I

without benefit. Admitting it to be a syphilitic involvement, other results than failure from such treatment are to be expected. The consultant has found thickening of the walls of the intestines. confess I could not. Again, I fail to see, admitting he has had syphilis, how the slightest connection has been established between his symptoms and syphilitic discase. At any rate I would take advantage of the doubt and put the man through a vigorous mixed treatment, and if I failed. with that I would give up the diagnosis of syphilis.

Dr. H. A. Cottell said: I know I can add but little to what has already been said in reference to this very interesting and at the same time very obscure case. I should be inclined to concur in the opinion of most of the speakers who have adopted the hypoth esis of syphilis. Excluding trauma and congenital deformity, as explaining the condition of the nose, a point is made in favor of syphilis. This is strengthened by any narrowing or stricture of the bowel in any part of its course. But I wish to speak especially of the specimens Dr. Mathews has presented. They might lead to a suspicion of syphilis in themselves. I have seen, from the bowel of old syphilitics, exfoliated masses which showed organization, epithelial cells, and embryonic elements. One of these would seem to be a mass of fibrine; the other is mucous or perhaps pus passed in the presence of an alkaline urine. But what association can this have with the condition of the bowel described? But one that I can see, and that is, that in narrowing of the sigmoid flexure the accumulation of fecal matter which may have taken place above has impinged upon the kidney pelvis, and by pressure has set up inflammation.

It seems strange that the patient has passed such specimens with the urine, and still no pus has been found. Still, he might have trouble in the kidney pelvis not manifest in all specimens of the urine. I have noticed cases of that kind; one I now call to mind, a woman who has pyelo-nephritis.

The diagnosis from the clinical history and the derivatives in the urine is quite clear. At one examination the urine will present tube casts and albumen, at another they are absent. If such a condition exists here, the case could be cleared up only by an examination of the urine week after week for a considerable period.

Is

Dr. Cecil, continuing his remarks, said: It would appear, from the remarks that have preceded, that a diagnosis would be best, and most accurately reached in this case by exclusion, and I think almost every possible cause has in this discussion been excluded, except that which is generally concurred in. Dr. Mathews says he can not understand why narrowing of the gut is not attended by pus, blood, or mucus in the discharges. it not possible that this man may have had ulceration, attended by such discharges at one time, and under the influence of antisyphilitic treatment recovered to such extent that he now has cicatricial contraction? The paroxysms of pain in his case could be explained by the ordinary motions of the bowels. The contents of the bowel moving down till opposed by the stricture would suddenly cause spasm of the bowel or sudden beginning of pain, which under the influence of an anodyne would gradually pass away at a variable length of time. gard to the history of syphilis, the fact that he has had no secondary symptoms I should regard as of no value whatever. I should proceed to the thorough saturation of this man with the mixed treatment, for I believe there are many cases of this kind that do not get the good effect from either the mercury or the iodide alone that they do get from the two combined.

In re

Dr. Bloom asked that neuralgia be not overlooked in the consideration of the pain. Dr. Satterwhite, resuming, said: This case is the more interesting as adding one to that class in which the ordinary phenomena of syphilis, after the occurrence of the initial sore, is far from regular. It calls to my mind the case of a young railroad clerk in this city, who, after having the initial sore, passed over the secondary symptoms en

tirely, to be later affected by severe pain in the head. He was finally confined to his bed, and was regarded as fast approaching imbecility, if not death. He was placed on large doses of iodide of potash, 3iss a day, and recovered. He is now a useful member of society.

Dr. Ouchterlony said: There are two points in the case that especially interest me, viz., the subjective and the objective symptoms. The first is of course the pain. We know very well that neuralgia, due to a permanent condition, is not necessarily a permanent pain. An organic disease of the nerves is attended often enough by neural: ia that is paroxysmal, yet the morbid state is there all the time. Some of the worst forms, due to injury of the nerves, as in those cases about the wrist where the nerves have been partially cut across by pieces of glass or other means of violence, are attended by most violent paroxysms. Another instance is the inclosure in the stump of an amputated limb of nerve fibers in a mass of cicatricial tissue giving rise to violent paroxysms of pain in the nerves. So we can very well understand, it seems to me, that there may be a permanent morbid condition of the parts, and yet only paroxysmal attacks of pain in consequence. Then, again, the man is now practically an opium-eater, and we know very well that when the effect of the dose wears off the patient suffers all sorts of uncomfortable sensations, so it is difficult to say how much of the pain is due to the disease and how much to the wretchedness consequent to the cessation of the effect of the drug.

