VOL. VI. [NEW SERIES.]

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else. — RUSKIN.

Original Articles.

A CASE OF LAPARO-COLOTOMY.*

BY DOUGLAS MORTON, A. M., M. D.
Consulting Gynecologist to the Louisville City Hospital.

Patient a negro woman, aged thirty, in the City Hospital for cancer of rectum of about two years' standing. At the time of the operation the gut was nearly closed by the growth, and there was a recto-vaginal fistula through which feces constantly pa-sed. There was much abdominal distension, which caused severe pain. She also suffered very acutely in the act of defecation through the rectum, and always wore an expression of anguish. Early in the summer I had removed the growth as much as possible with a curette, by which great though temporary relief was given. Though the case was too far advanced to expect much prolongation of life by opening the colon, I hoped the operation would materially lessen the patient's intense suffering.

Accordingly, on September 25th, with the valued assistance of Dr. Cartledge and of the resident staff, I did a colotomy through the abdominal wall. I made the incision in the left linea semi-lunaris, extending from the level of the umbilicus to that of the anterior superior spine of the ilium—about three inches in length. In order to considerably narrow the lumen of the gut at the opening, so that passage of feces into the pouch below might be prevented as much as possible, enough of the wall of the colon was drawn out to make a protuberance

*Read before the Louisville Medico-Chirurgical Society, October 19, 1888. For discussion see p. 296.

No. 10.

about an inch in height. To secure this in position it was transfixed with acupuncture needles which lay transversely upon the parietes. The protruding bowel was then sutured to the parietal opening. Pains were taken to have the visceral and parietal layers of peritoneum in broad contact.

The antiseptic used in the wound and upon the exposed peritoneum was a ten-volume solution of hydrogen peroxide. This was chosen because the operation was done in air of questionable purity, and I could in some measure compensate for this by enveloping the field of operation in an atmosphere well charged with nascent oxygen. This agent, moreover, by its powerful oxidizing action not only destroys germs, but decomposes any organic matter, as pus or blood, with which exposed tissues may be soiled, and renders its presence harmless as a medium for the development and multiplication of germ life. I have been using it in surgery for some months, and my experience, which includes one other laparotomy done recently under unfavorable conditions, inclines me to expect great things of it.

After forty-eight hours the knuckle of colon. was found thoroughly adherent, and this was opened by cutting out an elliptical section,

procedure in rectal cancer as well as in other conditions, it has never been held in favor in this city, having been done only once or twice, and never successfully before. It may, therefore, be considered a most appropriate subject for discussion by this Society, and I will add a very few remarks to the simple narration of the case in order to bring before you one or two questions that are important to the subject, and especially that as to the applicability of the operation in cases of rectal cancer.

On the question of danger attending the operation as done under present surgical methods, it is to be regretted that the most comprehensive and thoroughly analyzed statistics ever collected-those of Dr. W. R. Batt, published in the American Journal of Medical Sciences for October, 1884-do not throw much light, for in this collection of 351 cases, which includes that of Van Erckelens, published in Langenbeck's Archives in 1879, are gathered all cases recorded throughout the history of the operation, and it is not known how many were done under antiseptic precautions.

It is sufficient, however, for our purpose to state that the mortality in these 351 cases was 38 per cent, that the mortality after all operations for malignant disease was 30 per cent, Amussot's operations giving a mortality of 25 per cent and Littre's 45 per cent.

No large collection of cases, in which the operation was done since the era of antisepsis, has been made that I know of. Many cases have been published, however, and I would judge from the results in these that the antiseptic method has raised the standard of success fully as high in this as it has in any other field of surgery.

As to choice between the intra- and the retroperitoneal methods at present, Greig Smith, in the second edition of his "Abdominal Surgery," says "Laparo-colotomy is steadily and surely coming into favor, and properly so," and indeed it is difficult to see why this operation should be attended with more danger than an ovariotomy or an operation for removal of the uterine appendages without troublesome complication.

The feeling that has been quite generally entertained until recently in America toward

the operation is no doubt to be explained by the very strong expressions against it used by two at least of our leading authors in surgery.

