fermentation. 2 Lectures on Appendicitis. Instruments are sterilized by boiling for ten minutes in 1:100 bicarbonate of sodium solution. The boiling sterilizes, and the bicarbonate of sodium prevents oxidation of the bright metal and of the cutting edges. At the time of the operation, instru- ments are allowed to remain, while not in use, in boiled water. Towels are sterilized by boiling for ten minutes just before using, if they were boiled for half an hour after use at a previous opera- tion. Sponges.—Reef sponges, costing less than two dollars a pound, are used in my work. They are soaked in warm water for a day to soften the dry sarcode which covers the spicules. After a gen- eral washing, they are placed in hydrochloric acid solution, one part to ten, and left there until all shell sand is dissolved. Ten hours will suffice for some of the sponges, but an addition of acid will be necessary if the original amount is used up on excessively abun- dant lime salts. The cleansed sponges are placed in permanganate of potassium solution, 1:100 for ten minutes, and are afterwards rinsed before going into the bleach bath of oxalic acid solution, 1:30. As soon as they are white, a few minutes' immersion being sufficient, the ones that are wanted for early use are immersed in 1:4000 bichloride of mercury solution, containing glycerine in the proportion of one ounce to the pint, and they are left in the solu- tion for ten hours. After being squeezed dry, they are placed in glass jars ready for use. Sponges that are not to be used for sev- eral months are stored dry, tied up in paper bags. A repetition of the treatment, minus the hydrochloric acid, will answer for sponges that have been used. The permanganate of potassium combines with the organic sarcode, and stains the inorganic spic- ules, acting as a germicide. The oxalic acid decomposes the potassium compounds, and is destructive to bacteria and their spores. The bichloride of mercury acts further as a germicide, and glycerine is employed because it is hygroscopic, and prevents for several weeks the change of the bichloride of mercury to calo- mel—a change which occurs rapidly when dry bichloride is ex- posed to the air in thin layers over the spicules. If a strong solution of bichloride of mercury is used, it makes the sponges too hard. Gauze.—Absorbent gauze, which constitutes the principal bulky dressing, is prepared by boiling cheesecloth or mull in a solution of carbonate of sodium (washing soda) 1:16, for two hours: chan- ging the water, rinsing, and boiling again in the same solution for Preparation of Surgeon and Patient. 3 two hours, then rinsing and boiling in pure water for ten minutes. The gauze is then absorbent, because the soda has saponified the fat and broken up the gummy elements of the cotton fibre. The gauze is finally washed in clean boiling water, and immersed in 1:2000 bichloride of mercury solution, containing one ounce of gly- cerine to the pint. After squeezing dry, the proportion of the lot that is likely to be used in less than two months is stored in glass jars, but the remainder, as with the sponges, should be securely tied up in paper bags, and again immersed in bichloride and gly- cerine before being placed in the jars for early employment. Iodoform Gauze is not used in my clinic for wound treatment, be- cause the iodoform and the fixing agents interfere with the capil- larity of the gauze, and thereby destroy the nice mechanical action which is the chief and great virtue of gauze dressings. Absorbent Cotton can be prepared from cotton batting by the process employed for gauze, and it makes a much cheaper dress- ing, but the absorbent cotton does not look attractive unless it is re-carded after treatment, and on that account is not often manu- factured by the surgeon at home. If the absorbent gauze and cotton are purchased from dealers, each lot must be tested sepa- rately, because a patient's life is often staked absolutely upon the capillarity of a filament of gauze, and I have bought alleged ab- sorbent dressings which would have betrayed the patient's trust in me. Test absorbent gauze and cotton by dipping one end of the filament of prepared and unprepared stuff, side by side into a glass of warm water. The water will be seen to shoot up into the absorbent stuff instantly. Drainage Apparatus.—Drainage is not often required for aseptic wounds, but it has a place of vital importance at times. I depend almost entirely upon the drainage wick, made by rolling absorb- ent gauze in gutta-percha tissue, very much as one rolls tobacco in a cigarette paper. The average wick is about the diameter of a cigarette, but longer. (See article on Drainage Wick.) Sutures and Ligatures.—Silk is used by me in one place only in surgery, and that is for ligating the inner tube of the appendix. The tiniest of buried knots is desirable at that point, and the finest strand of silk answers the purpose well. The silk is boiled for half an hour, and then stored on a glass rod in a glass tube filled with alcohol. Catgut.—Catgut is the ideal material for sutures and ligatures, if prepared according to the following directions: Every surgeon 4 Lectures on Appendicitis. must attend personally to the preparation of his catgut. No matter how good the intention of the dealer, the work is some- times given to workmen who do not know what responsibility they are to share with the surgeon, and the patient's needle may turn on a pivotal suture. I buy from L. H. Keller & Co., 64 Nassau Street, New York, the hanks of raw catgut in the form known as "bow-lines." Each bow-line is one metre in length, and the form is convenient because a few strands can be removed from the storage bottle and placed in a saucer of alcohol at the time of the operation, thus avoiding the danger of contaminating the mass remaining in the storage bottle. Different dealers num- ber their sizes of catgut arbitrarily, and in order to establish a standard I have proposed that the American Standard Wire Gauge be used. Such a gauge can be found in almost any me- chanic's shop, and there is no good reason why catgut should not be measured by this standard. The sizes that are employed for almost all of my work are No. 25 and No. 20, American wire gauge. The hanks of raw catgut are placed in a glass jar and freely covered with commercial sulphuric ether, in which they remain for a week. The ether removes the fixed oil, and acts as a germicide, becoming very foul, however, and unfit for further use. The foul ether is poured off at the end of a week, and fresh ether containing bichloride of mercury, in the proportion of 1 :4000, is added. After standing in this new ether for a week, the hanks are transferred to a storage bottle of absolute alcohol, containing bichloride 1 :4000, and are ready for use, unless the chromicizing process is preferred. I use chromic gut altogether, because smaller sizes of this will take the place of clumsy strands of simply prepared gut. To chromicize the catgut, it is first pre- pared by the simple process, and is then placed in a solution of bichromate of potassium and alcohol, fifteen grains to the pint, first dissolving the bichromate in one ounce of distilled or boiled water, and adding it to the alcohol in the form of a watery solu- tion. The catgut remains in the solution of bichromate of potas- sium and alcohol for fifteen hours, and is then drained, and placed in absolute alcohol for storage. The chromicizing process doubles the resistance to absorption of the catgut in the tissues. When first prepared, the resistance is not quite doubled, and after stand- ing in the alcohol for a year, it is rather more than doubled ; but this variation is of little practical importance. Catgut left in the bichromate of potassium solution for more than fifteen hours be- Preparation of Surgeon and Patient. 5 comes too resistant, and may not be absorbed in months. Pre- pared for fifteen hours in the fifteen-grain-to-the-pint solution, No. 25 is absorbed in about ten days, and No. 20 in about twenty days. At the time of the operation, a sufficient number of bow- lines are removed from the storage bottle, and placed in a saucer of alcohol ready for immediate use. Any bow-lines left over after the operation are thrown away. After preparing a lot of catgut, it is tested by cutting up a strand, placing the pieces in boiled distilled water for ten minutes, and then planting the pieces in a test tube of agar-agar. Irrigating Solutions.—The only irrigating solutions that I em- ploy are physiological saline solution and strong hydrogen dioxide. Hydrogen Dioxide is used in full strength for flushing septic cavities at the time of the operation, and is then washed out with the physiological saline solution. The dioxide of hydrogen is a powerful germicide, and it not only destroys the bacteria, but throws up pus and septic fluids in a foamy mixture, which is easily washed away. The same antiseptic is used in many septic cavities after operation until granulation begins, but we must dis- continue its use then, as a rule, because the peroxide follows leu- cocytes into granulation tissue, and thus delays repair. Physiological Saline Solution, representing the normal propor- tion of chloride of sodium in the blood, is the least irritating and the most useful general irrigating solution. It is made by boiling ninety grains of chloride of sodium in one quart of water. Common Boiled Water irritates the tissues, and is somewhat corrosive, as may be observed by dropping it on the eye, or placing a glistening piece of peritoneum in it for an hour. Water in the eye causes smarting, and it dulls the surface of the peri- toneum. In a peritoneal operation it injures the serosa slightly, and may cause vexatious little adhesions afterward. The injury to the serosa may be sufficient to close the mouths of the lymphatics upon which the surgeon depends for very important aid in carry- ing off septic matter. Therefore unsalted water should not be used for irrigating purposes. Chemical Antiseptic Solutions are still more irritating than plain water. We depended upon them until progress carried us to aseptic surgery. Physiological saline solution is used for all ordi- nary purposes of irrigation in surgical work, and it is practically unirritating. The sponges are kept in basins of it at an operation, 6 Lectures on Appendicitis. and the surgeon's hands are washed in it for neatness' sake while he is at work. Aristol.—Aristol is similar to iodoform in its action, but it is preferable to iodoform because it adheres to tissues much more tenaciously, because it seldom, if ever, produces any toxic effects, and because it smells better. Aristol is not directly an antiseptic, but it quickly forms with lymph a thin protect- ing coagulum which is almost impenetrable to bacteria. The free iodine which is given off, destroys irritating ptomaines, and allows leuco- cytes to marshal their forces on one side of the coagulum wall, while bacteria are making slow progress from the other side. Aristol is of the utmost importance in closing tissue planes against infiltration from a wound. For instance, after supra-pubic cystotomy, it will make a fine impenetrable wall about the drainage track. It will do the same thing after the removal of the gangrenous appendix, or a pus tube, and it makes very simple the question of drainage after operations upon the gall-bladder and bile ducts. The comfort that I find in the use of aristol according to a proper technique is very decided. The drug must be studied with reference to its use in forming a thin protecting coagulum. Aristol is apparently not absorbed readily in the tissues, but it becomes harmlessly encapsulated. In rabbits upon which 1 experi- mented, and in operations upon patients in whom I had previously employed it for prevent- ing secondary peritoneal adhesions, the aristol was found encapsulated in little spots, retaining its color, and producing an appearance which will puzzle pathologists who come across it without knowing that aristol has been used in the case. Aprons.—A very thin and light apron of rubber dam with rub- ber tube strings, is made for me by John Reynders & Co., of New York. These aprons can be packed in very small space, and they are boiled and otherwise cleansed with ease. One of the aprons rolled over a rope, and leaving half of the apron free, can be tied about the waist of a patient in Trendelenburg's posture. Used in this way it keeps the clothing of the patient dry, and conducts fluids into a proper receptacle. Fig. i. Culture Tube. A, cotton plug. B, swab carrier. C, swab. D, agar-agar. Preparation of Surgeon and Patient. 7 Culture Tubes.—Four or five culture tubes of agar-agar are car- ried in a little case in my instrument bag. A swab fastened to a copper tube rests in the tube, not quite touching the culture medium. The mouth of the tube is filled with scorched cotton. At an operation in wrhich it is interesting to note what species of Fig. 2.—Portable set of culture tubes for the surgeon's bag. bacteria have been at work, the swab is touched against the in- fected tissues, and then carried to the agar-agar. The swab is then thrown away, and the mouth of the tube again plugged with scorched cotton, after which the tubes are handed to the bacteri- ologist for further investigation. 8 Lectures on Appendicitis. Results.—The efficiency of the comparatively simple resources above described is shown very well in one of the hospitals at which I have none of the complete advantages which are furnished at our Post-Graduate Hospital, and in other hospitals in New York, where my patients receive elaborate preparatory treatment and detailed after-treatment under my personal supervision. I refer to the Ithaca City Hospital, which is a transformed wooden dwelling-house, having meagre advantages as a hospital. Almost none of my patients there received any preliminary treatment, but were prepared on the day of the operation, and frequently on the operating-table only. I saw most of these patients for the first time then, and not again afterward. The medical staff con- sists of a large number of physicians and surgeons, and yet during a period of two years there has been but one death among the surgical cases at that hospital in the service of any of the oper- ators. That death occurred after a hip-joint amputation in one of my patients who had suffered for years with suppuration from the whole length of the femur, following osteo-myelitis, and who had amyloid kidneys and puffy feet on the day of operation. I am at liberty to give my own statistics only. From the hospital years February 6, 1893, to February 6, 1895, I operated upon the fol- lowing 193 cases, in 178 patients, at the Ithaca Hospital. No patients were refused operation excepting hopeless cases of carci- noma and sarcoma, and exploratory operations were done in five cases of this sort to determine if an involved organ, such as the gall-bladder or intestine could possibly be operated upon with a prospect of benefit to the patient. Acute appendicitis ; perforation of cecum ; abdomen distended with pus and gas, not encapsulated.................................................... r Acute appendicitis ; perforation opening into abscess cavities, encysted.......... 4 Acute appendicitis ; mucosa desquamating.................................. I Chronic appendicitis ; various adhesions and complications.................... 11 Typhlitis, perforative ; abdomen full of sero-pus............................. 1 Abdominal hysterectomy for very large myomata and fibromata............... 6 Abdominal hysterectomy for a placental hemorrhage........................... 1 Vaginal hysterectomy for cancer, 1 ; procidentia, 1 ; chronic metritis, 3......... 5, Abdominal hystero-pexy for retroversion of uterus............................ 5 Abdominal hystero-pexy and removal of destroyed adnexa..................... 6 Removal of large ovarian cysts............................................. 6 Celiotomy for conservative treatment of adherent or diseased adnexa of the uterus, non-suppurative..................................................... 7 Celiotomy for removal of pyogenic oviducts................................. 2 Exploratory celiotomy to determine if malignant growths could be operated upon. 5 Gastrorrhaphy for chronic dilatation of stomach.............................. 1 Bassini's operation for hernia.............................................. 2 Preparatio7i of Surgeon a:id Patient. 9 Macewen's operation for hernia............................................ i Closure of ventral hernial opening......................................... 2 Supra-pubic cystotomy, stone, I ; tuberculosis, I ;............................ 2 Nephrorrhaphy for loose kidney............................................ 3 Removal of navel for eczema.............................................. 1 Removal of breast and axillary glands for cancer.............................. 11 Repair of rupture of perineum............................................. 7 Repair of perineum and cervix simultaneously............................... 3 Repair of cervix.......................................................... 2 Removal of decomposed fetus 5 months (vaginal route)........................ 1 Von Bergmann's hydrocele operation (excision of sac)......................... 4 Lister's varicocele operation (excision of veins)............................... 14 Ligature of dorsal vein of penis for impotence............................... 2 Excision of varicose veins of leg............................................ 1 Circumcision for phimosis................................................. 6 Amputation of penis for cancer............................................. 1 Internal urethrotomy for stricture........................................... 9 Removal of sphacelus of bone, tibia, 2 ; femur, 1 ; maxilla 1................... 4 Amputation of forearm.................................................... 1 Re-amputation of leg..................................................... 1 Hip-joint amputation (death immediately, shock)............................. I Amputation of thumb for sarcoma. . ....................................... 1 Suture of fractured ulna.......................................,........... 1 Tenotomy for talipes...................................................... 2 Excision of tuberculous tendon of biceps brachialis............................ 1 Suture of cut tendons of hand or wrist.................................... 3 Suture of dislocated acromial end of clavicle................................ 1 Ligation of hemorrhoids.................................................. 4 Obliteration of fistula in ano.............................................. 5 Coccygectomy for coccygodynia........................................... 2 Removal of sarcomatous neuromata, ulnar, 2 ; circumflex, 1 ; peroneal, 1....... 4 Removal of melano-sarcoma of brachial region............................... 1 Mastoid bone opened for evacuation of abscess............................... 1 Incision for periostitis of tibia............................................. 1 Extirpation of tuberculous inguinal bubo.................................... 1 Extirpation of tuberculous mass of cervical glands............................ 3 Extirpation of coccygeal dermoid cyst....................................... 2 Extirpation of vulvar fistulous tract for embedded hair-pin.................... 1 Extirpation of hypertrophied tonsils, child, 1 ; adult, 1....................... 1 Plastic operation after removal of cancer, lip, 3 ; cheek, 2..................... 5 Poncet's operation for goitre............................................... 1 Removal of cancerous glands of neck........................ .............. 2 Removal of branchial cyst of neck.......................................... 1 Removal of large fibroid tumor of neck...................................... 1 Plastic operation on anus, incontinence stricture.............................. 3 Fracture and replacement of deviated nasal septa............................. 2 Removal of extensive papilloma of anal region and buttocks................... 1 Whole number patients, 178 ; Operations, 193 ; Deaths, 1. The reduction of a general surgical death-rate to a fraction of one per cent, under such circumstances is due to the resources of to-day rather than to any particular skill on my part. CHAPTER II. THE APPENDIX VERMIFORMIS CECI. THE lengthened cecum of mammals has degenerated to a vermiform appendix in some species. The cecal appendage is vermiform in man and in all of the man-like apes—gorilla, orang, chimpanzee, and gibbon (several species). It is also vermiform in certain lemurs, and perhaps in some of the monkeys. Curiously enough the marsupial wombat has a vermiform appendix. In Fig. 3.—Normal appendix vermiformis ceci {Homo sapiens) showing mesappendix and solitary artery. man, the cecal appendage is apparently a rudimentary structure which once formed an important part of the alimentary tract in the days when we needed a wisdom tooth for crushing palms and ferns, and a large absorbing surface for extracting their scanty 10 The Appendix lermiformis Ceci. 11 nutriment. Now, as degenerate structures, the cecal appendix, and the wisdom tooth, with its insufficient calcification, perish easily when attacked by bacteria. The microscope does not show the comparative vital energy of different cells or structures, but it is fair to assume that the unused appendix has low vitality, because we know analogously that other unused normal struc- tures lose to a certain extent their resistance to infection by bacteria. The appendix vermiformis in man was recognized as a struc- ture in the sixteenth century, and was described in the eighteenth century. It appears at about the tenth week of fetal life. As compared with the length of the colon, it is largest at birth, and smallest after seventy years of age. It is one of the structures which flutters before going out in the descent of man, and is conse- quently of extremely variable dimensions. The length of an average appendix vermiformis in a young adult is not far from three and three-quarter inches, with a diameter of the quill of the primary feather from the wing of a Canada goose. We occa- sionally find a normal appendix two inches long, or eight inches long, and I have removed several which were about half a foot long. Measurements taken post mortem will give too great an average length, because the appendix becomes lax and elongated after the period of rigor mortis has passed. Measurements taken from specimens removed at operation will give too short an average length, because the structure contracts almost immediately on separation from the cecum, unless it is gangrenous or tense with exudates. We must therefore make our estimates from normal appendices observed while we are engaged in other abdominal work. The position of the appendix is usually behind the cecum, and pointing toward the spleen, but its tip may touch almost all boundaries of the peritoneal cavity. It is ordinarily supplied with a mesappendix, which is given off from the left layer of the mesentery of the ileum. There is good authority for the state- ment that the appendix is sometimes extra-peritoneal, but in all observations by myself, in which structures were not too badly damaged for accurate determination of that point, the appendix possessed a mesappendix. This is a matter of little practical im- portance to the surgeon, because an appendix situated behind the peritoneum could be easily released by a slit through the peri- toneum at that point. 12 Lectures on Appendicitis. A transverse section of the appendix shows it to consist of the structures which belong to the cecum, but with an excess of lymphoid tissue, amounting in some cases to half of the entire mass. From without inward, the layers are : peritoneum, external non-striated circular muscle, internal non-striated longitudinal muscle, lymphoid tissue, and mucosa. This does not include the connective-tissue layers, the most important of which, lying between the lymphoid tissue and the longitudinal muscle, becomes so greatly distended with serum as to form a strong factor in exudate strangulation of the lymphoid layer in some infected appendices. The principal arterial supply of the appendix is from a branch of the ileo-colic artery, which passes along the free margin of the mesappendix. This artery may be described as the solitary terminal artery of the appendix, and its anatomical arrangement is a matter of great clinical importance. In some women the appendix receives a little collateral circulation by way of the ap- pendiculo-ovarian ligament. The lymphatics of the appendix pass largely to a ganglion at the cecal extremity. The nerves of the appendix are from the superior mesenteric plexus of the sympathetic system, which is widely distributed to the small intestine, and this explains the reason why patients often suffer from colic and general abdominal pain, or pain at the navel, without realizing that its origin is at a little part of the whole, at the appendix (Fowler). It is almost an exception for the pain to be localized at the vicinity of the appendix at the outset of an attack of appendicitis. The contents of the appendix usually consist of mucus with more or less fecal matter. Under ordinary circumstances semi- solid fecal matter and gas find easy entrance to and exit from an appendix with a large lumen, as the appendix has abundant muscular ability to empty itself, and it has at the cecum a good fixed point for muscular action. It is not an uncommon sight when we are employed in abdominal work to see an appendix empty itself of distending contents when it is stimulated to contraction by the touch of the surgeon's finger. Although an average appendix can empty itself when in a normal condition, a very little hyperplasia or swelling of the lymphoid coat will suffice to lock in the contents of the lumen, and there are very many normal appendices containing concretions which cannot escape because the lumen is too small. The Appendix Vermiformis Ceci. 13 Appendix concretions are of three principal sorts—fecal, phos- phatic, and fatty. Fecal concretions are formed in normal appendices by the action of the muscularis rolling a bit of fecal matter into a ball or rod, which is cemented with mucus. Insolu- ble salts are precipitated out of the fermenting mucus, and as stagnant mucus is very apt to undergo decomposition, the fecal concretions are usually arranged in layers, alternately or Fig. 4.—Phosphatic appendix concretions. One bisected, showing concentric layers. homogeneously, with calcium salts. Phosphatic concretions are formed in normal appendices, and in chronically infected ap- pendices as a result of decomposition of mucus. Phosphate of calcium is the common, and sometimes the only ingredient of a concretion which may become as large as a hickory-nut. Examina- tion of three typical phosphatic concretions from three chronically infected appendices gave the following results: (1) Patient had repeated slight attacks of appendicitis; con- cretion about as large as a No. T shot ; color, brown ; external layer and internal portion of neutral calcium phosphate, with traces of organic matter and potassium ; no magnesium or oxalic acid. (2) Patient had repeated attacks of appendicitis, some of the attacks violent. Concretion was of the size and appearance of a date seed ; grayish-brown in color ; external layer as in specimen No. 1 ; internal portion contained more organic matter. (3) Patient had repeated violent attacks ; concretion size of robin's egg; of a whitish-clay color; external layer and internal portion composed of fifty per cent, of fat ; the remaining fifty per cent, consisted of alkaline calcium phosphate. I was at a loss to account for the large proportion of fat in this and in other similar calculi, but it seemed possible that fatty metamorphosis of lymphoid cells in a chronically ulcerating ap- pendix might furnish enough fat to make a concretion, and the following analyses were accordingly made, the inner tubes com- 14 Lectures on Appendicitis. posed of mucosa and submucosa from three sets of appendices being used : (i) Four normal appendices. Inner tubes dried at ioo° C, weighed ................. 1.0095 gm. And yielded fat weighing.............................. 0.0860 Percentage of fat............................. 8.52 (2) Three appendices with small ulcerating areas. Inner tubes dried at ioo° C, weighed................. 0.7276 gm. And yielded fat weighing.............................. 0.1410 Percentage of fat............................. J9-38 (3) Three appendices with extensive chronic ulceration. Internal coats dried at ioo° C, weighed...................0.6580 gm. And yielded fat weighing................................0.1701 " Percentage of fat...............................25.S5 The inner tubes of the normal appendices weighed dry 9.2 per cent, more than those of the ulcerating appendices, but contained only about one third as much fat. Several observers have reported the finding of gallstones in appendices, but these specimens were probably appendix stones. Even though the composition of the concretions was largely cholesterin, it is a tenable belief that they were formed in chronic- ally ulcerating appendices. There is a theory extant to the effect that gallstones are formed in the gall-bladder by the pre- cipitation of their constituents by colon bacilli, the bacteria which are constantly present in ulcerating appendices. Appendix concretions are round, oval, flat, or rod-shaped. Some of them occur singly, and some of them in such numbers as to make the appendix look like a rosary. Various kinds of seeds are closely simulated by these concretions, and this accounts for the popular error that seeds are apt to get caught in the appendix. The deception is all the more complete when the appendix mucus becomes condensed, and rolled into yellowish prolongations from the concretions, giving almost exactly the appearance of a sprout from a seed. I have not as yet found a seed in any of the appen- dices from my series of cases, the nearest approach to one being a small piece of apple core encrusted with phosphates. The formation of fecal and phosphatic concretions, while more apt to The Appendix Vermiformis Ceci. 15 occur perhaps in patients whose intestinal contents ferment, may be independent of any disease of the appendix; but fatty con- cretions probably occur only as a result of long ulceration of the lymphoid coat. Bacteria are by all means the most important things found in the appendix. The colon bacilli which have their normal habitat in the colon are almost invariably present in the lumen of the appendix, and they are harmless dwellers there unless an infec- tion atrium gives them an opportunity to migrate into the tissues. The pyogenic streptococci are also pretty constant dwellers in the normal appendix. Many of the less important pyogenic bacteria and saprophytes, or bacteria of fermentation, harmlessly lurk in the nook of the appendix awaiting the advent of conditions which will be favorable for their rapid multiplication. When an infec- tion atrium is made, the infection is at first mixed in character, as observed in a number of my specimens of infected appendices which Avere removed in the very early stages of appendicitis. The streptococci are apt to outstrip other bacteria in the second part of the race, and the colon bacilli are apt to lead finally. Thriving colonies of bacteria are daily swept along through the normal colon, and are moved out of most appendices; but we must always look at the appendix as a test tube full of culture media, and forming a nook in which bacteria lurk dangerously when once the protecting structures of the appendix have been disabled. Some of the higher entozoa are frequently found in the appendix, and the nematode oxyuris is fond of making it a nest. CHAPTER III. APPENDICITIS. ACCORDING to my observations to date, appendicitis is an infective, exudative inflammation of the appendix vermiformis ceci, originating in any local cause for the production of an infec- tion atrium in the tissues of the appendix, and progressing by bacterial invasion into the layers of connective tissue, and the layer of lymphoid tissue, all of which are partially or completely disabled by interstitial exudate compression within the narrow Fig. 5.