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THE 
 
 Profit and Loss Account of 
 Modern Medicine 
 
 AND 
 
 OTHER PAPERS 
 
 BY 
 STUART McGUIRE, M.D., F.A.C.S. 
 
 Profestor of Surgery, Medical College of Virginia; Surgeon in charge 
 St. Luke's Hospital; Visiting Surgeon, Memorial Hospital; Ex- 
 President of the Richmond Academy of Medicine and Surgery, 
 of the Medical Society of Virginia, of the Tri-State Medical 
 Association of Virginia and the Carolinas, of the South- 
 em Surgical and Gynecological Association, of the 
 Southern Medical Association, Etc. 
 
 ILLUSTRATED 
 
 RICHMOND. VIRGINIA 
 L. H. JENKINS, Publisher 
 1915 
 

 
Preface or Apology 
 
 Having occasion to refer to a paper I had written 
 several years ago, I was unable to find a reprint of it, 
 or the issue of the journal in which it appeared. 
 
 This led to an effort to secure a copy of all the 
 articles I had published and to put the collection in shape 
 for personal reference. 
 
 The possession of the material in concrete form sug- 
 gested the possibility of making it into a book, and this 
 at first rather vague idea finally became a desire so strong 
 that I determined to gratify it. In indulging myself I 
 have tried to show consideration for my prospective 
 reader by not printing all I have written. 
 
 The various papers have been arranged with refer- 
 ence to the subjects treated rather than the date at which 
 they appeared. 
 
 While I have serious misgivings as to the merit of 
 the volume, I have no doubts as to the extent of its circu- 
 lation, for it is intended for private distribution and will 
 not be offered for sale. 
 
 Stuart McGuire. 
 
 Richmond, Va., May, 191 5. 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/profitlossaccounOOmcgu 
 
CONTENTS 
 
 The Profit and Loss Account of Modern Medicine 7 
 
 Latent and Active Neurasthenia in Its Relation to Surgery 31 
 
 Evolution of the Treatment of Ectopic Pregnancy 49 
 
 Cornual Pregnancy with Report of a Case 61 
 
 Tradition Versus Embryology in Congenital Malformation 67 
 
 Treatment of Diffuse Suppurative Peritonitis 79 
 
 The Surgical Treatment of Dyspepsia 87 
 
 Analysis of the Last Five Hundred Cases of Appendicitis 
 
 Operated on at St. Luke's Hospital 95 
 
 Some Accepted Facts and Mooted Points in the Manage- 
 ment of Appendicitis 107 
 
 Appendicostomy 119 
 
 Pylorospasm 129 
 
 Etiology and Symptomatology of Gall Stones 133 
 
 Diagnosis and Treatment of Gall Stones 143 
 
 Analysis of the Last Fifty Cases of Goitre Operated on 
 
 at St. Luke's Hospital 153 
 
 The Thyroid and Hyperthyroidism 165 
 
 The Diagnosis and Treatment of Hypothyroidism 191 
 
 The Influence of the General Condition of the Patient 
 
 on the Result of a Surgical Operation 197 
 
 Surgical Shock 213 
 
 Sulphate of Spartine in Surgical Practice 229 
 
 The After Care of a Surgical Patient 233 
 
 Past, Present and Future of Cancer 245 
 
 Methods to Hasten Epidermization With Special Reference 
 
 to Skin Grafting 265 
 
 To Cut or Crush in Stone of the Urinary Bladder 277 
 
 Extra Peritoneal Implantation of the Ureters into the 
 
 Rectum in a Case of Exstrophy of the Bladder 285 
 
 Intestinal Obstruction from Meckel's Diverticulum 291 
 
 Obstruction of the Esophagus with Report of Illustra- 
 tive Cases 295 
 
 Diaphragmatic Hernia with Report of a Case 305 
 
ILLUSTRATIONS 
 
 opposit:!? 
 
 PAGE 
 
 Fig. 1. Photograph of Patient with Three Legs 69 
 
 Fig. 2. X-Ray of Knee Joint 71 
 
 Fig. 3. X-Ray of Foot 73 
 
 Fig. 4. Bed Elevator 81 
 
 Fig. 5. Bed Seat 83 
 
 Fig. 6. Bed in Moderate Elevation 85 
 
 Fig. 7. Specimens of Stones Showing Foreign Bodies 
 
 as Nuclei 283 
 
 Fig. 8. Catheterization of Ureters and Beginning Sepa- 
 ration of the Bladder 287 
 
 Fig. 9. The Bladder Separated and Rectum Exposed.... 289 
 
 Fig. 10. The Rectum Opened Ready for the Transplanta- 
 tion of the Bladder 293 
 
 Fig. 11. The Transplantation Completed 295 
 
 Fig. 12. Obstruction of Esophagus Caused by Cardio- 
 spasm 301 
 
 Fig. 13. Obstruction of Esophagus Due to Stricture; the 
 
 Result of Typhoid Fever 305 
 
 Fig. 14. Obstruction of Esophagus Caused by Cancer of 
 
 the Cardia 307 
 
 Fig. 15. X-Ray of First Case of Diaphragmatic Hernia 
 Before Operation Showing Stomach in Left Thoracic 
 Cavity 311 
 
 Fig. 16. X-Ray of Second Case of Diaphragmatic Hernia 
 Before Operation Showing Stomach in Left Thoracic 
 Cavity 313 
 
 Fig. 17. Incision in Operation by Thoracic Route for 
 
 Diaphragmatic Hernia 315 
 
The Profit and Loss Account of 
 Modern Medicine * 
 
 Mr. Chairman, Fellows of the Southern Medical Asso- 
 ciation, Ladies and Gentlemen : 
 
 My first duty is to repeat my thanks which I fear were 
 but poorly expressed at the time of my election in Lex- 
 ington, Kentucky, as President of the Southern Medical 
 Association. 
 
 To be chosen to preside over a body of more than 
 three thousand men, representing the best element of the 
 medical profession in the sixteen Southern States, is a 
 trust and honor that causes mingled feelings of humility 
 and pride. No one elected to the position I occupy could 
 believe himself worthy, and no one could fail to be 
 proud of his good fortune. 
 
 It is especially pleasing to preside at a session of the 
 Association held in my own city, and to be one of many 
 to bid you welcome to Richmond and to Virginia. 
 
 The subject of my address is "The Profit and Loss 
 Account of Modern Medicine." Wonderful progress has 
 been made in medicine during recent years, but the profit 
 has been attended by loss, which must be considered in 
 balancing the account. In taking stock of the gain we 
 will find inspiration for the future; in counting the cost 
 we may guard against the undue sacrifices of the past. 
 
 * Address at the meeting of the Southern Medical Association, 
 Richmond, Va., November, 1914. 
 
 7 
 
THE PROFIT AND LOSS ACCOUNT OF 
 
 Modern Medical Education. 
 
 The most distinct profit and loss in modern medicine 
 have come about through changes in medical education, 
 which have been accomplished largely through the ef- 
 forts of the American Medical Association, the Asso- 
 ciation of Amierican Medical Colleges, and the Carnegie 
 Foundation for the Advancement of Teaching. 
 
 It was recognized that each year a progressively in- 
 creasing number of low grade practitioners were being 
 graduated by medical colleges and licensed by State gov- 
 ernments. An investigation of the medical schools 
 showed that many of them were poorly equipped, had 
 scant clinical material and lacked sufficient funds to se- 
 cure the necessary time of efficient teachers. 
 
 To remedy this evil a deliberate and systematic move- 
 ment was inaugurated to lessen the number and improve 
 the quality of the men who are being added to the ranks 
 of the profession. By moral suasion, by State legisla- 
 tion and by the combined efforts of the better schools, the 
 entrance requiremients were advanced, the number and 
 length of the teaching sessions were increased, the char- 
 acter and scope of the curricula were improved, and 
 the minimum number and approximate pay of the full 
 time teachers were specified. 
 
 The result of th's movement has been that in the last 
 ten years the total number of medical schools in the 
 United States has been reduced from i86 to loi and 
 the total number of medical students from 28,142 to 
 16,502. In other words, 85 medical schools, weak either 
 educationally or financially, have ceased to teach, and 
 over 10,000 medical students not properly qualified for 
 
 8 
 
MODERN MEDICINE 
 
 the profession have ceased to study. And the end is not 
 yet. 
 
 In no section of the country has this campaign been 
 more effective than in our own. The Council of the 
 Amierican Medical Association, in its last report said : 
 "The most serious problems of medical education are 
 no longer to be found in the South, but rather in some 
 of the large cities of the East and North." 
 
 The benefit of this movement is already markedly seen 
 in the medical colleges, where the qualifications of the 
 student are found improved and the character of the 
 instruction more satisfactory. A medical student now 
 begins his studies with a knowledge of the elementary 
 sciences. He it taught the fundamental medical facts in 
 laboratory and dissecting hall by trained instructors who 
 give their entire time to the work. When he comes to 
 study disease, it is disease in people, not in books. He 
 is brought to the bedside of the patient and encouraged 
 to observe, to weigh and to decide. The new idea in 
 teaching tends to make of the student an active investi- 
 gator instead of a passive hearer, and of the teacher a 
 sympathetic guide rather than a verbose expositor. 
 
 There has not yet been time for the benefit of the 
 change to be very apparent in actual practice, but the 
 lessened number and improved quality of the graduates 
 turned out each year will unquestionably in the end re- 
 sult in a great improvement in the ethics and efficiency 
 of the profession. 
 
 The profit, however, has not been without its loss, 
 and while we congratulate ourselves on what has been 
 gained by this educational movement, it is only just to 
 
 9 
 
THE PROFIT AND LOSS ACCOUNT OF 
 
 count what it has cost. Many worthy although struggling 
 colleges have been put out of existence and their prop- 
 erty practically confiscated, and many earnest and promis- 
 ing young men have been denied an opportunity to study 
 medicine because of some defect in their preliminary 
 high-school or college education. Again the modern medi- 
 cal school is not self-supporting and is a heavy financial 
 tax on public funds or private philanthropy. Expensive 
 laboratories, salaries of full time instructors and the 
 necessary provisions for clinical teaching, impose a cost 
 that can never again be met by tuition fees. Each matri- 
 culate is an added burden, and the school of today finds 
 itself in a vicious circle; the better it teaches the more 
 students it gets, the more students it gets the more 
 money it loses. If each student were charged what 
 it actually cost to teach him, none but the rich could af- 
 ford to study medicine. Doctors are a necessity, not a 
 luxury, and as the rich do not care to become doctors, 
 then the rich in the future will have to be educated to 
 contribute of their wealth to make doctors. Medical edu- 
 cation has ceased to be a business and become a philan- 
 thropic work which must be supported by State appro- 
 priations and individual benefactions. 
 
 Finally, the cost of the modern method of teaching is 
 seen in the graduate himself. If he has not paid in 
 money he has been made to pay in time for his edu- 
 cation. He has been kept in laboratory, lecture hall and 
 hospital ward, a non-producer, dependent on others for 
 his support, until he reaches an age at which most of 
 his contemporaries are married and settled in life. He 
 is conscious of the sacrifice he has made, and usually 
 over appreciative of the attainments he has acquired. 
 
 10 
 
MODERN MEDICINE 
 
 He desires to be a specialist, and will only do general 
 practice as a means to an end. He is determined to 
 locate in a city and unwilling to settle in the country, 
 preferring to starve himself in the one rather than to 
 starve his ambitions in the other. 
 
 This results in an urban congestion and rural deple- 
 tion of medical men which has reached a point to give 
 serious concern, and for which some remedy must be 
 found. It has been proposed that special medical schools 
 be operated to produce low-grade practitioners for coun- 
 try consumption, but this is impracticable and unthink- 
 able. 
 
 The remedy for the evil is to make country practice 
 less arduous and more profitable, and this will come 
 about in time with the evolution of our social, economic 
 and political life. When we compare the conditions that 
 exist in the country today with those which existed 
 even twenty years ago, and recall the changes that have 
 resulted from the good-roads movement, the development 
 of the automobile, the installation of telephones, the in- 
 troduction of parcel post and rural mail delivery, the im- 
 provement of the public school system, the perfection of 
 heating and lighting plants and the invention of labor 
 saving machinery, it is not difficult to believe that in the 
 not far distant future, the increased population due to 
 emigration of health and pleasure seekers from the city, 
 and the increased prosperity due to intensified and scien- 
 tific farming, will make the life of the country doctor 
 one that will attract and hold the best representatives of 
 the profession. 
 
 Having considered the profit and loss account of 
 modern medical education, we now come to what we have 
 
 II 
 
THE PROFIT AND LOSS ACCOUNT OF 
 
 gained and lost in the doctor himself. The physician of 
 the old school was usually a gentleman by birth and breed- 
 ing. He was given a classical education not because of 
 his future profession, but because it was a privilege ac- 
 corded his brothers as well as himself, without refer- 
 ence to their future vocations in life. His preparation 
 for practice consisted in reading medicine for a few 
 months in a preceptor's office and then attending lectures 
 for one or two years at a medical college. His very lack 
 of technical training gave him independence and resource- 
 fulness, and with experience he gained an ability to make 
 a diagnosis by intuition and to apply treatment, which, 
 while often empirical was usually effective. He was no 
 specialist, but attended every member of a household, 
 because a family was a unit and his art was catholic. 
 He knew the constitution of his patient because neigh- 
 bor married neighbor and lived where they were born. 
 He was not only physician but friend, confidant and 
 counsellor as well. In his personal affairs he was un- 
 business-like, rarely sending bills and accepting such hon- 
 oraria as were tendered him in settlement of his accounts. 
 In public affairs he was prominent and his views and 
 opinions had weight in matters of church and State. He 
 had his weaknesses and his faults. Measured by modern 
 standards he was ignorant and sometimes mischievous, 
 but he served well his day and generation and was a 
 most lovable old aristocrat. 
 
 The modern medical man begins to be trained for his 
 profession while yet a boy. His preliminary education 
 in high-school and college is scientific rather than classi- 
 cal, and gives him knowledge rather than culture. When 
 he completes his four year's course in a medical college 
 
 12 
 
MODERN MEDICINE 
 
 1/ 
 
 and one year post-gradnate work in a hospital, he repre- 
 sents an investment of time and money covering a period 
 of from fourteen to sixteen years. He is no longer a 
 boy, but an eminently practical man, and he regards his 
 calling as more a business than a profession. He recog- 
 nizes the fact that he lives in an age of specialization, 
 that no one man can now meet all the professional needs 
 of a patient, and that the day of the domination of the 
 family physician, on the one hand, and the dependence 
 of the family on the other, has passed. He understands 
 that with the freedom now customary of choosing differ- 
 ent attendants to treat separate ailments, the factors of 
 social position, family connection, and even personal 
 
 friendship count for little, but that a doctor is employed 
 because he is believed to be the most efficient man avail- 
 able to relieve the patient or cure the disease. He recog- 
 nizes the necessity of sobriety, industry, honesty and 
 clean living, but he also knows that the public no longer 
 measures experience by age, virtue by matrimony, or 
 morality by affiliation with the Church, and that the first 
 and last prerequisite for success is professional ability. 
 
 Such being the situation with which he has to deal the 
 modern medical man early chooses a special line of work, 
 and devotes every effort and utilizes every opportunity to 
 perfect himself and impress the community with his pro- 
 ficiency. His attitude to the public has changed, and he 
 no longer cloaks his reasons in secrecy or his actions in 
 mystery, but deals frankly with his patients, explains 
 cause and effect, and secures their co-operation in car- 
 rying out treatment. The modern doctor has discarded 
 the silk hat and frock coat of his predecessor and put 
 on the sack suit of the business man. In a sense he has 
 
 13 
 
THE PROFIT AND LOSS ACCOUNT OF 
 
 become commercial. His offices are not only provided 
 with instruments of diagnostic precision, but also with 
 modern methods of keeping accounts and collecting fees. 
 From the foregoing crude pen picture must be in- 
 ferred what has been the profit and what the loss to the 
 public and to the profession from the modern doctor. 
 We have lost a character dear to literature, and gained 
 a type, perhaps less ethical and more mercenary, but 
 which is certainly a scientific instrument of greater pro- 
 fessional efficiency. 
 
 The Modern Specialist. 
 
 The development of the modern specialist is a source 
 of both profit and loss to medicine. The profit is too 
 apparent to need emphasis. The specialist, by concen- 
 tration of study and limitation of practice to certain defi- 
 nite organs or diseases, is able in a few years to acquire 
 greater diagnostic skill and more successful methods of 
 treatment in his special line of work than another man 
 of equal ability would obtain in a lifetime of general 
 practice. 
 
 The presence of a specialist in a community not only 
 gives to patients suflFering with certain diseases oppor- 
 tunities for efficient treatment, but also offers to the sur- 
 geon and general practitioner a consultant whose opinion 
 and advice are often invaluable in the determination of the 
 cause of obscure symptoms, and in the decision as to the 
 therapeutic treatment or operative intervention most like- 
 ly to effect a cure. While the profit side of the special- 
 ists account is large, still on the opposite page we find 
 some items of loss. The high esteem in w^hich the special- 
 ist is held, the pecuniary rewards which his services com- 
 
 14 
 
MODERN MEDICINE 
 
 mand and the advertising opportunities offered by his 
 position, have made him a victim of imitators and im- 
 postors, both inside and outside the pale of the profes- 
 sion, who deceive and defraud the pubHc. Modern medi- 
 cine is not responsible for the quacks and charlatans, but 
 it is responsible for the members of the regular profes- 
 sion found in every town and city who claim to be 
 specialists, but who really do a general practice, and for 
 others who, while they may limit their work to certain 
 diseases, are not qualified as experts, and have no more 
 knowledge or experience in their diagnosis and treatment 
 than the average general practitioner. 
 ^^ Again the specialist, although an expert, is often nar- 
 row in his views and prejudiced in his opinions, so that 
 he finds explanation for every symptom in the derange- 
 ment of the organs he treats. His patients often suffer 
 from_special attention and general neglect. Motes are 
 pulled out of the eyes and beams are left in the belly, or 
 the abdomen is invaded for real or supposed appendi- 
 citis and the lungs are left to fight their own battle with 
 tuberculosis. 
 
 Finally, the specialist is an expensive friend of both 
 the patient and the general profession. It is an every- 
 day experience for the surgeon or general practitioner to 
 send an obscure case, first to the pathologist for the ex- 
 amination of his blood, urine, sputum, feces or stomach 
 contents, then perhaps in turn to the roentgenologist, the 
 cystoscopist, the ophthalmologist and the dermatologist. 
 V The patient goes the rounds submitting his anatomy and 
 [ functions to exhaustive examinations and reports, and his 
 I pocketbook to depletion. The system is not essentially 
 wrong. Unquestionably the patient is better cared for 
 
 15 
 
^ 
 
 } 
 
 THE PROFIT AND LOSS ACCOUNT OF 
 
 than formerly. To the well-to-do, while the cost is great, 
 it is not prohibitory. To the poor, the public and private 
 charities are open where they can get the same services, 
 dispensed in less luxurious fashion, but no less efficiently. 
 The real sufferer in the transition stage of rapid differen- 
 tiation and delayed organization is the great middle class. 
 Caught between penury and pride, without the price to 
 pay, but with the desire to conceal their poverty, they are 
 often limited to an inferior grade of service. 
 
 Team work is essential to carry out the modern sys- 
 tem of examinations. It is best seen in the staff of a 
 modern hospital where ever patient has at his command 
 the services of specialists in all diagnostic lines. The 
 same principle must sooner or later come into vogue in 
 private practice. Ultimately doctors will have their offices 
 in large buildings .instead of at their private residences. 
 Here composite groups will unite in close business and 
 professional association as a firm or corporation. Pa- 
 tients will be treated jointly, conveniently and expediti- 
 ously, and a combined bill will be presented through a 
 central office. 
 
 Modern Diagnostic Methods. 
 
 One of the most wonderful gains made in modern 
 medicine is in the exact diagnosis of disease by laboratory 
 methods. For a time our knowledge of etiology and 
 pathology was vague and indefinite, but one after another, 
 great discoverers have cleared the field and given us 
 definite facts with which to work. Diatheses and dys- 
 crasias, miasmatic and idiopathic diseases are no longer 
 mentioned ; the terms scofula, blood poison and typho- 
 malarial fever are no longer employed, and even the 
 
 i6 
 
MODERN MEDICINE 
 
 identity of neurasthenia and auto-intoxication are 
 questioned. 
 