Secondly: In cases of disease of the sigmoid flexure the induration or neoplasm sometimes disappears; it may not be felt at all and yet be there. This is a very movable part of the intestine, and the Fellows examining this man may not have discovered what certainly exists there, viz., an increase in volume and resistance at that point; even while conducting the examination I have noticed this to slip away.

We can not well overestimate the importance of the fact that the bowel is always

empty. If that does not indicate that there is an obstruction somewhere above, what can it mean? I would like to ask the opinion of the gentlemen present as to the likeli hood of malignancy, and whether malignant degeneration ever takes place in syphilitic neoplasmata, and with what frequency?

Dr. Mathews, concluding, said: I heard a distinguished English surgeon say once that he had much rather meet with a case of cancer than syphilitic ulceration of the rectum. I asked him his reason for the declaration, when he replied: "In cancer the victims die early; syphilitic ulceration is never curable, and the unfortunate subject of it may go on through a comparatively long life in great distress."

Fourteen years in the special practice has taught me that syphilitic stricture of the rectum is never curable. I have studied such cases for months, and treated cases for periods of a year or more, and I have never yet seen the least diminution whatsoever in the syphilitic deposit in the gut. If this be true of the rectum, the same applies with equal force to the sigmoid flexure. The process of involvement is the same; beginning as a neoplasm, contraction occurs in the course of time, and stricture results.

I see no reason to think that because a man suffers from syphilis he can not suffer from neuralgia also. Finally, the question just comes down to this-what shall we do to relieve the man? Shall we abandon a man to his fate at forty-six and admit we can do him no good? It seems to be settled that antisyphilitic treatment will avail nothing, and I could almost think with Dr. Bloom that the trouble might be otherwise than syphilitic.

Dr. Bloom referred to a case of carcinoma following syphilitic deposit, reported about two years ago. (Reported stenographically by H. A. Kelch, M. D.)

ONE-HALF-PER-CENT Solutions of creolin are becoming popular for vaginal injections, for washing out the bladder, and as injections in dysentery.

LOUISVILLE SURGICAL SOCIETY.

Stated Meeting, December 5, 1889, Vice-President J. M. Mathews, M. D., in the chair.

Dr. W. O. Roberts reported a case of compound fracture of both thighs, occurring on the 3d of June last. The wounds were washed and drainage was provided for; sufficient padding and plaster were put on over an absorbent dressing. No tube was used. One washing with a 1-2,000 bichloride solution salivated the patient. The plaster was left on nearly seven weeks. On removal of dressing I found some motion in left limb; the condyle having been split, motion in the knee was limited. There was fine motion in right limb.

Dr. Ap Morgan Vance said the objection of patients to amputation and antiseptic surgery have saved of late many a limb. Ho thinks that electricity and massage will restore the function of the limbs in such cases.

He

Dr. Turner Anderson showed a urethral calculus from a boy two years old. There were no symptoms of vesical calculus. first saw the child in his father's arms, and suffering great pain. The most urgent symptom was inability to urinate. Palpation revealed a calculus just back of the head of the penis. The doctor dilated the prepuce, and then the orifice of the urethra, under chloroform, and removed the calculus. The bladder was much distended. After coming out from chloroform the boy got an enema of warm water. Bowels and bladder were freely evacuated.

Dr. Vance had seen one similar case.

Dr. Grant had seen two. In one the patient was nine years old; under chloroform the stone was removed with forceps. Most writers say that urethral calculi occur very infrequently. Dr. Grant thinks they are formed in the bladder, and their infrequency is due to their being washed out by urine.

Dr. Roberts saw a case of calculus in a negro child who had not passed urine in twelve hours. A catheter found obstruction far back in the urethra. By means of a metal catheter he felt the stone and pushed it back.

The child urinated at once. Не came

the stone could not be found. The speaker has operated several times in similar cases in children. Once he had to split the urethra.

The essay of the evening was read by Dr. H. H. Grant; subject, Resection of the Hipjoint for Tuberculous Coxitis. (See p. 65.)

DISCUSSION.