The opposition of these authors was based, as will be seen, not less upon moral and esthetic grounds than those of attendant danger. Gross, in the third edition of his "System of Surgery," thinks it due his readers to apologize for even discussing the operation. He says that it is founded upon "misdirected sympathy," and that it "ought to be discarded as among the obsolete devices of surgery." He says, further: "When we consider the object for which an artificial anus is usually established, we are struck with astonishment . . . that any one possessed of the proper feelings of humanity should seriously advocate a procedure so fraught with danger and followed, if successful, by such disgusting results." Discussing the treatment of imperforate anus, he says: "Let the surgeon, if he be a parent, ask himself the question, whether he would not rather see his child die without an attempt at relief, than to place it in a condition that would inevitably render it an object of disgust to itself and of loathing to every one around."

Henry H. Smith, in his "Principles and Practice of Surgery," finishes his discussion of the operation with this remark, that "at first sight it would appear that this operation must evidently expose the patient to loss of life, and can at best prolong it only at the expense of a most loathsome condition. That the bowels may be thus opened is certainly an evidence of the efforts of the surgeon toward relieving the defects of nature, but the results are by no means positive that the operation can secure to the patient even a continuance of a miserable existence."

These expressions, if applied to the operation in its present status, would not only immensely exaggerate its danger, but unduly magnify also, its disgusting accompaniments. Enough has been said already of the danger. To the objections that are moral and esthetic, it is sufficient, I think, to reply that after making a clear statement of facts to the patient the surgeon has done his duty, and it is the right of the former to decide whether or not he will under

go the operation. If there be any, however, who entertain such strong feelings as those of Dr. Gross, they should remember that the value of a life is not always limited by conditions of bodily health and vigor, and that there are many who are bowed down by pain and infirmity, whose lives are yet very valuable by reason of the far-reaching beneficence with which they are filled.

But it is a point of much practical importance that the “disgusting results" of colotomy are really much less than Dr. Gross seemed to think, and less than some think now. Until her death, in the early part of the summer just past, I had under my observation for a good part of two years a most estimable lady, in whose case I had the privilege of seeing Dr. W. T. Bull do a la paro-colotomy for cancer of the colon in New York, in August, 1886. During this time I had frequent occasion to see her: sometimes while ill myself, sometimes while nursing some ill member of her family, and sometimes socially. The results of the operation never caused any suffering that I know of, and never seemed to be more than an inconvenience to her. She was not to any great extent debarred by them from her duties or pleasures as head of a peculiarly devoted family, or as a useful member of society. Any prejudice that I may have entertained against the operation. on the score of "disgusting results" has been effectually removed by my knowledge of the history of this case.

As testimony to the positively beneficial results of colotomy, Mr. Samuel Benton, of London, speaking before the Ninth International Congress at Washington with reference to the operation done for cancer, said, "By colotomy the patient's life is prolonged and the pain is immensely relieved." In the same discussion, Dr. Hamilton, of Columbus, maintaining that under certain conditions it is the surgeon's imperative duty to do the operation for cancer, spoke of a patient, in whose case it "gave relief from horrible torture, and added about twenty months to his life." Allingham, after having done the operation for cancer sixteen times, said he never had occasion to regret it in a single instance.

LOUISVILLE.

GRANULAR CONJUNCTIVITIS.*

BY W. CHEATHAM, M. D.

Lecturer on Diseases of the Eye, Ear, Throat, and Nose. University of Louisville, Attending Eye, Ear, and Throat Physician to the Masonic Widows and Orphans' Home and Infirmary of Kentucky.

The profession at large make no distinction. between a simple papillary hypertrophy of the conjunctiva and true granulation. That the true granulation (trachoma) seldom exists alone, makes the distinction more difficult. There is not much difference in the treatment of the two affections, yet pathologically, clinically, and in point of prognosis, they are entirely distinct. The anatomy of the conjunctiva must be understood to thoroughly differentiate the two affections.

The conjunctiva has an epithelial layer, which is cylindrical superficially, but deeper has a layer of flattened cells. There is a conjunctival tissue proper or supporting membrane, which is a fine reticulated structure, "which at the points where the meshes intersect, disclose numerous nuclei." " Very few elastic elements enter into this net-work, it being wholly occupied by masses of lymph-like cells, which give it an appearance not unlike that of the adenoid tissue of the intestinal mucous membrane." There is a subconjunctival tissue also everywhere except over the tarsal cartilage, which is made up of more open meshes of the conjunctival tissue proper with lymphoid cells in abundance, and partly of numerous elastic tissue fibers.