 We now diagnose the existence of tuberculosis, not by 
 hectic fever, but by the demonstration of Koch's bacillus. 
 We diagnose malaria, not by the therapeutic test of 
 quinine, but by the presence of the plasmodium of Laver- 
 an. Wldal has given us the agglutination test for typhoid, 
 and Wasserman the reaction which shows the presence or 
 absence of syphilis. The white blood count tells the 
 degree of infection and resistance of the patient, and is 
 not only a test of importance in making prognosis, but 
 often indicates the proper time for intervention. The 
 microscopic examination of tissue differentiates benign 
 from maligant tumors, and in operation for cancer the 
 frozen section will often tell the surgeon when he has 
 reached the limit of the disease. The X-ray shows the 
 existence of fractures and the position of fragments, 
 locates the presence of stones in the kidney, ureter or 
 bladder, and by recent perfection of technique makes 
 moving pictures showing the passage of food from the 
 stomach to the rectum. 
 
 The inspection of the modern laboratory is impressive 
 to the visitor. The rows of reagents, retorts and test 
 tubes; the microscopes, centifuges and microtomes; the 
 refrigerators, incubators and culture media ; the polaris- 
 copes, hematocytometers, sphygmomanometers and other 
 instruments of precision, make a layman, and even some 
 of the profession, think that the work done and the final 
 report made must settle all questions in a given case. 
 
 But the laboratory method of diagnosis entails a loss 
 as well as a gain and has its dangers and disadvantages. 
 While it is true that chemical reactions are always con- 
 
 17 
 
THE PROFIT AND LOSS ACCOUNT OF 
 
 stant, that the microscopic field shows the cellular struc- 
 ture of tissue and the physical form of bacteria, and that 
 the X-ray picture truly depicts the shadow of the object 
 between the Crooke's tube and the photographic plate, it 
 must always be remembered that there is a personal and 
 uncertain factor in the result, namely, the laboratory man 
 who construes what he sees. A poor pathologist or 
 Roentgenologist is worse than none at all, and even the 
 opinion of the most experienced and proficient is oc- 
 casionally wrong. 
 
 As valuable as are his services, the laboratory man is 
 sometimes too highly regarded. Seated upon his kingly 
 stool and surrounded by a rarefied scientific atmosphere, 
 he tends to tyrannize the clinician. His reports are too 
 often accepted as final in their decrees and become ener- 
 vating in their influence. Owing to a tendency to lean 
 too much on laboratory reports, case histories and bed- 
 side records, the profession is in danger of neglecting the 
 examination of the patient. Sick people are just as in- 
 structive today as in the time of Sydenham, Addison and 
 Bright. Laboratory data and clinical findings must be 
 studied together. They must be compared, and one used 
 to check a possible error of the other. 
 
 The Modern Hospital. 
 
 The hospital, while an old institution, is modern in its 
 distribution and function. It has lived down its stigma 
 of a death house. It has overcome the prejudices of the 
 masses and appealed to the pride of the classes. Prac- 
 tically every town of five thousand inhabitants has a hos- 
 pital, and every well-regulated hospital is an asset to its 
 community. A hospital is now accepted as the safest 
 
 i8 
 
MODERN MEDICINE 
 
 most comfortable and most economical place for the 
 seriously sick, and it is also recognized as a local centre 
 for the dissemination of knowledge among the public, the 
 training and education of nurses, and the uplift of the 
 profession by the demands made for good records, 
 thorough examinations, accurate diagnoses and rational 
 treatment. 
 
 Many hospitals through a mistaken sentimentality on 
 the part of Boards of Managers refuse to allow clinics to 
 be held in their wards. By this prohibition they do not 
 protect the patients from anything to which they object, 
 but expose them to a possible danger from which they 
 could be shielded. Experience has shown that sick peo- 
 ple are egotists, and that the more they are examined 
 and discussed the better they are pleased ; also that the 
 greatest safeguard against neglect or improper treatment 
 on the part of the staff, is the knowledge that the work- 
 done is under the constant observation and critic'sm of 
 students and physicians who visit the institution. The 
 hospital of the future should not only care for its patients, 
 but also be a centre for medical research, a stimulus for 
 the understanding v'sitor, and a training-school for nur- 
 ses, students and doctors. 
 
 The modern hospital, however, is not without its dan- 
 gv.rs and disadvantages, as it offers opportunity and hence 
 temptation to members of its staff, especially those with 
 surgical ambition, to undertake work for which they are 
 not qualified. The following is a familiar illustration : 
 A small town feels the need of a hospital, the women 
 organize, ra^'se the money and build one. The people of 
 this community had formerly made it a practice to go 
 
 19 
 
THE PROFIT AND LOSS ACCOUNT OF 
 
 to some neighboring city when in necl of special medical 
 treatment or a serious surgical operation. They are now 
 urged to patronize the home hospital, and as that course 
 appeals to their desire to help a local institution, and 
 also avoids separation from family and friends, the ad- 
 vice is often followed. For a time an experienced sur- 
 geon is sent for to operate on difficult cases, and one of 
 the local practitioners acts as his assistant. The success- 
 ful result which usually follows in these early cases in- 
 spires the community with confidence in the hospital, and 
 in time creates a desire in the mind of the local man to 
 do the work himself. He spends six weeks or three 
 months at a post-graduate school, and returns with a 
 h'ghly embellished certificate. He performs a herniotomy 
 or removes an appendix, and the pat'ent does not die. 
 He comes to be known in the community as a man of 
 wonderful nerve. He hopes later to drop his other work 
 and do nothing but surgery. 
 
 The evil goes further. This newly developed surgeon 
 has no regular assistant, and makes it a rule to get the 
 family doctor of the patient to help him with the opera- 
 tion. As the physician does part of the work it seems 
 only proper that he should get part of the fee. When 
 this practitioner has a patient who desires to go to a 
 specialist in a large city, what is more natural than that 
 he should go with him, and explain that he was reluctant 
 to come because of the loss of the financial benefit he was 
 accustomed to receive from such cases at home ; or what 
 more human than for the city surgeon to endeavor to 
 meet this competition by ofifering to split the fee in this 
 and future cases provided it was made sufficiently large ; 
 and what more necessary than that this secret understand- 
 
 20 
 
MODERN MEDICINE 
 
 ing between the two be kept from the knowledge of the pa- 
 tient. And so has come about the great modern evil of 
 the secret division of the fee, a practice by which the doc- 
 tor sells the patient to the highest bidder, and by which the 
 surgeon robs the patient to pay the doctor. Happily this 
 practice does not exist in Virginia, and is limited to a 
 very few communities in the South. Wherever it does 
 occur it is denounced in strong and unmeasured terms by 
 the best element of the local profession. 
 
 The evil of incompetency in the shape of the unquali- 
 fied surgeon, and the vice of dishonesty in the form of the 
 secret division of the fee, are being fought in the pro- 
 fession by the establishment of a special organization 
 known as "The American College of Surgeons." If the 
 remedy is not found, action will be taken sooner or later 
 by an indignant public through State legislation. 
 
 The Modern Trained Nurse. 
 
 The advent of the trained nurse marked an epoch in 
 medicine almost equal to the introduction of anesthesia 
 and antiseptics, and the name of the founder of the order, 
 Florence Nightingale, deserves to rank with those of 
 Long, Pasteur and Lister. The rapid and general adop- 
 tion of the trained nurse was due, not only to the pro- 
 fessional needs of the doctor, but also to the domestic 
 necessities of the public. In times past a sick person was 
 nursed by servants and relatives. In every family there 
 were old mammies and old maids who had considerable 
 practical experience in nursing, and who derived a cer- 
 tain morbid pleasure from the temporary authority of the 
 sick room. The modern servant problem, and the recent 
 migration of the unmarried female members of the family 
 
 21 
 
THE PROFIT AND LOSS ACCOUNT OF 
 
 from the home to the office, did away with this supply of 
 amateur nurses, and created a demand for the profes- 
 sional nurse. 
 
 At one time, especially in the South, there were but 
 two respectable things for a young woman to do, get 
 married or teach school. Now many avenues are open 
 to them, and of these none is more attractive or offers 
 greater opportunities for service than the field of nurs- 
 ing. 
 
 In the early part of the last century the only paid nurse 
 was a servant, without education or technical knowledge. 
 In America today the professional nurse is a woman .of 
 good social position, adequate general education and 
 trained in the art of her calling by three years practice 
 and study in a hospital. 
 
 Time will not permit an attempt to show the contribu- 
 tions of the trained nurse to the progress of medicine. 
 In every department she has proved a faithful, efficient 
 and trusted worker, without whose aid the end attained 
 could not have been accomplished. At the bedside of the 
 patient in the silent vigils of the night, in the operating 
 room during the stress and strain of nerve-racking or- 
 deals, and today in Europe on battlefields torn with shell 
 and red with carnage, she has shown a courage, a fixity 
 of purpose and a devotion to duty rarely equaled in either 
 sex or in any profession. 
 
 The nurse is a woman, and therefore has her faults, 
 but the faults are those of the woman, not of the nurse. 
 If she is sometimes spoiled, occasionally a trifle tyranni- 
 cal, and more rarely a bit supercilious from real or sup- 
 posed superiority of knowledge, it shows the weakness of 
 her sex and not of her profession. If her services are 
 
 22 
 
MODERN MEDICINE 
 
 sometimes prostituted to pamper the whims of the neuras- 
 thenic invahd, or to indulge the selfish indolence of the 
 idle rich, it is not her fault, hut the fault of our present 
 system of living. 
 
 <^ 'The Modern Medical Society. 
 
 The medical society is an important factor in the pro- 
 gress and development of medicine. While some mem- 
 bers of the profession do not appreciate the advantages to 
 be derived from regular attendance and active co-opera- 
 tion in medical organizations, it is a fact that the busy and 
 successful practitioners are usually present at all the meet- 
 ings of their County, State and National Associations. 
 This can only be explained by the fact that those of the 
 profession, whose experience and judgment have proven 
 to be the soundest, believe that medical meetings are 
 profitable. 
 
 Medical societies usually hold their regular sessions 
 in different cities, and their meetings educate and stimu- 
 late the local profession, and advertise to the laity the 
 fact that medicine is not bound by dicta and dogmas, but 
 is a progressive science ready to discard the old, if it is 
 proved to be fallacious, and to adopt the new, if it is 
 found to be of value. The meeting of a medical society 
 enables its members to read papers, thus giving them a 
 legitimate opportunity to show their capacity ; and to 
 present new and original views as to the treatment of 
 disease, thus adding to the knowledge of the profession. J 
 It enables its members to hear papers read by others, thus 
 giving them an opportunity to gain an amount of infor- 
 mation they could get in no other way with so little labor 
 and in so short a length of time. The discussions that 
 
 2Z 
 
THE PROFIT AND LOSS ACCOUNT OF 
 
 follow these papers are especially profitable. In them 
 is an impressive personal element that is totally lost in 
 the stenographic report published in the transactions. 
 
 In addition to the educational and professional advan- 
 tages derived from these meetings there are equally im- 
 portant social and personal benefits. The occasion is a 
 holiday, a recreation, a vacation. It breaks the monot- 
 ony of life and enables a man to do better work when he 
 returns home. It offers the opportunity to meet men who 
 are doing the same kind of work in different sections of 
 the country, and results in pleasing and profitable ac- 
 quaintanceships which often lead to permanent friend- 
 ships. And last but not least, it brings together men 
 who live in the same community, but who owing to petty 
 jealousies or lack of time for social intercourse, see little 
 of each other. Either in the session of the society, or in 
 the committee room, or on the journey to and from the 
 place of meeting, they are thrown into an intimate con- 
 tact which frequently leads to explanation of misunder- 
 standings, adjustment of differences, appreciation of good 
 qualities, and to the establishment of the most friendly 
 and cordial relations. 
 
 Despite the manifest and manifold benefits of the medi- 
 cal society, it is necessary from the profit to deduct a 
 loss. There are many medical societies which have no 
 right of being, and have been organized simply for poli- 
 tical or personal motives. Originally established to give 
 office or secure patronage for a certain group of men, 
 they are often supported for years through a mistaken 
 pride or patriotism on the part of their members, to the 
 great injury of the legitimate societies whose territory 
 they cover. There is need for a movement to standardize 
 
 24 
 
MODERN MEDICINE 
 
 medical associations, and until this is done through the 
 proper channel the profession should try to minimize the 
 evil by withdrawing its membership from superfluous or- 
 ganizations. Leaving out of consideration the societies 
 of the specialists there are but four medical associations 
 entitled to support: the county, the state, the regional 
 and the National. Each organization should be self-gov- 
 erned, but each should have its representatives in the next 
 higher body, and all work together for the common good 
 of the profession and people. 
 
 Woodrow Wilson, in speaking of the new banking sys- 
 tem, said : "We have developed by regions and there is 
 every reason why we should function by regions." It is 
 because the South has developed as a region and is drawn 
 together by a common spirit that we are met together to- 
 day. The Southern Medical Association is not a section- 
 al, but a regional society. 
 
 Twenty years ago it was considered derogatory to the 
 dignity of one clinician to visit the workshop of another. 
 To do so would be to invite the criticism of a confessed 
 inferiority, or of a desire to spy on the work of a com- 
 petitor. Then all one practitioner knew of the work of 
 the other was through printed matter, and some things 
 that were true were not believed and some things that 
 were not true were accepted. It has now become almost 
 a custom for the busy surgeon and physician to devote 
 two or three weeks of the period previously assigned for 
 a vacation to the duty of seeing, at first hand, what his 
 fellows are doing. At the various recognized medical 
 centres every provision is made for the convenience and 
 instruction of visiting doctors. No fees are charged and 
 the veriest stranger is made to feel welcome. By actually 
 
 25 
 
THE PROFIT AND LOSS ACCOUNT OF 
 
 observing the methods practiced in these various clinics 
 the visitor is able to decide whether or not they are pre- 
 ferable to the technique he has hitherto employed. 
 
 Surgeons, as a rule, attend clinics more frequently 
 than do physicians. This is a pity, for even in a strictly 
 surgical clinic the points of greatest interest are not the 
 methods of operating, but the explanation of symptoms 
 by the pathological conditions found. It is a curious 
 fact that many physicians, who would travel miles to 
 see a post-mortem examination, will not go around the 
 corner to witness an operation which demonstrates the 
 same changes produced by disease in living tissues before 
 they are obscured by terminal results. To correct the 
 loss entailed by the failure of the average physician to 
 avail himself fully of the advantages offered by the 
 modem clinic the internist must learn that to keep abreast 
 of the times it is necessary not only to study but to travel 
 as well. 
 
 Europe, in time of peace, may offer peculiar advan- 
 tages for instruction in medical subjects, but America 
 can truly claim to have the best surgical clinics in the 
 world. Rochester, Chicago, Cleveland, Philadelphia and 
 Baltimore are universally known for their surgical teach- 
 ing, and some of our Southern cities are beginning to be 
 the objective points of the seekers for surgical knowledge. 
 
 Public Health Service. 
 
 For centuries the world suffered from pestilence and 
 scourge. People in desperation abandoned themselves to 
 their fate, discarded even the crude laws of the Mosaic 
 Code, and attributed their condition to the visitation of 
 the devil, or the wrath of an offended deity. But medi- 
 
 26 
 
MODERN MEDICINE 
 
 cal men have ever labored to discover the cause of disease, 
 and the means to prevent its occurence. With an aUruism 
 rarely approached in other professions the physicians of 
 of the past and the present have given unceasingly of 
 their time and labor to destroy the very source of their 
 living. 
 
 Time will not permit a record here of the victories 
 that have been achieved in preventive medicines, begin- 
 ning with small-pox and now approaching a successful 
 issue in the case of yellow fever, malaria, typhoid and 
 other diseases. The recent completion of the Panama 
 Canal, a task rendered possible only by the sanitary regu- 
 lation promulgated and enforced by the distinguished 
 member of this association, Surgeon-General Gorgas, 
 stands as an unquestioned tribute and enduring monu- 
 ment to the perfection and efficiency of the measures 
 which modern science has developed for the maintenance 
 of health and the prevention of disease. 
 
 The public Health Service is now recognized as one 
 of the most important departments of our general and 
 local government. The work in this service offers the 
 present day graduate one of the most attractive fields 
 open to him. It does not hold out the promise of fortune 
 that goes with rare eminence in private practice, but it 
 guarantees to every worker a reasonable income, the op- 
 portunity for scientific study and research, the certainty 
 of performing a useful service for his community, and 
 the possibility of becoming a great benefactor to the 
 human race. 
 
 The state and local health boards are securing the 
 service of an increasing number of the best men of the 
 profession who are devoting their time and energies, not 
 
 27 
 
THE PROFIT AND LOSS ACCOUNT OF 
 
 only to sanitation and preventive medicine, but also to 
 an educational campaign to arouse the profession to a 
 sense of its duty as guardian of the public health, and 
 to acquaint the laity w^ith a knowledge of the cause and 
 means of preventing disease. The attendance of these 
 trained workers and practiced speakers at the meetings 
 of our county and state medical societies has already had 
 the effect of raising the value of the papers read, and of 
 making the discussions more interesting and scientific. 
 
 Public health work marked the beginning of a new 
 era in the relations between the profession and the public. 
 It was characterized by an effort on the part of the pro- 
 fession to take the public into its confidence. Its purpose 
 was to make the people a partner in the conservation of 
 health. A short time ago if a doctor addressed a lay 
 audience on a medical subject, his motives were ques- 
 tioned. Now the profession employs every agency of 
 publicity to spread the propaganda against disease. The 
 columns of the newspapers and magazines, the walls of 
 public conveyances, the lecture platform, the pulpit, the 
 school and the drama warn and plead against the danger 
 of the mosquito and house-fly, the communicability of 
 tuberculosis, the insidiousness of cancer, and the pathos of 
 "Damaged Goods." 
 
 Publicity in medical matters has undoubtedly done 
 good, but it has also done harm, and here as elsewhere 
 we must record not only the profit but the loss. 
 
 The first loss is seen in the schools, for an examination 
 of the text-books employed in physiology and hygiene 
 will show that just as at one time the children of the South 
 were taught false history, so now they are often taught 
 false science. Investigation will show that these text- 
 
 28 
 
MODERN MEDICINE 
 
 books are prepared by literary hacks employed by fanati- 
 cal associations to impress their views on various sub- 
 jects, especially with reference to the action of alcohol. 
 No one questions the evil of the abuse of this drug, but 
 neither the cause of temperance nor of science is advanced 
 by untruthful statements or manufactured statistics. 
 Another evil in the schools is the attempt to teach sex 
 hygiene. It is a difficult question to decide in an indi- 
 vidual case when and how to impart this delicate infor- 
 mation. If parents hesitate to discuss the matter with 
 their child at home, it is certainly an evasion of responsi- 
 bility attended by great danger to turn the subject over 
 to an old maid teacher to deal with in a mixed school. 
 
 The second loss from the general information given 
 the laity on medical subjects is seen in its effect on women. 
 Matters are now discussed in a mixed audience with a 
 freedom and frankness that would have been thought un- 
 believable a generation ago. Beginning with co-education 
 and equal suffrage, subjects suggestive of sex differences, 
 the field of activity of the female mind has broadened, 
 until now the average high-school girl is more or less 
 familiar with the problems embraced under the terms 
 eugenics, race suicide, the social evil, the age of consent, 
 the white slave traffic and the regulation of the red light 
 district. 
 
 The woman of today has lost her prudery. Let her 
 bew^are lest she lose her modesty as well ! If such should 
 prove the case it would be necessary to change from the 
 credit to the debit side, the balance now found in "The 
 Profit and Loss Account of Modern Medicine." 
 
 29 
 
Latent and Active Neurasthenia in Its 
 Relation to Surgery * 
 
 We have met at this the twenty-second annual session 
 of the Southern Surgical and Gynecological Association, 
 some to learn, some to teach, and all to secure a well- 
 earned vacation, and for a time, at least, be free from the 
 complaints of nervous and exacting patients. This being 
 the case, some of you may think that in choosing as the 
 subject for a presidential address, "Latent and Active 
 Neurasthenia in its Relation to Surgery," I have shown 
 a lack of tact by introducing a topic which brings to 
 mind unpleasant experiences, which for the occasion you 
 wish to forget. I trust this will not be the case, and hope 
 there will be found, if not in what I write, at least in 
 what you read between the lines, something which will 
 be of practical value. 
 
 Specialists usually divide functional neurotic disorders 
 into hysteria, neurasthenia, and hypochondria. 
 
 Hysteria is a spec-al psychical state often produced in 
 certain individuals by suggestion, and capable of being 
 relieved by persuasion. It is a condition of nervous insta- 
 bility, stigmatized by emotional storms, crises, contrac- 
 tures, and paralyses, by a craving for sympathy, a desire 
 for an audience, and a tendency to pose. 
 
 Neurasthenia is a fatigue neurosis due in part to mal- 
 nutrition, and in part to functional overexertion, occur- 
 
 * Address at the meeting of the Southern Surgical and Gyne- 
 cological Association, Hot Springs, Virginia, December, 190Q. 
 