Dr. Roberts said: The question of resection had been sufficiently discussed. In the stage of abscess he favors it, and where there is disease of the bone' and cartilages. such cases, if neglected, the disease will go to an extent necessitating amputation. When the deposit is in the lungs no good will come from the operation.

Dr. Vance said: Resection has gained favor as antiseptic measures have improved. He favors operative procedure where suppuration has occurred, and where there is diseased bone present, but by early expectant treatment many cases may be cured. The speaker once resected in a case and got restoration of the bone; the periosteum was good, but the whole femur was tuberculous. Whitehead alone advocates forcible movement of tuberculous joints. It opens up fresh absorbent surfaces and incites general trouble.

Dr. John G. Cecil thinks that manipulation is specially objectionable. No treatment is as good as excision when the disease is not extensive. He has seen curetting and scraping do good when the disease was extensive.

Dr. Grant, closing discussion, said: Operation by removing source of possible general infection is desirable. Irrigation and cleanliness are paramount. Some authorities say disturbance of the local disease favors general infection. Cases constitutionally affected improve rapidly after operation. Phelps says that diathesis is not present as a rule. The disease in most cases is a purely local tuberculosis. Better open and remove the diseased bone than to attempt by irrigation and scraping to cure.

Laparotomy four hours after shot; four large wounds of ileum were found; temperature 99°, pulse 90, and full. Patient began to sink in twenty-four hours. He died fortyfour hours after operation, pulseless. He died of hemorrhage into the bowels from an overlooked vessel. He vomited considerable blood. The Lembert continuous suture was used. Nice apposition of parts was secured. But for the failure to find the one vessel the speaker believes the case would have been successful. Dr. Vance had resected the gut in dogs with perfect success.

Dr. Cecil said that the getting at these wounds generally required large openings. If we can keep the gut inside a small opening and yet be sure we have all points of injury exposed, results would be better. He thinks Dr. Vance should have made Senn's test, a dependence on washing not being enough.

Dr. Vance: After forty-eight hours, if any wound be left, we would have had distension and peritonitis.

Dr. Roberts advocates a free opening so as to examine all viscera. The wound should be low enough to drain well. He once had a case which died in four days in delirium tremens. The post-mortem showed dark blood in the pelvis. The tubes won't do for drainage.

Dr. Vance agrees about size of opening. His cut was below the umbilicus. There was no blood in the urine; the wound was too low to involve the kidney. The abdomen was tight. On opening it the guts crowded out; it took rough handling to get them back. Finding all wounds close together, he felt his man had the better chance to get well by not making a larger incision.

Dr. W. L. Rodman reported the case of a peddler who had been cut ear to ear, and stabbed twice in the abdomen. He saw the patient seven hours after the accident. He got hydrogen gas; made Senu's test; was able to light ten or twelve matches. He resected the omentum that protruded, closed the intestinal wounds, and sent the man to the ward. He is now doing well. The man in addition to the wounding was badly burned,

which accounted for a considerable temperature rise. No adverse abdominal symptoms developed. He is hungry all the time. Dr. Rodman is much pleased with Senn's test. He got the gas in twenty minutes after he ordered it. In order to get at the intestinal wound he pushed the omentum out of the way with the forceps. Next time he will put a tube into the wound.

Abstracts and Selections.

THE TREATMENT OF APPENDICITIS BY EARLY LAPAROTOMY.-Dr. Senn, of Milwaukee, in a paper published in the Journal of the American Medical Association, November 2, 1889, and Dr. McBurney, of New York, in a paper read before the New York Surgical Society November 13, 1889, make contributions to the subject of the successful treatment of appendicitis which indicate that the advance in the management of affections of the appendix, proposed by Treves in the early part of the present year (Lancet, February 9, 1889), has taken a permanent place in surgical endeavor, with much promise of advantage in future attempts to control this so often fatal affection. Both surgeons call attention to the fact that the primary and essential condition present in the cases of so-called typhlitis, perityphlitis, or paratyphlitis is an affection of the ver miform appendix, inflammatory or ulcerative, with tender cy to perforation or gangrene. Dr. McBurney would elide from the medical vocabulary these hitherto commonly used terms, and would substitute for them simply the term appendicitis, as more correct pathologically and less likely to obscure the indications for treatment. He clearly states the dictum that all this class of cases are intra-peritoneal in their origin and throughout their course, and urges an early resort to ablation of the diseased appendix as a comparatively safe method of preventing the development of more redoubtable symptoms. Dr. Senn calls attention to the fact that in many cases the development of so-called perityphlitis is preceded by a well marked complexus of symptoms pointing directly to the existence of appendicitis. Repeatedly recurring attacks. of pain, tenderness and induration in the region of the appendix, indicative of the presence of chronic disease thereof with occasional exacerbations, are especially to be regarded as warnings of impending danger.