—Section of air-distended normal appendix. Fig. 6.—Section of infected appendix which was becoming disabled from interstitial exudate compression. muscular and peritoneal sheath of the appendix. The principal cause for appendicitis is mixed bacterial infection from the lumen of the appendix. The chief cause for bacterial infection from the lumen of the appendix is the formation of an infection atrium in the mucosa of the appendix by force applied in any way. I formerly surmised that the appendix was sometimes injured by pressure between a full cecum and the hard pelvic wall, supposing that the cecum was often filled with fecal matter ; but after exten- sive opportunities for observation, I have not as yet seen fecal 16 Appendicitis. 17 matter in the cecum at any operation, and there is doubt if so- called impaction is not often lymph exudate instead. Excepting in elderly people I believe that injury to the mucosa occurs most often from accidental twisting of the appendix upon part of its long axis. An infection atrium is also commonly produced by erosion of the mucosa at the site of a concretion, or by entozoa. Bacterial infection may extend into the tissues of the appendix from an infected cecum, as in typhoid fever or dysentery. An infection atrium is formed in its peritoneal outer wall at times by destruction of serosa consequent upon peritonitis extending from adherent infected oviducts or other near-by structures. The principal structures involved in appendicitis may be grouped as follows: (1) a soft, distensible inner tube of mucosa and lymphoid tissue within a confining outer tube of muscle and peritoneum ; (2) lymphatics leading to the lymphatics of the colon and mesentery ; (3) veins leading to the superior mesenteric vein ; (4) a solitary terminal artery ; (5) connective-tissue planes ; and (6) nerves belonging to the mesenteric plexus. The above definition and brief statement of the salient points needs some repetition and elaboration. The mechanical feature of interstitial serum pressure appears as soon as bacteria have entered an infection atrium—the term applied to any gateway which gives entrance for bacteria to the tissues. The toxines which are the products of bacterial growth are irritating, and as a result of their invasion, serum is exuded into the tissues of the appendix, placing such tissues under the influence of serum com- pression. The lymphoid coat of the appendix and its connective- tissue cushion, forming the principal part of the inner tube of the appendix, are so much like the faucial tonsil, that I shall take the liberty of speaking of the one as the tubular tonsil, and of the other as the flat tonsil, for purposes of illustration. The flat ton- sil and its connective-tissue cushion can swell enormously because there is a whole pharynx to give room to them. Even then the flat tonsil sometimes fills the throat and its connective-tissue cushion sloughs. The infected tubular tonsil and its connective- tissue cushion try to swell just as the flat tonsil does, but they are promptly subjected to pressure within the narrow confines of the muscular and peritoneal tube of the appendix. The imprisoned tube is then further compressed by contraction of the muscular coat upon the inner tube, in tonic spasm, as a result of toxic stimulation of the branches of Auerbach's plexus. Over-stimula- i8 Lectures on Appendicitis. tion of these branches leads to tonic contraction of the muscu- laris at the appendix. Stimulation extending to the branches of Auerbach's plexus at other parts of the intestine leads to irregular spasm, giving the symptom known as colic, and if over-stimulation of the sympathetic system extends still farther, the vaso-motors cause the heart to contract rapidly in partial spasm, and the heart muscle being unable to relax completely, muscular spasm of the arterioles being also present, the result is a small, rapid pulse. The tonic spasm of the outer tube upon the inner tube of the appendix is very much like putting a tight thimble upon a finger which is already tense from a felon, with serum exudate under the perios- teum. The inner tube of the appendix is composed of the same Fig. 7.—Section of normal mucosa and lymphoid layer of appendix x 600. structures as the inner tube of the cecum, but in the cecum there is abundance of room, and the lymphoid coat continues its func- tion as a strainer for bacteria, even when tense with interstitial exudates. The inner tube of the appendix, on the other hand, anemic from compression, cannot strain out bacteria well, and its cells readily undergo toxic destruction from bacteria. The in- fected appendix with its lymph and blood circulation obstructed, is not reached in men by a collateral circulation which can bring Appendicitis. 19 poly-nuclear leucocytes to throw out nuclein, and give protection, and consequently the bacteria are free to carry on destructive processes. In some ulcerating appendices the inner tube may not be swollen enough to fill the lumen of the appendix, excepting when irritation of the muscular sheath excites tonic muscular spasm of that sheath, and then compression anemia again dis- ables the inner tube. Although short or long periods of muscular spasm are of regular occurrence in infected appendices, we do not 1. Free border once occupied by mucosa. 2. Necrotic area. 3. Broken-down mucous follicles. 4. Breaking-down lymphoid tissue x 600. need that phenomenon for the production of compression anemia in a swollen ring of lymphoid tissue, as we are all familiar with the mechanical parallel in which a swelling barrel strains against the hoops—an exaggerated illustration, but one in which the principle is the same. The attacking bacteria which are causing interstitial exudation in the appendix, with their toxines, may be called early to a halt by the processes adopted by nature for stop- ping the progress of bacteria elsewhere. Thus, when poly-nuclear 20 Lectures on Appendicitis. leucocytes can be carried freely to the place of infection, they pour out nuclein in large quantities, and it is very difficult for bacteria to pass the nuclein wall. The bacteria, confined within a small territory, then commit suicide with their own tox- ines, just as saccharomyces commit suicide with their own alcohol in vinous fermentation. So complete is this destruction of bacteria that an appendix lumen closed against further entrance of bacteria from the cecum may sometimes become distended with sterile serum or mucus. The appendix, however, is particu- larly unfitted to receive help, because when its single-artery circu- lation is blocked by interstitial exudates the appendix stands out as an infected peninsula, cut off from the source of protection from leucocytes, and the bacteria are at liberty to continue with their work without receiving that opposition which would meet them through a collateral circulation if the infection were in the colon. A sufficient degree of exudation compression having cut off the access of leucocytes, the toxine destruction of the inner tube of the appendix progresses to various degrees. In milder cases there is simply desquamation of patches of mucosa, but the injury is not easily repaired, and the bacteria lurking in such a disabled appendix keep up a certain degree of malign influence, sometimes for many years, though the patient be unaware of the fact. Bacteria in the lumen of the appendix are ready to make new incursions at any favorable moment, so that the appendix which has been disabled at one attack of appendicitis may be fairly said to be chronically infected afterward, because when the bacteria are not actually in the tissues of such an appendix during the interval between attacks, they are in contact with an exposed lymphoid tube, and their toxines are particularly apt to maintain a constant influence when the very common scar constrictions of the lumen of the appendix lock in septic mucus. Acute mixed infection will cause all of the acute destructive processes which occur in the appendix, and it is not necessary to look for any specific microbe for appendicitis. I have obtained cultures of bacteria from appendices removed in different stages of progress of the disease, and although the colon bacillus was always present, the infection was regularly mixed in character at first, and in some cases up to the last point of destruction of tis- sues. As previously stated, however, there is a very decided ten- dency on the part of the streptococci and colon bacilli to outstrip all others, and finally to enter into a race with each other, the Appendicitis. 21 colon bacilli usually gaining the mastery. That is why appar- ently pure cultures of colon bacilli are often found in the large abscesses, and in the fluid of peritonitis in far advanced cases of appendicitis, giving to such collections of fluid their disgusting fecal odor, which is really the odor of products of colon bacilli. The ordi- nary odor of feces is due to the harmless growth of colon bacilli in the j bowel, and it was form- erly supposed that the odor of appendicitis ab- scesses was due simply to their close contact with the bowel. It was apparent, however, that the odor of a small ap- pendicitis abscess was sometimes out of all pro- portion to its size, and it was found that ovi- duct abscesses bearing the same relation to the bowel, and not contain-Fig. io.—Chronic ul- ing cultures of colon ceration of inner tube, bacilli, were free from from an interval case of appendicitis. fecal odor. Mixed bac- teria and nearly pure cultures of streptococci are destructive locally, but wide infection seems to be Fig. 9.—Destruction of inner done principally by the flagellated, far- tube of appendix at two traveling colon bacilli, which may appear points by acute ulceration. . .. . , ,. i v : in the liver or lung during an attack of appendicitis. The colon bacilli when once aroused seem like a swarm of angry bees about an over-turned hive, ready to attack anything in sight. It would be unwarrantable with our present knowledge to ascribe to the lowly bacteria anything so high as nocturnal habits, and yet it is certain 22 Lectures on Appendicitis. that a disproportionate number of the attacks of appendicitis among my cases came on between the hours of one and five o'clock in the morning. The temperature of appendicitis is interesting because of its lack of importance. Though failing to indicate the extent of infection, it gives a clue, I think, to the character of the infection. Thus, the high temperatures in appendicitis more often occur when infection is mixed, or when caused by streptococci. A tempera- ture of 1030 F., or more, at the outset of an attack of appendicitis seems to mean that the toxines of mixed bacteria are sending the temperature up. When streptococci become ascendant, the tem- Fig. 11.—Section of muscular coat of appendix, showing infiltration of leucocytes in lymph spaces. perature may go to 1050 F., but as soon as the colon bacilli con- trol the field, the temperature of the patient may be expected to drop, and to fluctuate within a range of one degree on either side of ioo° F., while the disease is in progress, and no matter how widespread the infection. The temperature in appendicitis is not often elevated after the lapse of a few hours, and a colon bacillus temperature may be normal or subnormal from the outset, and so Appendicitis. 23 continue while the most disastrous effects are being produced by the bacteria in the tissues. While the toxines of the colon bacil- lus apparently do not send the patient's temperature up, they nevertheless pull the vital signs apart most insidiously, and it is not uncommon in cases of appendicitis with pure cultures of colon bacilli, to find a temperature averaging 990 F., and the pulse rate averaging 120 beats per minute for several days in succession. We must not look to the temperature then in trying to judge of the severity of an attack of appendicitis. But the pulse becomes important when it indicates the degree of intoxication of the sympathetic nervous system. Complete destruction of the Fig. 12.—Longitudinal section of vein in mesappendix, showing thrombus surrounded by leucocytes. walled-in appendix, however, may take place without producing much change in the character of the pulse, so that neither pulse nor temperature in appendicitis gives an indication of the extent of the destruction of the appendix proper. The lymph spaces of the lymphoid coat, together with the lymphatic vessels of the appendix and mesappendix, are often completely blocked with exudates and infiltrates a few hours after infection has com- 24 Lectures on Appendicitis. menced. Blocking of the lymphatic spaces interferes quickly with the lymph circulation. Infective lymphatitis frequently ex- tends from the lymph channels of the appendix to those of the colon and mesentery. The veins of the appendix are variously thrombosed by the infection, and the process may go on to ex- tensive mesenteric thrombo-phlebitis, pyle-phlebitis, portal embol- ism, and abscess of the liver. Abscess of the liver from septic appendix emboli may be looked for in almost any stage of appen- dicitis. The earliest case that has come under my notice occurred on the fifth day. There is no doubt that hepatic abscess appears in some cases of appendicitis that are too mild to attract the at- tention of the physician directly to their original character, as I have found thrombi ready to become emboli in the mesappendices of such cases. Fig. 13.—Proliferating endarteritis of solitary artery of appendix. Arterial complications give rise to some of the most strikino- phenomena of appendicitis. When the solitary terminal artery of the appendix becomes the seat of proliferating endarteritis, round sloughs form at the ends of the arterial twigs that are first obliterated, or the whole appendix sloughs from deficient blood Appendicitis. 25 supply. In some cases in which endarteritis causes obstruction, but not occlusion, slow ulceration occurs opposite the most affected branches of the artery. The com- plication of proliferating endarte- ritis I first described in September, 1893, but had previously examined several examples of it, finding that the tunica intima had undergone rapid proliferation as the result of acute infection. The solitary ar- tery of the appendix is obstructed sometimes in accidental disloca- tion of the appendix. The ex- pression, " dislocation of the ap- pendix," is almost an unsafe one to use, because the appendix may occupy such a variety of positions in relation to the cecum ; but when any one appen- dix which belongs behind the cecum is thrown out from behind the cecum by a sudden blow or by an unusual muscular effort, and when it cannot return to a position for which its mesappendix was adapted, that particular appendix may be spoken of as a dislocated one, and it may remain so strongly twisted upon itself, including the mesappendix, that arterial and venous circulation is interfered with. This, I think, is the origin of a cer- tain proportion of cases of appendicitis. The connective-tissue planes of the ap- pendix conduct infection to neighboring loose connective tissues, and very exten- sive sub-peritoneal abscesses may form, sometimes at such a distance from the appendix as to mislead the surgeon be- cause of their simulating peri-hepatitis or peri-nephritis, or psoas Fig. 14.—Two round sloughs. 26 Lectures on Appendicitis. abscess. In two of my cases, phlebitis of the veins of the left leg occurred as a result of infection travelling from the appendix across the pelvis by way of the sub-peritoneal connective tissues. In another case, an abscess formed along the left pelvic brim. The nerves of the appendix are acutely inflamed in progressing in- fection, but the most interesting nerve complications occur after the attack of appendicitis has subsided. Nerve filaments caught in contract- ing scar tissue are the source of per- sistent discomfort for the patient, but the principal symptoms appear to be due to chronic sclerosis following acute neuritis. The interstitial con- nective-tissue elements of the nerves undergo marked hypertrophy. In some cases in which the appendix has disappeared with the exception of a fibrous string of connective ■" "" tissue, ill-defined muscularis and peritoneum, the sclerosed nerves yet keep the patient more or less of an invalid, because they ex- ert an influence which inhibits the peristaltic movements of the colon, and predisposes to constipation, in- testinal fermentation, and general dyspeptic symptoms. I supposed that this influence was due to old adhesions until I found that patients in whom few adhesions existed were relieved from their discomfort and rapidly gained in health and strength Fig. 15.—Single round slough, after the removal of sclerosed ap- pendix remains. Peritonitis is the most important complication of appendicitis. and one which formerly attracted our attention so closely that the appendix was often overlooked. The simplest form of peri- tonitis complicating appendicitis is limited to the peritoneum of the appendix and mesappendix. The irritating products of bac- Appendicitis. 27 'J teria at work within cause a reddening and roughening of the serosa of the appendix and mesappendix. The latter contracts firmly, re- maining contracted and fixed by adhesions if the inflammatory process is severe enough to cause the formation of plastic peritoneal exudates on the layers of the mesappendix. When the leucocytes fail to limit the peritonitis to the region of the appendix, by their anti-toxine, the peri- toneum over near-by structures throws out plastic exudate, and the appendix is entirely surrounded \ by adhesions which wall it in. This is a very £1 pretty subterfuge on the part of Nature, and it protects the patient unless bacteria have gained too much headway. Nature is appreciative of success, however, and when the bacteria have proven themselves to be very enterprising, she transfers her interests from the patient to the fine colony of bacteria whose claims for vested inter- ests outweigh those of the patient. In such a case the protecting peritoneal exudate is liquefied by the bacteria which escape into the general peritoneal cavity in large quantities, and which excite a diffuse peritonitis if the patient is under the influence of opium. If we help the patient, however, by passing hygroscopic salts through the alimentary tract, and allow natural events to fol- low, toxic fluids are drawn into the intestinal canal by osmosis, and active phagocytosis takes place so rapidly in the broad field of the peritoneum that the patient may be saved. Our intense fear of pus in the peritoneal cavity is unwarranted by present knowledge, and some pus in some peri- toneal cavities is certainly harmless, if we manage the peritoneum well. Before its functions were well understood the peritoneum was often mis- used, and it responded in kind, so that we feared peritonitis. In our day the peritoneum has be- come the surgeon's best friend, and with its aid the most extensive abdominal operations are done with safety. We call it to our aid in Fig. 16.—Whole appendix, gangrenous and sloughing. 28 Lectures on Appendicitis. walling in the buried stump after the removal of the appendix, and we direct it to dispose of bacteria and toxines. To-day, the peritoneum does yeoman service for or against the patient, according to the dictation of the surgeon. The extent of in- fection in a case of peritonitis with appendicitis bears no direct relation to the extent of destruction in the appendix itself. The most violent peritonitis can occur in cases in which bacteria have migrated out of the appendix by way of the blood-vessels, lym- phatics or loose connective-tissue planes, not going through the walls of the appendix. On the other hand, a very little local peritonitis may suffice to wall in a perforated or completely f****^' ; . "S^ Fig. 17.—Gangrene of mesappendix. A. Appendix not yet dead. B. Mesappendix. sloughing appendix. We therefore over-estimated the relative importance of perforation of the appendix formerly. The fallacy has gone abroad that the appendix is usually destroyed in cases in which abscesses have formed. We opened such abscesses without doing anything further in former years, before the principles in- volved were clearly in mind, and have subsequently removed from these patients appendices which had suffered comparatively little damage. There are certain cases in which it is wise to leave an infected appendix at the bottom of an abscess cavity, but such appendices cannot be left on the theory that they will give no Appendicitis. 29 further trouble after the patient has recovered. In one of my cases, in which a flood of intra-peritoneal pus was discharged by way of the mouth and vagina simultaneously, entering the mouth after perforation of the lung, the patient had subsequent attacks of appendicitis, and the appendix on being finally removed was found to present simply two scar- strictures and a honeycombed lymphoid coat, the outer tube of the appendix being unperforated. ^ When bacteria have liquefied the peritoneal \ plastic exudate about a walled-in appendix, the peritoneum usually protects by putting up new plastic walls farther and farther away, so that enormous walled-in ab- W" scesses frequently result. Very often '\ Fig. 18.—Perforated appendix. Fig. 19.—Multiple perforations of appendix. 3Q Lectures on Appendicitis. the plastic exudate becomes liquefied by bacteria at several points, leaving firm exudate in the intervals, and we then have multiple abscesses. That fact forms the rational basis for the procedure of separating all adhesions in some operations upon acute appen- dicitis cases with pus. If we evacuate one large abscess, a very small undiscovered abscess may prove fatal to the patient. Intra- peritoneal abscess cavities sometimes fail to evacuate their con- tents spontaneously, or to prove fatal to the patient, and such collections of fluid may remain encapsulated for many years, making the patient an invalid, and subjecting him to the distress of acute exacerbations of inflammation from time to time. If in such encapsulated collections the bacteria kill themselves and their spores with toxines, the sterile fluid and contained debris may undergo absorption. Abscess fluids, whether formed within the peritoneal cavity or in the sub-peritoneal connective tissues, if neglected by the surgeon, may open externally upon the abdo- men, or they may perforate the ureter, the bladder, the bowel, the iliac vessels, or even the pleura and lung. An appendicitis patient with an abscess cavity that is seeking a point for evacua- tion of its contents, is consequently in a most critically dangerous position. A large, intra-peritoneal abscess may form with com- Fig. 20.—Appendix kept partially alive by adhesion circulation after destruction of its artery. paratively little pain, but intense suffering results from abscess formation about the iliac arteries, because the strong pulse gives an increasing succession of blows to the sensitive structures that are bound to the spot by plastic exudate. When an abscess forms about the large nerves of the pelvis, a distressing neuralgia complicates the case. Adhesion bands are extremely common after recovery from acute appendicitis. The plastic exudate which is thrown out for the protection of the patient may undergo nearly complete absorption if the case is one of short duration, and in other cases short, firm adhesions Appendicitis. 3i remain permanently, but cause little trouble. In a less fortunate group of cases, the adhesions are pulled out into long bands by Fig. 21.—Interval case. Circulation interfered with by adhesions. the action of the moving viscera. A complication similar to adhesion bands is caused by the omentum, which is very com- monly caught in adhesions at that part of its border which Fig. 22.—Interval case. Three pus cavities formed by scar strictures. A. Pus cavity. B. Scar strictures occluding lumen of appendix. touches the appendix. The movements of the viscera then roll the free mass of omentum up into a rope, or divide it into fila- ments, which, fixed above and below, set a trap for loops of bowel. Adhesion bands cause volvulus and kinking of the bowel. They mechanically inhibit peristalsis of the colon, and strangula- tion of the bowel occurs in such adhesion bands years after an attack of appendicitis has been forgotten, if it was ever recog- nized. The most frequent complications caused by intra-peri- toneal adhesion bands are not the dangerous ones, but consist simply in chronic constipation from mechanical inhibition of peristalsis, or in occasional attacks of distress from temporary incarceration of knuckles of bowel. A phlebitis of the iliac and femoral veins is a common complication of infective appendicitis, and may cause death in a case which is otherwise a moderate one. Acute suppurative nephritis may suddenly appear in a very sim- 32 Lectures on Appendicitis. pie case of appendicitis by infection travelling up the ureter. I lost one such patient, a student who came into the office smiling, with his books under his arm, and saying that his physician thought he had appendicitis, and wished to have me see the case. I found an appendix somewhat tender and firm with interstitial exudate, but the patient had no constitutional symptoms of in- fection. I asked him to enter the hospital the next day and have the appendix out. When I saw the patient on the follow- ing day, he was in a hopeless condition from acute suppurative nephritis, which proved fatal. Fig. 23.—Post-appendicitis adhesion band from cecum snaring a loop of ileum. Septic pleuritis and pneumonitis suddenly and unexpectedly develop in any stage of progress of infective appendicitis. Tuber- culosis and neomata of the appendix are not often complicated by infective appendicitis, because the progress of these diseases is slow, and the structures of the appendix have ample time to ad- Appendicitis. 33 just themselves to the new conditions, just as they do in hydrap- pendix where slowly accumulated mucus, dammed by a stricture and sterile from suicide of its bacteria, gradually forces the lym- phatics and blood-vessels to become hypertrophic in a compensa- tory way. Such compensatory hypertrophy and multiplication of structures is impossible under ordinary conditions of acute, infec- tion. Catarrhal appendicitis has not been observed by me as yet, because I differentiate infective appendicitis from catarrhal colitis with involvement of the appendix, and do not operate in the latter cases, nor do I call them cases of appendicitis. When I operate it is upon cases of infective appendicitis in various stages of progress, and the responsibility that goes with the making of a diagnosis is such that I believe it to be morally wrong for us to make the diagnosis of catarrhal appendicitis at the bedside before the specimen has been seen. The simplest stage of infective ap- pendicitis, and one which is perhaps most often wrongly called catarrhal appendicitis, causes symptoms when exudate-compres- sion-anemia and toxic destruction of cells cause a small portion of the inner tube of the appendix to disappear by ulceration, or by sloughing, before the resistance factors are in control of the tissues. When infection halts, the gap left in the tissues of the inner tube is closed by granulation, and eventually by connective tissue, which slowly contracts and narrows or closes the lumen of the appendix. In such a case the patient may be free from symptoms of appendi- citis in two or three days, but the progress of mild infective appendi- citis is often protracted, and marked by slow erosion of mucosa and lymphoid tissue, caused by pressure of interstitial exudates; by muscular spasm of the outer tube, by obliterating hyperplasia of the tunica intima of small arterial branches, by plugging of lymph channels, or by direct toxic destruction of cells. Connective tissue gradually replaces the broken-down inner tube, and if it is evenly replaced without the formation of stricture nodes, the dis- ease may eventually disappear without causing disaster or even very marked symptoms. In these chronic cases of infective ap- pendicitis, all structures excepting the mucosa frequently become excessively hypertrophic during the period of infection, but finally nothing remains excepting a string of connective tissue surrounded by ill-defined remains of muscle and peritoneum, and containing sclerotic nerves. We cannot reasonably expect that any particu- lar case of appendicitis will end in this way, because the accidents of acute exacerbations of the infection too often bring the case 3 34 Lectures on Appendicitis. to a more abrupt termination. In the more vicious forms of acute infective appendicitis, all structures of the appendix are partly or wholly destroyed quickly. If the appendix is well walled in with plastic lymph, the sloughs which form are decomposed by sapro- phytes, and the stump of the appendix or the opening in the cecum gradually heals. Rhexis of the appendix, a condition in Fig. 24.—Rhexis of middle segment of appendix—A. which the capillary vessels allow their contents to escape inter- stitially into all the structures of the appendix, dissecting tissues apart, and distending structures with blood, indicates a savage type of infection, but one which occasionally fails to give symp- toms of importance until the condition of gangrene supervenes. Appendicitis occurs principally in young males. The fact that women do not suffer from this disease so often as men has been well established by post-mortem examination statistics, and is not based on the theory that in women diseases of the ovaries and ovi- ducts are more often mistaken for appendicitis, because such mistakes in diagnosis are easily avoided. There are three fairly good reasons why women suffer less often from appendi- citis, viz.: (1) There is sometimes collateral circulation by way of the appendiculo-ovarian ligament; (2) women expose them- selves less to the production of traumatic infection atria; and (3) the flaring pelvis in women is not so likely to hold a displaced appendix in a cramped position. About twenty per cent, of the cases of appendicitis occur in women. It is most common in both sexes between the ages of ten and thirty-five. But it may occur Appendicitis. 