 31 
 
LATENT AND ACTIVE NEURASTHENIA 
 
 ring in persons with an hereditary or acquired predispo- 
 sition. It is characterized by exhaustibiHty of the nervous 
 system, sHght exertion causing prostration and bringing 
 on the various distressing symptoms from which the 
 patient suffers. 
 
 Hypochondria is a mental disease marked by obses- 
 sions, depressions, and morbid fears concerning the 
 heahh of the individual. It is not very common, is easily 
 diagnosticated, and is usually incurable. 
 
 Hysterical patients give a great deal of trouble before 
 an operation, but do very well after the ordeal is over. 
 A nervous woman who describes her symptoms with 
 hesitating vivacity, who desires to discuss every detail of 
 her operation and subsequent treatment, and who is pos- 
 sessed of exaggerated fears of complications which may 
 develop, or of the ultimate result which may follow, 
 usually, after the operation is over, becomes a model 
 patient. Her imagination enters upon fresh fields; she 
 becomes hopeful and courageous, and begins at once to 
 plan a new life of activity. 
 
 Neurasthenic patients usually discuss their cases calmly 
 and logically: they describe their symptoms systemati- 
 cally, and employ technical terms correctly. They com- 
 plain of nearly every organ in the body. The essential 
 feature of their clinical picture is fatigue, exhaustion, and 
 incapacity for prolonged physical or mental exertion. 
 They suffer from general weakness, headache, backache, 
 and insomnia. Their mental condition is one of hesita- 
 tion, doubt, and indecision. They do not reach conclu- 
 sions, and are unable to fix their attention for any period 
 of time. They usually have digestive and sexual dis- 
 orders, and often grossly exaggerate the importance of 
 
 32 
 
IN ITS RELATION TO SURGERY 
 
 their symptoms. They frequently have psychic depres- 
 sions, shown by irritabiHty, introspection and selfishness. 
 They are firmly convinced as to the nature of their di- 
 sease, and come to the surgeon for what they believe to 
 be a necessary operation. 
 
 Hypochondriac patients are the victims of what is often 
 a hopeless psychosis. The individual is possessed of the 
 idea that she has some strange and horrible malady. She 
 soon wears out the patience of her family and friends, 
 and in order to secure a sympathetic listener, and to 
 demonstrate to the community the serious nature of her 
 disease, she goes from surgeon to surgeon, and from 
 hospital to hospital, offering herself as a bloody sacrifice 
 to her curious obsession, and glorying in her martyrdom. 
 
 As simple hysteria is easily recognized and controlled, 
 and as pure hypochondria is usually unmistakable and 
 incurable, I will dismiss these two subjects and devote 
 the time at my disposal to neurasthenia. I shall not limit 
 the term to the definition given by the scientific neurolo- 
 gist, but shall employ it in the broad sense in which it is 
 used by the practical surgeon. This is necessary because, 
 while in theory it is easy to distinguish between hysteria, 
 neurasthenia, and hypochondria, in practice it will be 
 found that the symptoms of two or more of them are 
 often present in the same patient at the same time. Thus, 
 one writer says all hysterical patients are neurasthenic, 
 but all neurasthenics are not hysterical. Name and 
 classify neuroses as you please, the trail of the serpent 
 is over them all. 
 
 None of us want neurasthenics as patients, but all of 
 us have them constantly in our practice. Some of them 
 are referred to us by the general practitioner ; some come 
 
 33 
 
LATENT AND ACTIVE NEURASTHENIA 
 
 to us from other specialists ; and some develop their per- 
 nicious symptoms under our personal observation and 
 treatment. In deploring the frequency of neurasthenia, 
 and in criticising practitioners in other departments of 
 medicine for the occurrence of the disease, it should be 
 remembered that we, as surgeons, are responsible for the 
 development of a large number of these cases. A surgical 
 operation injudiciously performed, or carried out without 
 proper precautions on a susceptible patient, will fre- 
 quently be the beginning of a neurosis, and terminate in 
 the condition known as traumatic or surgical neuras- 
 thenia. 
 
 It is the object of this address, first, to emphasize the 
 importance of refusing to operate on a neurasthenic 
 patient unless the symptoms can be clearly shown to be 
 due to organic disease ; and second, to impress the neces- 
 sity, if an operation is undertaken on a patient with either 
 latent or developed neurasthenia, to protect the nervous 
 system from psychical and physical shock, not only by a 
 proper preliminary preparation, but by careful and often 
 prolonged post-operative and post-hospital treatment. 
 
 A surgeon cannot be expected to be an expert neurolo- 
 gist, but for his own happiness, if not for his patient's 
 welfare, he must study functional neurotic disorders, as 
 well as organic diseases. He must learn to know his limi- 
 tations, as well as recognize his abilities ; and to estimate 
 the possible injurious effects as well as the probable bene- 
 ficial results to be expected from surgical intervention. 
 He must remember that the patient does not come to him 
 primarily to be cut, but to be cured ; and that an operation 
 is not a success unless the individual is restored to health, 
 not only physically, but also psychically; not only anato- 
 
 34 
 
IM ITS RELATION TO SURGERY 
 
 mically, but also symptomatically. In surgery the main 
 question is no longer one of mortality, but one of mor- 
 bidity. In endeavoring to forecast the end results of an 
 operation, the mental and nervous condition of the patient 
 must be carefully considered. If neuroses exist, without 
 anatomical disease, an operation will do no good, and may 
 result in harm. If neuroses are found coincident with 
 pathological lesions, an operation may prove of great 
 benefit; but in relieving the physical disease, care must 
 be taken to avoid increasing the nervous disorder. If 
 neuroses are present, reflex in character and due to rem- 
 ediable causes, an operation may be undertaken with 
 assurance of complete success. In other words, the sur- 
 geon should divide these cases into three classes : the first 
 to be avoided ; the second to be undertaken with caution ; 
 and the third to be cheerfully given the relief to which 
 they are entitled. 
 
 Of the class to be avoided, because the neurasthenia 
 has no organic basis, Goodell says : "The sufferer may 
 be a jilted maiden, a bereaved mother, a grieving widow, 
 or a neglected wife, and all her uterine symptoms — yes, 
 every one of them — may be the outcome of her sorrow, 
 and not of her local lesions. She is suffering from a sore 
 brain and not from a sore womb." Here an operation 
 will not relieve, but will aggravate, the symptoms. 
 
 Of the class to be undertaken with caution, because the 
 neurasthenia is merely coincident with anatomical disease, 
 it is often a question whether the patient had better en- 
 dure the evils he has, or fly to those he knows not of. 
 An illustration of where one of our greatest surgical 
 philosophers elected the first course is quoted from Mum- 
 ford's recent article: ''Said John Hunter to a patient 
 
 35 
 
LATENT AND ACTIVE NEURASTHENIA 
 
 with a chronic running sore who was brought to him for 
 consultation: 'And so, sir, you have a chronic running 
 sore ?' 
 
 "'Yes, Mr. Hunter/ 
 
 " 'Well, sir, if I had your chronic running sore, I should 
 say, "Mr. Sore, you may run and be damned." ' " 
 
 In other cases it may be deemed best to operate — not 
 to cure the neurasthenia, but to relieve the pathological 
 condition. Great care must be exercised to avoid increas- 
 ing the nervous weakness by the very means used to cure 
 the physical discomfort. This is especially true in patients 
 who have been previously the subject of other opera- 
 tions. 
 
 Of the class where the neurasthenia is directly due to 
 anatomical disease, it may be said that if the diagnosis 
 can be made and the cause removed, the patient will be 
 cured. Often the symptoms are obscure and misleading, 
 and much patient investigation will be necessary to reach 
 the proper conclusion. A distinguished modern surgeon 
 relates the following experience occurring in his early 
 professional life. One of his friends developed digestive 
 disturbances and came to see him with periodical regu- 
 larity. He first treated him along accepted lines ; then 
 gave him all the samples of proprietary medicine left at 
 his office, and as he did not improve, he decided that the 
 man was a neurasthenic. One day he was hurriedly 
 called to see him, and found that he had acute appendi- 
 citis. He operated on him, and hoped that by taking out 
 the appendix he had not only relieved the immediate 
 danger, but had also removed the cause of his previous 
 symptoms. Much to his disappointment, the patient, after 
 leaving the hospital, complained as before, and he was 
 
 36 
 
IN ITS RELATION TO SURGERY 
 
 therefore confirmed in his opinion that he was a neuras- 
 thenic. Later, the patient developed jaundice and symp- 
 toms of cholecystitis. He was operated on a second time 
 and a number of gallstones removed, and it was again 
 hoped that the cause of his trouble had been diagnosti- 
 cated and relieved. Before he left the hospital, however, 
 he began to have his old pains, and then the surgeon said 
 he knew he was a neurasthenic. Despite his failure to se- 
 cure relief, the patient persisted in coming to the office, 
 and one day called just after the installation of an x-ray 
 apparatus. More to test the new instrument than with any 
 expectation of benefiting the patient, a skiagraph was 
 made of his abdomen, and it was found that he had a 
 stone in his right kidney. A third operation was per- 
 formed, the stone removed, and from that time to this 
 the patient has been absolutely well. This is not a unique 
 case. All of us have had similar, if not quite such aggra- 
 vated, experiences. The story is told to impress the fact 
 that even an apparently hopeless neurasthenic should not 
 be condemned without a trial, as some of them may be 
 cured provided a correct diagnosis is made. 
 
 The means employed by surgeons to distinguish be- 
 tween hopeless and curable neurasthenia cover the entire 
 field of diagnostic medicine, and cannot be discussed. The 
 precautions to be observed in operating on a patient who 
 is likely to develop neurasthenia will now be considered. 
 
 Two separate and independent preliminary examina- 
 tions should be made of every surgical patient : the first 
 for the purpose of diagnosis, or the determination of the 
 condition to be corrected; the second for the purpose of 
 prognosis, or the determination of the safety of the opera- 
 tion, and the probability of a complete cure resulting 
 
LATENT AND ACTIVE NEURASTHENIA 
 
 from it. To do this satisfactorily it will usually be found 
 necessary to secure the aid and cooperation of several 
 specialists. Few busy surgeons have the time or skill 
 to make the necessary physical examination of the heart 
 and lungs, or the laboratory investigation of the urine, 
 blood, and stomach contents, to say nothing of the special 
 work which is sometimes required of the bacteriologist, 
 ophthalmologist, neurologist, rontgenologist, and other 
 experts. Patients will not object to frequent and pro- 
 longed examinations, but will be inspired with confidence 
 in the surgeon by the realization that nothing is taken 
 for granted, and that every effort is being employed to 
 ascertain the nature of their trouble and the best method 
 to effect a cure. In fact, the laity are now so educated 
 in medical matters that failure to give a case a thorough 
 preliminary examination is a cause for criticism and 
 distrust. 
 
 An important exception to this, however, is in the 
 case of a young, unmarried woman who complains of 
 pelvic symptoms. She may be of neurotic temperament, 
 and, owing to backache and painful menstruation, become 
 convinced she has uterine or ovarian disease, when, in 
 fact, she has no local trouble. On the other hand, she 
 may have cervical stenosis, uterine displacement, or 
 ovarian cystoma. In such a case a physical examination 
 should be made to ascertain whether the trouble is neuro- 
 logical or gynecological. In order to minimize the psychi- 
 cal shock and to avoid physical pain, the examination 
 should be made under a general anesthetic. If her symp- 
 toms are found to be due to some defect of her nervous 
 system, she should be positively assured she has no local 
 lesion, and be referred to a suitable attendant for general 
 
 38 
 
IN ITS RELATION TO SURGERY 
 
 treatment. If, on the other hand, her symptoms are 
 found to be due to actual disease of the pelvis, she should 
 be given the surgical relief her case demands. Noble has 
 emphasized the fact that virgins rarely suffer from trau- 
 matism and infection of the genital organs, and when 
 pathological disease exists they almost invariably demand 
 operative treatment. Repeated examinations, local appli- 
 cations, and other manipulations do them little good, and 
 often convert them into chronic nervous invalids. The 
 "pelvic woman" of the old author is the ''sexual neuras- 
 thenic" of the modern writer. 
 
 The preparation of a patient for operation should be 
 both physical and psychical. In the past much attention 
 has been paid to the first, and but little to the second. 
 We now recognize that we have overdone starvation, pur- 
 gation, and sterilization, and have neglected to study the 
 patient's mental attitude to the operation, in order to 
 lessen apprehension, if it is unduly present; to inspire 
 confidence, if it is lacking; and to lay the foundation for 
 a philosophy which will be needed during convalescence. 
 
 The surgeon's first efforts should be directed to reliev- 
 ing the patient's dread of going to the hospital. The laity 
 are being rapidly educated to a just appreciation of the 
 advantages afforded by such institutions, but some people 
 still regard them as a cross between a prison and a pest 
 house. The easiest and most effective way to overcome 
 this belief is to induce the patient to enter the hospital 
 several days before the date fixed for the operation. In 
 the environment of a well regulated sanatorium excite- 
 ment and fear will soon be replaced by calmness and hope. 
 
 The surgeon should see the patient daily. His bearing 
 should be kindly but not oversympathetic. The patient 
 
 39 
 
LATENT AND ACTIVE NEURASTHENIA 
 
 should not be the object of commiseration because of the 
 anticipated operation, but the subject of congratulation 
 because her case is one that can be cured by surgery. 
 She should be made to realize that operations are but an 
 incident in the day's work, and that, while her case will 
 receive all needful attention, she is not the most important 
 individual in the hospital. Care should be taken, in talk- 
 ing to her, not to magnify the importance of her lesions 
 or the difficulty and danger incident to their correction. 
 The relatives and friends should, of course, be informed 
 of the facts in the case, but the patient should not be 
 burdened with doubts and fears. It is also well to avoid 
 giving unnecessary information about the etiology and 
 pathology of her disease, or to describe the different 
 methods by which her abnormality might be corrected. 
 While she will listen eagerly to any statement with refer- 
 ence to her case, and will enter into a discussion of what 
 is best to do for her, she realizes that she does not fully 
 comprehend what has been said to her by the surgeon, 
 and is worried by the responsibility she has assumed in 
 the opinion she has expressed to him. 
 
 It is, however, important at this time that the surgeon 
 warn the patient against certain symptoms, complications, 
 and sequelae which may develop after the operation, tell- 
 ing her that while they entail no danger and will not 
 effect the final result, it is well that she should realize 
 their possibility, in order that, if they develop, she may 
 know they were foreseen. For instance, a patient to be 
 operated on for hemorrhoids should be told that possibly 
 she will require catheterization for a day or two ; a patient 
 with a goitre, that her throat will feel sore, and it will 
 hurt her to swallow; a patient with gallstones, that a 
 
 40 
 
IN ITS RELATION TO SURGERY 
 
 drain will be used for a week or ten days ; and a patient 
 with fibromyoma of the uterus, that artificial menopause 
 will follow, with symptoms such as usually occur at the 
 ''change of life." A word of warning before the opera- 
 tion will be found to be worth more than an hour's 
 explanation afterward to prevent discouragement from 
 ordinary sequelae, whose significance and importance are 
 not understood. 
 
 Finally, the patient's fear of the anesthetic should be 
 relieved by reassurance, reason, or ridicule. A badly 
 frightened patient should never be sent to the operating 
 room. Psychical shock is a greater factor than traumatic 
 shock in the production of surgical neurasthenia. 
 
 Some patients are in good nervous and physical condi- 
 tion and require practically nothing but the mechanical 
 correction of a local trouble. Others are as bad off ner- 
 vously as they are physically, and often will be more bene- 
 fited by a modified form of rest cure than by the operation 
 itself. Most surgeons recognize this fact, but are often 
 unable to carry out the principles of seclusion, rest, full 
 feeding, bathing, massage, and electricity, as taught by 
 Mitchell, because of the present attitude of the public to 
 surgery. Not many years ago an operation was consid- 
 ered, in the words of the marriage ceremony, as something 
 not to be entered into unadvisedly or lightly, but discreet- 
 ly, soberly, and in the fear of God. Today it has come 
 to be regarded as a comparatively trivial event, and the 
 principal dread is the surgeons fee. In the old days it was 
 understood that a patient requiring a serious operation 
 would have to remain two or three months in a hospital. 
 At present patients enter the hospital one day, are oper- 
 ated upon the next, begin to ask when they can go home 
 
 41 
 
LATENT AND ACTIVE NEURASTHENIA 
 
 before they stop vomiting, and usually are permitted to 
 leave before it is wise for them to do so. 
 
 Nearly all surgeons admit the injurious results which 
 frequently follow the premature discharge of a case from 
 the hospital, but most of them try to evade responsibility 
 by attributing the evil to the unreasonable insistence of 
 the patient to be permitted to return home. The fault, 
 however, is not with the laity, but with the profession. 
 Patients would consent to longer detention in the hospital 
 just as submissively today as they did some years ago, 
 if they believed it to be necessary. The fault is with a 
 few surgeons who, for various reasons, have entered into 
 a competition to see who can get their cases out quickest, 
 and have thereby set a precedent which others have fol- 
 lowed. Some have been actuated by a desire to save the 
 patient time and money ; others by a desire to advertise 
 themselves. The public is prone to estimate the ability 
 of a surgeon by the apparent rapidity of the recovery of 
 his patients, and to make comparisons between different 
 operators on the basis of the length of time they keep 
 their patients in the hospital. This is not surprising, as 
 even some of the profession do not seem fully to realize 
 that, all things being equal, a wound will not heal quicker 
 for one man than it will for another, and the number of 
 days a surgeon keeps the patient in bed is not a measure 
 of his surgical dexterity, but of his surgical judgment. 
 
 In order to appreciate the dangers to a patient of pre- 
 mature discharge, it is necessary to contrast the condi- 
 tions of hospital and home life. The change is as decided 
 and the influence as great to either sex, the man on return- 
 ing home being confronted by financial obligations and 
 
 42 
 
IN ITS RELATION TO SURGERY 
 
 business complications, and the woman by family cares 
 and domestic duties. 
 
 By way of illustration, we will take the case of a 
 woman. While in the hospital she is free from responsi- 
 bility, and has comforts and conveniences which are often 
 as new as they are delightful. Her room is clean and 
 well heated ; dainty meals are served with clock-like 
 regularity; and an electric bell commands the services 
 of an attractive and efficient nurse. Other patients recov- 
 ering from more serious operations inspire her with 
 courage, and she emulates their example and tries to 
 surpass them' in rapidity of progress. It is like playing 
 a game to see who can get well first. Above all, she is 
 conscious of being under the watchful eye of the surgeon, 
 and appreciates the fact that complications, if they occur, 
 will be promptly corrected. 
 
 Now compare the condition of this woman when she 
 returns home. At the very outset she has to meet either 
 injudicious sympathy or unreasonable expectations. 
 Sometimes her friends and relatives, by a combination 
 of commiseration and indulgence, induce her to believe 
 that she has been the most unfortunate woman on earth, 
 and is therefore entitled to lead a life of invalidism for 
 the remainder of her existence. Or, again, her husband 
 and family may show in their manner, if they do not 
 express it in words, the conviction that she ought to be 
 in good working order after so much money has been 
 spent in repairing her, and, as a result, she feels impelled 
 to exert herself to discharge duties for which she is not 
 physically competent. During the woman's absence from 
 home the domestic economy often gets sadly out of gear. 
 Undesirable relatives have come to make visits ; servants 
 
 43 
 
LATENT AND ACTIVE NEURASTHENIA 
 
 have grown slack and impudent; children have been 
 spoiled and pampered ; and the husband's sexuel appetite 
 has not been gratified. As a consequence, in the first 
 few days after her return, she has to snub her mother-in- 
 law, discharge her servants, clean her house, cooik her 
 dinner, spank her babies, and resist or yield to her 
 husband's advances. 
 
 If she lives in the country, as is often the case, the 
 contrast between hospital and home life is even greater. 
 The house is often inadequately heated ; servants are gen- 
 erally unreliable and incompetent; food is usually indi- 
 gestible in character and monotonous in variety ; outdoor 
 exercise is difficult to practice; a bath can only be obtained 
 by bringing in a wash-tub and heating water in a kettle; 
 and an evacuation of the bowels can only be effected by 
 an excursion to the garden, along a grass-grown path 
 overhung with boxwood bushes, and by the exposure of 
 a vulnerable portion of the anatomy to the chilling wintry 
 blasts. Is it a wonder that the woman becomes neuras- 
 thenic and fails to get well ? 
 