The papillæ are eminences and depressions made by the tarsal portion of the conjunctiva, which is thrown into pleats as it passes over the tarsal cartilage.

Waldeyer and other good authorities deny that the conjunctiva has any lymph follicles; just as good authorities say there are always follicles to be found in the culs-de-sac. Krause says, in the region of the culs-de-sac a series of acinous glands are found situated in the subconjunctival tissue which terminate on the epithelial layer by narrow excretory ducts.

An affection of the conjunctiva following acute catarrh and the suppurative inflammations of the conjunctiva, which is nothing but a chronic blennorrhea or hypertrophy of the

*Read before the McDowell Medical Society, Nov. 1, 1888.

normal papillæ of the conjunctiva, is improperly called granular conjunctivitis. A close examination of all such cases should be made, as it is quite possible to have this disease combined with true granulations, and the papillæ may be so hypertrophied as to completely hide them. But hypertrophy of the papillæ (which are nominal constituents of the conjunctiva) should not be confounded with a true granulation, which is a new formation entirely foreign to the conjunctiva naturally, by many said to be a specific disease, and consequently acquired by contagion only.

De Wecker says: "Granulation tissue in appearance so similar to that of the follicle or congested lymphatic comports itself very dif ferently. It lives and dies feeding on the parent that gave it life; it consumes the conjunctiva. A granulation is therefore a malignant product, while the ultimate elements of a follicular or purulent conjunctivitis are essentially benign. A granulation consists of a mass of lymph-like cells mingled with conjunctiva connective tissue in increased proportions as we proceed from the external surface to the base. A granulation differs from a follicle in its shape, which is oval rather than round, and never takes on the peculiar yellow tint peculiar to the follicle. Granulations differ in shape from the hypertrophied papilla. The papilla is more or less elongated and pedunculated. Hy pertrophied papillæ can only appear on those parts of the conjunctiva to which they are distributed. Granulations can and do appear even on the cornea."

There is another form of conjunctivitis given by some authors, known as follicular. Mittendorf speaks of it as follows: First, he says, true granular lids or trachoma is characterized by the presence of a special micrococcus and by the large number of lymph cells found in the conjunctiva. These cells accumulate in points, are elevated above the surface of the conjunctiva usually, or they may be hidden. by the hypertrophied papillæ, or thickened conjunctiva. When this condition takes on a blennorrheic form, and some of the cells are in the stroma, it is called the trachoma, and as a result we will have cicatricial tissue. If, however, there be an absence of the inflamma

tory symptoms, and the cells spoken of remain superficial, leaving the granules very prominent and easily seen, it is the follicular form.

Any thing that will produce any of the other forms of conjunctivitis predisposes to an attack of trachoma, for it is like fallowing the ground or preparing the soil for the reception of the seed or micrococcus. Bad lights, poor ventilation, dust, nasal catarrh, bad teeth, indigestion, errors of refraction, bad health in any form, all contribute to preparing the conjunctiva for trachoma. So the first thing in all inflammations of the conjunctiva is to find the cause, whether proximate or remote, and correct it.

Granulations may be quite small at first, but often grow rapidly, and rapidly increase in numbers; many may be run into one and produce a peculiar mass, this being the beginning of the third or cicatricial stage. It is possible to open the little granule and squeeze out its contents. This has been recommended by some as the proper treatment. Trachoma is of course contagious, but, like other contagious di-eases, the soil must be in good condition for the reception of the seed; and in this way can be explained why but few of the many exposed have the disease. From some unknown cause but very few negroes have trachoma. Their method of living, their hygienic surroundings, their exposure to cold, heat, light, dust, and many other of the well-known exciting causes of trachoma should render them by far more liable to the disease than the whites, yet a negro with trachoma is exceedingly rare. Now as to the treatment of this, which I consider the most obstinate and one of the most dangerous of the diseases of the eye with which we have to deal:

The treatment may extend through months or years. The patient should be advised of this. My list of local applications is as follows, and I give them as I rank them in importance: Cupri sulph., hydrarg. oxid. flav. ointment, argent nitratis, tannin and acid boric, ammon. muriate, squeezing the cells out to be followed by the above treatment, electrolysis, and chromic acid. The two latter may be objected to, on account of the danger of their increasing cicatricial tissue. I doubt if they do