35 in the infant at the breast, or in the old man in his dotage. The very young, and those past middle life, expose themselves less often to the production of traumatic infection atria. Another reason why the disease occurs more rarely after middle age is be- cause the appendix undergoes a certain involution process, which sometimes leaves it bare of mucosa and lymphoid tissue in old age. A nomenclature has been sought for the description of various kinds of appendicitis, but apparently there is only one kind of appendicitis which produces acute symptoms,—infective, exuda- tive appendicitis,—caused by bacterial invasion of a structure which is peculiarly unfitted to resist the effects of such an inva- sion. The various phenomena of infective appendicitis should not be described as indicating different kinds of appendicitis, but rather as marking different forms of one kind of disease. Thus we may speak of the acute or chronic form, the form of endo- appendicitis, or of perforation, or of hydrappendix, and so on in- definitely ; but as endo-appendicitis may be present on Monday and perforating appendicitis may appear on Wednesday in the same case without our being able to state what Friday appen- dicitis may be like, we might classify these cases as " Monday," " Wednesday," and " Friday " appendicitis. The diagnosis in each case would be made afterward. We cannot know that any attack of infective appendicitis will stop at any one form short of complete destruction, because the power of the principal resist- ance factor in any one case is absolutely unknown. By " resist- ance factor " I mean so-called phagocytosis. We can place a case in a certain sort of classification after we have seen the specimen, but such a post-diagnosis is not more fair than a game of whist after an opponent's hand has been seen. If we classify cases as fulminating cases, or as cases with abscess, we are classifying them from the symptoms of complications without reference to the actual condition of the appendix, or the form of the appendicitis proper. There are no groups of symptoms which will allow us to make a rational prognosis as to the eventual outcome, or the prospec- tive complications in any progressing case of appendicitis, and we must abandon the hope of having any such classification of symptoms for a guide in the future. Attempts will be made from time to time to classify symptoms for prognosis from small groups of cases, but they will fail because of the nature of the disease. 36 Lectures on Appendicitis. I speak, then, unequivocally, knowing that some patients are to die and others are to suffer unnecessarily because their advisers will believe themselves to be upon a prognostic track. There is but one rule to be followed, and that is to isolate an infected appendix as promptly as we would isolate a case of diphtheria and for practically the same reasons, viz.: the infected appendix will probably infect other structures, and the infected throat is likely to infect other throats. An infected appendix is isolated when it is out of the patient. All cases of appendicitis that are otherwise within surgical limitations, and that are within reach of competent surgical services, are cases for prompt isolation of the appendix. Various periods of waiting have been tried with the effect of proving that the question is wedge-shaped, with the greatest number of deaths at the broad waiting end, and the smallest number of deaths at the point of isolating an infected appendix while infection is limited to the confines of the appendix. We are held to our rule by two cardinal principles, viz.: (i) Every hour of progress of any acute attack of appendicitis means in- creased damage to viscera ; and (2) with no infected appendix the patient would have no complications of appendicitis, and there- fore the patient would have no complications of appendicitis if we leave him with no infected appendix. It then becomes a matter of interest to note the comparison between the death-rate of medical and surgical treatment of appendicitis. Statistics from a large number of observers give an average death-rate in the prin- cipal attack of appendicitis of about fifteen per cent, under medi- cal treatment, and I assume from experience, without being able to obtain available data for reference, that nearly ten per cent. more die from the numerous chronic complications resulting from previous acute attacks. According to Bull's statistics, from a large number of selected operators, the surgical death-rate of appendicitis is not far from two per cent, in cases operated upon at a time when infection is limited to the confines of the appen- dix. Bull's statistics, however, include only " interval cases"— cases which were already of the complicated class. I believe that a surgical death-rate of two per cent, is illegitimate in cases oper- ated upon in the first attack before infection has extended beyond the confines of the appendix. If the surgical death-rate were fourteen per cent, and the medical death-rate fifteen per cent. our duty would still be clear. We have learned that the peri- toneum is not to be feared by the surgeon in such cases, and now Appendicitis. 57 that we know the possible dangers of ligating the appendix like an artery, there are no further dangers in sight excepting from an imperfect aseptic technique, a responsibility which rests with the individual surgeon, and from ordinary causes which have no direct connection with the appendicitis. From experience I judge that we must place the surgical standard at less than one per cent, mortality rate in cases of appendicitis operated upon by skilled operators at the proper time for removal of infected appendices. The surgical treatment of appendicitis has made three distinct steps in progress within the past decade. Ten years ago we simply opened the abscesses of appendicitis when they were strongly in evidence. The first planned operations for the removal of infected appendices were done about the time when Dr. Fitz, of Boston, gave a great impetus to the investigation of the subject in his classical paper in the American Journal of the Medical Sciences in 1886. Intense interest in the subject was soon aroused, and surgeons generally began to search for infected appendices, but at such a late stage in the progress of the disease that statis- tics at first showed little if any advantage in favor of surgical treatment. The reason for that was because infection at the time chosen for operation was beyond the reach of resources of the surgery of that day. Then came the period of operating in the interval between attacks, or in the early stages of the first attack, and statistics at once showed the very great advantages of this treatment. There remained then only the necessity for perfecting the operation in such a way as to avoid the occurrence of post-opera- tive ventral hernias and of unsightly scars, and this has now been done. Medical treatment, which cannot reach the bacteria that are invading the tissues in the appendix, will nevertheless give very decided comfort in many cases in which surgical services are not obtainable. Opium will cover up distressing symptoms, and allay the feeling of unrest which is very marked in appendicitis. Hot fomentations over the inguinal region will relax the exhaust- ing spasm of the abdominal muscles, and may sometimes relax the outer tube of the appendix temporarily, but the tonic spasm of the muscular tube of the appendix is caused by direct toxic irritation, whereas the tonic spasm of the abdominal muscles is sympathetic, and due to a reflex from the appendix region. The orthopedists are the only members of our profession who, as a 38 Lectures on Appendicitis. class, are able to appreciate the exhausting effect and the disas- trous influence of long-continued muscular spasm. When hot fomentations fail to relax the muscles of the anterior walls of the abdomen completely, we may be quite sure that muscular spasm of the outer tube of the appendix is persisting down below, unless that outer tube is destroyed or paralyzed by interstitial exudates. Olive oil or saline cathartics passed through the alimentary tract will remove fermenting intestinal contents, and decidedly lessen the so-called auto-intoxication which is an element of much importance in these cases. Personally, I should prefer the saline cathartics for the purpose, but the Homeopathists have used olive oil with success for a great many years, and we may rest assured that its popularity with them is based upon observations of its usefulness. By usefulness I mean the obtaining of comfort for the patient. His chances for recovery are not much improved by any treatment which fails to remove the nest of infection, and that nest is out of the road of medical resources in appendicitis. So many patients will recover from one or more attacks without any treatment of any sort that we are apt to be misled as to the value of medical treatment excepting as to the comfort which it gives a distressed patient. Appendicitis patients who are in a position to receive surgical treatment should have very little preparatory medical treatment. Opium is to be particularly avoided, especially if the case is compli- cated by peritonitis. We need to have the peritoneum active if it is to serve the surgeon well. With an active peritoneum we may open the abdomen and remove the tubular tonsil almost as safely as we open the mouth and remove the flat tonsil, provided that the operator is expert. Our recognition of the safety of such work under the principles of new surgery would tempt us to remove the normal appendix when it appears in the field of our other abdominal work. To this I am opposed on the principle that the death-rate of no surgical operation can be reduced absolutely to zero, and the surgeon who would protect his patient must not remove an appen- dix until there is infection, and consequent occasion for removing it. I refuse to remove uninfected appendices, and can find at the same time no rational excuse for failing to promptly remove infected appendices. The cause of prompt operative treatment for appendicitis has had to labor against the prejudice aroused by unnecessary ovarian surgery, just as diphtheria anti-toxine to-dav Appendicitis. 39 has to labor against the reaction which followed the trial of Koch's lymph. The operative treatment of inflamed ovaries and tubes had a pendulum movement—too many operations were done because the reasons for operating were not always founded on a sufficiently rational basis. Then came a reaction, and to-day, not enough operations are done in some localities. Eventually the equilibrium will be found. The treatment of infected appendices has never had any pendulum simile, but rather the simile of a door which has gradually closed upon the question of immediate opera- tion, leaving it no longer an open one. An inflamed ovary seldom threatens life unless it is the seat of a dangerous neoma or abscess; it usually responds to palliative treatment, and may be a very useful organ. An appendix, on the other hand, is never a useful organ, and it always threatens life when infected. I frequently spend half an hour in the attempt to save a damaged ovary, separating adhesions, freeing agglutinated fimbriae, and opening a closed oviduct, instead of removing the mass, which at first looks so unpromising. With the damaged appendix I spend only time enough for its removal. Sometimes when engaged in other abdominal work I find phosphatic or fecal concretions in appendices, and liberate them by pushing them through into the cecum, not disturbing the appendix if it shows no evidence of infection. In some cases so-called ovarian neuralgia could have been relieved if the surgeon, on finding a normal ovary, had turned to the appendix and liberated a concretion. -It is rather unsafe to leave an appendix which has contained a concretion, unless the surgeon is familiar with the appearance of normal appendices, and it is only within the past year that I have dared to do it. There is one position in which the surgeon may hesitate about operating when he finds a far advanced case of appendicitis at his first visit, and that is in a town where the people are not likely to distinguish between the post hoc and the propter hoc, if the patient dies after the operation, and not because of the operation. The surgeon knows if he waits for the bacteria to kill themselves by their toxines, or to be killed by the anti-toxines, he can remove the appendix with safety as an "interval case." He also knows that the patient may die before the bacteria cease work in that particu- lar case. If he operates, and the patient dies because bacteria were in advance of surgical resources, all operating for appen- dicitis may be stopped in that town, and lives may be lost, and much unnecessary suffering will ensue because the people will 40 Lectures on Appendicitis. fail to avail themselves of proper resources at a proper time. Consequently, as a matter of policy, the surgeon may find it right to adapt himself to his surroundings, and to sacrifice the indi- vidual patient by refusing to give him help,—in the interest of the public. More lives will really be saved in such a town if in such a case we refuse to give a father a chance to live for his family, or refuse to try to help a son who is the sole support of aged parents. This picture is by no means a fanciful one, as we all know very well. Personally, I have never been able to refuse to help the individual, and other patients have been lost from neglect because a far advanced case of appendicitis died in spite of all the resources which could be applied. No such opprobrium follows the death of an appendicitis patient under medical treatment. The progress Avhich has been made in the treatment of appendicitis has been based on accurate information relating to the problems that are involved, just as we have made recent progress in many other lines. Not many years ago, when a woman came into the office complaining of sick-headache, or nervous dyspepsia, we thought first of medical treatment, and such medical treatment was usu- ally unsatisfactory because we obtained temporary relief only from the treatment of symptoms. To-day, in making a diagnosis by exclusion in such a case, we are called upon to eliminate the possibilities of irritation from errors of refraction or inflamed rec- tal papillae, or a uterus out of position, or septic oviducts, or a loose kidney, or carious teeth, or hypertrophies of the turbinated bones; and the proportion of such cases that are found to be essentially surgical is very large. The insane asylums are now robbed of many of their victims by our present knowledge of the accurate methods of giving relief—a knowledge which makes it easy for the patient and difficult for the physician, in contra-dis- tinction to the not very old plan which was easy for the physician, and hard for the patient. Our advances in the field of appendi- citis, however, now make treatment easy for both physician and patient. Ten years ago most of our appendicitis cases were s treated under the aliases of acute indigestion, bilious colic, mala- rial fever, la grippe, peritonitis, entero-colitis, cecitis, neuralgia of the bowel, intussusception, volvulus, intestinal obstruction, typhli- tis, perityphlitis, typhoid fever, salpingitis, ovaritis, gall-stones or gravel; while some of the abscess complications caused the cases to be classed as psoas abscess, coxitis, abscess of the abdominal Appendicitis. 4i wall, peri-hepatitis or peri-nephritis. Appendicitis is of such common occurrence that we have all lost friends and acquaint- ances from that disease, and such multitudinous forms of abdom- inal disease are simulated by appendicitis that we must press with our fingers at " McBurney's point " in almost any case of acute abdominal inflammation of sudden onset as regularly as we would look at the tongue. I have seen appendicitis overlooked on post- mortem examination in former years, because the appendix hap- pened to be buried in adhesions, and because it was only a little thing anyway ! The symptoms of appendicitis do not indicate the condition of the appendix more closely than they do the condition of the in- fected wisdom tooth in which a very small carious point of infec- tion may excite an intolerable neuralgia, or it may be the cause of suppurative alveolar disease, pyemia, septic meningitis or abscess of the neck. Another wisdom tooth may become entirely carious without giving any symptoms beyond an occasional tooth- ache. We may find a completely gangrenous appendix in a case in which the patient is resting quietly in bed with normal tem- perature, pulse, and respiration. The reason why the appendix is free from tenderness is because it is dead, nerves and all. The temperature and pulse are normal because toxines are not escap- ing into the general circulation. The face of such a patient, however, usually looks " wrong " to the members of his family. In another case with trifling ulceration of a part of the inner tube of the appendix we may find the patient throwing himself out of bed on the floor, rolling in agony, and striking himself upon the head with any near object in an insanity of pain from irregular spasm of the muscular coats of the intestine, otherwise known as colic. His temperature may be 103 ° F., and his pulse rapid. Such extreme cases as the above two are seen by all of us who are engaged much in abdominal work. The presence or absence of an inguinal tumor is a matter which must not be taken into consideration in estimating the value of the testimony of symp- toms, because an acute general peritonitis may appear in a case of appendicitis in which the appendix is not perforated, and not surrounded by plastic lymph ; and a perforated or dead appendix may be walled-in by plastic lymph which is barely sufficient to close the opening or surround the slough. In the latter case there is danger in an examination for tumor, unless the surgeon is prepared for immediate operation when he has accidentally separated the 4- Lectures on Appendicitis. frail adhesions in making an examination. On the other hand, a large mass of plastic exudate may form about an appendix which is whole, or perforated, or sloughing in its entirety. For these reasons the presence or absence of an inguinal tumor is not impor- tant as giving a clue to the condition of the appendix itself. The groups of symptoms which belong to the various forms or com- plications of appendicitis are so multitudinous as to be extremely confusing to one who attempts to study the subject from the elaborate descriptions of authors, unless he has had considerable practical experience; and yet the disease is diagnosticated as readily as a broken leg by any one who has accustomed himself to looking for it. The correctness of such diagnoses are verified by operation. In most cases of appendicitis, the surgeon is guided well by certain symptoms which are of pretty regular occurrence, and in order to give a clear view I will adopt the plan of describing one typical case only. TYPICAL CASE--FIRST DAY. Subjective Symptoms. (a) General abdominal pain of sudden onset. (b) Waves of colic. (c) Nausea and vomiting. (d) Tenderness on finger-point pressure at McBurney's point. Objective Signs on Palpation and Inspection. (e) Abdominal muscles firmly contracted and resisting pressure. (f) Appendix feels harder than the cecum. (g) Fulgurant spasm of the external oblique muscles near their costal attachments when the region of the appendix is sharply tapped with the finger. Testimony of Little J'alue. Pulse, temperature, respiration, condition of the bowels and bladder. Analysis of Symptoms. General Abdominal Fain is due to the reflection of irritation along the widespread branches of the superior mesenteric plexus, suddenly ap- pearing when toxic irritation of the muscular tube of the appendix has -caused it to contract firmly upon its contents. Colic is sympathetic spasm of the muscular coats of the bowel due to over-stimulation of Auerbach's plexus, but such spasm of the small Appendicitis. 43 intestine and colon occurs at intervals, instead of persisting, as it usually does at the centre of infection in the appendix. Nausea and Vomiting mean reversed peristalsis of the stomach, caused by toxic irritation of the sympathetic nerves at the appendix. If the vomiting is bilious in character, it shows that the duodenum is also re- versed, and is filling the stomach with bile. Tenderness on finger pres- sure at McBurney's point is due to inflammation of various structures of the appendix lying beneath. McBurney's point is situated about two inches from the anterior superior spine of the ilium on a line drawn from that spine to the navel. The appendix sometimes occupies vari- ous positions in the abdominal cavity, but we almost invariably find at least the proximal end of the appendix at the normal site. The tonic contraction of the muscles of the anterior abdominal wall is a reflex phenomenon, and one which we read as meaning that the inflamed appendix is to be protected against traumatism. It has the same significance in appendicitis that tonic contraction of the muscles of the thigh has in coxitis. It is interesting to note that the abdominal muscles protect an inflamed appendix regularly, but that they usually fail to take interest in an inflamed ovary and tube situated a couple of inches away and remain normally relaxed. This point is one of import- ance in some cases in which a diagnosis between salpingitis and inflam- mation of the appendix lying in the pelvis becomes difficult. Hardness of the appendix is due to interstitial exudate, and palpa- tion easily reveals this condition in the "interval cases" of appendicitis after the period of acute infection has passed. In the primary stage of acute infection, the firm contraction of the abdominal muscles often makes palpation of the appendix difficult unless the patient is anesthe- tized, and in the stage of recent perforation or gangrene of the appendix, it is dangerous to palpate. Excepting in the acute stages of inflam- mation, palpation of the appendix is easily done, as soon as one has taken pains to become a little expert at it. Dr. Edebohls's plan of pal- pating the appendix is as follows : The patient lies upon his back with the legs comfortably flexed. " The examiner standing at the patient's right begins the search for the appendix by applying two, three, or four fingers of his right hand, palmar surface downward, almost flatly upon the abdomen, at or near the umbilicus ; while now he draws the ex- amining finger over the abdomen in a straight line from the umbilicus to the anterior superior spine of the right ilium, he notes successively the character of the various structures as they come beneath and es- cape from the fingers passing over them. In doing this, pressure exerted must be deep enough to recognize distinctly, along the whole route traversed by the examining fingers, the resistant surface of the posterior abdominal wall and of the pelvic brim. Only in this way 44 Lectures on Appendicitis. can we positively feel the normal or the slightly enlarged appendix. Pressure short of this must necessarily fail." Dr. Edebohls's method of palpating is very satisfactory, but I have lately found that for myself an easy way is to stand on the patient's right, using three right-hand fingers to feel with, and three left-hand fingers placed upon these to press with. The fingers that are to do the feeling are pressed by means of the three others down under the border of the right rectus abdominis muscle at the level of the navel, and slowly drawn toward the examiner. My sole landmark, the ascending colon, is then felt to slip out from under the fingers, and by repeating the process toward the cecum, we soon come to the end of the cecum, and there begin to hunt for the appendix by rolling the cecum to one side or the other of the finger tips. The proximal end of the appendix is found near the distal extremity of the cecum, and we then follow the rest of the appendix in any direction. The proportion of appendices that cannot be palpated will become smaller and smaller as the finger tips become educated. The point about using no muscular effort in the hand that is to be used for feeling is as important in pal- pating appendices as it is in palpating ovaries and tubes. The very delicate sense of touch is preserved if the left hand is used for pushing upon the examining hand. The only structures that need to be differ- entiated from the appendix in palpating are, the iliac artery, the epiploic appendages, and subperitoneal lymph glands. Pulsation distinguishes the iliac artery ; an epiploic appendage is usually much shorter than the cecal appendage, but it is often necessary to roll an epiploic append- age about under the fingers several times in succession in order to accurately get its proportions. Subperitoneal lymph glands feel pre- cisely like the tip of a normal appendix when they are swollen, but they are not freely movable, and are short. Fulgurant spasm of the external oblique muscles I so name because of the quick tremulous flashes of contraction which are easily observed near the costal attachments of these muscles when the region over the appendix is tapped quickly with the finger if a patient is not too fleshy. It is a reflex spasm which indicates extraordinary attempts at protection of the abdominal contents by a set of muscles which are already protecting up to a last degree consistent with the retention of their power. The reason why the pulse, temperature, and respiration give no testi- mony of particular value at the outset of the attack of appendicitis is because different patients respond so differently to the first impress of toxines on the great sympathetic nervous system, and because in ap- pendicitis the character of the toxines changes rapidly as different bac- teria become ascendant. The effect is as varying in character as is the Appendicitis. 45 effect of the toxine of saccharomyces (alcohol) upon the same patient if used in different media such as champagne, beer, and absinthe. Constipation and diarrhea are of little value as first signs, because toxines may inhibit peristalsis and may stop the production of mucus by paralyzing portions of Meissner's plexus. If the infected appendix lies near to the hypogastric sympathetic plexus and excites its branches, the patient may be compelled to empty his bladder every half hour ; if the sacral plexus is first involved, the patient may have spastic dysuria ; if neither plexus is disturbed, the bladder will not be disturbed, and consequently the character of the disturbance of the bladder is of little consequence except as showing where some part of the appendix prob- ably lies. TYPICAL CASE--THIRD DAY. Subjective Symptoms. (a) Pain, localized in the right inguinal region. (b) Anorexia. (c) Tenderness on pressure anywhere in the right inguinal region. (d) Constipation. Objective Signs. (e) Face anxious. (g) Abdominal muscles contracted and resisting. (//) Peritoneal lymph adhesions obscure the outlines of the appendix on palpation. Symptoms of little value are given by the temperature and pulse. Fain is localized in the right inguinal region, because reflex pains in other parts of the abdominal cavity are not likely to continue for more than one or two days in appendicitis. Tenderness on pressure any- where in the right inguinal region is due to inflammation of structures round the appendix. Constipation is probably symptomatic of Na- ture's attempt to keep the vicinity of the appendix undisturbed, and adhesions of the cecum aid very materially in inhibiting the peristal- sis at that point. So marked is the constipation in many cases that it amounts practically to bowel obstruction. The patient's face is anxious, presumably because of toxic paralysis of motor nerves supplying mus- cles of the face. A much more destructive process two inches from the appendix, in an ovary in which other species of bacteria are at work, will not often give this face. Respiration is short because the patient dreads to take a full breath which would cause pressure on a sensitve abdomen, and it is increased in frequency in order that the full func- tion of the lungs will continue in spite of the limitation of working sur- face, by short inspiratory efforts. The tonic spasm of the muscles of the abdominal wall continues to guard the contents within, but a certain 46 Lectures on Appendicitis. degree of exhaustion of the muscles is indicated by less responsive ful- gurant spasm when the region over the appendix is tapped with the finger. This plainly tells also of the exhausting effect upon the patient of continued over-use of one set of muscles—a strain which a strong man who is not being undermined by bacteria could not well afford to bear. He cannot hold an ounce weight in the extended hand for five minutes, yet he must suffer contraction of the abdominal muscles, per- haps for days. Peritoneal lymph coagulates about the infected appen- dix for the purpose of walling it in so well that the bacteria will be confined to a restricted field, and the subterfuge is successful unless bacteria have gained such headway that they attack and destroy this wall. The pulse and temperature are still unimportant as indicating the actual character or extent of the destructive process. Toxines from streptococci may excite the sympathetic nerves which control the muscles of the arteries and heart, and stimulate them until the pulse is full and bounding, and the streptococci may cause increased liberation of animal force in the form of heat, so that the temperature is high ; or a more destructive process may be taking place under the in- fluence of colon bacilli, the toxines of which are not liberating energy in the form of heat, but which are over-stimulating the sympathetic nerves until the heart cannot relax well before each contraction, and we have the rapid, feeble pulse. I dread a normal temperature in appen- dicitis more than a high temperature, because the colon bacilli infect so insidiously. As a general statement, however, it is best to say that the temperature of the patient must be entirely left out of our calculation in forming an estimate as to the condition of a case of appendicitis. TYPICAL CASE—TENTH DAY. (a) Vital signs nearly or quite normal. (b) Appetite returning. (e) Bowels moving irregularly. (d) Little exudate to be felt about the appendix. ( v^ Tuberculous appendix. General peritoneal tuberculosis, most marked in appendix region. Long incision. Removed ap-pendix. Buried stump. Wick drain. Ventral hernia. Wound had to be left open because whole peritoneum was suppurating. Recovery from op-eration. Recov-ering from tuber-culous peritonitis. Inner tube gone. Outer tube hypertrophic, connective tissue principally. Chronic as to appendix. Ad-herent to septic oviduct. Ex-tensive firm old adhesions. Acute general suppurative peritonitis. Mid-line incision. Removed uterine adnexa and appendix. Flushed abdomen with 1I20» and saline solution. Wick drain. Recovery, with ven-tral hernia. Small. No truss worn. Several. Inner tube ulcerating. Five concretions. Mucosa absent. Sub-mucosa replaced by fibrous connective tissue. Chronic. Adherent to mesen-tery only. Incision ij inches long. Buried stump. Closed wound. Recovery. One. Wholly gangrenous. One concretion. Acute. Abscess. Large mass of new adhesions. Portions of cecum and colon sloughing. Long incision. Removed ap-pendix. Sutured sloughing bowel to margin of abdominal incision after flushing vicinity with H202 and saline solu-tion. Wick drain. Recovery. One. Greatly swollen. Gan-grenous almost wholly. Sev-eral perforations. Acute. General