 What has been said with reference to the short stay of 
 patients in the hospital, and the conditions which fre- 
 quently exist at home work adversely to their recovery, 
 makes it plain that those interested in their welfare should 
 thoughtfully consider the situation and endeavor to 
 remove the evil. The remedy obviously consists in the 
 patient's remaining longer under the care of the surgeon, 
 and on returning home being placed under the close 
 supervision of the family physician. 
 
 A patient should not be detained an unnecessary time 
 in the hospital, as it is not only a waste of the individual's 
 time and money, but also tends to the creation of 
 
 44 
 
IN ITS RELATION TO SURGERY 
 
 invalidism. A patient should not be dismissed too soon, 
 as failure to secure the expected benefit from the opera- 
 tion may lead to discouragement, which finally results in 
 well-established neurasthenia. Convalescence is a ques- 
 tion of temperament, and must be psychical as well as 
 physical. People are coming to regard surgeons as 
 mechanics, and patients as machines which are to be re- 
 paired. They must be taught that the operation is not 
 everything, and that the after-treatment is often of equal 
 importance. They must be made to understand that the 
 operation merely corrects an abnormal condition and puts 
 Nature in a position to effect a cure ; that often the first 
 effect of an operation is injurious, and that the beneficial 
 results are only experienced after the system recovers 
 from the shock and readjusts itself to new conditions; 
 that sometimes it takes weeks, months, or even years for 
 this to be accomplished. They must be impressed with 
 the fact that surgical patients are not well because their 
 wounds have healed, but should remain in the hospital 
 until they have regained to a certain extent their physical 
 strength and nervous equilibrium, and that, after return- 
 ing home, for a time they should lead a life of prudence 
 and restraint. 
 
 The surgeon usually attempts to direct the treatment 
 of patients after they return home by giving them verbal 
 instruction when they leave the hospital, and by subse- 
 quently corresponding w4th them, but the end desired 
 can be more effectually and properly secured by referring 
 the patient back to the family physician. The reason 
 verbal instructions are not satisfactory is because they 
 cannot cover all eventualities, and are frequently not 
 understood. When a surgeon takes charge of a new 
 
 45 
 
LATENT AND ACTIVE NEURASTHENIA 
 
 case he is on his mettle both to make a good impression 
 and to solve the diagnostic problems presented. Con- 
 sultations are usually held with other members of the 
 staff, and for a day, at least, the case receives more 
 attention than any other patient in the hospital. The 
 diagnosis made, the operation performed, the danger 
 period passed, and convalescence established, it is only 
 natural that the surgeon's time and thoughts are occupied 
 with more recent cases, so when the time comes to say 
 good-bye and give parting instructions, he simply utters 
 a few perfunctory injunctions, tells her to be patient and 
 prudent, and to write him if she has any untoward symp- 
 toms. The patient's expectation and disappointment are 
 often apparent, but she hesitates to ask the many ques- 
 tions which are uppermost in her mind for fear of weary- 
 ing or irritating the busy man, the value of whose time 
 she has been taught to respect. 
 
 The reason subsequent treatment by mail is not satis- 
 factory is because patients usually fail to give important 
 facts, and either exaggerate or underestimate their symp- 
 toms. Also, because the surgeon cannot remember their 
 idiosyncrasies and peculiarities, and even if he prescribes 
 correctly, his advice lacks the personal element of sug- 
 gestion which is so essential to make it efficient. 
 
 How much better it would be if the patient were ex- 
 amined before she left the hospital, and told that the 
 operation which had been performed had satisfactorily 
 corrected the condition which had given rise to her 
 symptoms, but that she was not well and that it would 
 require some months of proper living to restore her to 
 full health and activity. She should be directed, on 
 returning home, to place her case in the hands of her 
 
 46 
 
IN ITS RELATION TO SURGERY 
 
 family doctor. This would safeguard the patient's future 
 welfare, and would overcome to a large extent the grow- 
 ing feeling on the part of the general practitioner that 
 he is not always fairly treated by the surgeon. Few 
 surgeons are willing to turn patients over to a physician 
 immediately after a serious operation. Complications 
 are often so sudden and dangerous, symptoms so slight 
 and misleading, diagnosis so difficult, and correct treat- 
 ment so essential, that no one except a man who has had 
 long and constant experience in the management of this 
 special class of cases is competent to have charge of 
 them. When, however, the danger of the operation is 
 over, and the subsequent treatment consists in regulating 
 the various functions of the body, restoring lost flesh and 
 strength, and reestablishing nervous and mental equi- 
 librium, the family physician becomes the safer adviser. 
 With the rapidly increasing amount of surgery and the 
 consequent number of convalescent patients under treat- 
 ment, an educational move ought to be instituted for the 
 study of the many peculiar factors involved. Papers 
 ought to be written and discussions ought to be partici- 
 pated in by both surgeon and family doctor, taking up 
 the various details and discussing them from their 
 different standpoints, until finally there is evolved a con- 
 sensus of opinion with reference to the very many 
 important points in the treatment of these patients. These 
 should include the question of a proper dietary; of the 
 best method of regulating the bowels ; of treating bladder 
 irritation; of the number of hours of sleep, and of the 
 necessary periods of rest during the day ; of the amount 
 of exercise that is permissible, whether steps are 
 injurious, how soon the sewing machine may be employed, 
 
 47 
 
LATENT AND ACTIVE NEURASTHENIA 
 
 or house work taken up ; the question of driving, riding 
 horseback, dancing, swimming, and athletic contests; the 
 sort of clothing to be worn, whether corsets are injurious 
 or an abdominal binder necessary; the question of pru- 
 dence at menstrual periods and the relief of pain often 
 experienced at that time ; the treatment of headache, the 
 administration of tonics, nervines, and hypnotics ; the 
 use of baths, massage, and electricity; the protection of 
 wounds ; the employment of douches ; the use of tampons ; 
 the period at which sexual relations may be resumed — 
 these and a hundred other questions all require considera- 
 tion in order that they may be settled. 
 
 When surgeons appreciate the influence of neurasthenia 
 on the result of an operation, and the influence of an 
 operation on the production of neurasthenia; when the 
 family physician is educated in the details of posthospital 
 treatment and given legitimate work with proper com- 
 pensation, then and not until then will there be harmony 
 in the profession and the greatest good accomplished to 
 the greatest number of patients. 
 
 48 
 
Evolution of the Treatment of Ectopic 
 
 Pregnancy * 
 
 The subject of ectopic pregnancy seems to have exer- 
 cised a pecuHar fascination for the medical mind. Since 
 its recognition in the eleventh century men in all countries 
 have given it much study. 
 
 At the outset it is well to recall the fact that rupture 
 of the tube usually occurs between the eighth and twelfth 
 weeks. If this danger period be passed, the problems of 
 treatment are quite distinct from those in the early stages. 
 In the late cases nature sometimes attempts a crude 
 surgery of her own, and spontaneously delivers the fetus 
 by rupture into the rectum, through the abdominal wall, 
 or into the bladder. As far back as the fifteenth century 
 we find the surgeons of that day operating to facilitate 
 delivery by these erratic routes. Primrose, in 1594, was 
 the first to undertake section of the abdomen for this 
 purpose. But he, too, had a natural suggestion hardly 
 to be overlooked ; for his patient, three years before, had 
 suffered from the same condition, and the sac had 
 ruptured through the abdominal wall. The first Ameri- 
 can surgeon to perform this operation was John Bard, of 
 New York, in 1759. The second was William Baynham, 
 of Virginia, who, in 1791, operated successfully upon 
 the wife of a planter; and in 1799 did another upon a 
 negro servant. His work earned for him title to a high 
 
 * Read in the Section on Surgery of the Southern Medical 
 Association, Lexington, Ky., November, 1913. 
 
 49 
 
EVOLUTION OF THE TREATMENT OF 
 
 place on the roll of those country practitioners whose 
 sturdy self-reliance has so often done honor, not only 
 to themselves, but to their profession. 
 
 In 1842 William Campbell, of Edinburgh, published 
 a work on the subject, presenting an exhaustive review 
 of the literature up to his time. It did not, however, 
 contribute materially to the evolution of the treatment in 
 the early stages. For forty years yet the profession was 
 to wander in a barren wilderness of half-hearted surgical 
 measures. The following review of these attempts ex- 
 hibits at once their desperation and their futility. 
 
 1. Destruction of the Ovum Through the System of 
 the Mother. — Von Ritgen, in 1840, advised starvation 
 and purgation. Cazeaux, in 1861, advocated copious and 
 repeated bleeding. Keller, in 1872, urged the adminis- 
 tration of iodide of potash and mercury. Janvrin, in 
 1874, gave ergotin hypodermically. Barnes, in 1874, sug- 
 gested large doses of strychnia, and later advocated 
 syphilization. 
 
 2. Puncture of Fetal Cyst. — James Y. Simpson, in 
 1864, punctured the fetal cyst through the vagina, and 
 evacuated the liquor amnii. The patient died after two 
 days. Hicks, in 1865, punctured the cyst and attempted 
 to destroy the fetus by direct violence. The patient died 
 from internal hemorrhage on the fifth day. Greenhalgh, 
 in 1867, punctured the cyst through the vagina. The 
 patient did well for three weeks, then had a chill, abdomi- 
 nal pain and a bloody vaginal discharge. Finally, she 
 passed clots and membranes and recovered. Tanner, in 
 1867, reported a similar operation. His patient was 
 desperately ill for three weeks, and then passed the de- 
 composing fetus through the rectum. Martin reported 
 
 50 
 
ECTOPIC PREGNANCY 
 
 puncturing the cyst through the skin of the abdomen. 
 The patient died. Thomas, in 1875, reported having 
 punctured the cyst in two cases. Both died, one from 
 hemorrhage and the other from septicemia. 
 
 3. Removal of the Embryo by Section of the Vaginal 
 Vault ivith the Galvanic Cautery. — T. Gaillard Thomas, 
 of New York, in 1875, advocated and practiced this 
 method. He opened the sac, removed a three-months' 
 fetus, but, in attempting to get out the placenta, had 
 bleeding and was forced to abandon the operation and 
 to inject subsulphate of iron to stop the hemorrhage. 
 The woman recovered after a stormy convalescence. 
 
 4. Galvanism and Electricity. — Bachetti, in 1857, re- 
 ported that he had destroyed a fetus by inserting needles 
 into the cyst, and passing through them an electro- 
 magnetic current. Cazeaux, in 1861, suggested using 
 electric shocks. Hicks, in 1866, placed one pole in the 
 vagina, the other on the abdomen, and passed a galvanic 
 current. The fetus was not killed. Barnes, in 1874, 
 used miniature lightning shocks by means of a Leyden 
 jar, one pole introduced into the rectum and the other 
 into the vagina. 
 
 5. Injection of Narcotic Substances into the Cyst. — 
 Joulin, in 1863, suggested the hypodermic injection into 
 the cyst, through the vagina, of morphia or some other 
 narcotic agent to kill the fetus. Friedriech, in 1864, 
 claimed to have cured a case by this method ; but from 
 the history he gives, it is doubtful if the patient really 
 had ectopic pregnancy. 
 
 6. Compression of the Cyst. — Malin proposed to de- 
 stroy the fetus through severe and prolonged compression 
 of the abdomen by means of sand bags. 
 
 51 
 
EVOLUTION OF THE TREATMENT OF 
 
 During all this time the abdomen was being opened for 
 other purposes; ligatures for the control of hemorrhage 
 were in common use. But the very magnitude of the 
 catastrophe seemed to cause the profession to view from 
 afar the rational method of treatment. In 1849 Harbert 
 hinted at the possible value of the "Caesarean operation." 
 Again, in 1866, Stephen Rogers, of New York, ventured 
 to renew the suggestion. But not until the seventies did 
 opinion begin to take real shape. Brown in 1870, Routh 
 in 1871, Playfair, Meadows and Darby, of South Caro- 
 lina, 1872, all wrote advocating what was then termed 
 "gastrotomy." Spencer Wells and other leading abdomi- 
 nal surgeons of that day, however, refused to carry out 
 the suggestions; and Parry, in 1876, was led to lament 
 "But no person has yet performed gastrotomy for the 
 relief of this accident." The uncertainty of diagnosis, 
 and the fear of not being able to arrest the hemorrhage 
 after the abdomen was opened, stayed the hand of that 
 generation. 
 
 In 1876 John S. Parry, of Philadelphia, collected and 
 analyzed 500 cases of ectopic pregnancy. Of these 336 
 died and 163 recovered — a mortality of 67.20 per cent. 
 The recoveries were due, not to primary operation, but 
 to rupture of the sac externally. The percentage of re- 
 coveries (32.8 per cent) is larger than would be the case 
 in a similar series today without operation, because in 
 Parry's time many of the early fatal cases were unrecog- 
 nized, and most of the late abdominal cases were 
 recorded. Parry was not a surgeon, but his studies led 
 him to a clear conviction of the treatment to be followed 
 in the early cases, both before and after rupture. Being 
 himself convinced, he voiced an appeal so clear and strong 
 
 52 
 
ECTOPIC PREGNANCY 
 
 that the profession, in the person of Lawson Tait, was 
 inspired to a grapple with the death-deaUng emergency. 
 But let Parry speak for himself : 
 
 "From the middle of the eleventh century, when Alubcasis de- 
 scribed the first known case of extra-uterine pregnancy, men 
 have doubtless watched the life ebb rapidly from the pale victim 
 of this accident as the torrent of blood is poured into the ab- 
 dominal cavity, but have never raised a hand to help her. Surely 
 this is an anomaly, and it has no parallel in the whole history 
 of human injuries. The fact seems incredible, for if one life 
 is saved by active interference it may be triumphantly pointed 
 to as the first and only instance of the kind on record. In the 
 whole domain of surgery — for we cannot look to other than 
 surgical measues under the circumstances — there is now left no 
 field like this. In this accident, if in any, there is certain death. 
 How often do we see persons recover from injuries which their 
 surgeons tell them will be mortal if they do not submit to a 
 grave and terrible operation? . . . But in rupture of 'an 
 extra-uterine fetal sac, in the early stages of pregnancy, a whole 
 lifetime — a whole century — is not enough to enable one person 
 to make two errors in regard to the prognosis of this accident. 
 
 "The only remedy that can be proposed to rescue a woman 
 under these unfortunate circumstances is gastrotomy — to open 
 the abdomen, tie the bleeding vessel, or to remove the sac en- 
 tire. . . . 
 
 "The question is not, Will the patient die after the operation? 
 It is. Will she live if abandoned to nature? This was answered 
 in the sobs and sorrows of stricken households long ago. . . . 
 
 "This operation, therefore, appears to be feasible, at least, 
 no one has demonstrated its impracticability, and in these days 
 when Durham removes the kidney, Pean and Koeberle the spleen 
 and Billroth the larynx successfully, this procedure ought to 
 be tried." 
 
 In Lawson Tait's book on Diseases of Women and 
 Abdominal Surgery, published in 1889, we find recorded 
 
 53 
 
EVOLUTION OF THE TREATMENT OF 
 
 the response to Parry's appeal. He tells the story of a 
 cai>e to which he was called by a Mr. Hallwright, who 
 had already made the diagnosis of ruptured ectopic 
 gestation. Tait says: 
 
 "This gentleman made the bold suggestion that I should open 
 the abdomen and remove the ruptured tube. The suggestion 
 staggered me, and I am ashamed to say that I did not receive 
 it favorably. I saw the patient again, in consultation with Mr. 
 Plallwright and Dr. James Johnson, and again I declined to 
 act upon Mr. Hallwright's request, and a further hemorrhage 
 killed the patient. A post-mortem examination revealed the per- 
 fect accuracy of the diagnosis." 
 
 Emboldened, or, to use his own expression, shamed by 
 this incident, on January 17, 1883, Tait opened the ab- 
 dominal cavity for ruptured tubal pregnancy. The first 
 operation was unsuccessful. He refers to this case as 
 a bitter disappointment, attributing his failure to over- 
 caution and time-consuming work. But, within the next 
 six years, he had reported 39 cases, with only two deaths. 
 Truly, through disappointment and failure, did he achieve 
 a triumph. 
 
 It is interesting to note the different positions taken 
 by Parry and Tait on the question of diagnosis. Parry 
 stated as the greatest impediment to the adoption of the 
 treatment he urged, the uncertainty of diagnosis. Tait 
 said : 'The diagnosis of tubal pregnancy at the time of 
 rupture may be made with certainty seven times out of 
 eight, and may be guessed at in the eighth instance." He 
 is equally postive in his skepticism of the diagnosis be- 
 fore rupture. "Much discussion," he says, "has taken 
 place of late years as to the possibility of diagnosing tubal 
 pregnancy before the period of rupture, and many 
 
 54 
 
ECTOPIC PREGNAXXY 
 
 strangely dogmatic assertions have been made to the ef- 
 fect that such cases have been diagnosed and effectually 
 treated. I am bound to say that I am exceedingly skepti- 
 cal concerning the correctness of these statements." On 
 the other hand, Parry, while recognizing the difficultues, 
 believed ''that it may be discovered at a much earlier 
 date than is generally supposed," and that "a more ex- 
 tended clinical experience would probably show that the 
 existence of misplaced gestation can be detected quite as 
 easily, if not more easily, than normal pregnancy in its 
 early stages." This phophecy of Parry's was not slow 
 of fullfillment. In the early eighties Joseph Price, a 
 native of Rockingham County, Virginia, and a pupil of 
 Tait's, turned his attention to the subject. His master- 
 ful presentation of the symptomatology and course of the 
 disease put the diagnosis within the power of the gener- 
 al practitioner. 
 
 With Price the history rests. Problems still face us, 
 but the condition was mastered when Parry, Tait and 
 Price had finished their work. 
 
 So much for the evolution of the modern surgical 
 treatment of ectopic pregnancy, because of its historical 
 interest. Now for a brief discussion of some of the still 
 unsettled questions, because of their practical import- 
 ance. 
 
 I. The Question of Drainage. 
 
 This should be decided by the special indications in the 
 individual case, but more often is governed by the prac- 
 tice or prejudice of the operator. All surgeons drain 
 some cases, but some surgeons drain all cases. The abil- 
 ity of the healthy peritoneum to take care of a large 
 
 55 
 
EVOLUTION OF THE TREATMENT OF 
 
 quantity of free blood is being more generally recognized, 
 and injurious irrigation and useless drainage of the abdo- 
 minal cavity are now rarely employed. In a case of rup- 
 tured tubal pregnancy, unless there is evidence of pelvic 
 infection, the wound may be safely closed without drain- 
 age. 
 
 2. The Question of Saving the Ovary on the Affected 
 Side. 
 
 This is not a question of principle, but of practice. We 
 all know that a healthy ovary should not be removed ; but 
 many of us in the stress of critical operations, clamp and 
 remove the ovary with the tube as the quickest and easi- 
 est way of dealing with the situation. In many cases there 
 will be no reason to regret the method practiced, but in 
 other cases there will be cause for regret and condemna- 
 tion. If disease develops in the remaining ovary, requir- 
 ing a second operation for its removal, the woman is 
 made sterile, suffers from premature menopause, and fre- 
 quently becomes the victim of hopeless neurasthenia. 
 
 3. The Question of Immediate Operation. 
 
 All surgeons agree that an operation should be done 
 on a case of unruptured tubal pregnancy as soon as the 
 diagnosis is made. Instances are so numerous of rup- 
 ture occurring while the patient was waiting to go to the 
 hospital, or, while in the hospital, waiting for the sur- 
 geon to come, that it is now the universal practice to op- 
 erate on these cases with the greatest promptness. There 
 is, however, a serious difference of opinion among the 
 best surgeons as to when to operate on a case after rup- 
 ture occurs. One school advises an immediate operation 
 
 56 
 
ECTOPIC PREGNANCY 
 
 to arrest the bleeding, claiming that 5 per cent of all cases 
 will die from primary hemorrhage, and if the patient es- 
 capes this danger, a fatal secondary hemorrhage may 
 occur at any time. The other school advises waiting 
 until hemmorrhage ceases, reaction takes place, and the 
 operation can be done under more favorable conditions. 
 They admit that 5 per cent of the patients will die, but 
 claim that these cases would not be saved unless the sur- 
 geon was present at the time of the accident and operated 
 with a ''jack-knife and shoe string;" and maintain that the 
 greatest good to the greatest number is achieved by wait- 
 ing for an opportune time to do the operation. This ques- 
 tion has been so often fought out on the floor of medical 
 meetings, such as this, that most of my audience have 
 formed a definite opinion, which is not likely to be 
 changed. I wish to go on record, however, as favoring 
 an immediate operation, not only because it is in ac- 
 cord with general surgical principles, but also because, in 
 personal experience, I have seen the practice save appar- 
 ently moribund patients. 
 
 4. The Question of Removing or Ligating the Opposite 
 
 Tube to Prevent Repetition. 
 