If the condition is recognized before dangerous complications have developed from perforation and general septic infection, he also recommends extirpation of the appendix, assuming that it can be done at this early date with comparative ease and almost perfect safety. Dr. Senn recites two cases in which this practice has been resorted to, once by himself and once by Dr. Hoegh, of Minneapolis, at his suggestion. In both

cases there was a history of repeated previous attacks of the local symptoms recognized as indicating the presence of appendicitis. In both the appendix was removed with facility, and uninterrupted recovery was secured. In both the mucous lining of the organ was deeply ulcerated. Dr. McBurney relates eight cases in which he has done laparotomy and excision of the appendix upon patients who presented wellmarked symptoms of appendicitis, prior to any development of symptoms of perforation. All recovered without unfavorable symptom except one who died. The latter case was one in which the appendix was buried in a mass of inflammatory exudate demanding for its complete removal an amount of violence, exposure, and handling of the parts that provoked the fatal result. The author in another such case would be content to leave the organ in situ after making provision for drainage.

Chronic appendicitis is characterized by acute exacerbations of short duration, the attack, of greater or less severity, occurring at intervals of a few months or weeks. Between the attacks the patient may be in perfect health, unless the attacks recur with great frequency, when impairment of the digestive functions produces general ill health. According to Senn, recurring attacks of pain in the region of the appendix with a circumscribed area of tenderness over the same point are presumptive evidences of the existence of appendicitis, and if the other symptoms and signs point in the same direction laparotomy is indicated.

As a matter of course, the strictest asepsis is presupposed in the conduct of the operations recommended. The incision should be directly over the center of the cecum, about four inches long, extending to within one inch of Poupart's ligament. The peritoneal cavity having been opened, a compress should be packed about the cecum, so as to prevent prolapse of the small intestine; in some cases the appendix will come into sight at once, in others it will have to be sought for; the raising of the lower margin of the cecum generally will suffice to

expose it. The mesentery of the appendix is next to be ligated in sections as far as to the cecum; adhesions, if present, are to be separated, and bleeding points tied; finally, the isolated appendix is tied around its base close to the cecum with silk, and the organ cut away about one quarter of a inch below the ligature.

As to the treatment of the stump, Senn recommends first, that it be carefully disinfected, then that it be dusted with iodoform, and finally, that it be shut in by drawing the adjacent serous surfaces of the cecum over it and securing them with a number of Lembert's sutures. Drainage in these cases is unnecessary.

In corroboration of these views of Treves and Senn, Baldy, of Philadelphia, has recently published (Medical News, November 23, 1889) an account of three cases in which, having done laparotomy for diseases of the uterine appendages, he found also the appendix so diseased as to call for its excision. In each case good recovery ensued with subsequent good health.

Notwithstanding these cases of Senn and McBurney, the indisputable soundness of their pathology and the brilliant success of their own efforts, it ought not to be forgotten, nor will it be when the final judgment of the profession is made up, that by far the greater portion of cases of acute appendicitis, those which have been hitherto classed as typhlitis or perityphlitis, recover spontaneously and permanently without suppuration, at least without intra-peritoneal suppuration. The cases classed by Senn as chronic appendicitis form a group by themselves; spontaneous and permanent recov ery, however, from this condition is also not infrequent. A very grave responsibility, therefore, must attach to the surgeon in any given case in deciding upon laparotomy and excision of the appendix. It is evident that at present, at least, it could only be proper for one who was a perfect master of aspetic abdominal technique to offer such a procedure as less dangerous than the policy of delay and palliation. It is doubtless true that if, in all cases in which there were present symptoms pointing to trouble with the appendix, the abdomen should be opened immediately and the appendix excised; the occurrence of immediate perforation would be anticipated in some cases, the production of general peritonitis would be prevented, and lives would be saved; on the other hand, many would be subjected to the hazards of laparotomy and excision in which there was no danger of perfora