septic peri-tonitis. Enormous abscess, in which loops of ileum hung free from adhesions. Long incision. Removed ap-pendix. Flushed with H202 and saline solution. Wick drain. Recovery. One. Appendix wasted to a thread, excepting distal half inch, which was distended to shape and size of a marble. Chronic. Extensive old firm adhesions. Short incision. Removed ap-pendix. Closed wound. Had used buried silk-worm gut sutures instead of catgut, and they worked out later. Recovery. Two. Whole inner tube gan-grenous. Perforation near cecum. Acute. Abscess. Large mass of new adhesions. Long incision. Appendix re-moved. Fragile cecum sutured to margin of abdominal in-cision after flushing with IL08. Wick drain. Long incision. Fragments washed out with H,G8. Fragile cecum sutured to margins of abdominal wound. Recovery. Two. Sloughing fragments only. Acute. General septic peri-tonitis with rhexis of colon and ileum. New adhesions everywhere. Recovery with tiny fistula ; sometimes closed, sometimes open. C/3 s . v*> Number of Acute Attacks and Con- dition of Appendix. Several during 20 years. All structures hypertrophic. Punc- tate ulceration of inner tube. Several. Ulceration of inner tube. Two concretions. Whole appendix gangrenous. Perforated. Several. Two very large con- cretions. Hypertrophic ap- pendix not actively inflamed. Mucosa almost perfectly pie- served. Endothelial coat of arteries hyperplastic. Arte- ries large and tortuous. Sub- mucosa composed of fibril- lated connective tissue. Several slight attacks. Fibrous replacement of portions of inner tube. Otherwise nor- mal. Two. Perforation at middle segment. Two old scar stric- tures nearly occluded lumen. One. Ulceration of inner tube. Lumen full of pin worms (oxyuris). Stage and Complications. Acute. Fragile local adhesions Acute. Adherent to mesen- tery at tip. Adhesion band at middle of appendix. Operation. Post-Operative Com- plications. Acute. General peritonitis, with general adhesions wall- ing off numerous widely dis- tributed collections of pus. Chronic. OKI adhesion band from tip of appendix to meso- colon had formed a ring, through which nearly whole of ileum had slipped. Nearly whole length of ileum strangu- lated. Gangrenous, with large perforations. Chronic. Mesappendix con- tracted firmly at middle seg- ment with hyperplastic band. No adhesions. Acute. Abscess. Extensive new adhesions. Chronic. No adhesions. Long incision. Removed ap- pendix. Buriedstump. Closed wound. Incision 1 i inches long. Re- moved appendix. Buried stump. Closed wound. Long incisions on both sides of abdomen for evacuation of abscesses. Flushed with j IL,02. Wick drainage. No~ Another case in which I tried buried silk-worm gut sutures. They worked out later. Long incision. JNo operative work could help the patient. inches long. Re- ppendix. Buried Incision IJ moved ; stump. Closed wound Short incision. Removed ap- pendix. Buried stump. Flushed with H202. Wick Incision ii inches long. Re- moved appendix. Buried stump. Closed wound. Wound suppurated. Due to injury from retractors. Recovery. Recovery. Death later. two hours Shock. Death few hours later from original cause. Operation made no impres- sion either way. Recovery. Recovery. Recovery. N Co, '8. ^ Two. Appendix divided into three nodes by internodal com- plete scar strictures. Nodes distended with thick opaque fluid. One. Round ulcer penetrating inner tube. Smaller round ulcer nearly penetrating inner tube. One ? Inner tube sloughing. l'erforation between layers of mesappendix. Whole dis- tended with pus, which was escaping through the thin mesappendix. Two. Appendix wasted to a string, excepting distal inch, which was tense with inter- stitial exudate. One. Tuberculous appendix. Several. Ulceration of inner tube. One scar stricture nearly occluded lumen near proximal end. Acute. Extensive adhesions. old Acute. Contraction of middle segment of mesappendix. N( adhesions. Acute. Abscess. Intense general peritonitis of eight hours' duration. Extensive new adhesions. Chronic. Extensive old firm adhesions. Chronic. Extensive old firm adhesions. Peritoneum of cecum studded with tubercle. Chronic. Adhesions abundant but not firm. Several ? Lumen almost oc- cluded and filled with coagu- lated mass of remnants of cells from mucosa. Mucosa com- pressed. Lumen surface ragged and eroded. Sub- mucosa densely fibrous. Peri- toneal coat thickened. Chronic. Found this appendix bound in adhesions while op- erating for removal of a chron- ically infected oviduct. -ong incision. Removed ap- pendix. Buried stump. Closed wound, Long incision. Appendix re- moved. Fragile swollen cecum would not allow inser- tion of sutures for burying stump. Stump ligated like an artery. Long incision. Removed ap- pendix. Flushed with Ha02. Sutured swollen cecum to margin of abdominal incision. Wick drain. Long incision. Removed ap- pendix. Could not bury stump. Closed wound. Incision i^ inches long. Re- moved appendix. Buried stump. Closed wound. Incision ii inches long. Re- moved appendix. Buried stump. Closed wound. Mid-line incision. Removed appendix. Buried stump. Wick drain. Another case in which I tried buried silk-worm gut sutures. Su- tures worked out later. Primary union fol- lowed nearly week later by suppura- tion within ab- dominal cavity. Opened, Wick drain. Primary union fol- lowed few days later by suppura- tion within ab- dominal cavity. Recovery. Recovery. recovery. Recovery, except for fistula (not fecal) for several months. Recovery. Recovery. Reci very, Co ft N ok S" u s Age. Sex. Number of Acute Attacks and Con-dition of Appendix. Stage and Complications. Operation. Post-Operative Com-plications. Result. 4(3 II F. One? Round slough, penetrat-ing middle segment of inner tube. Acute. Well marked new ad-hesions. Adhesion band from tip of appendix to mesocolon was strangulating cecum. Incision 1^ inches long. Re-moved appendix. Buried stump. Closed wound. Recovery. 41 iS M. Several. Hydrappendix. Scar stricture near cecum closed lumen. Lumen distended with several drachms of clear thin fluid. Chronic. Extensive old firm adhesions. Incision 1^ inches long. Re-moved appendix. Buried stump. Closed wound. Recovery. 42 29 ~2~r M. One. Appendix nearly dis-appeared. Small portion of lumen and portion of outer tube remained. Chronic. Extensive old firm adhesions. Incision 1^ inches long. Re-moved appendix. Buried stump. Closed wound. Recovery. 43 Normal appendix. Mistake in diagnosis. Tuberculosis of peritoneum not including that of appendix particularly. Incision 1^ inches long. Re-moved appendix. Buried stump. Drained wound. Hernia appeared in wound some months later. Hernial opening closedbyDr. Coley. Recovery. 44 20 30 M. One. Stiff with interstitial exu-dation. Inner tube not ex-amined. Chronic. No adhesions. Incision 1}, inches long. Re-moved appendix. Buried stump. Drained wound. Long incision. Removed ap-pendix. Could not bury stump. Ligated it. Wick drain for oozing from torn adhesions. Recovery. 45 M. Two. Appendix in two parts. A short healed stump attached to cecum. Another portion i\ inches in length, situated about two inches from the stump, made a round ball kept alive by adhesions. Acute. Firm old adhesions from pelvis to diaphragm. Septic peritonitis. Recovery. 46 27 F. Several. Appendix broadened out into a large pyogenic sac containing brownish pus and a large round concretion. In-ner tube structures gone. Chronic. Extensive old firm adhesions. Long incision. Removed pyo-genic sac. Wick drain for oozing from adhesions. Another case in which silk-worm gut sutures slowly worked out. Recovery. 4^ S 8 Co M. M. M. Two. Several small ulcerating points in inner tube. Two concretions. Chronic. Adhesions to border of omentum. Incision ii inches long. Re-moved appendix. Buried stump. Closed wound. Recovery. Several. Tense and congested. Mucosa nearly gone. Acute. No adhesions. Incision ij inches long. Re-moved appendix. Buried stump. Closed wound. Recovery. One ? Unknown. Acute. Enormous abscess. Extensive new adhesions. Long incision. Evacuated ab-scess only on account of con-dition of patient. Tube drainage. Recovery, but car-ries an appendix which must come out, judging from symptoms. Several. Inner tube replaced by connective tissue at several points. Chronic. No adhesions. Incision i-J- inches long. Re-moved appendix. Buried stump. Closed wound. Made another incision at same sit-ting to examine descending colon. Recovery. Several. Same case as No. 3. Outer tube whole except for scar at tip. Hypertrophic. Inner tube sloughing. Acute. Extensive old firm ad-hesions. New adhesions encapsulating thin purulent fluid. Long incision. Removed ap-pendix. Could not bury stump. Wick drain. H202. Recovery. Two. Half inch long. Mar-ble-shaped from distension. Stricture complete at cecal end. Chronic. No adhesions. Tuber-culosis of peritoneum in vicinity of appendix. Incision i| inches long. Re-moved appendix. Buried stump, dosed wound. Tuberculosis ex-tended to whole peritoneum ? And involved lung six months later. Recovery from operation. Has tuberculosis. One. Appendix in two parts from former sloughing. Sepa-rated part kept alive by adhe-sions. Chronic. Old adhesions bind-ing appendix to cecum only. Incision 1^ inches long. Re-moved appendix. Buried stump. Had to enlarge wound to suture layers. Guy line not used. Recovery. Two. Whole mucosa desqua-mating. Two round sloughs had nearly perforated appen-dix. Acute. Mass of new adhesions. Incision ij inches long. Long incision. Removed ap-pendix. Buried stump. II,02. Wick drain. Phlebitis of left leg, after getting out of bed. Recovery. ()ne. Perforation near tip. Acute. Abscess. Mass of new adhesions. Recovery. Co 0^ '*. Si Ok ok u £ 3 Age. Sex. Number of Acute Attacks and Con-dition of Appendix. Stage and Complications. Operation. Post-Operative Com-plications. Result. 56 30 M. Several. Gangrenous and per-forated at two points. Re-mainder of appendix replaced by fibrous tissue. Acute. Abscess. Extensive old and new adhesions. Long incision. Removed ap-pendix. Could not bury stump. II2Os. Wick drain. Recovery. 57 23 M. M. Tl Several. Outer tube hyper-trophic. Inner tube nearly gone. Chronic. Extensive old adhe-sions. Incision 1^ inches long. Re-moved appendix. Buried stump. Closed wound. ----- Recovery. 58 25 One. All structures gangre-nous excepting proximal half inch. Acute. Thin new adhesions. Incision 1^ inches long. Re-moved appendix. Buried stump. Closed wound. Recovery. 59 46 One. Sclerotic stump. Chronic. Extensive old adhe-sions. Removed stump. Buried cecal portion. Incision 1^ inches long. Re-moved appendix. Buried stump, but cecum thick and fragile. Primary union for eight days. Sup-puration within abdomen. Opened. Wick drain. Recovery. 60 46 M. ~M. mT Several. Occluding structure at cecal end. Lumen of remain-der distended with brown fluid. Mucosa gone. Lym-phoid honeycombed. Chronic. Extensive old adhe-sions. Recovery. 61 j 36 Distended with interstitial exu-date. Otherwise normal. Chronic. Associated with chronic colitis. Incision i-jj, inches long. Re-moved appendix. Buried stump. Closed wound. Recovery. 62 | 16 One. Mucosa desquamating. Acute. New adhesions. Incision 1+ inches long. Re-moved appendix. Buried stump. Closed wound. Incision li inches long. Re-moved appendix. Buried stump. Closed wound. Incision i| inches long. Re-moved appendix. Buried stump. Closed wound. Recovery. 63 IS i M. M. "M. Several. Ulceration of inner tube about a large concretion. Chronic. Adhesions to pos-terior surface of cecum. ■ - - - Recovery. 64 24 One. Stricture at middle seg-ment encapsulating thin fecal matter and mucus. Chronic. No adhesions. Acute. General tuberculous peritonitis. Recover}'. 65 j 12 One. Appendix replaced by a string of masses of tubercle. Incision 1 J, inches long. Ap-pendix not worth removing. Recovery from tu-berculosis. S M. M. M. One. Sclerotic remains. M. M. M. Cancer of cecum involving ap- pendix. Mistake in diag- nosis. One. Perforation near cecum. Chronic. hesions. Extensive old ad- Cancer involving cecum as far as ileo-cecal valve. Acute. General septic plastic peritonitis binding all surfaces together. Appendix free in large cavity containing gas only. Several. Perforation near tip. Two old scar strictures. One. Distal sixth sloughing. Rest of inner tube ulcerating. One large concretion near tip. One. Rhexis. All structures infiltrated with blood. Tuberculosis of appendix. Several. .Scar stricture at junc- tion of proximal and middle thirds encapsulated ; half a drachm of muco-pus. Acute. Phlebitis of left leg from sub-peritoneal infection going across pelvis. Bowel adhering to pelvic floor. Ad- hesion where perforation emptied sub-peritoneally. Septic fluid among new ad- hesions. Acute. Abscess. new adhesions. Abundant Acute. Abscess. Extensive new adhesions. Tuberculosis of all structures of cecum and ascending colon. Long incision. Patient very fleshy. Removed appendix. Wick drain. Chronic. Local old adhesions. Incision i^ inches long. Re- moved appendix, cecum, and ileum at valve in one mass. Lateral anastomosis. Long incision over appendix and in mid-line to separate adhesions for flushing with II2 Os and saline solution. Removed appendix. Ligated stump. Incision on both sides of abdo- men to facilitate separation of adhesions. Appendix re- moved. Buried stump. Wick drain. Incision i| inches long. Re- moved appendix. Could not bury stump. Ligated. II2 02. Wick drain. Incision i-| inches long. Re- moved appendix. Could not bury stump. Ligated. II, 02. Wick drain. Long incision. 1 >id not remove appendix. Wick drain. Incision ii inches long. Re- moved appendix. Buried stump. Closed wound. Recovery. Superficial suppu- Recovery. ration of wound. Recovery. Recovery, Recovery. Septicemia. Acute right lobar pneumonia began on 8th day after operation. Recovery. Recovery. culosis ing. elapsed. Recovery. Tuber- disappear- 8 months Co o>. 8 r of Acute Attacks and O ditioii of Appendix. Two. Proximal two inches sloughing. Several. Extremely hyper- trophic. Old perforation near cecum opened into chronic pyogenic sac. Several. Scar stricture Jth inch from distal extremity. Inner tube ulcerating near cecum. None. One concretion lumen of normal appendix. Several. Mucosa desquamated. Several. Ulcerating about two white concretions. Shape and size of muskmelon seeds. Two. Gangrenous and frag- mentary. Two. Mahogany-red from rhexis. Distended with several drachms of brown pus. Inner tube honeycombed. Stricture at cecum. Stage and Complications. Acute. Abscess. Mass of new adhesions. General septic peritonitis. Chronic. Small pyogenic sac filled with muco-pus. Exten- sive old adhesions. Chronic. Pyosalpinx and con- tact infection of appendix from the oviduct. Extensive old adhesions. Ovarian tumor. Acute. Well marked new and old adhesions. Chronic. Adhesions at tip of appendix only. Vcute. Suppurative nephritis of right kidney. Abscess. New adhesions. weeks after Chronic. Two last attack. N adhesions. Operation. Long incision. Removed ap- pendix. Could not bury stump. Ligated. Wick drain. II3 Os. Did not use saline solution for flushing. Incision i\ inches long. Had to enlarge it to work by sight. Removed appendix. Wick drain. Long incision. Removed ap- pendix. Buried stump. Re- moved pus tube. Wick drain. Incidentally discovered con- cretion while operating for removal of tumor and pushed it into cecum. Did not re- move appendix. Incision i\ inches long. Re- moved appendix. Buried stump. Closed wound. Incision i^ inches long. Re- moved appendix. Buried stump. Closed wound. Long incision. Removed gan- grenous fragments. Wick drain. Incision i^ inches long. Re- moved appendix. Buried stump Closed wound. Post-Operative Com- plications. Recovering until 4th day. Bowel obstruction super- vened. Result. Died on 5 th day. Bowel obstruction. Recovery. Recovery. Recovery. Recovery. Recovery. Died 5 days later. Acute suppurative nephritis. Recovery. 00 S 8 Co 8 8 82 27 "83' 20 "84"' ~2S~ "V 20 86 34 ~8r" ~26~ "esT 21 ^9 3'J 90 24 91 __1 33 M. M. M. Several. Sclerotic stump. ; Chronic. Small ovarian tumor. Appendix replaced by masses of tubercle. History of in- flammation beginning at ap- pendix. Several. Ulceration of inner tube. One. Appendix nearly gone. Several. Ulceration of inner tube. Lymphoid nearly gone. Two. Three complete stric- ture nodes. Internodes dis- tended with purulent fluid. Several. Gangrenous and per- forated at tip. One large con- cretion. M. j One. Appendix gone. One. Appendix gangrenous and perforated at several points. M. Two. Appendix gangrenous. General peritoneal tuberculosis: Chronic. Firm old adhesions. Acute, multiple abscesses. Sub- peritoneal and intra-perito- neal on both sides of lower ab- domen and pelvis. Chronic. Extensive old ad- hesions. Chronic. Extensive old ad- hesions. Acute. Few adhesions. Acute general septic peritonitis. Chronic. Extensive old ad- hesions, causing bowel ob- struction. Acute. Abscess. Extensive new adhesions. Acute. Abscess. Extensive new adhesions. Incision in middle line. Re- moved remains of appendix. Buriedstump. Removed cyst. Closed wound. Long incision. Separated ad- hesions. Appendix not worth removing. Wick drain. Incision il inches long. Re- moved appendix. Buried stump. Closed wound. Incision on both sides of ab- domen for separation of ad- hesions, and flushing with II, 02 and saline solution. Wick drainage. Incision il inches long. Re- moved appendix. Buried stump. Closed wound. Incision i^ inches long. Re- moved appendix. Buried stump. Closed wound. Long incision. Removed ap- pendix. Ligated stump. Could not bury it. H2 02. Saline solution. Wick drain. Incision i| inches long. Sepa- ration of adhesions from ce- cum colon, ileum, and omen- tum. Long incision. Did not remove appendix, because of its close connection along the iliac vein. H2 Os. Wick drain. Long incision. Portions of ap- pendix removed piecemeal. II, C. Wick drain. Phlebitis of right leg on day after operation. Recovery. Recovery. Recovery, Recovery. Recovery. Recovery. Recovery. Recovery. Co 8 o>. rs. o^ <*> S5 8 Ok 8 S4, 92 93 21 M. 15 ; M. 19 lVL 21 M. m.~ 96 26 97 24 18" 21 99 30 100 "35" F. F. Number of Acute Attacks and Con- dition of Appendix. Appendix twisted upon itself, damming mucus in the lu- men. Normal otherwise. A dislocated appendix. Two. One very large concre- tion. One small one. Great hypertrophy of muscularis. One. Mucosa ulcerating. Stage and Complications Patient weak from continued vomiting. No evidence of in- flammation about appendix. Acute. Extensive old and nev adhesions. Two. Mesappendix gangre- nous. Appendix swollen, but not yet gangrenous. Many attacks of violent appen- dicular colic. Appendix nor- mal, containing two concre- tions. Two. One pea-sized slough of inner tube near cecum. Two. Perforation at middle. Inner tube sloughing. Several. Two scar strictures. M ucosa gone. Two. Distal four-fifths of in- ner tube gone. Acute. New adhesions to parietal peritoneum only. Acute. Abscess. Extensive old and new adhesions. No complications. Giving evi- dence of inflammation about appendix. Acute. Extensive adhesions. ild and new Acute. Abscess. ExtensL new adhesions. Chronic. Old adhesions from pelvis to diaphragm. Chronic. Adherent to right ovary and tube. Operation Post-Operative Com- plications, Incision I moved stump. Closed wound. inches long. Re- ppendix. Buried Incision ij inches long. Re- moved appendix. Could not bury stump. Ligated it. Closed wound. Incision i\- inches long. Re- moved appendix. Buried stump. Closed wound. Long incision. Removed ap- pendix. Buried stump. II, O,. Wick drain. Mid-line incision for examining ovaries. Pushed concretions out of appendix into cecum. Did not remove appendix. Incision ii inches long. Re- moved appendix. Ligated stump. Could not bury it. Closed wound. Long incision. Removed ap- pendix. Ligated stump. Could not bury it. II, O,. Wick drain. Long incision. Removed ap- pendix. Ligated stump. Wick drain for hemorrhage from adhesions. Mid-line incision for hystero- pexy. Removed appendix. Buried stump. Closed wound. Primary union fol- lowed by intra- abdominal suppu- ration five days later. Opened. Wick drain. Primary union, fol- lowed ten days later by intra-ab- dominal abscess. Opened. Wick drain. Recovery. Recovery. Recovery, Recovery. Recovery. Recovery. Recovery. Recovery. Recovery. CO O S 8 Surgical Treatment of Appendicitis. 81 Summary. Fifty-nine of the cases were without infection, excepting in the immediate vicinity of the appendix, and although many of these cases involved extensive operative work on account of adhesions there were no deaths in the series. Seven of the cases were of peritoneal tuberculosis, involving the appendix, and apparently having origin at the appendix in six of them. All recovered from the operation. Three recovered and three others are recovering from the peritoneal tuberculosis. In one the tuber- culosis continued. One case of cancer involved the appendix and cecum. I exsected all of the cancerous structures, and the patient has had no recurrence of the disease to date. Fourteen months elapsed. Six cases of intense general septic peritonitis, with the whole abdom- inal cavity bathed in a flood of pus, were of the type that belonged to the most fatal class until very recently. In this group, however, I lost only one case, the moribund patient dying of shock two hours after the operation. Four cases with intense general septic peritonitis not marked by the presence of pus gave two deaths. One of these cases (No. 29 in the list) does not really belong in these statistics at all, as the case was one of gangrene of a strangulated ileum, but it must be included because I happened to remove the appendix, which was right at hand and which was valuable as a peculiar specimen, though it had no bearing on the outcome of the case. The other death resulted from bowel obstruction, in a case in which the whole serosa had apparently been destroyed by the peritonitis. Twenty-three cases were of the walled-off abscess form, presenting the most varied complications, from that of a small excapsulation of pus up to abscess cavities containing quarts of pus in one or more compartments and reaching from the pelvis to the liver, but sep- arated from the remaining uninfected peritoneal cavity by protecting lymph walls. There were five deaths in this group. Two of them in my first two appendicitis cases, tube drainage having been used and the resources of hydrogen dioxide and saline solution not employed. Both patients died of septicemia. Three of the patients died after I had adopted wick drainage and the use of hydrogen dioxide and saline solution. One of these died of acute suppurative nephritis, which be- gan a few hours before the operation. Another died of intestinal obstruction from adhesions which could not be separated at the time of operation on account of the patient's condition ; and the third one, weak from several months of septicemia, died of shock. If the seven appendicitis patients in this list who died could have had 6 82 Lectures on Appendicitis. the benefit of the methods resulting from a fuller experience I believe that three of them would have recovered. I feel that the death-rate in one hundred such cases as this list contains should not be more than four or five per cent., notwithstanding the fact that many of the cases were in a condition which seemed almost to prohibit operative interference. Ventral hernia has appeared in only two of the cases, because of my method of closing the abdominal wound. One of the hernias appeared in an inch-and-a-half-incision case which had to be drained, and the hernial opening has since been closed by secondary operation. The other hernia appeared in one of the general suppurative peritonitis cases, in which a long incision had to be kept widely open. This hernia is controlled by a truss, as it cannot be easily corrected by operation. Fecal fistula has persisted in one case only (No. 15), and there are two cases of superficial fistula which the patients do not wish to have repaired as yet. Mistakes in diagnosis were seldom made in suspected cases of appen- dicitis. Thus, in the series of one hundred cases everything is included in which I made a diagnosis of appendicitis before the operation, and error was made but three times. No. 17 had a normal appendix sur- rounded by adhesions, due to typhoid perforation of the bowel. No. 43 had a normal appendix in a case of general peritoneal tuberculosis. No. 67 had cancer of the cecum, involving the appendix. The con- sequences of these three mistakes in diagnosis are as follows : (1) The patient with typhoid adhesions has been decidedly benefited by separation of the adhesions which had caused constipation almost to the point of obstruction. (2) The peritoneal tuberculosis patient is cured. (3) The cancer patient is perfectly well to date, fourteen months after the operation, with no sign of recurrence as yet. No doubt the proportion of cases in which one would find difficulty in making a diagnosis is larger in a general medical practice, for almost all of the appendicitis cases which are sent to the surgeon have first been differentiated as such by the general practitioner, and that gives the surgeon an evident advantage. Then, again, the proportion of appendicitis cases in a general medical practice fluctuates markedly. One physician of my acquaintance has had sixteen cases of appendicitis during the past five years, diagnosis having been verified by operation in all of them. Another physician of large practice assures me that he has never seen a case of appendicitis. The death-rate in cases of appendicitis treated without operation fluctuates also. Thus, one physician has recently reported fourteen attacks of appendicitis in four- teen patients treated medically, with six deaths. Another reports eighty- Surgical Treatment of Appendicitis. 83 five cases with fourteen deaths, and another reports twenty cases without a death. I would like details in such a report. In this con- nection I wish to say that the expressions " case " and " attack " must not be used synonymously, because we are to expect that " when one attack is done the patient's troubles have just begun." Statistics from countries in which appendicitis is classed as typhlitis cannot be used by us. I have been through the wards of large European hos- pitals and have been shown series of typhlitis cases which included ordinary catarrhal colitis, coprostasis, and tuberculous enteritis, but not appendicitis. Data bearing upon the subject of appendicitis should be collected only from physicians who differentiate these cases distinctly. I hope that another century will see the establishment of a medical court with a judiciary which has no other occupation than weighing evidence and giving rulings upon that large part of medical knowledge which can be classified. If judges upon the same bench sometimes find it difficult to know what is good law, how much more difficult must it be for the members of our profession to deduce the truth and the right from a mass of in- complete testimony and hearsay evidence that is presented to us in good faith by medical advocates, but which requires for correct analy- sis a judicial temperament and long training in methods. Yet every one of us is assumed to be not only a judge but a good one and im- partial. Matters of fact that have been settled beyond all peradventure in one locality are bandied about as subjects for debate in other locali- ties. If nothing more than property were involved this would be a matter of comparatively small moment, but human life is directly at stake, because physicians must carry into practice their individual de- cisions. From appendicitis to vaccination and from antitoxine to vivi- section there are questions which demand rulings from a local, state, national, and international medical court. CHAPTER V. / /NOTES. THE ACTION OF VARIOUS SOLVENTS ON GALLSTONES. FOUR years ago I experimented with various gallstone solvents for the purpose of simplifying the operation in cases in which an impacted gallstone is found in the common duct, my intention being to avoid the operation of section of the duct, or the danger of injury to the duct in crushing a gallstone in position, by inject- ing solvents through a soft catheter introduced into the common duct; the gall-bladder having first been fastened to the skin to form a fistula. Now, however, with the use of aristol to wall off a drainage canal, and the use of the drainage wick to draw away bile rapidly by capillarity, the operation has been reduced to such a simple one that I do not care to follow out the idea of dissolv- ing impacted stones; but the experiments which were made at that time as to the solubility of gallstones are interesting. The object was to find a liquid which could be best applied through a temporary biliary fistula ; hence, solvents destructive to living tissues were excluded, and the experiments were therefore limited to gallstones consisting largely of cholesterin, since there seemed no possibility of dissolving inorganic concretions with noncorro- sive solvents. The solvents tried were divided into four classes, viz.: (i) General solvents.—Liquids known to possess the power of dissolving many organic substances of different constitutions. These include the " text-book solvents," or those mentioned in the books as readily dissolving cholesterin. (2) Natural solvents.—Those which are said to hold cholesterin in solution in the body. (3) Allied solvents.—Those which, being akin to cholesterin in chemical constitution, should, according to the law of " like dis- solves like," be good solvents for cholesterin. (4) Indicated solvents.—Those which being akin in chemical constitution to solvents found to act well, are those indicated as possibly able to act better. 84 Gallstone Solvents. 85 The general organic solvents are: Acetic acid, acetic ether, acetone, alcohol, amyl alcohol, benzene, carbon bisulphide, chlo- roform, ether, petroleum ether or naphthol (three kinds were used), and xylol. Ether is excluded as it boils below blood heat. All the others were tried, as were also glycerine, paraffin oil, and olive oil. The natural solvents are the soaps (salts of the fatty acids—two kinds were used) and the salts of the bile acids. The allied solvents. Since cholesterin is a benzene derivative, and contains a hydroxyl group, and is nearly allied to the turpenes and camphors, the following solvents were tried: turpentine oil, eucalyptol, phenol, naphthol (alpha and beta), disolved in alcohol, menthol in carbon bisulphide, Caucasian petroleum. The indicated solvents are bromoform, carbon tetrachloride, and ethylene dichloride, which were used because chloroform was found to be a good solvent. Other substances used were chloral hydrate and alcoholate, for either of these mixed with camphor lique- fies it. But they were found to be without action on cholesterin. Altogether twenty-nine solvents were used. The gallstones examined were from six patients: (1) Black stones ; ash small. (2) Yellow-brown stones ; ash small. (3) Gray stones; ash small. (4) Brown stones ; ash large. (5) Yellow-gray stones ; ash small. (6) White stones ; ash small. The first experiments were made with set No. i,and the others were tried as specimens were obtained. As it seemed most desirable to use a natural solvent, soaps were first tried. Pre- liminary experiments showed that their solvent power was slight. Thus: GALLSTONES--SET NO. I. Temperature. Time. Action. IOO°C. IOO°C. 27°C 1 min. 3 min. 72 hrs. Slight. Slight. Slight. 