 The frequency with which a woman, after being op- 
 erated on for pregnancy in one tube develops the same 
 condition later in the other tube, makes it necessary to 
 consider the advisability of removing both tubes at the 
 first operation to avoid a repetition, which the pathologic 
 tendency of the patient, as well as clinical experience, 
 makes probable. 
 
 The removal of both tubes would not add appreciab- 
 ly to the danger of the operation, would not interfere with 
 
 57 
 
EVOLUTION OF THE TREATMENT OF 
 
 the function of menstruation, and would not increase the 
 chance of distressing physical or nervous sequalae. It 
 would simply render the woman sterile. But is this de- 
 sirable? To secure a postive immunity, have we a right 
 to sacrifice a possible maternity ? This involves two ques- 
 tions. First, what proportion of women operated on for 
 tubal pregnancy have a recurrence in the remaining tube ; 
 and what per cent of women after such operation be- 
 come normally pregnant and give birth to a living child? 
 Second, what is the danger of an operation, and what 
 is the value of a baby? 
 
 The first question can easily be answered by com- 
 piling statistics. The second is almost impossible of so- 
 lution, as there is no basis for comparison. 
 
 In 191 1, Smith, of Grand Rapids, tabulated 2,998 oper- 
 ations for tubal pregnancy, in which recurrence followed 
 in 113 cases, or 3.8 per cent. He believed this percentage 
 was too low, as he thought it was impossible to follow 
 up such cases accurately over a sufficient period of time 
 to get final results. His investigation as to normal preg- 
 nancy following the operation was even unsatisfactory. 
 In thirty of his own cases, three had borne children since 
 the operation, one being pregnant in utero at the time of 
 the operation. He concluded that normal pregnancy fol- 
 lowed less frequently than might be expected. 
 
 Essen-Moller, of Lund, after reviewing fifty-six cases 
 of ectopic pregnancy of his own, and the reports of 
 others, concluded that intra-uterine pregnancy may oc- 
 cur after recovery from tubal gestation without operation 
 in the proportion of 46 to 100; and further, that there 
 seemed to be no difference in this respect between the 
 patients operated on and those not operated on, except 
 
 58 
 
ECTOPIC PREGNANCY 
 
 that drainage after ectopic gestation tends to make the 
 occurrence of intra-uterine pregnancy afterward less fre- 
 quent. 
 
 I have recently reviewed the case histories of the last 
 fifty cases of tubal pregnancy operated on in my private 
 hospital. Six of these patients have had recurrence in 
 the remaining tube. This I know, for I did the second 
 operation myself. There may be other cases in the series 
 who went elsewhere for treatment and who would add 
 to this 12 per cent of repetition. 
 
 I have tried to ascertain how many of the patients oper- 
 ated on for tubal pregnancy subsequently became normal- 
 ly pregnant and gave birth to a child. The result was 
 very unsatisfactory. One patient never had a husband ; 
 another became a widow shortly after leaving the hos- 
 pital ; some could not be located ; others would not 
 answer, etc. I know, certainly, that seven have borne 
 one, or more, children ; and I believe the number would 
 be doubled if I could get the true figures. 
 
 Smith, the author previously referred to, believes that 
 before an operation for tubal pregnancy the patient 
 should have the situation explained to her, and she should 
 decide whether or not the opposite tube should be re- 
 moved. But a woman just before an operation for rup- 
 tured ectopic pregnancy is in no condition to understand 
 or settle a complicated proposition. If she decides either 
 for or against the removal of both tubes she may regret 
 the responsibility of the decision, fearing, on the one 
 hand, a repetition of the former accident, or indulging 
 on the other in morbid longings for a child whose advent 
 she has caused to be made impossible. The operator 
 should settle the question for himself without taking the 
 
 59 
 
ECTOPIC PREGNANCY 
 
 woman into consultation, remembering all the time that 
 a surgeon's and a patient attitude to an operation are of- 
 ten very different, and that their estimate of the desira- 
 bility of a baby is often very far apart. 
 
 Personally, I am opposed to the removal of the oppo- 
 site tube, unless it is obviously hopelessly diseased. If, by 
 leaving it, I have subjected some patients to a second 
 operation that might have been avoided, I have equally 
 certainly allowed to remain possible the birth of some 
 babies that otherwise would not have come into existence. 
 As a surgeon I fear operations little and as a bachelor, I 
 value babies highly. 
 
 60 
 
Cornual Pregnancy, With Report of a 
 
 Cas 
 
 e 
 
 Much has been written with reference to tubal preg- 
 nancy, but little attention has as yet been paid to cornual 
 pregnancy. A recent mistake in diagnosis which led me 
 to operate on a bifurcated uterus about to rupture from 
 pregnancy in one of its horns has interested me in the 
 subject, and I wish to report the case and briefly discuss 
 the condition. 
 
 Mrs. S. ; aged 28; married for eighteen months; history of 
 one miscarriage. — Patient began to menstruate at the usual age 
 and her periods were regular and natural. Her general health 
 was good and she had no reason to suspect that she had any 
 uterine or other pelvic trouble. In March, 1902, she missed a 
 period and shortly afterward began to pass blood in small quan- 
 tities at frequent intervals from the vagina. Three months later 
 she was suddenly seized with severe pain in the lower right 
 abdomen. The pain was characterized as cutting or tearing, 
 was attended by nausea and faintness, and confined the patient 
 to bed. The patient's regular medical attendant was sent for, 
 who stated that he thought the trouble was tubal pregnancy 
 and advised an operation. Several days later the case was 
 transferred to me. 
 
 I found the patient in bed, suffering with paroxysms of pain 
 and passing blood from the vagina. The abdominal walls were 
 rigid, but on making a bi-manual examination I succeeded in 
 palpating a soft but elastic mass to the right of the cervix, 
 which corresponded exactly in tactile impression and in anatomi- 
 
 * Read at a meeting of the Tri-State Medical Association of 
 Virginia and the Carolinas, Columbia, S. C, February, 1903. 
 
 61 
 
CORNUAL PREGNANCY 
 
 cal location with cases of unruptured tubal pregnancy I had 
 previously diagnosticated. I stated that I agreed with the 
 opinion of my predecessor; that I thought the case was un- 
 doubtedly one of extra-uterine gestation, and I advised im- 
 mediate operative intervention. The patient was moved to my 
 private sanatorium and as soon as the necessary preparations 
 could be made the abdomen was opened. 
 
 The uterus I delivered through the wound was the queerest 
 specimen I ever saw. But for the fact that as a boy I had dis- 
 sected many cats and was familiar with the double horned 
 uterus found in the female of that animal, I would have been 
 at a loss to recognize the condition with which I had to deal. 
 
 The uterus was cleft from fundus to cervix; the two di- 
 verging sides tapering to, and terminating in, the Fallopian 
 tubes. The left horn was flaccid and empty, but the right was 
 distended by a swelling until its walls were so thin that they 
 were transparent. Evidently the case was one of cornual preg- 
 nancy, with imminent danger of rupture. In deciding what to 
 do I realized I had three alternatives. First, I could return 
 the uterus, suture the abdominal wound, and endeavor to pro- 
 duce an abortion. But this was deemed unsafe, as the uterus 
 might not have sufficient contractile power to expel its con- 
 tents, or if it did, would probably rupture its walls in the 
 attempt. Second, I could incise the pregnant horn, turn out 
 the embryo, and suture the incision as in a case of Caesarean 
 section, but this entailed danger of sepsis, and even if success- 
 ful would leave the woman in a position to become pregnant 
 again. Finally, I could do a complete hysterectomy, thereby 
 not only relieving the present situation, but also preventing 
 future complications. The last plan was adopted. The ovarian 
 and uterine arteries were ligated on each side, and the uterus 
 removed. 
 
 The patient made a rapid and uneventful recovery and is 
 now in perfect health. 
 
 My post-operative study of available literature in re- 
 gard to cornual pregnancy has been unsatisfactory. What 
 has been written is to be found either as practical points 
 
 62 
 
WITH REPORT OF A CASE 
 
 under descriptions of uterine malformations or as inci- 
 dental allusions under the treatment of tubal gestation. 
 
 Cornual pregnancy is not an extra-uterine pregnancy, 
 but a true uterine pregnancy, which, by malformation of 
 the uterus, has become pedunculated and walled off from 
 the main uterine cavity. The malformation of the uterus 
 is congenital and due to imperfect fetal development. 
 The Fallopian tubes, uterus, and vagina are formed from 
 two embryonal structures called the ducts of Aluller. 
 These ducts become fused first at their lower ends. 
 Sometimes one duct fails to develop, so that the uterus 
 becomes one sided or one horned — the uterus unicornis. 
 Sometimes the ducts may unite only as far as the top of 
 the vagina, thus two distinct uterine bodies resulting, 
 the double uterus — uterus didelphys. Sometimes the 
 ducts may unite externally to form one uterine body, 
 but there is no fusion of the cavities, which open sepa- 
 rately, the ttterus bicornis duplex. 
 
 Sometimes the ducts may unite to form a normal cer- 
 vix, but the upper part of the body of the uterus is bifur- 
 cated and the two sides diverge sharply from each other, 
 resulting in the two horned uterus — the uterus bicornis 
 unicoUis. 
 
 Sometimes the ducts may unite throughout, but exter- 
 nally on the fundus there is a slight depression, demon- 
 strating the imperfection of development and giving the 
 organ the conventional heart shape — the uterus cordi- 
 fornis. 
 
 Finally the ducts may unite so that the uterus presents 
 externally a normal appearance, but contains a septum 
 which divides its cavity into two compartments — the 
 iiterus septus. 
 
CORNUAL PREGNANCY 
 
 The result of impregnation of an imperfectly developed 
 uterus depends on the degree of malformation, and the 
 site of implantation. Often full term gestation is im- 
 possible, no matter what the location of the embryo. 
 Again, in an unequally developed uterus pregnancy in 
 one horn would probably go to term, while in the other 
 horn it would certainly terminate in abortion or rupture. 
 Impregnation of the two horns at the same time or at 
 different times is possible, leading to superfetation. Ross, 
 of Brighton, reports a case in which a patient miscarried 
 of twins and three months later was delivered of a 
 healthy, full-term child. Careful examination showed 
 the existence of a complete double uterus, each side of 
 which had been impregnated. This woman had formerly 
 given birth to six living children and nothing remark- 
 able had been observed at any labor. 
 
 Symptoms in cornual pregnancy are absent when the 
 impregnated horn has sufficient capacity to accommodate 
 the growing fetus. Symptoms are present, however, 
 when pregnancy occurs in a horn of the uterus too rudi- 
 mentary to fulfill the task imposed upon it. The symp- 
 toms consist of intermittent pain, due to the contraction 
 of the muscular coats of the uterus; bleeding from the 
 vagina, due to the detachment of the decidua in the 
 unimpregnated side; and, finally, either abortion from 
 discharge of the contents of the pregnant horn into the 
 uterus, or intra-abdominal hemorrhage due to rupture 
 of its over-distended walls. 
 
 Kelly, in his work on Operative Gynecology, states that 
 an accurate diagnosis of cornual pregnancy is always 
 difficult to make. If the case is seen after rupture there 
 will usually be no time to do more than determine that 
 
 64 
 
WITH REPORT OF A CASE 
 
 there is intra-pelvic hemorrhage, due to an abnormal preg- 
 nancy. If the case is seen before rupture two signs will 
 be of value, the first that the developed side deviates at 
 an angle of from 40° to 60° from the normal position ; 
 the second, that the pregnant horn is found by rectal 
 examination to be connected with the uterus by a broad 
 band which is attached at the lower part of the uterine 
 body. 
 
 Pregnancy in a rudimentary horn of the uterus usually 
 ruptures from the fourth to the fifth month, somewhat 
 later than is the case with tubal pregnancy. Authorities 
 seem to agree that the same treatment should be applied 
 to both conditions. If rupture has occurred the abdomen 
 should be opened and the uterus removed. If rupture 
 has not occurred and pregnancy is still in the first six 
 months a section should be done and the condition cor- 
 rected. If the diagnosis is not made until after the sixth 
 month, then, in view of the lessened danger of rupture, 
 the operation may be postponed, provided the patient can 
 be kept under careful observation until the child is viable, 
 when it should be removed by an abdominal incision. 
 
 65 
 
Tradition Versus Embryology in 
 Congenital Malformation * 
 
 "And Jacob took green rods of poplar and of almond and of 
 plane trees and peeled them in part; so when the bark was 
 taken off in the parts that were peeled, there appeared white- 
 ness; and the parts that were whole remained green; and by 
 this means the color was divers; and he put them in the 
 troughs, where the water was poured out, that when the flocks 
 should come to drink they might have the rods before their 
 eyes, and in the sight of them might conceive. And it came 
 to pass that in the very heat of coition, the sheep beheld the 
 rods, and brought forth spotted, and of divers colors, and 
 speckled." 
 
 Seventeen years ago a baby with three legs was brought 
 to my father, Dr. Hunter McGuire, for examination and 
 advice as to treatment. The mother attributed the defor- 
 mity to a maternal impression. She stated that one day 
 when she was about eight weeks pregnant she heard 
 strange noises in her kitchen. None of the other mem- 
 bers of the family were in the house and although alarmed 
 she determined to investigate the cause of the distur- 
 bance. Going to the kitchen she threw open the door 
 and discovered a man having sexual connection with her 
 cook on the floor. She seized a stick and belabored the 
 couple until they fled from the house. 
 
 The shock of the incident was very great and for 
 weeks she was nervous and hysterical. When awake she 
 constantly recalled the sight of exposed anatomy and at 
 
 * Read at the meeting of the Medical Society of Virginia, Nor- 
 folk, Va., October, 1912. 
 
 ^7 .... 
 
TRADITION VERSUS EMBRYOLOGY 
 
 night her dreams were filled with visions of moving legs. 
 She dreaded the effect on her unborn child and her fears 
 seemed realized in the deformity already mentioned. 
 
 On examination the baby was found to be healthy and 
 well developed. He had three legs of equal size and 
 length. The extra limb was attached to the pubis above 
 the penis. Except for a double foot it was symmetrical 
 with the other legs. When the child lay on his back he 
 kicked vigorously with all three legs and sucked the toes 
 of each with perfect impartiality. 
 
 The case was exhibited at the clinic of the University 
 College of Medicine and at the time attracted much at- 
 tention. My father advised the woman to take the boy 
 home and return when he was two or three years old 
 to have the superfluous leg amputated. 
 
 Nothing further was heard of the case until last June 
 when the patient walked into my office. He was a stal- 
 wart youth, evidently accustomed to outdoor work, and 
 weighed about one hundred and fifty pounds. His gener- 
 al health was excellent but the extra leg, he said was a 
 nuisance and he wanted to get rid of it. 
 
 On stripping the boy I found he carried the third leg 
 extended on his abdomen and chest, the limb being kept 
 in place by means of a strap which encircled the body. 
 Owing to long disuse the leg was much emaciated but its 
 length was approximately that of the other limbs. The 
 leg was attached to the patient's body by three bony 
 processes, a median and two lateral. They sprang from 
 the anterior surface of the pubic bones and united in a 
 knob that formed the acetabular cavity. 
 
 The head of the femur was perfectly formed. The 
 knee-joint was normal except that it had no patella. The 
 
 68 
 
Fig. 1— Photograph of Patient. 
 
IN CONGENITAL MALFORMATION 
 
 foot was deformed and had nine toes. The accompany- 
 ing photograph and X-ray pictures give a better idea of 
 the patient's condition than any verbal description. 
 
 I operated on the boy at St. Luke's Hospital on June 
 i8, 1912, incising the soft structures and cutting the bony 
 attachments to the pelvis with a chisel and mallet. The 
 patient made a rapid and uninterrupted recovery and a 
 recent letter states that he is now well and doing manual 
 work on the farm. 
 
 The case is reported partly because it is unusual and 
 interesting, but chiefly because it again raises the much 
 discussed question of the influence of maternal impres- 
 sions on fetal development. 
 
 Belief in the efficacy of some profound impression upon 
 the mother to produce upon the body of her unborn child 
 a direct and definite effect coinciding more or less accur- 
 ately with the object causing the impression, began ap- 
 parently with the dawn of history and in certain quarters 
 exists today with scarcely less prestige than it did a thous- 
 and years ago. 
 
 The biblical incident recording the success of Jacob's 
 stratagem with the peeled rods reads no more strangely 
 than the gravely recited case of a great present-day 
 authority whose pregnant patient, after being seized by 
 an ear and dragged about the room by her drunken 
 spouse, gave birth to a child having a triangular piece 
 lacking from the corresponding lobe of the ear. 
 
 In the realm of fiction and philosophy we find Dickens, 
 Goethe, Scott and others of equal note apparently firm' 
 adherents of the impressionistic idea, and the great mass 
 of medical testimony of their day decidely of their point 
 of view. Even at the present time we find cases of sup- 
 
 69 
 
TRADITION VERSUS EMBRYOLOGY 
 
 posed maternal impression reported so frequently in our 
 scientific journals that one questions why there is either 
 not a world full of monsters or else a race of rare and 
 radiant beings moulded at will by professional guardians 
 of impressionable mothers. Associated with the belief 
 in maternal impression is a cloud of superstition with 
 reference to the nature and the cause of monstrosities. 
 The purposes of this paper do not permit even mention 
 of the various fanciful theories which attributed the ori- 
 gin of terata to the sport of the gods, to the anger of 
 offended Deity, to cohabitation with Satan, to a malign 
 stellar assemblage, or to one or another of a hundred 
 more causes. 
 
 With the discovery of the ovum and the advent of 
 modern embryological research, the theory of maternal 
 impression suffered some decline, but the stubborn re- 
 currence of fresh ''proofs" has invariably fanned the 
 flame whenever it seemed in serious danger of flickering 
 out. As we have said these proofs are still accumulating 
 and the result, in our own day, is that while the theory 
 has lost many adherents, particularly in the professional 
 ranks, it is still firmly rooted in the minds of the laity, 
 and indeed yet claims the serious attentions, if not the 
 actual outright belief of many trained medical men. An 
 examination of numerous obstetric texts of recent years 
 reveals a degree of credulity astounding to the modern 
 scientific enquirer. So considerable an authority as Hirst 
 states in his fifth edition that there are "well authenti- 
 cated cases of congenial defects or peculiarities which 
 bear too startling a resemblance to the cause of the im- 
 pression upon the mother during pregnancy to be dis- 
 missed as mere coincidence." Many more names might 
 
 70 
 
Fig. 2— X-Ray of Knee Joint. 
 
IN CONGENITAL MALFORMATION 
 
 be added to the list and from the rank and file of the 
 profession might easily be collected a legion of those who 
 have observed in private practice enough to win them to 
 the ancient superstition. 
 
 These men are as earnest and as thoughtful as we and 
 it is by no means the effort of this paper to cast ridicule 
 upon those who honestly hold to convictions opposed to 
 our own ; at the same time the subject is of such practical 
 importance that if we can show the impressionists the 
 error of their way we shall have served many anxious 
 mothers well and gained a step amply repaying the loss 
 of a few broken idols. The pregnant woman already has 
 to endure enough without being constantly harried with 
 the dread that some temperamental excess will stamp her 
 child for life or some accident will cause her to bring into 
 the world a monster upon which man will hate to gaze. 
 
 Would it not be a boon to the expectant mother to have 
 it authoritatively stated that she can now dismiss at least 
 this one danger of her pregnancy ? Is it not time for us 
 to realize that we are sheltering a superstition and en- 
 couraging unnecessary fears, instead of relieving the men- 
 tal stress of a class of patients often painfully in need of 
 a comforting word ? 
 
 At the outset it is well enough to admit that as yet the 
 embryological evidence advanced in contradiction of the 
 impressionistic idea is neither clear nor definite, though 
 it is of sufficient weight to warrant the belief that we are 
 actually approaching an understanding of some hitherto 
 baffling problems involving not alone this idea but the 
 whole vexed question of heredity itself. At the same 
 time it cannot be denied that when the negative results 
 of maternal impressions are ignored, as is persistently 
 
 71 
 
TRADITION VERSUS EMBRYOLOGY 
 
 done, and the long list of cited cases are considered on 
 their face without regard to whether or not they clash 
 with scientific probability as justified by modern research, 
 the argument might well be convincing to the laity, and 
 even to the members of the profession who by habit or 
 inclination have come to value their eyes and ears more 
 than their microscopes. 
 
 A careful study of the cases reported in the past and 
 a close scrutiny of the instances likely to arise in the 
 future will show that in the vast majority the impression 
 which was supposed to have left its mark upon the fetus 
 occurred long after the development of the affected part. 
 Embryologists have proved rather conclusively that the 
 matrix of the new being is laid down during the first five 
 weeks of intrauterine life and that thereafter the process 
 is concerned no longer with the production of new parts 
 but chiefly with the mere growth of those already formed. 
 In other words organogenesis takes place before the 
 mother even knows she is pregnant and impressions oc- 
 curring thereafter can no longer affect the type, certainly 
 so far as multiplicities are concerned. 
 