37°C. 37°C. 46 hrs. 45 hrs. Small stone broke up on shaking. No change. 38°C i\ hrs. Slight. 38°C. 24 hrs. No more. 1 vol y soap uiaaui vcu 111 v* o.l^x....... Strong solution................... Same solution..................... Ivory soap dissolved in 20 per cent, alcohol,....................... Ivory soap dissolved in 20 per cent. alcohol......................... Castile soap dissolved in 20 per cent. alcohol......................... Castile soap dissolved in 20 per cent. alcohol......................... 86 Notes. Preliminary experiments were tried with a number of other solvents, with the result that glycerine and menthol were rejected. Experiments were next tried with weighed stones and measured liquids. To obtain an equal weight of solid for use with each solvent it would have been necessary to cut or powder the stones, but it semed better to test them in the natural state, though this made necessary the use of stones of unequal weight for the various tests. To diminish the effect of this difference on the results, a large excess of the solvent was used—always the same volume of each solvent in each set of experiments. The method was to note the time at which the solvent and the stone were brought together; then to plunge the test tube containing them in an oil- bath, kept in an incubator at blood heat, and to note at intervals the appearance of the stone. In this way tables were made, from which the final result is copied below. The action was taken as complete when the stone was thoroughly broken up, for it is unnecessary that it should be completely dissolved ; and this is the time given in the table below. At first the effect was not noted at very short intervals, so that here " the time " is only the maximum result. In later experiments the effect was noted every minute for the first few minutes, and later at gradually increasing intervals. AT BLOOD HEAT. GALLSTONES--SET NO. I. Solvent. Alcohol and acetic acid..... Alcohol and potash........ Benzene.................. Carbon bisulphide......... Carbon bisulphide......... Carbon tetrachloride....... Chloroform............... Eucalyptol................ Paraffin oil............... Petroleum (American)...... Petroleum (Caucasian)...... Phenol................... Xylol.................... Weight. Time. Dissolved per minute. .021 gm. 48 hrs. plus. .020 27 hrs. plus. .020 24 hrs. minus. • 030 1.30 .0003 .016 1.30 .00015 .020 0 hrs. 7 min. .003 .017 24 hrs. .org 27 hrs. .018 27 hrs. .023 24 hrs. 017 27 hrs. .017 4S hrs. .023 24 hrs. Gallstone Solvents. 87 GALLSTONES--SET NO. 2. Solvent. Alcohol and acetic acid Alcohol and potash . . . Benzene............. Carbon bisulphide..... Carbon bisulphate..... Carbon tetrachloride... Chloroform.......... Eucalyptol........... Paraffin oil........... Petroleum (American). Petroleum (Caucasian). Phenol............. Xylol............... Weight. .023 gm. .024 .025 .020 .Ol6 .020 .047 .021 .024 .023 .Ol8 .024 .020 .027 Dissolved per minute. 48 hrs. 27 hrs. O hrs. o hrs. o hrs. o hrs. o hrs. o hrs. 2 hrs. 27 hrs. 24 hrs. 2 hrs. 48 hrs. I hrs. plus. plus. 56 min. 15 min. 6 min. 5 min. 15 min. 15 min. 15 min. plus. 15 min. .0005 ■0013 .0027 .004 .003 .0014 .0004 GALLSTONES—SET NO. 2. Camphor in alcohol....... Carbon bisulphide........ Carbon tetrachloride...... Chloroform.............. Naphthol in alcohol (alpha) Naphthol in alcohol (beta). Petroleum (Caucasian).... GALLSTONES--SET NO. 3. Solvent. Carbon bisulphide.. Carbon tetrachloride Chloroform........ Weight Time. o hrs. 10 min. O hrs. 7 min. O hrs. 5 min. Dissolved per minute. .008 • 005 .OI2 From the column giving—for the best solvents only—the weight dissolved per minute, it is seen that these are carbon bisul- phide and tetrachloride, and chloroform. These were therefore more closely compared in testing the remaining gallstones, and bromoform and ethylene dichloride were also tried. It was found that the gallstones in set No. 4, which contained much inorganic substance, were not much attacked by any of the solvents, although some of them were deeply colored by these stones. Notes. GALLSTONES—SET NO. 5. Solvent. Weight. Bromoform........................ Carbon bisulphide................ Carbon bisulphide................. Carbon bisulphide 10 per cent, and tetrachloride 10 per cent........ Carbon bisulphide 50 per cent, and chloroform 50 per cent.......... Carbon tetrachloride............... Chloroform....................... .0235 gm. .064 .025 .065 .061 .029 O hrs. 30 mm. 12 min. 6 min. 12 min. 15 min. 12 min. 6 min. Dissolved per minute. .0008 .005 .004 .005 .004 .0024 ■OO35 GALLSTONES--SET NO. 6. Solvent. Bromoform........................... Carbon bisulphide..................... Carbon bisulphide..................... Carbon bisulphide go per cent, and tetra- chloride, 10 per cent................ Carbon bisulphide 90 per cent, and chlo- roform 10 per cent................. Carbon tetrachloride................... Chloroform........................... Weight. Time. Dissolved per minute. .032. gm. 24 min. .0013. .020. 1 min. .020. .031. not much attacked. .020. 2 min. .010. .025. 3 min. .00S. .029. 8 min. .0036. .027. 3 mm. .009. Carbon bisulphide and chloroform still surpass all others, and the addition of carbon tetrachloride to the bisulphide is seen to be no improvement. The two best solvents were now particularly com- pared with regard to their action on gallstones in set No. I. GALLSTONES--SET NO. Solvent. Weieht. Carbon bisulphide. Carbon bisulphide Carbon bisulphide. Chloroform....... Chloroform......, Chloroform....... .024. .020. .145- .024. .020. •154- Time. 55 mm. 42 min. 23 min. 60 min. 70 plus. 35 plus. Dissolved per minute. .0005) mean. .005) .023. .070) .0004) mean. .0003) .015. .044) Here it is seen that the large stones were dissolved in much less time than the small ones; that the time for unit weight should be less in the case of the large stones is comprehensible, for the proportion of the outer, deeply colored, difficultly soluble layer is less. Besides the thorough breaking up of the large stone does not involve its breaking into such small pieces as are obtained Gallstone Solvents. 89 from a small stone. But this would hardly account for the differ- ence observed. It seems probable that the larger sfones are less compact than the smaller ones, i. e. that they have a lower specific gravity. But it must not be forgotten that the smaller stones of the same set differ enormously in themselves—witness the failure of chloroform on a small No. 1 stone in set No. I, and the failure of bisulphide in a stone in set No. 6. These results place carbon bisulphide at the head of the list. Pure cholesterin was next prepared and tested with the solvents. It was found that there was such a parallel between its solubility and that of the gallstones that new solvents might fairly be tested with it instead of with the stones. The solvents dissolved choles- terin in the following order, small quantities, approximately equal, being used in test tubes : Carbon bisulphide—instantly on touching. Chloroform—almost instantly. Carbon tetrachloride—almost instantly. Bromoform—almost instantly. Ethylene dichloride—more slowly. Benzene—more slowly still. Xylol—about as benzene. Turpentine—more slowly. Amyl alcohol—more slowly than turpentine. Alcohol—slowly. The petroleum had little action ; paraffin oil and glycerine, none. On the strength of this parallel, the solvents acetone, acetic ether and olive oil, and gall acids were rejected because they had but little action on cholesterin. The acids were especially pre- pared from ox-gall, and dissolved in alcohol. Their potassium salts were also tried. A conspectus of the action of the best solvents on the dif- ferent stones is as follows: GALLSTONES--SET. NO. I. Solvent. Stone 1. Stone 2. Stone 3. Stone 5. Stone 6. Mean. Carbon bisulphide. . Carbon tetrachlo- .023. .015. .003. .0065. .0065. .004. .008. .012. .005. .0045. .0035. .0024. .020. .009. .0036. .0124. .009. .0036. 9o Notes. Conclusions. The best solvent is carbon bisulphide, though for some stones chloroform may. prove better (see stone, set No. 3). A mixture of the two in equal quantities would probably have the best gen- eral effect. Stones from the same subject differ enormously in solubility, as much as do stones from different subjects; but in the latter case the difference is regular, in the former only occa- sional. Any solvent which will not instantly dissolve cholesterin may be rejected as a solvent for gallstones, although it is possi- ble that a solvent may readily dissolve cholesterin and yet not act readily on gallstones. This gives a ready means of testing any solvents which may suggest themselves. We have no evi- dence that gallstones are ever dissolved by substances taken internally for that purpose by patients. Olive oil is very fre- quently administered. There are several reasons why it does not act therapeutically as a solvent. (1) Oil cannot be expected to travel up the gall-ducts from the duodenum because the peristaltic action of the ducts is toward the duodenum from the liver, and this peristaltic action is presumed to be unceasing. (2) If oil could travel against the peristaltic effort of the gall-ducts and enter an open gall-bladder—many are not open—it would be at once mixed with bile. (3) Undiluted sweet oil in which I kept gallstones for weeks at various temperatures produced no appre- ciable effect beside a softening of the external layers of some stones. So unimportant was its action, that it was not thought worth while to include it in the further tests. What sweet oil does do is to carry toxines out of the alimen- tary tract pretty rapidly, and it relieves patients of the element of intoxication from that source. The fact that biliary colic often ceases after the administration of sweet oil is a coincidence to be expected if we simply remember that such colic ceases as quickly without the aid of sweet oil. Biliary colic means extraordinary efforts on the part of the muscular walls of the gall-bladder and ducts to force out an irritating substance, and the colic ceases when a stone has passed out of the canal or when it has failed to engage and has moved back into the gall-bladder, where it may remain quiescent for days, months, or years. Drugs given internally, on the theory that they will prevent any further formation of gallstones, are handicapped if gallstone formation is due to fermentation of mucus in the biliary tracts, because fermentation is caused by bacteria only; and the colon Gallstone Solvents. 9i bacillus, which is apparently the principal culprit, is not influenced so far as we know by any drug after that drug has been exposed to digestive processes and has been excreted by the liver. Post- mortem examination of patients who were supposed to have been cured of gallstones has revealed the fact that stones were still in the gall-bladder. Personally, I would much prefer to depend upon our successful new surgical resources, rather than suffer the agony of a single attack of gallstone colic, in the hope that some fanciful line of treatment might reach and dissolve a set of gall- stones snugly hidden away in the gall-bladder. Medical treat- ment which would aim to prevent the formation of gallstones must apparently have for its first object the prevention of the development of colon bacilli in the gall-bladder, and we have no available resources for that purpose as yet. THE INFLUENCE OF REMAINS OF THE EMBRYONIC VITELLINE DUCT IN THE PRODUCTION OF MOIST NAVELS, AND OF ECZEMATOID INFLAMMATION ABOUT THE NAVEL. The primitive intestine and the umbilical vesicle in the human embryo are in connection through the vitelline duct until the abdominal plates close at about the end of the sixth week of fetal life, and shut in that part of the duct which unites navel and umbilical intestinal loop. The umbilical intestinal loop having Fig. 30.—Microscopic section from eczematoid navel, showing mucous follicles developed from embryonic remains. been drawn into the abdominal cavity, subsequent development of the alimentary tract causes rupture or thinning of the remains of the vitelline duct, which should then become absorbed. Some- times omphalo-mesenteric remains, instead of undergoing absorp- 92 Embryonic Remains. 95 tion, become developed in whole or in part, and form intestinal diverticula; open intestinal fistulse at the navel; fibrous intra-ab- dominal bands, with or without mesenteric blood-vessels; intra- abdominal retention cysts ; and so-called adenomata of the navel, consisting of hypertrophic intestinal gland tissue. Such well defined structures have attracted the attention of many observers, but there is another and larger class of cases in which microscop- ical remains of the vitelline duct at the navel cause annoying complications, which do not present features pointing to their real origin. Tiny embryonic remains at the navel, which develop columnar epithelium or tubular glands, may empty their secretions externally, and this mucus, though small in amount, is sufficient to keep the navel and the skin in its vicinity constantly moist. In children with delicate skins, the exposed mucus decomposes, and sometimes causes an irritation resulting in dermatitis, or " eczema of the navel," which may extend to the formation of a reddish, angry-looking patch as large as the hand, just as it does from the secretion from a patent urachus. Such a dermatitis is rather intractable under the ordinary plans of treatment because the original cause persists, and though palliative treatment will lessen or control the amount of irritation, there is a tendency toward exacerbations of local dermatitis from time to time until the skin becomes less sensitive as the patient grows older. It is a very easy matter to hook up the navel with a tenaculum in such a case, and to excise the little button of tissue which contains micro- scopic remains of the vitelline duct. MALIGNANT ISLANDS AT THE NAVEL, OCCURRING SIMULTANEOUSLY WITH MALIGNANT DISEASE OF THE ABDOMINAL OR PELVIC ORGANS. When malignant disease is present in the abdominal or pelvic organs, the navel sometimes becomes involved in disease of the same type. I have obtained notes from four cases of this sort, and in two cases microscopic remains of the vitelline duct were found in abundance in the involved navels. The other two were Fig. 31.—Embryonic remains in a navel which was elsewhere carcinomatous. not examined with reference to that point, as my attention had not at that time been attracted to the subject. In these cases the secondary malignant disease had occurred at a point particularly rich in embryonic cells, and this may have some bearing on Cohn- 94 Malignant Islands at the Navel. 95 heim's theory relative to the development of tumors from latent embryonic cells. The causative elements of sarcomatous and of carcinomatous disease situated at a distance from the navel, apparently found their way through the blood current to the navel in four patients, and the navels of these patients became infected islands of dis- ease, similar in character to that which was present in the other structures at the time. The four cases were as follows : Case i.—A woman, seventy years of age ; diagnosis of cancer of the pylorus. Six months from the beginning of her symptoms the patient began to have pain at the navel, and she noticed a small lump there, which became very hard, and about as large as a chestnut, bluish-red in color, and with a smooth superficial, ulcerating external surface that Fig. 32.—Adeno-carcinoma of navel from Case I. discharged a little straw-colored serum. I removed the diseased navel, and found that it was not in contact with anything but normal struc- tures. The patient died two months later with ordinary symptoms of cancer of the pylorus, but a necropsy was not permitted. The disease at the navel was adeno-carcinoma, evidently developing from embryonic gland tissue. 96 Notes. Case 2.—A man, fifty-four years of age ; carcinoma of the glands of the left groin for two years ; intra-abdominal symptoms of malignant disease. For four weeks a small, fungating mass, which was the seat of much pain, had been developing at the navel. The navel, as a whole, was not enlarged or hardened in this case, but from its centre sprang a tuft of purplish-red granulations about as large as a small pea. I removed the navel, and at the same time made an exploratory opening Fig. 33.—Adeno-carcinoma of navel from Case 2. for an examination of the abdomen. The omentum was the seat of colloid carcinoma, but there were no adhesions of omentum to furnish a route for infection to the navel. The disease of the navel was adeno- carcinoma, and the specimen contained numerous minute dots of intestinal gland tissue. Case 3.—Extract from a letter from Dr. Grinnell, of Burlington, Vermont: " Patient, a male, sixty-eight years of age ; diagnosis of cancer of the pylorus. Eight months before the patient's death, the navel be- came hard and painful, and the discharge from it was malodorous. Five months later, the liver began to enlarge, and death was caused by cancer of the liver, as determined at necropsy. The disease at the navel had remained confined to that point, while the disease elsewhere made progress." Malignant Islands at the Navel. 97 Case 4.—Extract from an article by Dr. Daniel Lewis, in the New York Medical Record, October 12, 1889 : "The patient was suffering from a disease of the fundus of the uterus, diagnosticated as sarcoma. While this was in progress malignant disease attacked an umbilical hernial sac, evidently beginning at the navel and extending from there to the tissues of the sac. Examination of the navel showed it to be the seat of remains of the vitelline duct. Section of one part of the neoma showed large, round-cell alveolar sarcoma, and the deeper sec- tion showed a mixture of round and spindle cells." A LAST RESORT HERNIA OPERATION. A DOG pulled out some of the sutures which I had placed in his abdominal wall after an experimental operation, and part of a loop of bowel descended into the wound during the night. This loop of bowel seemed to be adherent to the wound margins, and it was allowed to remain undisturbed for observation. Healing took place, and there seemed to be no further progress of hernia. The dog was not disturbed by the fixed bowel. It seemed proba- ble that fixation of bowel at a hernial opening could be utilized as a surgical resource in some few cases of hernia in which other and simpler resources had failed. I tried further experiments on rabbits, suturing various portions of bowel to the margins of arti- ficial hernial openings, and found that the animals did not suffer any inconvenience. There has been no opportunity as yet to apply this resource in a femoral or inguinal hernia, but I have em- ployed it in one large umbilical hernia and in five appendicitis cases to prevent the progress of ventral hernias after large drained wounds. In none of these cases has hernia appeared as yet, the cases dating back twenty-four months, twenty-four months, twenty-two months, twenty months, eighteen months, and three months, respectively. The distal end of the cecum is the best part of the bowel to make fast at an opening in the right inguinal region, because it is less likely to kink as a result of peristaltic movements than any other part of the bowel. The danger from kinking or twisting from fixed bowel is real, but not great, if we are to judge from numerous cases in which intestine is adherent in large hernial sacs, and as a result of various acute inflammatory processes in the abdomen and pelvis which leave strong adhesions behind ; nevertheless the resource in question is not adapted to any of the ordinary curable cases of hernia while so many operations, practically free from danger, are at our service. The technique of the operation for fixation of bowel at a hernial opening, consists in suturing the bowel to the margins of the opening with sutures carried through the peritoneal and 98 A Last Resort Hernia Operation. 99 muscular coats of the bowel. The parietal peritoneum is first stripped away from the abdominal wall for a short distance, so that bowel peritoneum unites with connective tissue of the abdominal wall only, otherwise the approximated surfaces of Fig. 34.—Segment of bowel united to margins of hernial opening (Rabbit). A. Stick of wood inserted to show lumen of intestine. B. Skin and muscles. C. Peritoneum. D. Segment of attached intestine. Longitudinal ridge marks site of mesentery. peritoneum would be apt to advance conjointly at the weak spot. The mechanical effect of fixed bowel is to shunt loops of movable bowel away from the weak spot, and against solid walls on either side. THE EXPERIMENTAL PRODUCTION OF ILEAL INTUS- SUSCEPTION WITH CARBONATE OF SODIUM. At an abdominal operation in which normal peristalsis is retarded, it is sometimes difficult to know in which direction the bowel runs, and various substances have been employed for ex- citing a quick peristalsis, either normal or reversed. In the hands of Dr. Senn a satisfactory reversed peristalsis has been obtained by touching the peritoneal surface of the bowel with chloride of sodium, but recently a note went the rounds of the medical press, to the effect that sodium carbonate was still more efficient. In order to test the efficacy of this resource, I experi- mented upon rabbits, and found that a trifle of carbonate of sodium touched to the ileum of rabbits would produce intussus- ception in a few seconds. The danger of the production of the same effect in the ileum of man is so great, that proof of the harmlessness of sodium carbonate must be furnished before we can employ it for exciting reversed peristalsis at an abdominal operation. The production of ileal intussusception in a rabbit gives a very pretty demonstration of the mechanism of that form of intussus- ception if one wishes to employ it for teaching purposes. The rabbit having been chloroformed, an incision is made in the abdominal wall, and the loop of ileum is brought out. If the barometric pressure happens to be high at the time, it is well to rest the loop of bowel on moistened cloth or paper to prevent too rapid drying of the peritoneum of the loop. If a fraction of a grain of powdered sodium carbonate is then touched to the peritoneal surface of the loop of ileum, it will be observed that in twenty or thirty seconds the circular fibres of the bowel at that point suddenly contract in tonic spasm ; peristaltic movements of the longitudinal fibres of neighboring bowel then cause a slowly progressing engulfing of the portion of bowel which is in a state of spasm, and the ascending intussusception thus continues until the mass of engulfed mesentery becomes so large as to block further progress. An intussusception of about two inches of 100 Experimental Ileal Inlussztsception. I o I bowel can often be obtained in five or six minutes, and it would, without doubt, remain permanently in this position, subject to inflammatory complications, but I have not allowed any rabbits to live in order to determine that point. The mechanism of intussusception produced by the influence of sodium carbonate is the reverse of that which occurs as a post- mortem phenomenon, as I observed the latter in one case. In that case, a wave of peristalsis of the circular fibres of the segment of bowel formed a wide, lax intussuscipiens, into which the neigh- Fig. 35.—A few particles of carbonate Fig. 36.—Spasm of circular fibres of of sodium placed upon ileum of rabbit. bowel at site of sodium carbonate. Fig. 37.—Intussusception of contracted portion of bowel. boring segment of bowel was easily pushed for a distance of a few lines by normal peristaltic progression. Waves of peristalsis of the circular muscular coats seemed to sweep along the ileum, and several intussusceptions were on the point of forming. It is not unlikely that a few of the cases of intussusception in children may occur as a result of spasm of a portion of the bowel similar to the sodium-carbonate contraction, and caused by the toxines absorbed from the lumen of the intestine. We know that spasm of other muscles, manifested in the form of convulsions, very frequently arises from that cause in children whose intestinal con- tents ferment. THE REASON WHY PATIENTS RECOVER FROM TUBER- CULOSIS OF THE PERITONEUM. We have recently learned that patients suffering from tuberculosis of the peritoneum commonly make an excellent and rapid recovery when the peritoneal cavity has been exposed through an abdominal in- cision. In rare instances patients also begin to suddenly recover spon- taneously from tuberculosis of the peritoneum. When tuberculosis comes to a stop we presume that the tubercle bacilli have been killed, and there has been much speculation as to what could bring about that end in a class of cases in which infection was so diffuse as it usually is in the peritoneum. The following experiments were tried for the pur- pose of gaining a clew to the agent which proves fatal to the bacilli. I removed several ounces of fluid from the abdominal cavity in a typical case of peritoneal tuberculosis, and exposed the fluid to the air for twenty-four hours. It was then placed in an incubator for forty-eight hours, and kept at a temperature of about ioo° F. At the end of that time the fluid was swarming with saprophytes, and the toxines which they had produced were then separated from it. Small portions of the toxines proved immediately fatal to virulent test-tube cultures of tu- bercle bacilli, but it was thought best to subject these cultures to a further test for determining if they were capable of further develop- ment. Numbers i, 2, 3, 4, 5, 6, 7, and 8 are used to designate the rab- bits on which control experiments were made. Suspensions 1 and 2 are suspensions of tubercle bacilli in bouillon ; suspensions 3 and 4 represent suspension of tubercle bacilli in the ptomaine. jfuly 27, 1894.—No. 1 was inoculated in the eye with a pure culture of tubercle bacilli. On the same day No. 2 was inoculated in the eye with suspension No. 1. No. 3 was inoculated with suspension No. 2. These suspensions had been in the incubator for twenty-four hours. July 28th.—Nos. 1 and 2 seemed to suffer very little, but No. 3 was quite ill, and the infected eye was suppurating ; consequently suspen- sion No. 2 was not used again in the eye, but was injected under the skin of the abdomen. No. 4 was inoculated in the eye with No. 1 sus- pension, which had been in the incubator for forty-eight hours. No. 5 was inoculated on the abdomen with suspension No. 2, which had also been in the incubator for forty-eight hours. 102 Tuberculosis of Peritoneum. 103 July 2,0th.—Nos. 6 and 7 were inoculated like Nos. 4 and 5, respec- tively. Suspensions had been in the incubator for four days. As No. 1 control animal showed no specific effect from the inoculation with the pure culture, and only a small quantity of the fluid remained, the ex- periments were stopped to await results, and to obtain another culture of tubercle bacilli in case this culture should prove sterile. August 4th.—No. 3 died, and the autopsy showed the cause of death to be meningitis ; no tuberculosis. August 10th.—No. 1 died. The autopsy showed the cause of death to be coccidium ; no tuberculosis. No. 6 also died of coccidium ; no tuberculosis. August 31 st.—Another culture of tubercle bacilli was used, and sus- pensions 3 and 4 made like suspensions 1 and 2, respectively. No. 8 was inoculated on the abdomen with the new culture of tubercle bacilli. September 2d.—No. 2 was inoculated for the second time, but with suspension No. 3, and No. 7 was inoculated with suspension No. 4. These suspensions had been in the incubator for forty hours. September 4th.—No. 4 was inoculated with suspension No. 3, and No. 5 was inoculated with suspension No. 4. These suspensions had been in the incubator for four days. September 24th.—Nos. 4 and 5 were killed, and at the site of inocula- tion, as well as in the lungs, numerous submiliary tubercles were found. The three remaining animals show signs of tuberculosis, but have not yet been killed. Nos. 3 and 4, however, showed that the toxines in which that lot of bacilli was suspended did not render the bacilli sterile. It is apparent, then, that when the abdominal cavity is opened and drained, saprophytes which enter through the drainage opening produce toxines, which are fatal to, or which inhibit the growth of certain tubercle bacilli. In some cases the bacilli are not killed by the toxines, but their growth is probably inhibited for a sufficient length of time so that nuclein brought by the polynuclear leucocytes in the peritoneum can destroy them. This seems like a rational explanation for the reason why patients recover from tuberculosis of the peritoneum after opera- tion ; but on this theory the abdomen should not be closed imme- diately, but should be drained in order to allow the saprophytes to enter through the drainage opening. A case of tuberculosis of the peritoneum could suddenly begin to recover spontaneously, without operation, if saprophytes were to enter the abdominal cavity through a Fallopian tube. The reason why saprophyte toxines can produce such an immediate and widespread effect upon tubercle bacilli in the peri- toneal cavity is because of the character of the lymphatic circulation of io4 Notes. the peritoneum, such toxines being carried quickly to all parts of the peritoneum, and the polynuclear leucocytes which go to the help of the patient have very free access to all of the involved parts. In the lung, or in the knee-joint, we have no such favorable arrangement of lym- phatics and capillaries, and consequently saprophyte toxines cannot reach all of the involved structures in which tubercle bacilli are grow- ing. In some cases of peritoneal tuberculosis a change for the better occurs in the case almost immediately—sometimes within seventy-two hours, in cases in which intestines are firmly glued together, the lym- phatic circulation being sufficient to carry toxines through any adher- ent structures. In cases in which the peritoneal surfaces have been found to be firmly united, and masses of miliary tubercle were abun- dant in the abdominal cavity, a glistening peritoneum, free from adhesions, has been found on subsequent operation, or on necropsy years afterward. THE PREVENTION OF SECONDARY PERITONEAL ADHE- SIONS BY MEANS OF AN ARISTOL FILM. When adherent peritoneal surfaces have been separated from each other by surgeons, there is danger of secondary adhesion as soon as the surfaces which are bare of serosa have fallen together again, and various resources have been employed for preventing such adherence. I observed that if a layer of aristol were interposed between the margins of the wound, it would sometimes present a mechanical obstacle to primary union, and it seemed probable that if aristol were applied to peritoneal adhesion surfaces, it would form a film with lymph, and that this aristol film would offer an obstacle to secondary adhesion, and give the raw surfaces an opportunity to heal separately. A rabbit was anesthetized, and two inches of two intestinal loops were lightly scratched with a needle, and sutured together. One inch of each of the opposed surfaces was covered with a thin layer of aristol, and the other inch was left without protection. At the end of a week the rabbit was again examined, and it was found that the aristol-covered surfaces were adherent, but with such a succulent-looking mass of lymph that it was deemed advisable to experiment with other rabbits, and allow time for complete absorption of plastic exudate. Three more rabbits were treated like the first one, but with deeper scarification of the peri- toneum. Loops of ileum were approximated in one, and loops of colon in the other two. The rabbit with sutured ileum died of intestinal obstruction a few days later ; the other two were killed at the expiration of five weeks. In one there were close, dense adhesions at the parts that had been scarified and approxi- mated without aristol protection, and adhesion only at suture punctures in the aristol-protected segments. Elsewhere over the aristol-protected segments there were no adhesions, but the aristol remained encapsulated in the new serosa. In the other rabbit there were loose filamentous adhesions between the unprotected sur- faces, and none at all where aristol had kept the surfaces apart. In the second rabbit, as in the first one, the aristol remained 105 io6 Notes. encapsulated in the new serosa. What becomes of the encapsu- lated aristol eventually, I do not know. It is not soluble in blood serum, but it is soluble in fat, and it is quite possible that fatty metamorphosis of surrounding tissues may in some places cause its slow solution and absorption. The experiments in rabbits were severe ones because the wounded peritoneal surfaces were held actually in apposition by sutures. In practice, the peristaltic movements of the intestines, and the shifting of movable viscera aid us in our efforts to keep aristol-protected surfaces apart. Since the date of the preliminary experiments, I have had several opportunities for observation of the value of this resource in cases which were subjected to further operative procedures some months or years after adhesions had been prevented from re-forming. We cannot obtain an aristol film on deeply seated adhesion surfaces if blood serum or peritoneal fluid wash away the aristol before it has become fixed with lymph, but as half a minute will answer for this purpose—a minute is better,—the film can be formed on surfaces which can be well dried with a sponge or gauze, and exposed to the air for that length of time. The pedicle of an ovarian tumor, or any tissue bared of peritoneum, will not form troublesome adhesion to the bowel if protection is given by forming a lymph-aristol film upon such raw surfaces. ANOTHER METHOD FOR PALPATION OF THE KIDNEY. ISRAEL finds a kidney by placing the patient upon her back with flexed legs, and then while one hand makes pressure over the lumbar region of the patient, the tips of the outstretched fingers of the examiner's other hand are placed just below the costal cartilages, and on a line which runs from the middle of Poupart's ligament parallel with the median line of the abdomen. Then, with each expiratory movement on the part of the patient, the fingers are pressed deeper and deeper down toward the kidney, and the impression left upon the finger tips at each step of prog- ress is kept well in mind. When the lower end of the kidney is felt, the patient is instructed to take a deep breath, and force the kidney out under the fingers of the examiner. Guyon palpates in very much the same way, but introduces a new feature, which consists in making quick, forcible pressure with the fingers in the lumbar region, thereby causing a spasmodic contraction of the quadratus lumborum muscle, which lifts the kidney up toward the examining hand. When the patient is in a supine position, there is sometimes an obstacle to good palpation of the kidney in the presence of interposed omentum and intestine or stomach. A lobe of liver will sometimes be forced under the finger, and simu- late kidney very closely unless one is careful to first make out the sharp edge of the liver, and then be sure that the fingers are well under it. In placing patients in various positions for the purpose of ex- amining loose kidneys, I have found one position that is often very satisfactory. If the right kidney is to be palpated, the patient lies upon her left side with the legs flexed so that the abdominal muscles are relaxed, and the intestines and omentum sag toward the table side of the patient. If the kidney is loose, it then slides out in such a way that it becomes the highest round body found beneath the abdominal wall at a certain point. The intestines and omentum are out of the way, and the kidney has moved between peritoneal planes, or has swung upon a meso- nephron into a position to be easily examined. The certain 107 io8 Notes. point at which the kidney is found is somewhere in the cavity that forms along the margin of the right quadratus lumborum muscle when the abdominal viscera sag towards the table. Dif- ferent patients require somewhat different positions of the limbs, and different angles with the top of the examining table, in order that the point of greatest degree of relaxation of the abdominal wall be obtained. A very fleshy patient, for instance, may have to be rolled almost into a prone position because the weight of the viscera must be partly borne by the table before the tension of the abdominal wall is relieved. If a loose kidney does not at once slide out of the normal position when the patient is properly placed, a blow upon the lumbar region with the hand will displace it, and we can then obtain a more resonant percussion note over the site that the kidney formerly occupied. With some patients in the position described I have been enabled to hold the entire kidney in one hand almost as easily as if it were a potato in a bag. For examining kidneys that are not loose, I still prefer to ex- amine according to the method of Israel, or of Guyon. A great many patients who are at present being treated for obscure dis- ease of the pelvic organs, and for all sorts of abdominal distress, will be found to have a loose kidney, if a satisfactory method for palpation of the kidney is employed. The real proportion of loose kidneys is not determined in ordinary post-mortem exami- nations because a kidney which would slip between the peri- toneal planes almost to the pelvis, may glide back into place and become fixed by rigor mortis, or remain in place simply by its own weight, with the subject in the recumbent position. True floating kidney with a meso-nephron is of rare occurrence, but loose kidneys are very common. The right kidney is the one that usually wanders, presumably because corsets which fix the lower costal border prevent the liver from gliding forward on inspiration, and the liver then must move up and down like a piston, forcing the kidney away from its connective-tissue bed. A retroverted uterus may sometimes cause enough tension of the short right ureter to start a kidney out of its bed. There are many common causes for a kidney leaving its connective-tissue anchorage, and once it is loosened, gravitation increases the range of the wandering. Some years ago I prophesied that loose kidneys would form the next subject for general widespread interest in the medical pro- fession, but appendicitis and anti-toxines have come forward first. EXPERIMENTS GERMANE TO THE SUBJECT OF ABDOMI- NAL SUPPORTERS AFTER LAPAROTOMY. An abdominal incision about two inches in length was made in the middle abdominal line in a series of adult rabbits, and the incision was closed with catgut in two tiers. The first tier included peritoneum, muscle, and fibrous planes ; the second tier included skin. The method of examining the character of repaired tissues afterward, consisted in dividing up the abdominal walls into strips, half an inch wide, cut transversely across the abdomen after the rabbits had been killed with chloroform. The strips were then dissected in such a way that skin was separated from muscles and muscles from peritoneum. It was not possible to separate the peritoneum nicely in rabbits because of its close connection with the abdominal wall. The fresh strips were kept in saline solution while the experiments were being made. The testing apparatus consisted of a pair of screw clamps and a spring balance registering pounds up to fifty. One end of the strip of tissue was fas- tened between blocks of wood to prevent slipping, and the clamps were then screwed down upon it. The other end being treated in the same way, the spring balance was hooked to one clamp, and traction was made on the other, while the indicator was watched. First rabbit—three days after operation. A strip of unwounded ab- dominal wall, half an inch wide and three inches long, was first tested. The skin pulled apart with a traction of eighteen pounds. (In all of these experiments the pounds are given in round numbers.) The strip of muscle and fascia pulled apart at sixteen pounds ; the peritoneum containing a little muscular tissue from the abdominal wall, at seven pounds. Sutured structures removed—no tissue bore a pull of one pound. Second rabbit—killed seven days after operation. The peritoneum was injured in trying to dissect it away for experiment. Third rabbit—killed seven days after operation. The peritoneum could be dissected away fairly well by first pinching it up between the fingers, but some muscular fibres remained attached. All sutures removed. Normal peritoneum tore at eight pounds. Sutured peritoneum tore at eight pounds. Normal muscle wall tore at fourteen pounds. 109 I IO Notes. Sutured line in muscle wall tore at five pounds. Normal skin tore at seventeen pounds. Sutured skin tore at two pounds. Fourth rabbit, killed ten days after operation. The peritoneum was not tested as it was evidently perfectly repaired. The muscle gave way at stitch holes, but the tear extended into nor- mal muscle, as well as into wound line. The skin tore through wound line. Fifth rabbit, killed fourteen days after operation. The sutured peritoneum was normal. Muscle and fibrous structures did not tear along the wound line more readily than in normal tissue. The fibres slid apart, as threads slide in woven material which is subject to tension, in normal tissues and in the vicinity of the wound alike. The skin gave way in the wound line still, but sliding of the fibres instead of direct tearing began at this date. Sixth rabbit, killed eighteen days after operation. All repaired structures were found to be as strong as normal ones, but the tears beginning anywhere near the wound line always ran to a stitch depression, or else began there and ran to near tissues. Seventh rabbit, killed at twenty-one days. Eighth rabbit, killed at thirty-eight days. The same observations were made on these as in the sixth rabbit. /;/ practice I have not to my knowledge had ventral hernia follow operation in wounds which were closed at the time of operation with or without a drain. This includes several hundred laparotomies for all sorts of conditions requiring abdominal operation. The only patients whom I know to be wearing abdominal supporters to-day are two who had general suppurative peritonitis and whose wounds had to be left widely opened, one who came into my hands as a ventral hernia case, and a fourth whose abdominal wall feels weak from local paralysis of mus- cles near the incision, but who has no hernia. If any other patients of mine are wearing abdominal supporters or trusses of any sort for post- operative hernia I would like to be apprised of the fact, for quotation in a later edition. As a rule, patients were allowed to get out of bed on the seventeenth day after operation, and no abdominal supporters have been applied afterward excepting in the four cases mentioned, although a common abdominal bandage for general support has some- times been kept on by the patients for a short time after getting out of bed. Abdominal supporters seem to be unnecessary if the abdominal structures have been well sutured, but if suturing has not been done accurately, abdominal supporters I believe are useless for the prevention of hernia. I have always made it a rule to suture structures separately Repair of Abdominal Wall. 111 and with the utmost degree of precision, feeling that in that way only could structures be left as they ivere foutid. Silk or silver wire have never been used for closing my abdominal wounds. Silk-worm gut was employed in perhaps twenty cases. Kangaroo tendon was tried satisfactorily in a few, but small chromic catgut was used for the hun- dreds. Of late years my sutures have not been passed through the adipose layer of abdominal walls, as the fatty layers are perfectly approximated by atmospheric pressure after the deeper tissues and skin have been accurately sutured with fine catgut. AN ADDITION TO McGUIRE'S OPERATION FOR A SUPRA- PUBIC URETHRA. In only one case has there been occasion to try the following re- source, because patients with hypertrophy of the prostate gland under careful palliative treatment and management do not often require surgical operation. £•:.- .............. -■■ ■ Nf'^ Vju—A 1 J—a l 1 ' [/■'Tv Fig. 38.—A. Rectus abdominis muscles. B. Skin flaps outlined. C. Skin flaps dissected from attachments and turned down. This patient, sixty years old, could not be relieved by the resources which were faithfully applied, and he was suffering from chronic septi- Suprapubic Urethra. "3 cemia from an aggravated suppurative cystitis. He could not pass a catheter or empty the bladder completely without a catheter. His prostate gland was large and irregularly hypertrophied. An in- cision four inches long, was made in the middle abdominal line, end- ing at the pubes. Then an incision was made on either side of the mid-line incision, making two strips of skin which were to be employed later for forming a supra-pubic urethra. The bladder was brought up to the opening in the abdominal wall, and held temporarily with sutures. As in the Hunter McGuire operation, the bladder was then opened at the lowest anterior point. The strips of skin together with Fig. 39.—C. Skin flaps turned in and sutured to bladder. Fig. 40.—Wound closed and fistula formed. fat and subcutaneous tissue were dissected away from either side of the mid-line incision, leaving them attached at their distal ends. These strips were about one third of an inch broad. Their free ends were sutured with fine catgut to the mucosa of the bladder, each strip on its respective side. The temporary sutures which held the bladder against the abdominal wall were cut, and when the bladder dropped back, it took with it the two ribbons which had been sutured to the mucosa of the bladder and which then lay face to face with the cutane- ii4 Notes. ous surfaces in apposition. That made a fistula lined with skin, reach- ing from the mucosa of the bladder to the skin of the abdomen. Aristol was rubbed into the wound to prevent infiltration of urine, and a drainage wick with one end in the bladder and the other at the ab- dominal surface drained off urine while the process of repair was going on. Four weeks after the operation the wounds had entirely healed. The patient could then hold his urine for three hours, and pass it at will, using a glass tube to press against the abdominal wall to guide the urine away from his clothing. An ordinary expulsive effort was suf- ficient to empty the bladder by way of this fistula, and no urine passed through the penis. One year after the operation the patient could still hold his urine for three hours, but there was a trifle of moisture about the opening most of the time. Two years later, there was a still greater leakage of urine, although the patient was able to carry on all of his work as a farmer. The reason why the later trouble occurred was because the walls of the fistula were rather rigid, the strips of skin having con- tracted to form a firm, round canal. In another and similiar operation, I would make the strips more than half an inch wide in order to ob- tain a supra-pubic urethra with walls which would remain soft enough to keep them in apposition. THE DRAINAGE WICK. THE application of the principle of capillary drainage for wounds is potent for good if applied in full knowledge of the mechanical features of this resource, and potent for evil if applied wrongly. An illustration of its uselessness is observed if we place one end of the strip of absorbent gauze in the uterus, and leave the other end folded up in the vagina ; but if the end of gauze in the vagina is brought outside and allowed to rest in a mass of absorbent gauze, capillary drainage proceeds usefully and at once, until the mass of gauze becomes saturated with serum, when capillary power again decreases, and stops. A very large gauze drain or gauze packing in the abdominal cavity is potent or impotent rela- tively with its size as compared with that of a mass of absorbent gauze with which it is in contact upon the abdominal wall. The larger the mass of gauze within the abdominal cavity, and the smaller the mass on the outer wall, the less effective is the drain- age. A large mass upon the outer wall ceases action when it be- comes saturated with fluid. A mass of gauze within the abdomi- nal cavity is soon filled in its meshes with coagulated lymph, and its capillary action ceases. The lymph unites gauze and tis- sues together and repair begins, Nature attempting to encapsu- late the gauze. Then, when the gauze is removed, the tissues are rudely disturbed, and the excess of reparative lymph which has been thrown out makes an inviting field for bacteria. Repair cannot proceed until the excess of lymph has become absorbed or has broken down. Gauze is rendered still less useful if loaded with iodoform and fixing agents. In order to obtain the full benefit of capillary gauze drainage, and employ a small " drawing column " of absorbent gauze for the interior of the wound, a large " receiving mass " of absorbent gauze must be placed in contact with it, lying outside of the wound. The mass of receiving gauze must be changed when it becomes saturated to the point of decreased power, otherwise it will have little mechanical effect upon the column of drawing gauze within. Reparative lymph is prevented from encapsulating 115 u6 Notes. the drawing column of gauze, which I call " the wick," by sur- rounding it with gutta-percha tissue or Lister's protective oiled silk. This also prevents disturbance of the tissues when the wick is removed, as union does not take place between the tissues and the waterproof material. The wick is made of a strip of absorb- ent gauze not much larger round than a lead-pencil for most pur- poses, and this strip of gauze is rolled in gutta-percha tissue very much as one would roll a cigarette. Such a wick could draw quarts of serum or blood out of the abdominal cavity, and it forces op- posed peritoneal planes at a distance to act by capillarity from all parts of the abdominal cavity toward the point at which the greatest capillary power is being exerted. Little holes are snipped through the gutta-percha covering of the wick after it has been rolled, so that the fluids can enter at more than one point, but Fig. 41.—Drainage wick. the holes are not large enough to allow tissues to become adher- ent to the gauze within the waterproof material. The wick is not used for more than thirty hours, as a rule, in the abdominal cavity, for adhesions may be expected to wall off any sort of drainage apparatus in the peritoneal cavity by the end of that time. If further drainage is necessary, I carry a narrow strip of gutta- percha tissue into the wound, and then allow the pressure of the tissues to force fluids along the line of least resistance, which is along the strip of gutta-percha tissue. The gauze in the wick must be rolled loosely. A wick long enough to rest behind the uterus will adjust itself to curves so nicely, and will be so soft, that no shock is caused by its presence. After removing the drainage wick from a wound, balsam of Peru is generally injected into the sinus for a few days, and a final injection of iodoform and glycerine in the proportion of one part to seven is very efficient. ENDOSCOPIC TUBES FOR DIRECT INSPECTION OF THE INTERIOR OF THE BLADDER AND UTERUS. FOR direct inspection of the interior of the uterus in women, and of the urinary bladder in both sexes, I use a straight tube of thin silver-plated brass. A central stilette, which is removable, carries the obturator and the handle. Two centimetres of the handle end of the tube are belled to become twice the diameter of the rest of the tube. The tubes for the uterus and for the bladder in women are 9 mm. and 13 mm. in diameter, respectively. Fig. 42.—Endoscopic tube for examining male bladder. Fig. 43.—Forceps for introducing catheter or removing small objects from the bladder. The length, exclusive of plug and stilette, is 13 ctm. The tubes for inspection of the male bladder are of the same respective diameters, but of the length of 24 ctm. exclusive of handle and obturator. It is usually necessary in examining the male bladder with the large tube to first nick the meatus and pass a sound. The tubes for the examination of the uterus and the bladder in the female are furnished with a simple plug obturator, but for the examination of the male bladder a dilatable obturator is used in order to fit the shoulder of the entering end of the tube, and thus 117 n8 Notes. make an even surface which will not catch the urethra at curves. The obturator is dilated by turning the screw handle, which pushes a wedge rod, between the wings of which the obturator is com- posed. The obturator is composed of two sets of wings, sur- mounted by a removable knob. When the instrument is to be cleansed, the knob is unscrewed, the two sets of wings are pulled apart, and each separate wing is unjointed from its fixation pin. Straight tubes which have been invented for examination of the male bladder have been too small, and the obturators have been difficult to cleanse. The tube which I use does away with these objections. Formerly I examined the bladder with the patient in the supine position, but in a position which allowed the bladder to contract, and this gave a field of view equal to the diameter of the tube only, so that it was often a laborious process to find the openings of the ureters or to examine any definite part of the bladder. It was necessary to insert an elevator into the rectum to lift the trigone of the male bladder into view, and the elevator must still be used for that purpose where the finger in the rectum will not answer the purpose. Kelly, of Baltimore, gave us the greatest step in progress of the examination of the bladder through straight tubes, in a paper published in the American Journal of Obstetrics in 1894. Since the publication of that paper I have adopted his plan of elevating the hips of the patient until the intestines cease to make pressure against the bladder, and when the tube is then inserted, the blad- der becomes more or less dilated with air, and gives us an excel- lent view of its walls. It is now, by Kelly's technique, an easy matter to find the openings of the ureters in women, but in men, unless the bladder at the opening of the ureter is inflamed, we cannot find it until a little gush of urine marks the spot. As the ureter empties itself by a quick contraction at short intervals, however, the accumulated drops of urine which are forced out can be easily seen. Another reason why it is more difficult to find the ureters in men than in women is because the tube cannot be moved through as great a range of motion, being limited by the triangular ligament and the prostate gland. A suction apparatus, consisting of a syringe fitted with a small rubber tube, somewhat longer than the ordinary catheter, serves to empty the bladder of urine which collects while an examina- tion is being made. A very long and slender pair of slide forceps is useful for carrying a catheter or a whalebone bougie into the Endoscopic Tubes. 119 ureter, or for removing any small object, or specimens snipped from the wall of the bladder. In proceeding to examine the interior of the uterus, the cervi- cal canal is first dilated with any proper instrument. The uterus is then brought down and steadied with volsella forceps in cases in which that can be harmlessly done, and the tube is entered to the fundus. The obturator is removed, and with a head-mirror light is thrown through the endoscope. By turning the endo- scope properly, the openings of the oviducts can be readily in- spected, and then on slowly withdrawing the endoscope, the whole of the interior of the uterus is examined. In examining the interior of the bladder in men with light reflected from ahead- mirror, it is necessary to have a stronger light than that required for the female bladder or uterus on account of the length of the tube. Actual sunlight is by all means the best, and when it is possible to do so, I ask male patients to wait for a clear, sunny day for their examination. The endoscopes are practical for all common diagnostic purposes for which they are intended, although for examination of the male bladder in certain cases the Nitze cystoscope in the hands of a few experts is superior. THE ACTION OF TRYPSIN, PANCREATIC EXTRACT, AND PEPSIN, UPON SLOUGHS AND COAGULA. Masses of putrescible material which must be removed by the sur- geon sometimes require an extensive operative procedure unless such masses can be liquefied and washed away. A large psoas abscess may have upon the walls of its cavity a half pound of tenacious, partially organized lymph coagula which cannot be removed easily with the curette and spoon, but which will putrefy and cause dangerous septi- cemia if allowed to remain after the abscess has been opened. In some cases of empyema, or of traumatic pleurisy, large masses of lymph form bands and diaphragms within the chest cavity, and loose masses of coagula, which are too large to escape through the surgeon's incision, remain behind to decompose. The bladder is sometimes filled with blood clot.' Sloughs which are undergoing decomposition, but which cannot be peeled away from a wound, may require removal by operation to prevent septic complications. In all of these cases the masses of putrescible material can be liquefied promptly and harmlessly if a digestive ferment can be properly applied to them. The necessity for such a resource first came to me in a case of crushed liver resulting from a violent horse kick. A large part of the liver seemed to have been destroyed By the blow, and an abscess cavity filled with several quarts of blood and thin brownish pus had quickly formed, but was walled in with peritoneal exudate. A long incision below the right costal border evacuated the abscess contents, and dis- closed black and sloughing masses of crushed liver, which I tried to excise, but with the production of such alarming hemorrhage that it was impossible to proceed. Pultaceous lymph coagula were attached to the walls of the cavity in places, and fibrinous blood coagula formed stringy bridges across the lacerated structures. Into this unpromising wound we injected an acidulated solution of pepsin, which was washed out with hydrogen dioxide about two hours later. The process was then repeated at intervals during a period of forty-eight hours, by the family physician, who reported at the end of that time that the last of the sloughs and coagula had become lique- fied and had passed out of the wound in the form of a voluminous, treacly fluid, brownish at first and finally straw-colored. The cleansed cavity rapidly contracted, and the patient made an excellent recovery. 120 Digestive Ferments hi Surgery. 121 After experience with this case experiments were tried with different digestive ferments. On theoretical grounds I had supposed that trypsin would be the best liquefier, that pancreatic extract would stand next in value, and that pepsin would be used only when it was inconvenient to obtain other ferments ; but in the practical tests pepsin proved to be the most efficient. It is not necessary to actually digest the substances which are to be removed, as liquefaction of the masses is all that the surgeon requires of the ferment. For test purposes, tough, partially dried coagula from beef's blood were employed, and the trypsin, pan- creatic extract, and pepsin were obtained fresh from the works of Fair- child Brothers & Foster. As a result of several experiments, it was determined that four grammes of pepsin dissolved in three hundred cubic centimetres of wrater acidulated with one per cent, of hydrochloric acid and applied to one hundred grammes of the coagula at a tempera- ture of about ioo° F., would liquefy the coagula in thirty-six minutes. Pancreatic extract in alkaline solution, with proportions and conditions as in the pepsin experiment, required one hundred and forty-six minutes for liquefying the coagula, and some small knots of fibrin remained even then. Trypsin in alkaline solution, used with proportions and conditions as in the pepsin experiment, required one hundred and thirty minutes for liquefying the one hundred grammes of coagula. Two grammes of tough lining membrane from the cavity of a coxitis abscess were liquefied in fifty-five minutes with the pepsin solution. Since these tests were made, I have had occasion to employ pepsin solution for various surgical conditions, and have determined that there are some precautions to be observed. The pepsin solution used in the vicinity of new scar tissue will dissolve it, and cause the wound to gape. It will also liquefy catgut sutures and ligatures. Although pepsin attacks dead tissue rapidly, it does not seem to exert a harmful influence on tissues in which blood is circulating. Thus, the stomach walls do not digest while the tissues are normal and living ; but if an ulcer of the stomach causes a sufficient degree of exudation anemia at any one point, a perforation of the stomach may be caused by the digestion of the anemic spot. A very good illustration of the action of digestion of tissues is furnished in trout which have been caught on a warm day, particularly when the stomach has been torn by a swallowed hook. In such a trout the viscera are found to be partially liquefied when the trout are dressed a few hours later. A thick solution of pepsin is not so effective as a thin, watery solu- tion, for pepsin normally requires a good deal of water for its best action. The proportions of the solutions for surgical purposes are as follows : Distilled water, four fluid ounces ; hydrochloric acid, U.S.P., sixteen minims ; best scale pepsin, half a drachm. 