 When due consideration is given to the negative evi- 
 dence against the theory, the cases cited in its support 
 seem pitifully few and inadequate. Indeed we have right 
 here what, to most of us is sufficient to dispose of the 
 assumption, for to view on the one side the vast num- 
 ber of unimpressed and on the other the isolated few 
 who bear the stamp gives us ample warrant for the 
 conclusion that the few are the result of chance and not 
 of rule. There is in all the realms of science no natural 
 process that deals only in exceptions, and when we meet 
 such a situation we can safely question and refuse to ac- 
 
 72 
 
Fig. 3-X-Ray of Foot. 
 
IN CONGENITAL MALFORMATION 
 
 cept. Were the impressionistic theory true, as many be- 
 lieve, then would we be wondering and worrying, not 
 over those afflicted as we do now, but over the good for- 
 tune of those who escaped. 
 
 But though we accept the evidence of the many we 
 must somehow account for the few and therefore what is 
 the "chance" to which we have attributed their existence? 
 The appeal to "coincidence" often cloaks mere ignorance, 
 but we employ the word here deliberately and with full 
 regard for the improper uses to which it has so frequently 
 been put. With the existence on the one hand of a series 
 of possible irregular forms of development and on the 
 other a series of possible impressions upon the pregnant 
 woman, does it seem strange that occasionally the two 
 series should coincide. 
 
 There are many deep-rooted superstitions founded 
 upon just this coincidence. No argument however pro- 
 found can convince the old woman whose "man" gave up 
 the ghost soon after a sparrow perched upon the window 
 ledge and pecked at the pane. '7 seen it" is her sole, 
 withering and all-satisfying answer, and it must be admit- 
 ted that to those who judge all things by the evidence of 
 their own eyes and ears the appeal is a powerful one. 
 And yet with window-pecking sparrows surrounding us 
 and death ever lurking near, it appears not unreasonable 
 to believe that once in a while the visitation of the Grim 
 Reaper and the curiosity of the sparrow should coincide. 
 
 Before passing from this point it may be remarked 
 also that the pregnant state is peculiarly adapted to unin- 
 tentional self-deception and that many of the cited cases 
 cannot even claim the dignity of coincidence being merely 
 ex post facto explanations suggested by the deformity. 
 
 73 
 
TRADITION VERSUS EMBRYOLOGY 
 
 In other words, we can find that the deformity produces 
 the impression in many instances instead of the impres- 
 sion producing the deformity. When a woman discovers 
 in her child some pecuHar mark it is easy enough to 
 search through nine months of incidents, impressions, 
 dreams, emotions, fears and what not and find something 
 remotely resembling it. 
 
 The discovery of the reduction and division of the 
 chromosomes and the realization of its immense import- 
 ance as the basis for a satisfactory theory of heredity 
 marked an important advance and as Piersol says "has 
 given to our knowledge of fertilization an almost mathe- 
 matical precision and supplied an accurate morphological 
 basis for our understanding of heredity." We seem here 
 on the very threshold of that long-sought scientific knowl- 
 edge of the laws governing the transmission of peculiari- 
 ties from generation to generation. 
 
 As for the aberrant types and the variations which are 
 not transmitted from generation to generation but are pe- 
 culiar to the individual in question, in other words, those 
 often claimed to have been ''impressed" upon the fetus 
 through the mind of the mother, the biologist also has his 
 authoritative word. 
 
 It has already been noted that the details of the orga- 
 nism are determined in miniature in the early weeks be- 
 fore the woman even realizes she is pregnant. It should 
 also be stated that during this early period before the 
 placenta has developed, there is no organic connection be- 
 tween the segmenting ovum and the parent. Except that 
 the one rests within the other, the two in the human be- 
 ing during this early period are as distinct as the chicken 
 egg from the hatching hen. This being true, it is difficult 
 
 74 
 
IN CONGENITAL ]\IALFORMATION 
 
 to see how impressions could pass between the two. Later 
 on, after the placental circulation has developed and 
 the child begins to thrive upon the mother, there is indeed 
 a definite connection, but now the embryonal or develop- 
 mental stage has been passed and the stage of new growth 
 begun. Hence, even were the organic connection com- 
 plete, impressions could no longer affect the fetus in the 
 sense of producing multiplicities or duplicities, though 
 they might place their stamp upon organs or parts al- 
 ready formed. But the organic connection is by no 
 means complete. There is absolutely no link between the 
 nervous system of the mother and that of her offspring, 
 and since the impressionist evidently assumes that the ex- 
 ternal cause operates through the mind of the parent, we 
 are at a loss to see how it bridges this gap. While the 
 mother bears her child she merely supplies it with the 
 food necessary for its growth. There is even no admix- 
 ture of blood, the transmission being affected by osmosis 
 through a definite membrane which may be demonstrated 
 with the microscope. If the hen could speak we would 
 probably learn vastly more of the impressionists' side of 
 the case, since monstrosities are much more common in 
 birds than in mammals, and the process must be much 
 more complex, the &gg lying entirely outside the body and 
 the "impression" having, therefore, to travel a long dis- 
 tance through feathers, space and shell. Similarly the 
 incubator, were it not dumb, might throw much light on 
 the problem and entertain us with an account of the im- 
 pressions which it transmitted to the artificially hatched 
 chickens in which strange deformities are so often found. 
 And now what can we* say of the real cause of these 
 anomalies? "They are the result," says Ballantyne, "of 
 
 75 
 
TRADITION VERSUS EMBRYOLOGY 
 
 disorderly embryology, or disturbed ontogenesis and or- 
 ganogenesis ; many of them are arrested developments and 
 represent the stage which ought to have been temporary 
 in ontogenesis, but which have remained stationary while 
 other and neighboring parts were pursuing the path of 
 normal development." The marvellous combinations and 
 recombinations by which the three primary blastodermic 
 layers are woven into the human texture certainty offer 
 enough field for an occasional incongruous thread, par- 
 ticularly when it is remembered that the loss of a few 
 cells in the embryonic period may mean the absence of 
 the entire organ into which they would subsequently have 
 developed. Hence it needs no cataclysm to produce ''dis- 
 orderly embryology" and the influence of several definite 
 factors has been more or less definitely proven. The 
 germ plasm itself may be defective. Intrauterine pres- 
 sure, and even external traumatism, may so disturb the 
 fetus as to affect its development. Malposition of the 
 fetus in utero, abnormal diminution of the amniotic space 
 and adhesion of the membrane to the fetal parts may all 
 profoundly affect development, as has been proven by 
 numerous authenticated cases. 
 
 Finally, the state of the fetus may be seriously affected 
 by the general condition of the parent. It is conceivable 
 that a profound shock might so severely affect the health 
 of the mother as to impair the decidual circulation and 
 thus harm the child by an insufficient supply of food- 
 laden blood. The disturbance may be so severe as 
 to produce outright abortion or it may be less severe and 
 merely cause defective growth. But this is a very dif- 
 ferent thing from shocking into existence a new leg or a 
 
 76 
 
IN CONGENITAL MALFORMATION 
 
 frog-like head when both leg and head have already been 
 normally and perfectly developed. 
 
 With reference to the case cited at the beginning we, 
 therefore, attach no significance to the mother's explana- 
 tion, preferring to believe that it is but another instance 
 of ^'disorderly embryology" in the production of which 
 external impressions had no part. 
 
 17 
 
Treatment of Diffuse Suppurative 
 Peritonitis ^ 
 
 In studying the subject of suppurative peritonitis it 
 soon becomes apparent that the differences in the views 
 of various authors with reference to certain types of the 
 disease are due to a faihu'e to adopt the same classifi- 
 cation, and to a lack of a clear conception of what is 
 meant by the terms employed. We read of septic peri- 
 tonitis, local suppurative peritonitis, general suppura- 
 tive peritonitis and diffuse suppurative peritonitis. 
 
 The term septic peritonitis should be employed to des- 
 ignate those cases in which the pyogenic infection is so 
 acute and virulent that the patient dies before sufficient 
 time has elapsed for pus to form. 
 
 The term local suppurative peritonitis should be em- 
 ployed to indicate those cases in which, owing to the 
 character of the infection, pus develops slowly and na- 
 ture has time to form adhesions which confine the pus 
 to a limited portion of the peritoneal cavity. 
 
 The term diffuse suppurative peritonitis should be re- 
 served to designate the conditions in which the infection 
 is less virulent than in septic peritonitis, but more acute 
 than in local suppurative peritonitis; where there is time 
 for pus to form, but not time for nature to wall it in by 
 adhesions, and, as a consequence, pus is free in the peri- 
 toneal cavity. 
 
 * Read at meeting of the Southern Surgical and Gynecological 
 Association, New Orleans, December, 1907. 
 
 79 
 
TREATMENT OF 
 
 The term general suppurative peritonitis should be 
 discarded. It was originally used in contradistinction to 
 local suppurative peritonitis, and while its meaning should 
 be apparent it has been misconstrued, thus giving cause 
 for much discussion. The term was never intended to 
 mean that the whole peritoneal surface was involved. 
 The word "general" was used to indicate that the pus 
 was free, in contrast with the word ''local," where it was 
 confined. To avoid recurrence of unprofitable argument 
 and the statement by some that no patient with general 
 suppurative peritonitis ever recovered, and the reply by 
 others that, as the term was employed, no patient ever 
 lived long enough to develop it, it is to be hoped that the 
 title, general suppurative peritonitis, will be dropped from 
 surgical nomenclature, and diffuse suppurative peritonitis 
 substituted for it. 
 
 The confusion alluded to in the classification of peri- 
 tonitis is responsible for the condition which existed ten 
 years ago, when Abbe, McBurney, Finney and others 
 were reporting numerous successful operations for gen- 
 eral suppurative peritonitis, while at the same time, Senn 
 declared that he had opened, drained and washed out the 
 general peritoneal cavity in many cases of septic peri- 
 tonitis without a single successful result; Weir that he 
 had never been able to save a patient with general sup- 
 purative peritonitis, and had never seen one saved ; and 
 Granvin that, until recently, he had expected death after 
 general purulent peritonitis and was not at all ashamed 
 of his mortality rate of lOO per cent. At this period, 
 and for some years afterward, the accepted mode of 
 treatment was incision and removal of the focus of in- 
 
 80 
 
Fig. 4 — Bed Elevators 
 
DIFFUSE SUPPURATIVE PERITONITIS 
 
 f ection : evisceration, irrigation and sponging ; counter 
 incisions through the loins and the insertion of multiple 
 drains. The result was a mortality of about 80 per cent. 
 The present generally accepted method of treatment 
 was not adopted empirically, but was the result of de- 
 ductions from scientific observations. Its essential fea- 
 tures consist of Fowler's position and Murphy's procto- 
 clysis : hence, it may properly be called the Fowler-Mur- 
 phy treatment. In justice to others, however, the fol- 
 lowing history of the evolution of the method is given : 
 
 Muscatello demonstrated that the peritoneum of the 
 upper abdomen, or diaphragmatic region, possesses much 
 greater and more rapid absorptive power than the peri- 
 toneum of the lower abdomen or pelvic region. Clark 
 saw the possibilities of postural drainage and advised ele- 
 vating the foot of the patient's bed, thus throwing fluid, 
 by gravity, to the surface which would most rapidly ab- 
 sorb it. Fowler said that the principle of postural drain- 
 age was correct, but its application was wrong; that the 
 fluid should not be drained into the patient, but out of 
 him. Fie advised elevating the head of the bed to allow 
 the fluid to gravitate from the diaphragm where it would 
 be absorbed, to the pelvis where it would be collected 
 until removed by a drain. Bond demonstrated that par- 
 ticles of indigo-carmine placed inside the anus would be 
 carried upward by what he termed "reverse mucous cur- 
 rents." Cannon showed that except during defecation 
 antiperistalsis is the normal movement in the large intes- 
 tine, and that, owing to this fact, liquid feces are carried 
 back into the cecum, where the watery element is ab- 
 sorbed. 
 
 81 
 
TREATMENT OF 
 
 Murphy suggested utilizing the foregoing observation 
 in the treatment of suppurative peritonitis, by injecting 
 saHne solution slowly into the rectum, depending on re- 
 verse peristalsis to carry it to the cecum where it would 
 be absorbed. He reasoned that, owing to the patient be- 
 ing unable to take as much water as was being elimi- 
 nated, he became dehydrated and the empty vessels of 
 the peritoneum rapidly absorbed any fluid the cavity 
 contained. If, by introducing a large quantity of fluid 
 into the circulation, the vessels could be overfilled, then 
 the peritoneum would be changed from an absorbing sur- 
 face to a secreting surface, and in place of toxic fluids 
 going into the circulation, there would be a flow of cleans- 
 ing serum into the peritoneal cavity. 
 
 The practical steps of the Fowler-Murphy method are 
 as follows : Open the abdomen over the seat of the pri- 
 mary focus of infection and correct the trouble, whatever 
 it may be, so as to prevent the admission of further poi- 
 son. Make a second short incision immediately above 
 the pubes, and insert a large rubber drain to the bottom 
 of the pelvis. The work should be rapid, with as little 
 manipulation of the viscera as possible, and no effort 
 should be made to remove the pus by sponging or irriga- 
 tion. Place the patient in bed in an exaggerated Fow- 
 ler's position. Give saline solution by continuous low- 
 pressure rectal instillation ; administer morphine, in small 
 doses, for pain and spartein, in large doses, as a general 
 stimulant and prophylactic against suppression of urine. 
 Purgatives should not be employed, but bowel action se- 
 cured by the cautious use of enemata. If there is much 
 nausea or vomiting the stomach should be thoroughly irri- 
 
 82 
 
Fig. 5— Bed Seat 
 
DIFFUSE SUPPURATIVE PERITONITIS 
 
 gated, and no food should be given until the patient can 
 retain and assimilate it. 
 
 By the adoption of the method outlined I have seen 
 a great change in my mortaHty. A recent analysis of 
 the last 500 cases of appendicitis operated on in my pri- 
 vate hospital gives a record of twenty-four patients with 
 diffuse suppurative peritonitis. The first six were 
 treated by the old method of irrigation and multiple 
 drainage, with five deaths. The last eighteen were treated 
 by the Fowler-Murphy method, with but one death. 
 
 Coffey has demonstrated that there are three cavities 
 or basins of the peritoneum to be drained — the right and 
 left flank, separated from each other by the spinal 
 column and the pelvis, separated from the flanks by the 
 psoas muscle. When the body is horizontal each flank 
 holds more fluid, and is deeper than the pelvis. The 
 bottom of the flank cavity is four inches below the top 
 of the divide made by the psoas muscle. Hence, theoret- 
 ically, a patient's body must be elevated to an angle of 
 50 degrees to permit gravity drainage of the flanks. I 
 have found great difliculty in maintaining a patient in 
 this position, and recently, in visiting various hospitals, 
 I have always inquired what method or apparatus was 
 employed in managing such cases. 
 
 I have found two principles in practice, angulation of 
 the patient and angulation of the bed. The first is ef- 
 fected by keeping the bed horizontal and elevating the 
 patient's body by means of a shoulder rest; the second, 
 by elevating the head of the bed and allowing the patient 
 to lie flat on the inclined mattress. As one method must 
 be superior to the other, I have given their relative merits 
 
 83 
 
TREATMENT OF 
 
 considerable thought. The advantage claimed for the 
 "semi-sitting position" over "bed-elevation" is that it gives 
 better drainage. This I do not beheve is true, because, as 
 I will try to show, it is impossible to maintain a patient 
 in the proper position on a shoulder rest, while it is an 
 easy matter to prevent his slipping on an inclined mat- 
 tress, no matter what the elevation. 
 
 The disadvantages of the semi-sitting position are: 
 (i) It makes it difficult for the nurse to place the bed- 
 pan properly; (2) it is unnatural and subjects the patient 
 to mental and muscular tension; (3) he will slip down 
 when relaxed by weakness or sleep, so that his body will 
 bend at the costal arch and his abdomen will be on a 
 plane parallel with the surface of the bed. To prevent 
 the tendency to assume this false position, some sur- 
 geons use auxiliary straps attached to the shoulder rest; 
 some a double inclined plane to support the legs ; and 
 others go so far as to elevate the foot of the bed. None 
 of these methods, however, satisfactorily corrects the 
 trouble. 
 
 The advantages of elevating the head of the bed are: 
 ( I ) The mattress may be put at any angle ; (2) the patient 
 lies on a flat surface, often unconscious of his position; 
 and (3) he is completely relaxed and easily nursed. The 
 difficulty experienced in managing this position has been 
 to get a simple device for raising or lowering the head of 
 the bed, and to devise a means to prevent the patient from 
 sliding down the incline. Blocks, boxes and tables have 
 been used for the first, and pillows, hammocks and swings 
 placed beneath the buttocks and attached to the head of 
 the bed, for the second. 
 
 84 
 
Fig. 6 Bed in Moderate Elevation 
 
DIFFUSE SUPPURATIVE PERITONITIS 
 
 I herewith present a model and photographs of a sim- 
 ple and cheap apparatus which I have employed for more 
 than a year to accomplish both of the desired ends. The 
 bed elevator (Fig. i) consists of a wooden base and up- 
 right piece. There are a number of notches on the side 
 of the upright, into which fits an iron link which supports 
 a block to receive the leg of the bed. The link when 
 horizontal, slips up or down, but when oblique fits into 
 a notch, just as does the lock of an ordinary needleholder. 
 
 The bed seat (Fig. 2) consists of a board which either 
 bare or padded with a pillow, makes a shelf on which 
 the patient sits. A wooden shaft projects downward and 
 passes through a second board which rests against the 
 foot-piece of the bed (Fig. 3). In the shaft are a num- 
 ber of holes, and a peg placed in one of them will pre- 
 vent the shaft from passing through the bottom board, 
 and thus transfer the weight of the patient to the foot 
 of the bed. 
 
 The advantages of the bed seat over a hammock or 
 swing are its rigidity and consequent sense of security 
 given the patient ; the ease with which it can be removed 
 and replaced by the nurse when it is found necessary to 
 do so ; and also the fact that there are no straps or ropes 
 on either side of the patient's head or body to embarrass 
 the nurse or alarm the relatives. Both of the devices 
 described can be made by any carpenter at the cost of 
 a few dollars, and will securely maintain the patient at 
 any angle for any time without discomfort. 
 
 85 
 
The Surgical Treatment of Dyspepsia* 
 
 A generation ago nearly all of our knowledge with 
 reference to diseased conditions was derived from post- 
 mortem examinations made by pathologists. Today much 
 of our information is derived from ante-mortem examin- 
 ations made by surgeons. Observations taken during the 
 early stages of disease before the initial lesions are ob- 
 scured by secondary complications and terminal infections 
 have changed many of the theories formerly held by the 
 profession, and in no instance has this been more radical 
 than with reference to the so-called ''dyspepsia." 
 
 It was formerly taught that indigestion was purely a 
 functional disturbance of the stomach to be treated by 
 hygienic, dietetic and medicinal measures ; it is now ac- 
 cepted that indigestion when chronic or recurrent is al- 
 most invariably caused by organic changes in the stomach, 
 duodenum, gall-bladder or appendix, and that relief from 
 symptoms can only be permanently secured by surgical 
 correction of the anatomic lesions. 
 
 Every one suffers at times from indigestion due to in- 
 discretions in eating, but no one has constant, persistent 
 dyspepsia lasting for months or years unless it be due to 
 some organic disease. A case of indigestion ought not to 
 be subjected to surgery until it has been carefully and 
 properly treated by medical measures, but every case that 
 fails to secure relief in a reasonable time should be exam- 
 
 * Read at the meeting of the Medical Association of the State 
 of Alabama, Montgomery, Ala., April, 191 1. 
 
 87 
 
THE SURGICAL TREATMENT OF DYSPEPSIA 
 
 ined to see if there is not some indications for operative 
 intervention. 
 
 In investigating a patient it should be remembered that 
 while the symptoms may be due to disease of the stomach 
 itself they may also be due to reflex irritation from dis- 
 ease of some other abdominal organ. It is a fact that in 
 nine cases out of ten it will be found that the lesion is not 
 in the stomach but in some associated viscus, such as the 
 duodenum, appendix or gall-bladder. In other words, 
 while the symptoms are gastric and the treatment is sur- 
 gical the operation required is not necessarily on the 
 stomach. 
 