122 Notes. The glycerine extract of pepsin, and papoid, have been recently rec- ommended as particularly good preparations for the surgeon's use ; the papoid because it can be sterilized without destroying its efficiency, and because it is active in both acid and alkaline media, but I have had no opportunity to make accurate tests with anything excepting the diges- tive ferments as described. After liquefying sloughs and coagula, I usually cleanse the wound with hydrogen dioxide, and then stimulate the tissues to the formation of granulations with balsam of Peru ; but after the removal of clots from the bladder, special cleansing is unnecessary. THE REMOVAL OF NECROTIC AND CARIOUS BONE WITH HYDROCHLORIC ACID AND PEPSIN. Sometimes it is desirable to remove dead bone without subjecting the patient to an extensive operation. Attempts have been made with some success at clearing out this bone by a process of decalcification, but there was one chief reason why failures have resulted. It was dis- covered that superficial layers of dead bone were decalcified easily enough, but the acids did not reach deeply into the mass, especially if portions were infiltrated with caseous or fatty debris. After much ex- perimentation, I have adopted a method of work which is satisfactory in selected cases. An opening is made through the soft parts, if necessary, by means of a direct incision to the seat of dead bone, and if many sinuses are present they are led, if possible, into one large sinus. The large direct sinus is kept open with strips of gauze soaked in balsam of Peru, and the wound is allowed to remain quiet until granulation tissue is well formed. The next step consists in injecting into the sinus a three per cent, solution of hydrochloric acid in distilled water. If the patient is confined to bed, the injections can be made at intervals of two hours during the day ; but if it is best to keep the patient out of bed, the acid solution is thrown into the sinus less frequently, and the patient in either case must assume a position favorable for the retention of the solution. Decalcification of exposed layers of dead bone takes place in a few hours, and then comes the necessity for another and very important step in the progress. At intervals of about two days an acidulated pepsin solution is thrown into the sinus (distilled water, four ounces ; hydrochloric acid, U.S.P., sixteen minims ; scale pepsin, half a drachm). This solution will liquefy decalcified bone and caseous and fatty debris in less than two hours, leaving clean dead bone exposed for a repetition of the treatment. The treatment is continued until the sinus closes at the bottom, showing that the dead bone is all out; but in progressing cases of tuberculosis, it is advantageous to throw into the sinus at intervals of a week, a ten per cent, mixture of iodoform in glycerine, allowing this mixture to remain in place for twenty-four hours. In tortuous channels which will not receive the thick glycerine mixture, a seven per cent, ethereal solution of iodoform may be used in its place. In tuberculous cases, apparatus for immobilizing diseased parts, and 123 124 A'otes. tonic constitutional treatment are necessary in conjunction with the treatment for the removal of dead bone. If a cavity in which we are at work is suppurating freely, it should be cleansed with boiled water before medicated injections are employed. It is a popular impression that living bone is not attacked by very dilute solutions of mineral acids. In order to test this point I made the following experiments : A portion of the keratinoid layer was re- moved from the carapace of a live turtle (Nanemysguttatus), and the animal was then placed, tail downward, in a glass of five per cent, hy- Fig. 45.—Dark portion, decalcified bone, which is stained with carmine up to the light portion, living bone. drochloric acid solution. In the same glass I placed a segment snipped from the plastron of the turtle, and also a thin transverse segment from an old, dry humerus from a man. The piece of humerus was decalcified in six hours ; the piece of plastron was distinctly softened in twenty hours, and the submerged portion of the exposed living carapace was decalcified in thirty hours. I was then curious to note what effect the acid had produced on the carapace, and sections for microscopical examinations were made, which included both decalcified and normal bone. These Sections were stained with carmine. Investigation showed that all of the blood-vessels were destroyed wherever the bone • Removal of Necrotic Bone. \ 2 5 was softened, and the action of the acid had extended farther along the line of the larger blood-vessels than elsewhere. In the accompanying photo-micrographs taken from these slides, the dark portions show decalcified bone stained with carmine, and in the lighter portions normal bone is distinguished. In Figure 46 can be seen the line of extension of decalcification along the course of three blood- vessels. The difference in time required for decalcification of the dead bone (six hours) and of the living bone (thirty hours) is significant, a five percent, solution having been used. If we use a three per cent. Fig. 46.—Dark lines showing decalcification along lines of blood-vessels, carmine stain. solution of hydrochloric acid in practice, a wall of granulation sur- face is thrown out upon the surface of living bone so that dead bone only undergoes destruction, according to my observation in several cases in which the results of treatment could be watched. This plan of treatment is not to be depended upon for progressing cases of tuberculosis or osteo-myelitis of the bones, but sometimes it works beautifully in such cases. Its principal field for usefulness is in cases which are not progressing and in which dead bone has been left behind as the result of any destructive process. I f IS EVOLUTION TRYING TO DO AWAY WITH THE CLITORIS? During a period of twelve months I collected statistics from some three hundred cases, which showed that about eighty per cent, of Aryan- American women possess preputial adhesions, which bind together the glans of the clitoris and its prepuce. The condition evidently repre- sents a degenerative process that goes with higher civilization. It dates back to the embryonic life of the individual, and consists anatomically in Fig. 47.—Section of apex of normal glans clitoridis, and prepuce. a failure of the genital eminence to develop its epithelial surfaces per- fectly enough for complete cleavage between the opposed surfaces of the prepuce and glans of the clitoris. This degeneration sign is as well marked as those furnished by poorly developed mammary glands, early falling hair, and teeth which are prone to decay. Preputial adhesions in women are similar in character to those which occur less frequently in men, and the resulting disturbances are alike 126 Evolution and the Clitoris. 127 in both sexes, but greater in degree in women because of the more im- pressionable nervous system of that sex. Adhesions may bind down the prepuce so closely that no part of the glans clitoridis is in sight. They may involve half of the glans, or they may form only a small adherence which is of no importance excepting as an anatomical curi- osity. This curiosity is serious, is portent, however, for Nature in failing persistently to develop the part indicates that it is intended that the clitoris is to disappear as civilization advances. The adherent pre- puce is important not only as a degeneration sign, but in children and in young women it sometimes produces such an impression upon the Fig. 48.—Section of adherent glans clitoridis and prepuce. Dark line of adhesion. nerve centres that the whole sexual apparatus is influenced toward degeneration—a result, rather than a coincidence, in at least some of the observed cases which recovered from the beginning degeneration of the uterus and adnexa after circumcision had been performed. The glans clitoridis confined among adhesions, fails to develop, and remains small and compressed. The glands of the mucous membrane of the prepuce also fail to develop at the points of adhesion. It is a remark- able fact, however, that when adhesions have been separated, and the prepuce prevented from re-adhering to the glans of the clitoris, the glans will in a few weeks develop to what is apparently a normal size. The glands of the mucous membrane at the same time become perfect, 128 Notes. as determined from typical specimens removed for examination, fur- nishing abundant normal secretion ; and these restorative changes take place even after years of repression. I know of nothing analogous among the higher vertebrata. There were ten negresses among the patients examined, and prepu- tial adhesions were found in three who very likely possessed an admix- ture of Caucasian blood. In the others, the glans and prepuce were perfectly developed. A number of highly domesticated animals were examined for me by Professor James Law, who stated that in them the glans clitoi-idis was free, and the prepuce not adherent, excepting as the Fig. 49.—Space for encapsulated smegma in adhesion line. occasional result of parturition injury. A large number of Semitic women among the patients showed very little tendency to preputial adhesions, and the glans and prepuce were in them usually as well developed as were their mammary glands. This fact is extremely interesting, as compared with the great proportion of clitoris and mam- mary degeneration signs in Aryan American women, and would indi- cate that the Semitic people are to outlast us. Some of the phenomena of physical degeneration of civilized races are of interest only as evidences of retrogression, but preputial adhe- sions in children and young women are malevolent in influence when they involve much of the glans of the clitoris. The disturbance caused by preputial adhesions depends primarily upon irritation of the terminal Evolution and the Clitoris. 129 branches of the pudic nerve in the attempt of the erectile glans clitoridis to adjust itself to the less elastic prepuce ; and it depends secondarily upon the irritation caused by retained secretions. The retained smegma is usually found in the form of small, white inspissated particles, but sometimes a small area of developed glands secrete enough to cause tension among the adhesions, and when retained smegma happens to become transformed into an acrid, thin fluid, it finds a point for grad- ual escape, and causes pruritus or even excoriations about the vulva. Some of the cases of suppurating vulvitis in children begin at such small excoriations about the prepuce, in which local inflammation is caused by retained smegma, but these are not so common or so impor- tant as the ones of simple irritation from incarceration of the erectile glans clitoridis. The irritation of preputial adhesions early attracts the attention of the child to that part, which is frequently rubbed to give relief, until the habit often becomes a fixed one—innocently on her part—as the girl grows older, and neurasthenia results. Any one who has previously had no occasion to make inquiries of girls who suffer from adherent prepuces will be surprised at the answers to his inquiries relative to the frequency with which they feel impelled to rub the irri- table region. The subject needs the immediate and direct attention on the part of every woman physician in the country to-day. After collecting enough cases for statistical purposes, I dropped the subject, as it is naturally repelling to one of the opposite sex, but the proper persons must at once take up this work of looking after adherent prepuces in young girls. In making inquiries of the patient it is well to state that signs of local irritation are discovered, and then the patient, knowing that we have a clue, will freely state what she other- wise might deny. As a result of continued adhesion irritation, or of neurasthenia from the effect of rubbing, a second series of disturbances appears—the reflex neuroses, and in this group of symptoms we have the most com- plicated and the most harmful of the influences emerging from the peripheral irritation at the clitoris. Chronic peripheral over-stimula- tion of the centripetal nerves connected with the centres of the spinal cord and brain lead in ordinary concatenation (1) to the common acute reflex demonstrations; (2) to slow degenerative changes in organs the functions of which have been disturbed ; and (3) to complications dependent upon such degenerations. For instance, if preputial irrita- tion neurasthenia leads to relaxation of the uterine ligaments, and the resulting malposition of the uterus leads to degeneration of the ovaries, the patient may suffer more from the ovarian complication than from the original cause for that complication, but the removal of the ovaries will not make her well. The fast growing girl with preputial adhesions 9 13° Notes. may become languid enough to sag into scoliosis, and no amount of orthopedic treatment will stop the scoliosis, which is but a symptom in her case. The young asthmatic, the girl whose uterus is ante- flexed, the child who is listless and fretful and fanciful as to her food, the patient with enuresis or with dysuria, and with menstrual irregularities, the hysteric, the patient with epileptoid convulsions, the patient with nervous dyspepsia or spasmodic stricture of the oesophagus, or non-inflammatory paralyses of the legs—all of these must be ex- amined by the diagnostician for preputial adhesions. I do not wish to be understood as underrating the importance of any of the other well known causes for the same symptoms—errors of refraction perhaps standing first in causal relation for many of them,—but would simply state that preputial adhesions are the prime factor in a sufficient pro- portion of the cases to at least make it necessary for us to eliminate that factor whenever it is found. Before neurotic habits have become established, the symptoms which are dependent upon preputial adhesions will often disappear as quickly as does sciatica that is dependent upon Dupuytren's contraction of the palmar fascia, or the cough which is dependent upon a bean in the ear, when the cause is removed. With older patients in whom neurotic habits have become established, the results are not so immediate or so well marked as in children. In few patients beyond the age of twenty- five years is very much gained by the separation of preputial adhesions, although chronic local irritation may be stopped and some unresponsive wives find that the clitoris was at fault. The proper time for the Separation of preputial adhesions is when the babe is first born, and as a matter of routine practice. Baker Brown, I believe, was very near to the subject of preputial adhesions when he published his work on The Curability of Various Forms of Insanity, Epilepsy, Catalepsy, and Hysteria, but his method consisted, not in the separation of adhesions, but in the bodily removal of the offending clitoris, and he ignored as much physiology as is ignored by many other observers who find revelations along a new line of investigation, and who try to leaven too big a lump with their findings. Some of the results of separating preputial adhesions are so striking that one finds it hard to avoid giving too much importance to the sub- ject as a whole. One of my patients who suffered from epileptoid seizures, with several attacks weekly, simulating grand mat, is reported by the family physician as having had no attacks for a year since cir- cumcision was performed on her. In another case, with a separation of adhesions without circumcision, there was-a tendency to re-adhe- sion. The patient was free from epileptoid convulsions when the pre- puce was free, but suffered from such attacks when the prepuce became Evolution and the Clitoris. I3I re-adherent. Medication was discontinued at the time in both cases, and not resorted to while they were under observation. Nocturnal enuresis was promptly stopped in several of my patients by separation of preputial adhesions from the glans clitoridis. Very many neurasthenic girls made prompt and striking improvement as the result of the same treatment. In a word, I may say that separation of preputial adhesions in girls accomplishes just what it does in boys, plus relief from such uterine and ovarian complications as are dependent upon that cause, and they are not few. After separation of preputial adhesions, there is a marked tendency for them to recur, and excepting in infants, I now advocate the removal of the prepuce instead of simply separating it from the glans. The work can be done under cocaine, if cocaine is injected hypodermati- cally into the glans and into the prepuce, but on account of the sensi- tiveness of this region to the entrance of a needle, it is much better to give these patients ether, as that allows of much better work being done. The prepuce is first stripped away from the glans with the handle of the scalpel until the corona is free. The prepuce is then split through the middle and the folds on either side of the glans are picked up with a pair of thumb forceps and cut off with scissors. Enough must be cut off to prevent re-adhesion between the glans and any remaining prepuce. It is not worth while to stop the oozing of blood which follows the operation, as that will soon cease spontaneous- ly. Aristol is dusted on the wound daily until it has healed. It is not always an easy matter to strip a. glans clitoridis from preputial adhesions, and incomplete work by one who has not a clear idea of the appearance of the normal glans will result in disappointment. This work should be done by women physicians whenever it is possible to obtain their services. THE MECHANISM AND ANATOMY OF SUBLUXATION OF THE HEAD OF THE RADIUS. In order to verify a theory which had already been accepted by some as tenable in reference to the anatomy of that common injury of childhood known as subluxation of the head of the radius, I made the following experiments : Two arms from a child four months of age, and two arms from a child fourteen months of age, both children dead a few hours, were placed in a weak acidulated bichloride of mercury solution, and the experiments were made during the next twenty-four hours. Fig. 50.—Orbicular ligament in normal position. Fig. 51.—Orbicular ligament slipped between head of radius and capitellum. Experiment No. 1. Left arm of four-months-old child—all muscles dissected apart from each other, but not removed, and ligaments of elbow freely exposed. Traction with the hands was made upon the radius and humerus simultaneously, and with varying degrees of force. Observation. Separation of head of radius from capitellum, and of head of ulna from trochlea ; depression of ligaments into joint space as a result of atmospheric pressure ; spontaneous restoration of all 132 Subluxation of the Radius. 133 structures to their normal position immediately upon being relieved from traction force. Subluxation not produced. Experiment No. 2. The same arm ; all muscles removed. Repeated traction was made upon the radius and ulna with the bones of the arm in various positions of flexion and rotation. Observation. The same as in experiment No. 1. Experiment No. 3. Right arm of fourteen-months old child; muscles of arm removed with exception of biceps ; simultaneous traction upon radius and humerus. Observation. Separation of articular surfaces of radius and ulna from capitellum and trochlea ; depression of ligaments into joint space; sudden slipping of loop of orbicular ligament over head of radius, and into joint space between head of radius and capitellum ; orbicular loop remains interposed between head of radius and capitellum when trac- tion force is discontinued ; articular surfaces of head of ulna and trochlea remain slightly separated because of the ligamentous wedge made by the orbicular loop between radial head and capitellnm. Subluxation produced. Slight apparent deformity. A clicking sound is produced by rocking the articular surfaces of the ulna and humerus together. The joint movements are almost complete, but flexion is slightly limited through the last few degrees of range. Reduction of the orbicular ligament is difficult, but is finally accomplished by rotat- ing the radius into pronation and pressing the joint surfaces together at the same time. The reduction is sudden, and takes place with an aud- ible snap. There is then restoration of all structures to their normal positions, but the orbicular ligament appears to be more loosely attach- ed to the surroundings than before on account of the stretching of its connective-tissue attachments. Experiment No. 4. Same arm ; radius and ulna held in my left hand, and humerus in my right hand. The specimen was held with its elbow in an extended or partially flexed position, and pressure was made with my thumb on the outer surface of the head of the radius, forcing it slightly away from the capitellum, and mesially toward the ulna. Observation. Subluxation of the head of the radius is produced in the same anatomical way as when traction force was applied in the long axis of the radius. Experiment No. 5. Same arm ; subluxation reduced ; biceps put upon the stretch in its normal axis of traction, and efforts then made to produce subluxation by traction upon the radius and humerus with my hands, and by pressure upon the outer surface of the head of the radius with my thumb. Observation. It is at once apparent that subluxation of the head of 134 Notes. the radius cannot be produced by any mechanism while the biceps muscle is at work. Experiment No. 6. Left arm of the four-months-old child. Sub- luxation was produced after more violent movements of traction and of outer side pressure than I had applied at first. Experiment No. j. Right arm of four-months-old child. All mus- cles were removed excepting the brachialis anticus and supinator brevis. Simultaneous traction upon the radius and humerus produced subluxa- tion of the head of the radius, and a few fibres of both of the muscles were drawn down into the joint space between the radical head and the capitellum, along with the orbicular ligament and a part of the anterior ligament. The subluxation was reduced most easily by strong prona- tion of the radius, very slight flexion of the elbow, and upward pressure in the long axis of the radius. As reduction of the head of the radius is supposed to occur spontaneously after a few days in many cases, it seemed to me that such reduction could take place only as a result of synovitis, with increase of synovial fluid, and the consequent forcing of the orbicular ligament out of the joint space. For testimony bearing upon this point, I made the following trial : Experiment No. 8. Right arm of four-months-old child. Subluxa- tion produced. About forty minims of water were injected into the joint cavity through a fine hypodermic needle. Observation. Tension of the capsule, quick and strong flexion of the forearm upon the arm, and pronation of the forearm, made by pressure of the injected water. Orbicular ligament remains hopelessly locked within the joint space between the head of the radius and capitellum. Condition less favorable for spontaneous reduction than when the joint was empty of water. Experiment No. p. Left arm of fourteen-months-old child. Muscles dissected away from each other, but not removed. Attempts were made at producing subluxation by pressure with the thumbs upon the outer surface of the head of the radius, and resulted in ordinary luxa- tion of the head of the radius anteriorly. The head of the radius tore through the anterior ligament proximally to the orbicular ligament. Conclusions from these nine experiments. (i) Subluxation of the head of the radius consists in the separation of the head of the radius from the capitellum by the interposition be- tween them of a loop of the orbicular ligament, which is accompanied in some cases by a small portion of the anterior ligament of the elbowj and some fibres of the brachialis anticus and supinator brevis muscles. The articular surfaces of the head of the ulna and of the trochlea remain slightly separated at the time, because of the wedge of orbicu- Subluxation of the Radius. 135 lar ligament between the head of the radius and the capitellum. Pas- sive movements of the joints give rise to clicking sounds, caused by the rocking together of the separated ulnar and humeral articular surfaces. There is no appreciable deformity on inspection or palpation, but the range of motion of the forearm upon the arm is slightly limited. (2) The accident occurs at an instant when the biceps muscle is re- laxed, and as a result of direct traction force upon the radius while the forearm is in a position of partial or complete supination. It also oc- curs under the same anatomical conditions when the force is applied directly to the outer side of the radius, forcing the head of the radius anteriorly and a little proximally from the humerus. The former mechanism is brought into play when a child, led by the hand, stumbles and falls, its hand remaining grasped in the hand of the nurse. The latter mechanism is brought into play when in a fall the outer side of the elbow strikes a stone. (3) The mechanism of spontaneous reduction has not been deter- mined. It may occur as a result of swelling of the pinched ligaments and muscular fibres, but it is more likely to be due to absorption of the portion of loop which is subjected to the greatest degree of ten- sion and of pressure. A strand of catgut under the same circum- stances would be absorbed in a few days. (4) Reduction may be accomplished by the surgeon, as a result of various movements which tend to work the head of the radius back under the loop of orbicular ligament, and the most frequently success- ful movement seems to be pronation and pressure directed proximally along the long axis of the radius, the arm being at the time completely extended. An audible snap gives evidence of reduction. (5) In treating cases in which reduction cannot be accomplished by the surgeon, the arm should be fixed in a position of nearly complete extension, as this gives the loop of orbicular ligament the best oppor- tunity to escape according to the testimony of my small number of specimens. (6) The muscular disability of the arm during the early days of the injury is apparent rather than real, as I have demonstrated in one adult patient who made intelligent observations. Because of the pain consequent upon movements at the elbow joint the patient could with difficulty be persuaded to move the arm at all, but movements once begun, she could carry the forearm through almost its complete range of motion. (7) An injury which has for its principal feature a displaced orbicu- lar ligament, would be correctly described as " dislocation of the orbicular ligament " rather than as " subluxation of the head of the radius." POTT'S FRACTURE, AND THE FRACTURE OF THE FIBULA WHICH FOLLOWS ADDUCTION OF THE FOOT. The following experiments were made for verification of theories which are subject to variance among authors as to the mechanism which is involved. Pott's fracture is not so common as fracture following adduction of the foot, and yet the two are apt to be confused unless the surgeon on inquiry learns from the patient whether the foot " turned in or out." The large propor- tion of fractures which are recorded in clinical history books as cases of Pott's fracture, are really cases of fracture by adduction of the foot. Pott's fracture occurs when the foot "turns out," and fracture by adduction of the foot, when it " turns in." In making ex- periments at the morgue, cadavers of people of various ages were employed, and usually with adults not more than two days after death. The soft parts about the ankles were dissected away excepting the ligaments and tendons, and in some of these a little window was cut in the anterior ligament of the ankle joint. A stout piece of board was bound very firmly to the sole of the foot, leaving space to pass a broom-handle between the sole and the board for use as a lever. Fractures were then made by turn- ing the foot quickly and violently in one direction or the other by means of the broom-handle grasped in my hands, or by standing the cadaver erect upon the abducted or adducted foot, and apply- ing force by pressing the cadaver downward until structures near the ankle gave way. The mechanism of Pott's fracture was observed to be as follows in a series of cases : When the foot was turned outward (abducted) with a sufficient degree of violence, the astragalus rotated from without inward on its antero-posterior axis, and at that instant the tibia assumed the position of an opposing lever, the short arm of which was the internal malleolus, the long arm the shaft of the tibia, and the fulcrum was composed of the astragalus and os cal- cis, which retained their relative positions with each other. The principal object upon which this lever acted was the deltoid liga- 136 Fractures of the Fibula. 13 7 ment, and the ligament in some cases tore transversely, in other cases it pulled off the tip of the short arm of the lever (the inter- nal malleolus). Ligamentous resistance then being overcome, the external surface of the os calcis struck the tip of the internal malleolus, but transmitted no breaking force along the fibula. The fibula broke because of continued exertion of force, and usually at a point varying from two to four inches from the tip of the malleolus. When a man breaks his fibula, then, in sustaining a Pott's fracture, he breaks it after the deltoid ligament has lost its hold, and because the weight of the body is then transferred from the tibia to the fibula. The common fracture near the distal end of the fibula by ad- duction, on the other hand, occurs as the result of an entirely different mechanism from that of Pott's fracture. When the foot of the cadaver was turned in (adducted) with a sufficient degree of violence, the fibula was fractured, usually a little nearer to the tip of the malleolus than in Pott's fracture. Adduction force being applied, the astragalus rotated from within outward on its antero-posterior axis until limited in its rotation by the simultane- ous impinging of its superior external border against the external malleolus, and of its inferior internal border against the internal malleolus. In order that rotation be continued, the two malleoli need then an increased distance between them ; but the five liga- ments—the inferior interosseous, the anterior inferior interosseous, the anterior inferior and posterior inferior tibio-fibular, and the transverse—prevent separation at the inferior tibio-fibular articu- lation, and consequently, the required space can be gained only through fracture of one or both of the bony barriers (the malleoli) This regularly occurred in one, the external malleolus, or in the fibula just above the malleolus, allowing the malleolus to be pushed outward by rotating the astragalus. Such was the injury that occurred regularly in the experiments, but occasionally both malleoli snapped simultaneously when forcible adduction was made, and in such cases in practice, the diagnostic point for Pott's fracture—tenderness at the inner side of the ankle—would not be a differential point unless we determined that the point of frac- ture of the internal malleolus was near the tibia, as it usually is in Pott's fracture, or near the junction with the shaft, as it usually is in fracture of the fibula by adduction of the foot. The patient ordinarily remembers vividly whether the foot turned in or out at the time of the injury. In practice, we can pick out the line of 138 Notes. fracture by pressing on the skin over the bone with the end of a lead-pencil. The exact line of fracture can be determined in this way in any bone that is near the surface, the patient experiencing acute pain when the end of the lead-pencil touches the skin over the crack in the bone, but not when the pressure is made a quar- ter of an inch away. In fracture of the fibula by adduction of the foot, when the shaft of the fibula is broken at a point suffi- ciently far from the malleolus, the ends of the fragments bear about the same relation to each other that they do after Pott's fracture, and there is a depression in the soft parts over the seat of injury. The tilting outward of the external malleolus gives to the front of the ankle at the same time a broad- ened appearance. There is little displacement of the»ioot after this fracture by adduction, unless both tibia and fibula have suf- fered injury, but in the latter case the deformity is the same as that which accompanies Pott's fracture, the foot having a ten- dency to remain in an abducted and everted position by virtue of the action of the peroneus longus muscle, and the proximal end of the distal fragment of the fibula usually lies to the inner side of the distal end of the proximal fragment of the fibula. If there is much unreducible deformity about the ankle, it is well to cut down upon and wire the ends of the fragments. This I have done when the deformity was extreme in degree, for the ankle joint is not a good joint unless it is a good hinge, and many college athletes who suffer fracture near the ankle need a perfect hinge. The proportion of fractures by adduction or by abduction is shown in a consecutive series of nineteen cases which I have pre- viously published, viz.: six occurred by the mechanism of Pott's fracture; in two the mechanism was undetermined ; and the rest suffered fracture of the fibula from adduction of the foot. THE DOWEL-PIN IN DISLOCATION OF THE ACROMIAL END OF THE CLAVICLE. In two cases of dislocation at the acromial end of the clavicle I made a long incision over the seat of injury, drilled the articular surfaces of the acromion process and the opposed end of the Fig. 52.