 Appendicitis, cholecystitis and duodenal ulcer are sup- 
 posed to interfere with digestion by causing a spasm of 
 the pylorus. Pylorospasm is a protective effort on the 
 part of nature to prevent the passage of irritating gas- 
 tric contents into the intestinal tract. The most promi- 
 nent symptom is a cramping pain in the epigastrium 
 which may last only a few minutes or may continue sev- 
 eral hours. In some cases the spasm may relax suddenly, 
 in others it may terminate slowly and gradually. Some 
 patients have attacks several times a day, others at in- 
 tervals of weeks, and others still only once or twice a 
 year. In the interval between attacks digestion may be 
 normal. During attacks the peristalsis of the stomach is 
 increased, but food cannot pass through the pylorus and 
 often relief comes only after vomiting. Pylorospasm is 
 a symptom, not a disease. It is usually the expression of 
 disease of some remote abdominal structure. To effect a 
 cure the real cause of the condition must be removed, and 
 the patient treated until the hypersensitiveness of the 
 
 88 
 
THE SURGICAL TREATMENT OE DYSPEPSIA 
 
 pyloric muscle is relieved and its spasm habit overcome. 
 
 The essential role which surgery plays in the successful 
 treatment of the various forms of so-called chronic dys- 
 pepsia will be impressed by a brief review of the symp- 
 toms of duodenal ulcer, infection of tlie bile tract, chronic 
 appendicitis and gastric cancer. 
 
 Duodenal Ulcer, while formerly thought to be rare, 
 is now known to be a very common disease. Patients 
 give a history of indigestion of many years standing with 
 intervals of complete relief from symptoms. At first 
 there is the development of a sense of weight, oppression 
 and distension after meals. Later it is noted that dis- 
 comfort occurs regularly from two to three hours after 
 taking food. Pain comes on gradually, and slowly in- 
 creases. There is a sensation of fullness followed by 
 eructation of gas or bitter fluid. Symptoms are imme- 
 diately and completely relieved by taking food, and 
 patients frequently keep a biscuit or glass of milk easily 
 accessible in order to arrest the ''hunger pain" when it 
 develops. A characteristic feature of duodenal ulcer is 
 the recurrence of symptoms after intervals of complete 
 relief. Attacks come on as the result of exposure to 
 cold, imprudence in eating, worry, or over work. The 
 physical signs consist in some tenderness in the epigas- 
 trium and rigidity of the right rectus muscle. In the 
 later stages when stenosis develops there are the signs of 
 dilated and obstructed stomach. Still later there may be 
 hemorrhage, the blood appearing in either vomitus or 
 feces. Hemorrhage is usually a late symptom. It is an evi- 
 dence of deep penetration of the walls of the duodenum 
 
 89 
 
THE SURGICAL TREATMENT OF DYSPEPSIA 
 
 by an ulcer whose existence should have been recognized 
 by other symptoms at an earlier period. 
 
 Chronic Cholecystitis, with or without gall stones, is 
 another common cause of indigestion. Symptoms during 
 the early stage of the disease are always referred to the 
 stomach. There is usually gastric distress coming on 
 shortly after taking food and relieved by eructation of 
 gas. Frequently there is nausea and vomiting attended 
 by a dull pain beginning in the epigastric region and ex- 
 tending around the right side at the level of the tenth rib. 
 Later there may be typical attacks of biliary colic. The 
 pain is sudden in its onset and sudden in its relief, and is 
 attended by a sharp catch in the breath. It is cramp 
 like, goes through to the back and up to the right shoulder 
 blade. The pain is not produced nor is it relieved by 
 taking food. It is attended by nausea, retching and vomit- 
 ing, and followed by sweating and prostration. Still 
 later there may come the symptoms of duct obstruction 
 with jaundice, or duct infection with chronic pancreatitis. 
 Jaundice is not present in 50 per cent, of cases and its 
 absence should not prevent a proper diagnosis. 
 
 Chronic Appendicitis may exist for years and cause no 
 symptoms except dyspepsia. The patient has no pain or 
 tenderness at McBurney's point, but suffers with acid 
 stomach, eructation of gas and occasional vomiting. The 
 symptoms come on after eating but there is no regularity 
 as one meal may cause trouble while another produces no 
 ill effect. Food never gives relief and exercise usually 
 makes the symptoms worse. After a longer or shorter 
 time there comes an acute attack of appendicitis with 
 symptoms which make the diagnosis evident. An opera- 
 
 90 
 
THE SURGICAL TREATMENT OF DYSPEPSIA 
 
 tion is done to save the patient's ilfe and six months later 
 the individual comes back to say you have restored his 
 health. The removal of the appendix has cured his dys- 
 pepsia and he is able to eat what he pleases with im- 
 punity. 
 
 Cancer of the Stomach usually develops at the seat of 
 and old ulcer. A careful investigation of the patient's 
 symptoms will usually show history of indigestion ex- 
 tending over many years, first characteristic of hyper- 
 chlorhydria, then of gastric ulcer and finally of cancer of 
 the stomach. There is first indigestion with sour 
 eructation and pain two to five hours after eating. 
 Later vomiting of bitter acid fluid, constant discomfort 
 or distress and intense pain immediately after eating. 
 Finally obstructive symptoms with vomiting of retained 
 food mixed with blood. There is progressive weakness, 
 emaciation and cachexia. In the last stages there is usu- 
 ally the presence of a palpable tumor. 
 
 The foregoing histories cover a host of cases treated 
 by the general practitioner for gastralgia, chronic gas- 
 tritis, sour stomach or acid dyspepsia. They are definite 
 surgical diseases and should be recognized as such. 
 
 Spasmodic obstruction of the pylorus, or pylorospasm, 
 due to reflex irritation from chronic disease of the appen- 
 dix or gall-bladder should be relieved by removing the 
 cause, not by an operation on the stomach itself. 
 
 Organic obstruction of the pylorus from cicatricial 
 contraction of an ulcer of the stomach or duodenum 
 should be relieved by the provision of a new outlet by 
 means of a gastro-enterostomy. 
 
 91 
 
THE SURGICAL TREATMENT OF DYSPEPSIA 
 
 Non-obstructing ulcers and early carcinomas of the 
 stomach should be removed by resection. 
 
 I trust the views expressed will not be considered too 
 radical. None of them are original but are a compilation 
 from the writings of men of experience and authority. 
 With increasing knowledge of disease from observations 
 made by surgeons during operations, from investigations 
 conducted by scientists in laboratories, and from deduc- 
 tions made by internists from patients in actual practice, 
 we find our views as to the proper treatment of certain 
 conditions rapidly changing. 
 
 Today ex-ophthalmic goitre or hyperthyroidism is con- 
 sidered a surgical affection. I feel sure in time it will 
 be transferred to the department of internal medicine. 
 Until recently dyspepsia has been treated medically. I 
 feel sure the conscientious physician will soon refer all 
 cases which resist a reasonable amount of treatment to 
 the surgeon. 
 
 Conclusions. 
 
 1. Persistent or recurring indigestion is not due to 
 errors of secretion but to anatomical lesions of the 
 stomach or associated viscera. 
 
 2. A patient who is not relieved in a reasonable time 
 by medical treatment should have the abdomen opened 
 even if the operation is in the nature of an exploration. 
 
 3. While the symptoms are gastric in nine cases out 
 of ten the lesion will not be found in the stomach but 
 in an associated viscus such as the duodenum, gall-blad- 
 der or appendix. 
 
 4. Pylorospasm should not be treated by a gastroen- 
 
 92 
 
THE SURGICAL TREATMENT OF DYSPEPSIA 
 
 terostomy but by an effort to diagnosticate and remove 
 the irritation which produced it. 
 
 5. It is advisable at the time of the operation to ex- 
 amine all abdominal organs and correct every abnor- 
 mality lest the obvious may not be the real cause of the 
 symptoms. 
 
 6. It is important that these cases should have proper 
 post-operative and post-hospital treatment. 
 
 93 
 
Analysis of the Last Five Hundred 
 
 Cases of Appendicitis Operated On 
 
 at St. Luke's Hospital* 
 
 I have no apologies to make for reading a paper on 
 appendicitis, because the disease is so frequent as to 
 necessitate approximately one-third of all the abdominal 
 section done, and because, too, it is so many-sided as to 
 constantly present new features for discussion. I must 
 apologize, however, at the very outset, for the personal 
 character of this paper. It is not a review of the litera- 
 ture of the subject, but a statement of observations and 
 conclusions based upon my own work. xA.t another place 
 and to other audiences, I might be thought to be ego- 
 tistical, but here among my friends, many of whom have 
 brought me the cases reported, I trust the spirit in which 
 I write will not be misunderstood. As a further extenu- 
 ating circumstance, I would say that this is the first paper 
 on appendicitis I have ever read before this or any other 
 Society. 
 
 Surgically speaking, appendicitis and I are about the 
 same age. I saw my father open a "perityphlitic abscess" 
 in 1886, and was his assistant in the seventeen operations 
 which formed the basis of his original contributions to 
 the literature of the subject. For the past sixteen years I 
 
 * Read at meeting of the Medical Society of Virginia, Chase 
 City, Va., November, 1907. 
 
 95 
 
ANALYSIS OF LAST FIVE HUNDRED CASES 
 
 have operated on a progressively increasing number of 
 cases, but I have avoided the subject in my writings, be- 
 cause my views as to the treatment of certain types of 
 the disease have several times changed, and I have hesi- 
 tated to put myself on record until, by the careful study 
 of a large number of cases, I could satisfy myself of the 
 correctness of my conclusions. 
 
 The five hundred cases of appendicitis which form 
 the text of this article were all operated on at St. Luke's 
 Hospital, and cover a period of about five years' work. 
 The figures given have been tabulated by one of my 
 assistants. Dr. LaRoque, and I wish here to acknowledge 
 my indebtedness to him for his accurate and laborious 
 work. They are not selected cases, but are taken con- 
 secutively from the records of the institution, and there- 
 fore represent the disease as it occurs in this section of 
 the country. 
 
 These cases do not include the removal of 325 normal 
 appendices, which were done in the course of operations 
 for other troubles in the abdomen during the same period 
 of time. There was no death in this list of cases, but it 
 does not seem fair to include them, for while it is true 
 they were operations of appendectomy, the patients were 
 not suffering from appendicitis. Nor does the list em- 
 brace cases of appendicitis done during the same period 
 at the Virginia Hospital and other institutions, because, 
 first, of lack of accurate case records, and, second, a desire 
 to cover a considerable working period, so as to contrast 
 the results obtained under the old methods with those of 
 more recent adoption. 
 
 In order to facilitate the study of the cases reported, 
 
 96 
 
OF APPENDICITIS AT ST. LUKES HOSPITAL 
 
 it is necessary to classify them, and I have divided them, 
 not on a pathological, but on a surgical, basis. I have 
 separated them into four classes, which I always have in 
 mind when I am deciding what to do for a patient suf- 
 fering with the disease. 
 
 1. Chronic appendicitis, where the operation is done 
 between attacks, and the diagnosis is based on the history 
 of the patient, tenderness over the appendix, and, per- 
 haps, digestive disturbances. 
 
 2. Acute appendicitis, where the operation is done 
 early, before inflammation extends to adjacent structures, 
 whether the attack be primary or an exacerbation of 
 symptoms during the course of chronic disease. 
 
 3. Appendicitis zvith abscess, or a localized collection 
 of pus in the lower right quadrant of the abdomen. These 
 cases are again subdivided into : 
 
 (a) Abscesses which are adherent to the parietal peri- 
 toneum and can be opened and evacuated without infect- 
 ing the general cavity ; 
 
 (b) Abscesses which are not adherent to the abdomi- 
 nal wall and can only be approached by opening the gen- 
 eral peritoneum. 
 
 4. Appenicitis with diffuse peritonitis, where, owing to 
 the acuteness of the infection or the absence of resistence, 
 there is no wall of lymph or adherent bowel and omen- 
 tum to confine the pus, but it finds its way into the gen- 
 eral peritoneal cavity. 
 
 Under this classification, the five hundred cases divide 
 themselves as shown in the following table : 
 
 97 
 
ANALYSIS OF LAST FIVE HUNDRED CASES 
 
 Number. Deaths. 
 
 1. Chronic appendicitis (interval operation) . . 177 o 
 
 2. Acute appendicitis (early operation) 206 i 
 
 3. Appendicitis with abscess : 
 
 (a) Adherent to peritoneum beneath in- 
 
 cision 23 o 
 
 (b) Not adherent to peritoneum beneath 
 
 incision . . . /O 7 
 
 4. Appendicitis with diffuse peritonitis 24 6 
 
 Totals 500 14 
 
 Race. — St. Luke's Hospital does not receive colored 
 patients, and no record of the nationality of the white 
 patients was kept; hence on this subject the statistics are 
 valueless. It is a fact that appenicitis is not common 
 among the negroes ; still, during the same working period, 
 I am sure I have operated on more than fifty cases in this 
 race at another hospital. 
 
 Age. — The oldest patient in the series reported was 
 seventy-two, and the youngest, six years old. A casual 
 inspection of the figures giving the ages of all the patients 
 shows that appendicitis is not common at either of the 
 extremes of life. It is comparatively rare in infants and 
 young children on account of the funnel-shape structure 
 of the appendix and caecum, and relatively uncommon in 
 old age because the lymphoid structure in the appendix 
 atrophies just as it does in the tonsils. The mortality 
 of the disease in the young is high, due probably to 
 to their small omentum and intolerance to infection. In 
 the above cases there are thirty-eight occurring in chil- 
 dren — twenty attended by perforation, of which four 
 died. Thus, of the fourteen deaths in five hundred cases, 
 four occurred in thirty-eight operations on children. 
 
 98 
 
OF APPENDICITIS AT ST. LUKES HOSPITAL 
 
 Sex. — Of the five hundred cases, two hundred and 
 eight were males and two hundred and ninety-two fe- 
 males. This would seem to show that women, despite 
 the additional blood supply to the appendix through the 
 appendiculo-ovarian ligament of Clado, have no relative 
 immunity to the disease, as compared to men, but, on the 
 contrary, are more predisposed to the disease, probably 
 from the fact of the relation of the appendix to the right 
 tube and ovary, and its liability to infection from that 
 source. An analysis of the figures shows, however, that 
 appendicitis is more apt to assume a fatal form in men 
 than in women, for, despite the greater number of cases 
 occurring in women, there were only five deaths, whereas, 
 in the smaller number of cases occurring in men, there 
 were nine deaths. The fact that appendicitis is more fatal 
 in one sex than the other is believed to be due not only to 
 the additional blood supply of the appendix in the female, 
 to which attention has been already called, but also to 
 the fact that through hereditary immuntiy they have 
 greater resistance to peritoneal infection of the lower 
 abdomen. 
 
 Mortality. — In the 500 operations reported there have 
 occurred fourteen deaths. This gives a mortality of 2.8 
 per cent. Of the deaths, five occurred in the first hun- 
 dred ; five in the second hundred ; two in the third hun- 
 dred ; one in the fourth hundred, and one in the fifth 
 hundred. If it were my purpose in this paper to show 
 a low mortality, I would have only reported the last two 
 hundred consecutive cases, and claimed a death rate of 
 one per cent. I have purposely gone back in my records 
 and included cases operated upon as much as five years 
 
 99 
 
ANALYSIS OF LAST FIVE HUNDRED CASES 
 
 ago, in order to show the improvement which has fol- 
 lowed the adoption of more recent methods of operating. 
 A surgeon should not try to be a record maker, but a life 
 saver, and his ability should not be reckoned by the cases 
 he loses, but the cases he saves. The five hundred cases 
 reported are not selected, but are taken consecutively from 
 the hospital records. During the working period covered, 
 every case admitted was operated on except one, who 
 was moribund when first seen and died two hours later. 
 The rapidly decreasing mortality in the series of cases 
 will be partly explained when I describe the change 
 adopted in the technique of operating on certain types, 
 but also has explanation in the education of the pro- 
 fession and public as to the advisability of early opera- 
 tion, and the greater promptness with which a case is 
 now brought to the surgeon. It is an unquestioned fact 
 that the results obtained in operating for appendicitis 
 depend not as much upon the skill of the operator as the 
 conditions and the complications with which he has to 
 deal. 
 
 Symptoms and Diagnosis. — On this subject I have 
 little to say. When the clinical history and symptoms 
 are typical, there is no difficulty in making a positive 
 diagnosis. When the classical signs are absent, it is often 
 impossible to say that appendicitis does not exist. In 
 other words, in these five hundred cases, I have never 
 failed to find the appendix inflamed when I have made 
 a preliminary diagnosis of appendicitis, and I have often 
 found it to exist when I had not made a postive diagnosis, 
 but did an exploratory operation, like Elbert Hubbard 
 sends a new book — "on suspicion." 
 
 JOG 
 
OF APPENDICITIS AT ST. LUKES HOSPITAL 
 
 Treatment. — It is now a generally conceded fact that 
 there is but one treatment for appendicitis — namely, the 
 surgical removal of the diseased organ. The question 
 that has perplexed the profession is when to operate. 
 For a long time I held the opinion that no fixed rule could 
 be formulated and that every case should be decided on 
 its own mtrt. I then became a follower of Ochsner, and 
 claimed that some cases came to the surgeon too late for 
 an early operation, and too early for a late operation, 
 and that an effort should be made to carry them over 
 this period by gastric lavage, prohibition of food by the 
 mouth, and nourishment by the rectum. Finally, how- 
 ever, after much thought and careful observation, I have 
 become firmly convinced that Murphy was right in his 
 bold and dogmatic statement made many years ago, that 
 we should operate on all cases of appendicitis as soon as 
 the diagnosis is made. There are, of course, a few cases 
 where this rule will work hardship, but I am sure that 
 if it is rigidly applied, it will accomplish "the greatest 
 good to the greatest number," and that the man who 
 follows it will, in the end, save more patients than the 
 one who does not. The objections made to it are that 
 we should not operate upon the convalescent or the 
 moribund. The answer is that it is impossible to 
 differentiate between them and the others. Patients 
 apparently improving and on the road to recovery some- 
 times develop a fatal complication, and patients ap- 
 parently dying sometimes get well by means of a timely 
 operation performed by a courageous surgeon. 
 
 The question with me is no longer when to operate. 
 It is settled, and I am as free from doubts and misgivings 
 and as happy in the conviction of the truth of my doc- 
 
 lOI 
 
ANALYSIS OF LAST FIVE HUNDRED CASES 
 
 trine as an erring darky who has been long seeking and 
 suddenly found religion. The question now with me is 
 how to operate, and I think this can only be determined 
 by dividing cases into certain groups and applying a dif- 
 ferent method to each. 
 
 1. Chronic appendicitis, where the operation is done 
 between attacks, the patient being well, and the diagnosis 
 based on previous history, tenderness over the appendix, 
 and perhaps digestive disturbances. The technique of 
 an operation on this type of appendicitis is not of much 
 moment. Personally, I use McBurney's muscle splitting 
 incision, deliver the csecum into the wound, and ligate 
 and divide the mesentery of the appendix. I then crush 
 the base of the appendix, tie it with catgut, amputate 
 and bury the stump with a purse-string suture of linen. 
 I then close the peritoneum and the two muscular layers 
 of the abdominal wall with catgut, and sew the skin and 
 underlying fat with horse-hair. If no complications 
 exist, the time of the operation is from five to seven 
 minutes; the length of the incision from two to three 
 inches ; confinement in bed, ten to fourteen days ; and 
 detention from business, two to three weeks. I have 
 never had a hernia or death following an operation of 
 this type. It is one of the safest and most satisfactory 
 in surgery, not only removing danger of a subsequent 
 attack of appendicitis, but frequently relieving long- 
 standing digestive disturbances and causing marked im- 
 provement in the patient's general health. 
 
 2. Acute appendicitis, where the operation is done 
 before inflammation extends to adjacent structures. — The 
 technique in this class of cases is exactly the same as 
 the foregoing. It is necessary to work more slowly and 
 
 102 
 
OF APPENDICITIS AT ST. LUKES HOSPITAL 
 
 handle the appendix more carefully, in order to avoid 
 rupture of its walls and infection of the peritoneal cavity. 
 There is no necessity for the use of drainage, and re- 
 covery is as prompt as in chronic cases. The only death 
 I have had in the two hundred and six cases of the 
 present series was due to an error. The patient was a 
 young man just recovering from an attack of appendicitis 
 which had confined him to bed for two weeks. He had 
 stricture of the urethra, for which an operation had been 
 done by another surgeon. Before taking the anaesthetic, 
 he asked that while on the table the stricture be well 
 dilated. The appendix was found congested and ad- 
 herent, but was removed without difficulty. After the 
 abdominal dressings were applied, a large sound was 
 introduced into the urethra. He did well for some hours, 
 then had a hard chill, developed septicemia, and died 
 within forty-eight hours. As stated, the appendectomy 
 in this case was an uncomplicated one; and four other 
 abdominal sections done the same day, with the same 
 instruments and the same assistants, made uneventful 
 recoveries. I sincerely believe the man's death was due 
 to the urethral instrumentation, but as the primary 
 operation was for appendicitis, the result is classed under 
 that head. 
 