—Dislocation of acromial end of clavicle. Right shoulder broadened and drooping. End of clavicle projecting beneath skin. clavicle, and inserted a stiff silver dowel-pin, about one inch in length, into the drill holes. The two articular surfaces were then pushed together, and remained easily in normal position, held by 139 140 Notes. the dowel-pin. Catgut sutures were used for uniting the ruptured rhomboid and trapezoid ligaments. In one case, the injury had occurred a week previously. A photograph from this case before operation, shows the projecting acromial end of the clavicle, and the drooping and broadened right shoulder. The companion photograph, taken about eight weeks after operation, shows the effect of repairing the shoulder girdle, the shoulder being normal Fig. 53.—Dislocation of clavicle repaired by means of dowel-pin. in appearance, except for a wasting of the trapezius and deltoid muscles, which became perfectly normal two months later. Six months after the operation, although the acromio-clavicular articu- lation was immovably ankylosed, this patient carried on violent gymnasium exercises, and took his place in a college boat crew without further trouble. The movements of the shoulder are only slightly limited, because the repaired shoulder girdle is used Dislocation of the Clavicle. 141 as a whole more freely than the left one. In the other case, which was a dislocation of the left clavicle and of long standing, there was a complication consisting of a fracture of the clavicle near the acromial end, which had united in a somewhat angular position. In this case, a shoulder without deformity, excepting for the frac- ture angle, was obtained. There is firm ankylosis but some disa- bility, the arm not being quite as strong as the right one, although perfectly useful for all ordinary purposes. Nearly a year was required for restoring the wasted trapezius and deltoid muscles to a normal condition, by the use of massage, electricity, and strychnine injections in this second case. THE DOWEL-PIN IN FRACTURE OF THE CLAVICLE. The dowel-pin was employed in one of my cases of fracture of the clavicle, and this resource will be of value in other cases in which deformity is particularly to be avoided, as in cases of fracture of the clavicle in young women. In the case in question, an oblique fracture at the junction of the outer and middle thirds of the left clavicle of a muscular man would not permit of retention of the fragments in position. An impromptu dowel-pin was made from the silver bar of a watch chain. An incision not more than an inch in length was made through the skin. The outer fragment of the clavicle was first lifted with narrow volsella forceps, and the dowel-pin having been pushed for half its length into the cancellous structure of this Fig. 54.—Dowel-pin in fractured clavicle. fragment, the projecting remaining half of the pin was allowed to sink into a little slot cut into the anterior surface of the other fragment with a small chisel. The wound healed by primary union, and at the end of four weeks the patient resumed the free use of his arms in his work as a laborer. There was not the slightest trace of deformity, and the scar was barely apparent. A skin incision, half an inch in length, would have answered for this operation. An evanescent scar can be obtained in such cases by the technique which is employed for obtaining such a scar in an appendicitis operation. (See description of this technique under Appendicitis.) 142 MALLET-FINGER. THE deformity here described is not uncommon among men who engage in athletic sports. When the extensor tendons of the fingers are tense, a blow upon the end of a finger transmitting force in a direction which would ordinarily flex the finger, results in injury to the extensor tendon in the vicinity of its attachment to the dorsal surface of the last phalanx. The injury consists, not in a bodily separation of the tendon from its points of attachment, but rather in a thin- ning of the tendon proximally from the principal point of attach- FlG. 55.—Mallet-finger. Permanent flexion of tip of index-finger. ment to the phalanx, and from the fibres that form the posterior ligament of the last pharyngeal articulation. A few fibres of the tendons are undoubtedly ruptured, but most of them slide away from each other very much as the threads of a textile fabric sepa- rate when the fabric is violently stretched, but not torn, the struc- ture retaining its original general appearance. Immediately after the occurrence of the injury to the tendon the last phalanx of the finger assumes a semi-flexed position, and the deformity is usually permanent, the extensor tendon then having little or no influence upon the freed phalanx. Aside from the uncanny appearance of such a finger, the deformity is a source of much annoyance to the patient. 143 144 Notes. The tendon is repaired without much difficulty by making a longitudinal incision two centimetres in length over the site of the injury, dividing the thinned tendon longitudinally into the two principal fasciculi into which it naturally separates, dividing the Fig. 56.—Extensor tendon of index-finger thinned at point of attachment by arti- ficial production of mallet-finger upon the cadaver. tendon transversely, proximally from the thinnest point, and ad- vancing each fasciculus to a point upon its own side of the finger, near the base of the finger-nail. At this point the fasciculus is sutured to the under surface of the skin with a suture which -•^-^''^^^^'-^-^i-'-i' Fig. 57.—End of index-finger, showing line of incision and sutures. Two black dots mark sutures uniting fasciculi and skin. passes through the skin and is tied upon the outside. The fas- ciculi are sutured to skin rather than to periosteum and tendinous remains, because the former structure affords a firmer hold and the cut end of the tendon makes as good union with the phalanx as it would if sutured directly to periosteum. Fracture of the Clavicle. H5 The finger-nail is sometimes lost temporarily as a result of the operative disturbance near its matrix. When the advanced fasciculi are sutured in place there is an over-correction of the deformity of the phalanx, which causes Fig. 58.—Temporary flexion at middle phalangeal articulation after advancement of extensor tendon. also a flexion at the middle phalangeal articulation. This condi- tion is temporary, and disappears spontaneously in a few weeks, leaving a perfect finger. / TWO CASES OF CONSERVATIVE SURGERY OF THE ARM. A young woman, twenty years of age, caught her fingers between hot rollers in a laundry and the right hand and arm were drawn into the machine and destroyed to the bone wherever the tissues were held in contact with the rollers. The structures that escaped were three fingers and about one fifth of the hand, a narrow strip of skin along the ulna, barely an inch wide, and the tissues between that strip of skin and the Fig. 59.—Burned and sphacelated hand and arm. Fig. 60.—Sphacelated region excised. interosseous ligament, carrying the posterior interosseous artery. All other structures were destroyed, and they sloughed away for the greater 146 Conservative Surgery of the Arm. 147 part leaving the bones of the forearm and wrist bare. Where the burned tissues did not slough away they dried and clung to the bone. There was no sensation below the proximal portion of the spared strip of skin along the ulna. I excised the destroyed parts by cutting away the dried forefinger and thumb, and sawing transversely through all of the metatarsal bones at the distal portion of the injury, and through the radius and ulna at the proximal end of the injury, being careful to lift the strip of skin and the tissues carrying the interosseous artery out of the way before excising the bones. The soft parts at the lines of excision were cut transversely across, and very neatly, in order to FlG. 61.—Fingers transplanted to arm. Loop carrying interosseous artery. ensure good union of tissues if the small arterial connection should prove equal to the task. The portion of hand bearing the three living fingers was then carried up to the stump of arm, and ends of meta- carpal bones were placed in contact with the ends of radius and ulna. The flexor tendon of the third finger was sutured to the flexor carpi radialis muscle. The flexor tendon of the fourth finger was sutured to palmaris longus. The flexor tendon of the fifth finger was sutured to flexor carpi ulnaris. The reason why these connections were made instead of the natural ones was because I had to choose the most useful- looking structures of the arm stump, and selected muscles in which tendinous bands gave prospect of forming a union with finger tendons. The extensor tendons of the fingers were sutured to various fascial 148 Notes. bands, there being little opportunity to make definite connections. When the fingers had thus been sutured to the arm the ribbon of tissue carrying the interosseous artery stood out in the form of a loop several inches high. All skin margins were sutured and the loop of tissue was loosely packed in gauze in such a way as to avoid compres- Fig. 62.—Repair completed. Both arms placed side by side for comparison. From photographs several months after operation. sion or angulation. The dressing applied was the customary permanent one. The entire wound healed by primary union under this one dressing, and about two months later I cut away the loop carying the artery, having first determined that the fingers showed signs of circula- tion of blood while the loop was compressed firmly to cut off circulation by that route. I had not expected that sensation would return in the fingers, but believed that the fingers would, nevertheless, be more use- Conservative Surgery of the Arm. 149 ful than an artificial hand. Sensation began to appear, however, in the fingers about three months after the operation, and the ability to dis- tinguish heat from cold, the patient thinks, returned simultaneously with the sense of touch. Sensation began first in the little finger, and four months from the date of operation it seemed to be almost normal in degree in all of the fingers. The patient with eyes closed could not tell instantly which finger or what part of a finger was touched or pricked, although the sensation was instantly transmitted to the brain. Several seconds later she could localize the point at which contact was being made. The nails of the three fingers grew normally. Fig. 63.—Destruction of tissues of right arm. The flexor tendons made excellent connection at their points of suture, but the extensor tendons made a feeble connection, so that the fingers remained flexed, but could be voluntarily extended a little en masse. Flexion was strongly made en masse, but the patient could not dis- tinctly move each finger separately. Flexion could be made with suffi- cient degree of force to hold the handle of a brush or comb or knife, and the fingers were useful enough for such purposes, but the patient was a sensitive girl who was so much mortified at the interest shown in her uncanny deformity by friends and by strangers that she begged to have the fingers amputated so that she could wear a false arm and hand that would look more attractive. With much regret I complied with her demand about a year later and amputated through the stump of the i5<* Notes. arm on the proximal side of the scar, preserving in the specimen all of the connections that had been made between united tendons and nerves. I have not felt sufficiently expert to make such a dissection of the specimen as it deserves, and await the request of some anatomist at whose disposal it can be placed. Fig. 64.—Arm repaired. Both arms placed together for comparison. From photograph several years after operation. In another case a youth about fifteen years of age caught his right arm between a belt and a swiftly revolving wheel which almost com- pletely destroyed the involved portion of the arm (Fig. 63). Splintering the radius and ulna, tearing away soft structures, and leaving a narrow strip of tissue which carried the ulnar artery intact, but which was ground full of oil and shop dirt. More than two hours of time were re- quired for trimming and uniting injured structures, and an inch or more of ulna had to be resected later at a second operation. Although the injured arm is crooked, and four inches shorter than its fellow, it is practically a normal arm, and with it the patient plays the violin and does all ordinary work. If I had resected an extra inch of the radius and ulna at the first operation, non-union of the ulna would have been avoided and the arm would not have been crooked. / / / SKIN GRAFTING FROM BLISTERS. SKIN grafts for application according to the method of Thiersch may be obtained from blisters. The idea of using grafts of this sort first occurred to me while treating burns in which large blebs' had formed. After securing and cleansing the separated cuticle Fig. 65.—A. Blister. B. Gutta-percha tissue for making a roll with separated cuticle. in physiological saline solution it was replaced upon the sterilized wound where it adhered well in cases in which the skin had not been subjected to a destructive degree of heat. Since that time 151 152 Notes. I have obtained blister grafts and have applied them successfully to small wounds. The new epithelium which covers the site of a blister graft is more delicate than a Thiersch graft covering, and consequently is not so desirable for large wounds. Sometimes the blister graft does not become adherent, but conducts new epithelium across the wound so rapidly that repair is completed under one dressing, in cases which would otherwise require several weeks for granulation. My plan of procedure consists in steriliz- ing the skin from which a graft is to be taken, and then raising a blister of the desired shape and size with cantharides. The blister cuticle is snipped away by cutting around its margins. A piece of gutta-percha tissue is laid upon the graft and gutta-percha and graft are rolled up together, making a compact roll which is easily handled. The graft is then transferred to the wound and un- rolled upon it, leaving the gutta-percha tissue in place. The preparation of the wound, and the after-treatment, are conducted according to Thiersch's method, bearing well in mind the fact that any chemical antiseptics which have been employed for ster- ilizing the wound must be removed by flushing with physiological saline solution before the graft is applied. The gutta-percha tissue is not removed from the graft for ten days or two weeks, but sometimes the outer dressing will need changing if it becomes too dry and hard. An attached blister graft sometimes becomes several times thicker than the cuticle at the time when it was transplanted, but I have not as yet made a microscopic section of such thickened tissue to determine the nature of its structure. PHELPS' HARE-LIP OPERATION IN TWO STEPS. The prettiest hare-lip operation with which I am familiar is that of Dr. Phelps, which places the scar in the middle line of the lip, with no deviation of any part of the scar to either side of the middle line. This result is accomplished, if the fissure is to the right of the middle line, by making another similar fissure to the left of the middle line with a pair of scissors, and then cutting out the inter- vening tissues between the two fissures, and joining the walls of the fissures in the middle line. It is a case in which two equal wrongs make one right. A " V " of lip, with its base at the sep- tum of the nose, can be saved if we wish, when the piece of lip between the two fissures is cut out. Because of the loss of tissue in the Phelps operation, it is un- fortunately confined to a comparatively small proportion of cases, making too flat a lip in cases which require removal of much tissue, but I have made it applicable to a larger class by first repairing- a hare-lip fissure by the old-fashioned straight-line method, and then waiting a few months to allow the orbicularis muscle to draw the scar nearer to the middle line, as it may be expected to do. The scar will very often be drawn to a point not more than one fourth of the distance from the middle line of the lip to the angle of the mouth on that side, and then the second fissure can be made and the scar placed in the middle line. There are very many patients about the country who are carrying hare-lip scars that are a source of mortification to them, but whose scars can be placed in the middle line where they will not attract attention. The cheeks should be well loosened from their attachments to the superior maxillary bone if we wish to have the orbicularis muscle take up enough of the lower lip to lengthen a short repaired upper lip. New angles of the mouth will then form. At this point I will add a note on another plastic operation which has no connection with hare-lip. One of my repaired noses could not be supported because there was no septum. A most ex- cellent septum was made by turning up a large flap of lip, extend- ing from the nose to the mouth, and suturing it to the interior of 153 154 Notes. the nose where the septum was needed. The margins of the wound of the lip were then united, just as they are after the mid- line hare-lip operation. The septum is satisfactory in this case. DISTENSION OF FISTULOUS PIPES WITH PLASTER OF PARIS TO FACILITATE THEIR REMOVAL. In several of my cases of fistula in ano, and in one case of long, tortuous fistula of the plantar region, plaster of Paris was injected into the fistulous tracts, and allowed to set. Guided by the rigid plaster, it was then an easy matter to dissect out a fistulous pipe in its entirety, and muscles which were divided in following the pipe were closely sutured for primary union. Plaster of Paris will not set if any pus or blood remain in the fistulous tract, and the resource cannot be applied except in cases in which we can perfectly cleanse the tract first with. peroxide of hydrogen and saline solution. After this has been done, a small glass syringe is loaded with well salted plaster, prepared as for making a cast, and before the plaster begins to thicken the contents of the syringe are injected forcibly into the fistula, pressing the nozzle of the syringe closely against one opening, and closing any other opening with the end of the finger. The syringe and the finger which closes the opening must be kept in place for a few minutes until the plaster has set. The time can be determined by watching any plaster which remains in the syringe. The syringe is then thrown away, and the pipe, distended with a very hard core of plaster, is dissected out. It is not necessary to apply this resource in most of our cases of fistula, but it is sometimes very useful. PREVENTION OF ABORTION BY REMOVAL OF A UTERINE FIBROID. A patient thirty-two years of age in the fourth month of her first pregnancy began to have symptoms of a threatened abortion, uterine contractions occurring at intervals of about fifteen minutes. Opium, hot fomentations, and posture failed to stop the symptoms. On exami- nation by palpation through the abdominal walls I found a sessile subperitoneal uterine fibroid about as large as a man's fist situated upon the fundus of the uterus near the right oviduct. The abdomen was opened, and the tumor removed by enucleation. The wound in the uterus, about five-inches in length, but not penetrating, was closed with a continuous suture of catgut. Uterine contractions ceased at once, and a normal child was born at full term. Inversion of the Uterus. i 5 5 REDUCTION OF AN INVERTED UTERUS BY INCISING THE CONSTRICTING RING INTRA-ABDOMINALLY. A patient, twenty-four years of age, had a complete inversion of the uterus after parturition. Packing of the vagina for two months, by the family physician, had allowed good involution to take place, but it was found to be impossible to relieve the inversion by way of the vagina. I made an abdominal incision in order to effect reduction bimanually and by internal dilatation of the constricting cervix. This failing, the en- trapped bladder and uterine adnexa were drawn out of the way, and the uterine wall and the ring of cervix were divided with a long scalpel. The inversion was then easily reduced. I had been tempted to divide the constriction from the vaginal side, but when the abdomen was opened it was observed that the bladder or vessels of the broad liga- ment would have been cut if that procedure had been attempted. HYSTERECTOMY FOR PLACENTA PREVIA. V A woman, thirty-four years of age, in the fifth month of pregnancy, suddenly had an alarming hemorrhage from the uterus, wrhich stopped spontaneously, with the exception of a little oozing. On examination it was determined that one margin of the placenta was apparently so near the cervical region that it had become separated through unequal expansion of the uterus, although the case was not one of well marked placenta previa. I planned to dilate the cervix rapidly, and get past the placenta in time to deliver the child before hemorrhage could prove fatal, but one of the consultants had been present at two deaths result- ing from this plan of management. In both cases an attempt was made to hold the separated margin of placenta against the uterine wall with a finger in order to stop hemorrhage by compression while dilata- tion was being effected, but in both cases the blood, thus being prevented from escaping, instantly dissected off the whole placenta, and the patients died on the table. I feared to dilate, but knew that abdominal hysterectomy would be a safe procedure, and this was con- sequently done, the uterus with its contained fetus being removed in one mass. The patient recovered without complications. OVARIAN TRANSPLANTATION. WITHIN the past four months I have tried the plan of trans- planting a segment of normal ovary from one woman to the uterus or oviduct of another woman, in cases in which the uterine adnexa had been removed for disease, and in cases of infantile uterus with rudimentary adnexa. In another class of cases in which the adnexa had been rendered useless by disease, but in which a portion of at least one ovary was good, I have transplanted that piece of ovary into the patient's own uterus or oviduct. It is perhaps premature to describe these plans before practical results have been obtained, but the procedure is rational if we can judge from the well-known fact that transplanted portions of other organs continue in their function, and the operative work is so easily carried out that it seems best to describe certain prac- tical points that make it easy, but which have had to be learned by experience. In transplanting ovary from one woman to another there is abundant opportunity in hospital practice where it is not difficult to arrange for operation upon two or more patients in the same hour, and one woman whose ovaries contain normal tissue can spare for the other woman a segment of ovary as large as a pea without suffering any real loss. The method which I have found to be best consists in removing from the normal ovary a seg- ment about as large as a pea and placing it in warm physiologi- cal saline solution, temporarily. The fundus of the uterus that is to receive this piece of ovary is then split transversely down to the lumen. The piece of ovary is introduced into the slit in the uterus in such a way that peritoneal surface of ovary will rest against endometrium of uterus and raw surface of ovary remains in contact with raw surface of uterus, and is fastened in place by a fine catgut suture that serves at the same time to partially close the slit in the uterus. Other sutures that are necessary for clos- ing the wound are introduced, and a drainage wick of gauze 156 Ovarian Transplantation. 157 is placed in the uterine canal leading out through the vagina into a receiving mass of gauze at the vulva. The fundus of the FlG. 66.—A.—Suture of slit through which graft was inserted. B.—Ovarian graft. C.—Drainage wick. i58 Notes. uterus that is to receive a graft is reached by way of an anterior abdominal incision or preferably by way of the vagina through a button-hole opening into Douglas' cut de sac. The fundus is readily turned down into the vagina, and after receiving the graft is turned back into the abdomen again, and the patient is then ready to get out of bed in two or three days. The gauze drain from the uterus is removed at the end of forty-eight hours after the operation and the case should require little further treatment. C Fig. 67—A.—Peritoneum of oviduct. B.—Muscularis. C.—Mucosa. D.—Lumen. E.—Segment of transplanted ovary. F.—Suture for holding segment of ovary. G.—Suture for keeping mucosa and serosa together. H.—Suture for closing end of oviduct. In cases in which the oviduct is chosen as the place for insert- ing an ovarian graft, it is difficult to find the lumen of the tube if the latter has been cut short, because the muscular sheath con- tracts and inverts margins of the mucous tube. Before attempt- ing to insert the graft in such a case it is best to pass a probe through the lumen of the oviduct into the uterus first and'then amputate the oviduct about the probe, suturing mucosa and peritoneum together at any one point in the circular cut before completing the division. This will prevent inversion of mucosa Ovarian Transplantation. 159 when the muscularis contracts and will allow us to keep the graft in contact with mucosa later so that ova can escape into the lumen of the oviduct. The next step consists in dilating the stump of oviduct up to the point of paralysis of its muscularis so that further work can be done more easily. The segment of ovary that is to be engrafted is then taken out of the warm saline solution and its raw surface is sutured with one strand of finest catgut to the raw surface of the oviduct in such a way that these two raw surfaces will adhere to each other and allow normal sur- face of ovary to project into the lumen of the oviduct when the final step is taken of closing the abdominal end of the oviduct. Some patients object to the idea of carrying a piece of ovary from another woman, as the child from such a case would have treble parentage, but there are many women whose uterine adnexa have been removed who grasp at any opportunity for bearing children, and whose minds are much relieved at the thought of the possibility of such a prospect. It is not improb- able.that menstruation and normal sexual impulse may continue in women who carry an ovarian graft, and I shall obtain full testimony bearing upon this point. INDEX. A Abdominal wall, repair of, log Abortion, prevented, 154 Abscess, 28, 29, 30, 63 Adhesion separation, 30, 63, 58 " bands, 30, 35 After treatment, appendicitis, 67 Appendicitis, definition, 16 " causes, 16 " occurrence, 34 catarrhal, 33 " nomenclature, 35 " aliases, 40 symptoms, 41, 42 structures involved, 17 Appendix, occurrence of, 10 " Jiistory, 11 " size and position, 11 " anatomy, 12 involution, 35 locating, 58 Aprons, 6 Aristol, 6, 60 Arm, conservative surgery of, 146 Arterial complications, 13, 24 1! Bacteria, of appendix, 15 " suicide of, 20 " odor of, 21 Blister grafting, 151 Boiled water, 5 Bow lines, 4 C Carious and necrotic bone, 123 Catgut, 3 Chemical antiseptics, 5 Circulation, interference, 18, ig Clavicle, dowel-pin, dislocation, 139 " " fracture, 140 Colic, 42 Compensatory hypertrophy, 33 Compression anemia, 8, g Concretions, 13, 39 Constipation and diarrhoea, 45 Cotton, 3 Culture tubes, 6, 7 I) Death rate, appendicitis, 36 Digestive ferments, 120 Dislocation of appendix, 25 Drainage apparatus, 3 " canal, 59 " capillary, 64, 66 wick, 115 E Eczematoid navel, 92 Embryonic remains, 92 Endarteritis, 25 Endoscopic tubes, 117 Evanescent scar, 60 Exudate, liquefaction of, 27, 30 F Fades, 45 Fat layers, union of, 61 Fat tests, 13, 14 Fibula, fractures, 136 Fistulce, plaster, 154 Fulgurant spasm, 44 l62 Index. G Gallstone solvents, 84 Gauze 2, 3 General abdominal pain, 42 General cleanliness, 1 Guy line, 55 H Hand sterilization, 1 Hare lip, 153 Hepatic abscess, 24 Hernia operation, 98 Hernia, post operative, 50 Hydrogen dioxide, 5, 63, 67 I Ileal intussusception, 100 Incision, 51-54, 56, 62 Infection, acute, effects, 17, 18, 20 " atrium, 17 " chronic, 20, 33 Instruments, sterilization, 2 Inversion of uterus, 155 Irrigating solutions, 5 Isolation of infected appendix, 36 L Leaving infected appendix, 28, 64 Ligatures, 3 List of appendix operations, 68 List of general operations, 8, g Localized pain, 45 Lymph, blocking, 23 Lymph exudate, 46 Lymphatitis, infective, 24 M Malignant disease, navel, 94 Mallet-finger, 143 McBurney's point, 43 Medical treatment, appendicitis, 37 Moist navel, 92 Muscular spasm, 19, 37, 43, 45 N Nasal septum, plastic, 153 Nausea and vomiting, 43 Nephritis, as complication, 31 Nerve complications, 26 Nervous dyspepsia, 40 Normal appendix, removal of, 38 O Objections to operation, 49 Omental rope, 31 Opium, 37, 38 Ovarian transplantation, 156 Ovaritis and appendicitis compared, 39 P Palpation of appendix, 43, 44 " the kidney, 107 Pendulum simile, 39 Perforation, 28 Peritoneum, aid given by, 27 Peritonitis, complicating, 26, 28 Phagocytosis, 19, 20 Phlebitis, 24, 26 Placental hemorrhage, 155 Pleuritis, complicating, 32 Pneumonitis, complicating, 32 Policy in operating, 39 Prevention of peritoneal adhesions, 105 Progress, recent, 37 Pulse, in appendicitis, 23, 44, 46 Pus in peritoneal cavity, 27 R Radius, subluxation, 132 Repair, time required for, 51 Respiration, 45 Reversed peristalsis, 58 Rhexis, 34 S Salol, 1 Scar testing, 52 Scars, 51, 62 Serum pressure, 17 Silk, 3 Skin, sterilization, 1 Sloughs, 24 Special cleanliness, 1 Index. 163 Sponges, 2 Stomach and rectal tubes, 67, 68 Stump, burial of, 59 fixation to abdominal wall, 59 " ligation of, 50 Supra-pubic urethra, 112 Sutures, 3 T Temperature in appendicitis, 22, 44, 46 Time spent in bed, 52, 67 Tonsil, flat and tubular, 17 Towels, 2 Toxines, effects of, 17, iS, 46 Treatment, appendicitis, surgical, 49 Trendelenburg's posture, 62 Tuberculosis, peritoneum, 102 Tubes, appendix, inner and outer, 17 Typical case, 42 U Ulceration of appendix, 25 Stanbarb flDcbical {Publications. 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