 3. Appendicitis with abcess. — The technique of opera- 
 tions for this type depends entirely upon whether the 
 abcess is adherent to the abdominal wall and can be in- 
 cised and drained without opening the peritoneal cavity, 
 or whether it is not adherent and can only be reached 
 by opening the general peritoneum. 
 
 (a) If the abcess is adherent to the parietal peri- 
 toneum beneath the incision, it should simply be opened 
 
 103 
 
ANALYSIS OF LAST FI\^ HUNDRED CASES 
 
 and drained, and no effort made to locate or remove the 
 diseased appendix. W^ith all due deference to those who 
 do not agree with me, I consider it a surgical crime to 
 break up the protecting wall formed by nature, and to 
 liberate infectious fluid into the peritoneal cavity, when 
 a safe exit may be given the pus by simply following the 
 indication of nature and making an incision at the point 
 she is endeavoring to effect drainage. The only danger 
 in adopting this method is that there may be a secondary 
 abcess which will not be drained. This complication 
 should always be borne in mind, especially when the 
 patient has been sick many days. If a second collection 
 of pus is detected, the case should be treated as will be 
 described in the next class. 
 
 The safety of the operation advocated is shown by 
 the fact that of the twenty-three cases above reported 
 there were no deaths. In all these cases the patients were 
 told that they were operated on not for appendicitis, but 
 for an abcess which was the result of appendicitis, and 
 that their appendix had not been removed. They were 
 advised of the possibility of future trouble and warned 
 to apply promptly for surgical relief if in the future they 
 suffered abdominal pain. As far as I know, there has 
 been no subsequent trouble in any of the twenty-three 
 cases. 
 
 (b) If the abcess is not adherent to the peritoneum 
 beneath the incision, but is between the walls of the 
 intestines or folds of the omentum, in a position in which 
 it can only be reached after opening the general peritoneal 
 cavity, then an entirely different technique must be pur- 
 sued. After the abdomen is opened and the inflammatory 
 mass located by palpation it should be carefully and 
 
 104 
 
OF APPENDICITIS AT ST. LUKES HOSPITAL 
 
 effectually isolated from adjacent structures by numerous 
 pads of gauze wrung out of hot saline solution. Adhe- 
 sions should then be separated, until the pus collection 
 is opened. It should be sponged out and the appendix 
 sought for and removed. The infected area should then 
 be drained with strips of gauze enclosed in a protecting 
 layer of rubber tissue. One end of the drain should cover 
 the denuded surface in the peritoneal cavity; the other 
 should project through the upper angle of the abdominal 
 incision. In addition to this, a rubber tube should be 
 inserted through the lower angle of the incision so as to 
 drain the bottom of the pelvis, and the patient should 
 be put to bed in an exaggerated Fowler's position. 
 
 In the five hundred cases recorded, seventy were of 
 this type, giving seven deaths, or a mortality of lo per 
 cent. Most of the fatal cases occured before the use of 
 the pelvic drainage and Fowler's position, and in future 
 it is believed results will be much better. 
 
 4. Appendicitis with diffuse peritonitis, or cases where 
 there is perforation of the appendix and free pus in the 
 general peritoneal cavity. This type, until recently, has 
 been the terror of the surgeon. The old method of open- 
 ing the abdomen, removing the appendix, washing out the 
 peritoneal cavity with or without evisceration, and making 
 counter incisions for multiple drainage, was followed 
 by a mortality of about 80 per cent. There has been, 
 to my mind, no recent advance in surgery so brilliant in 
 theory or so practical in results as the new technique of 
 treating diffuse suppurative peritonitis. In these cases 
 a short incision should be made over the appendix, and 
 the diseased organ removed, if it is readily accessible. 
 A second incision, not necessarily more than an inch in 
 
 105 
 
ANALYSIS OF LAST FIVE HUNDRED CASES 
 
 length, should be made in the mid-line, above the pubes. 
 A rubber tube one-half inch in diameter, with openings 
 on the side, should be introduced through the suprapubic 
 opening and carried to the bottom of the pelvis. No 
 irrigation of the abdomen should be practiced, no effort 
 even made to sponge out the pus, but a voluminous dress- 
 ing should be applied and the patient quickly put to bed 
 in an exaggerated Fowler's position. Saline solution 
 should be slowly and continuously given by rectum, the 
 stomach contents washed out if vomiting is persistent, 
 and the heart and kidneys stimulated by the hypodermic 
 use of sulphate of spartine in large doses. 
 
 The difficulty often experienced is to keep the patient 
 in the proper position in bed, so that fluids in the abdomi- 
 nal cavity will be carried by gravity to the pelvis. To 
 obviate this, I have devised a bed-seat, which is easily 
 and cheaply constructed and which will maintain a 
 patient, with perfect comfort, at any angle it is desired 
 to elevate the head of the bed. (See figs, i, 2, 3.) 
 
 Of the twenty-four cases of appendicitis with diffuse 
 peritonitis in the cases reported, there were six deaths. 
 Five of these occurred in the first six cases operated on, 
 when the method of irrigation and multiple drainage was 
 practiced. Since the adoption of the new method, two 
 years ago, I have had but one death in the remaining 
 eighteen cases. In other words, the change of technique 
 has reduced the mortality from over 80 per cent, to 5.5 
 per cent. 
 
 106 
 
Some Accepted Facts and Mooted 
 
 Points in the Management 
 
 of Appendicitis * 
 
 Before certain societies it is both proper and desirable 
 that unusual cases should be reported, original opera- 
 tions described, and new theories advanced, but at a 
 meeting such as this, I think the time at our disposal 
 should be devoted to the discussion of the diseases we 
 are most frequently called upon to treat ; and hence those 
 we should endeavor to know most about. I believe we 
 should recognize the fact that we are practitioners, and 
 not scientific investigators, and that we should leave the 
 solution of new and complicated problems to the men 
 working in laboratories and large metropolitan hospitals, 
 and be satisfied ourselves if we adopt the best and most 
 accepted methods, and apply them skillfully and effi- 
 ciently for the relief of our patients. 
 
 Personally, entertaining these views, I am glad to 
 learn from the program that practically the entire time 
 of this meeting will be devoted to the consideration of 
 appendicitis and typhoid fever. Those who read papers 
 may have nothing essentially new to present, but the same 
 may be said of ministers, who have preached the Gospel 
 for many centuries, and whose labor is not in vain. 
 
 History. — Appendicitis was first clearly recognized and 
 accurately described by Fitz, of Boston, in 1886, and the 
 
 * Read at meeting of the Florida State Medical Association, 
 Pensacola, Fla., April, 1909. 
 
 107 
 
ACCEPTED FACTS AND MOOTED POINTS IN 
 
 profession of America has been largely instrumental in 
 working out the various problems with reference to its 
 diagnosis and treatment. The English and Continental 
 surgeons, for a time, derisively called it the American 
 disease, and were obstructionists in the advance of knowl- 
 edge concerning it, and although they have now fallen 
 in line, they have never been able to keep pace with the 
 work of the profession in this country. 
 
 Frequency. — The frequency of appendicitis is shown 
 by the fact that, according to Osier, it causes the death 
 of one out of every fifty who die, and by hospital records 
 which show that, in recent years, it is responsible for 
 from one-fourth to one-third of all the operations per- 
 formed. The disease, however, is not as frequent as one 
 might infer from the society notes in a daily paper as, 
 from personal observation, I have known many patients 
 to attribute confinement in a sanitarium to appendicitis, 
 when their disease was in reality a less interesting and 
 fashionable ailment. The laity are under the impression 
 that the number of cases of appendicitis is increasing, 
 but this, of course, is not so. Cases are now correctly 
 diagnosticated as appendicitis, whereas, before they were 
 called gastritis, peritonitis, and inflammation of the 
 bowels. Robert Morris said that if a torch were applied 
 to the tomb of every man dying of unrecognized appendi- 
 citis, the world would be a bon-fire. 
 
 Why the disease was not recognised earlier. — It seems 
 d'fficult for us to-day, to understand how a disease which 
 was so frequent could have escaped recognition by clini- 
 cians of the past, who were justly noted for their ac- 
 curacy of observation. The explanation lies in the fact 
 the symptoms of appendicitis, originating in an organ 
 
 io8 
 
THE MANAGEMENT OF APPENDICITIS 
 
 without function, were characterized by reflex disturb- 
 ances of the function of other and more important organs, 
 and hence were misconstrued during the life of the 
 patient. If death ensued and a post-mortem was made, 
 the secondary complications so obscured the original 
 lesion that it was overlooked. A physician told me that 
 while in New York taking a post-graduate course, in 
 1878, he saw a case in the ward of one of the hospitals 
 which was treated first for gastritis, then for peritonitis, 
 and finally for locked bowel. When the patient died, a 
 post-mortem was made, and the pathologist commented 
 on the fact that the inflammation had been so severe that 
 the appendix had sloughed off. Two years later, when 
 engaged in private practice, this physician saw another 
 case die with similar symptoms, and before making the 
 post-mortem, he told his colleagues that he was certain 
 that they would find the appendix gangrenous, and such 
 proved to be the case. In neither instance did it occur 
 to any of the physicians that the condition of the appendix 
 was the primary cause of the trouble. 
 
 Living versus Dead Pathology. — Post-mortem exami- 
 nations have, of course, been of inestimable service in 
 increasing our knowledge of disease, but conclusions 
 based on them have often been erroneous, because they 
 are made at a period when secondary complications and 
 terminal infections obscure the initial lesion. The patho- 
 logic picture of the early stages of disease as disclosed 
 during life, on the operating table, are immeasurably 
 more valuable than the findings after death, at autopsy. 
 This fact is apparently not appreciated by the physician, 
 or if it is, he fails to take advantage of it. Many will 
 drive ten miles to see a post-mortem, who would not 
 
 109 
 
ACCEPTED FACTS AND MOOTED POINTS IN 
 
 go around the corner to witness an ante-mortem demon- 
 stration of the same disease at a more instructive stage 
 of its development. In visiting the various surgical clinics 
 of this and other countries, I have often deplored the 
 fact that they were not attended more largely by medical 
 men. Last summer I made a trip to see work in Chicago, 
 Rochester, Cleveland, Boston and New York. In each 
 city I found a number of surgeons. Some were young 
 and some were old ; some were rich and some were poor ; 
 some were famous and some were unknown. All were 
 possessed by a desire to learn. I do not recall meeting 
 a single physician. They must have been either at home 
 pursuing their usual occupation, or at the seashore, in 
 the mountains, or abroad, taking a vacation. It is some- 
 times said that the professional and pecuniary rewards 
 of the surgeon are greater than those of the physician. 
 If this be so, where lies the credit or the blame of the 
 reversal of conditions previously existing? 
 
 Operate in Every Case. — The one generally accepted 
 fact in the treatment of appendicitis is that every case 
 should be operated on. There is a wide difference of 
 opinion, however, as to when the operation should be 
 done, how the various steps should be performed, and 
 the way the case should subsequently be treated. It is 
 admitted that many cases recover from acute attacks 
 under medical treatment: hence it is obvious that if 
 all cases are operated on, some cases will be subjected to 
 unnecessary surgery. Statistics show that in a hundred 
 cases, eighty will recover without the use of the knife, 
 but they also show that twenty will die. Of these eighty 
 who recover, many will have recurrent attacks, and most 
 of them will suffer from digestive disturbances which 
 
 no 
 
THE MANAGEMENT OF APPENDICITIS 
 
 cripple their usefulness. As it is impossible to say from 
 the history, clinical symptoms or laboratory findings 
 which cases need an operation, and which do not, it is, 
 therefore, better to operate on some who do not require 
 it, than to fail to operate on those who urgently need 
 it, especially as the operation in itself has practically no 
 mortality. I say this advisedly, for I do not believe an 
 appendectomy entails any more danger than a trip on 
 the railway. There are, of course, the danger of the 
 anesthetic and the risk of infection, but these, in skilled 
 hands, are accidents no more likely to occur than catas- 
 trophes on well regulated railroads. Frequently you see 
 in the daily papers, and sometimes in medical journals, 
 the statement that a patient has died on account of an 
 operation. Usually the fact is that he died from a disease 
 which the operation failed to arrest, and frequently be- 
 cause a surgeon was called in as a last resort to save life, 
 and not as an early effort to restore health. Let the pro- 
 fession differ on other points, but let it unite in teaching 
 the laity that appendicitis is a surgical disease, that every 
 case requires an operation, and that, barring accidents, 
 which occasionally happen in well regulated hospitals as 
 well as in well regulated families, there is no danger in 
 surgical intervention. 
 
 Appendicitis nozv a Question of Economics. — Years 
 ago, when many cases of appendicitis died because opera- 
 tions were postponed until the patient's condition was 
 hopeless, the great question with both the profession and 
 the laity was the mortality. Later, when results were 
 improved, but when operations were still delayed until 
 complications developed, and patients were left with 
 crippling sequelse, the question was morbidity. To-day, 
 
 III 
 
ACCEPTED FACTS AND MOOTED POINTS IN 
 
 when practically all cases recover, and are completely 
 restored to health, the question is economy. 
 
 A patient, when informed that he has appendicitis, no 
 longer asks what is the danger to his life, rarely discusses 
 the possibility of hernia or other complications, but wants 
 to know how much the operation will cost him in time 
 and money. The question of the length of his stay in 
 the hospital depends largely upon whether it is found 
 necessary to employ drainage. The question of the 
 amount of the surgeon's charge depends chiefly on the 
 patient's ability to pay. It is a fact that there is no case 
 on record where an operator has declined to do the work 
 without a fee if the patient was poor, or where he has 
 failed to require a munificent sum if the patient was rich. 
 The laity should be impressed with the fact that a sur- 
 gical fee covers three separate factors : First, the satis- 
 faction of having an operator of reputation; second, the 
 security of having one with skill and ability; and third, 
 the physical relief from the actual mechanical work. 
 
 When to Operate. — The question of when to operate 
 for appendicitis will perhaps never be satisfactorily set- 
 tled. Personally, I am convinced that Murphy was right 
 in his bold and dogmatic statement made many years ago, 
 that we should operate on all cases of appendicitis as 
 soon as the diagnosis is made. There are, of course, a 
 few cases where this rule will work hardship, but I am 
 sure that if it is rigidly followed, it will accomplish the 
 greatest good to the greatest number, and that the sur- 
 geon who follows it will, in the end, save more patients 
 than the one who does not. The objections made to it 
 are that we should not operate upon the convalescent or 
 the moribund. The answer is that it is sometimes im- 
 
 112 
 
THE MANAGEMENT OF APPENDICITIS 
 
 possible to diagnosticate these cases. Patients appar- 
 ently improving and on the road to recovery sometimes 
 develop a fatal complication, and patients apparently 
 dying sometimes get well by means of a timely operation 
 performed by a courageous surgeon. 
 
 Ochsner, by his teaching, has, in my opinion, caused 
 the death of more patients with appendicitis than his per- 
 sonal ability as an operator has enabled him to save, and 
 this not because his teaching was wrong, but because it 
 has been misunderstood, and his treatment misapplied. 
 Ochsner believes in operating on all cases of appendicitis, 
 but in a certain class he advises waiting, employing gastric 
 lavage, rectal alimentation, and Fowler's position, until 
 the inflammation becomes localized, and the patient in a 
 more favorable condition for surgical intervention. Per- 
 sonally, I believe that Ochsner's treatment will save some 
 cases which would otherwise be lost, but despite this 
 fact, I am satisfied that it would be better for the pro- 
 fession and for the public if his teaching had never been 
 disseminated. It has been seized upon by the general 
 practitioner as a medical cure for appendicitis, and has 
 been the excuse for procrastinations which has resulted 
 in many an untimely death. 
 
 How to Operate. — An extremely important factor in 
 the success of a surgeon in operating for appendicitis is 
 his ability to differentiate in cases, and to recognize the 
 fact that different groups must be treated in an entirely 
 different way. For practical purposes, cases may be 
 divided into three classes : First, those in which the in- 
 flammation is confined to the appendix; second, those in 
 which the inflammation has extended beyond the appendix 
 and resulted in a localized abcess ; and third, those in 
 
 113 
 
ACCEPTED FACTS AND MOOTED POINTS IN 
 
 which the inflammation has caused diffuse peritonitis, 
 with the presence of free fluid in the abdominal cavity. 
 
 I. Chronic and Acute Appendicitis. — In chronic ap- 
 pendicitis where the operation is done between the attacks, 
 or in acute appendicitis where the operation is done be- 
 fore inflammation extends to adjacent structures, the 
 technique of the operation is not of much moment. The 
 differences of opinion which exist among surgeons are 
 with reference to the location of the incision, the treat- 
 ment of the stump of the appendix, and the length of 
 time it is necessary to confine the patient to bed. 
 
 1. The incisions in most common use are a vertical 
 incision through the right rectus, or an oblique incision, 
 with separation of the fibres of the external and internal 
 oblique muscles at right angles one to the other. Either 
 method gives good results, although, personally, the grid- 
 iron incision appeals to me as the one inflicting less trau- 
 matism, giving most direct access to the field of opera- 
 tion, and guaranteeing the greatest assurance against 
 hernia. 
 
 2. The methods of dealing with the stump of the 
 appendix are endless. The two in most frequent use 
 are simple ligation, and ligation with inversion of the 
 stump by means of a purse-string ligature. I usually 
 practice the latter, as I have never experienced the com- 
 plications believed by some to be theoretically possible 
 from burying infected tissue, and I think the purse-string 
 suture lessens the possibility of the primary ligature being 
 blown off by gas pressure, and removes the probability 
 of adhesions which otherwise might form on a denuded 
 surface. 
 
 3. The question of the length of time it is necessary 
 
 114 
 
THE MANAGEMENT OF APPENDICITIS 
 
 to keep the patient in bed after a simple appendectomy 
 is one of great importance. The tendency is to make 
 the patient's stay in the hospital shorter and shorter. This 
 is partly due to motives of economy, but is also influenced 
 by a desire to advertise the surgeon. Between too great 
 conservatism on the one hand, with the attendant loss 
 of time and money, and too great radicalism on the other, 
 with the danger of hernia and other complications, there 
 must eventually be derived a happy mean. For my own 
 satisfaction, some time ago, I sent a circular letter to 
 fifty prominent surgeons, asking the practice of each. 
 The answers varied so widely as to be practically worth- 
 less, one stating that he had patients walking about the 
 following day, and another that he kept them in bed forty- 
 two days. My own custom is to keep patients re- 
 cumbent ten days, allow them to go about in a wheel 
 chair two days, and to discharge them at the end of four- 
 teen days. I heartily deprecate the tendency to compe- 
 tition which exists between some surgeons as to who 
 can get their cases out quickest. The laity and profession 
 ought to be made to understand that, under given cir- 
 cumstances, a wound will not heal quicker for one opera- 
 tor than for another, and the length of time it is thought 
 necessary to keep the patient in bed is not a measure of 
 surgical dexterity, but of surgical judgment. 
 
 II. Appendicitis with Ah cess. — The technique for 
 operations of this type depends entirely upon whether 
 the abcess is adherent to the abdominal wall, and can 
 be incised and drained without opening the general peri- 
 toneal cavity, or whether it is not adherent and can only 
 be reached after opening the general peritoneum. If the 
 abcess is adherent to the parietal peritoneum, it should 
 
 115 
 
ACCEPTED FACTS AND MOOTED POINTS IN 
 
 simply be opened and drained, and no effort made to 
 locate or remove the diseased appendix. With all due 
 deference to those who do not agree with me, I consider 
 it a surgical crime to break up the protecting wall and to 
 liberate infectious fluid into the peritoneal cavity, when 
 a safe exit can be given the pus by simply following the 
 indications of nature, and making an incision at the point 
 where she is endeavoring to effect drainage. 
 
 If the abcess is not adherent to the peritoneum beneath 
 the incision, but is located between the folds of the omen- 
 tum or behind the csecum, in a position in which it can 
 be reached only by opening the general peritoneal cavity, 
 then an entirely different technique must be pursued. 
 After the abdomen is opened and the inflammatory mass 
 located by palpation, it should be carefully and effectually 
 isolated from adjacent structures by numerous pads of 
 gauze wrung out of hot saline solution. Adhesions should 
 then be separated until the pus collection is opened. The 
 abcess should be gently sponged out, and the appendix 
 sought for and removed. The infected area should be 
 drained with strips of gauze enclosed in a protecting 
 layer of rubber tissue, and a tube should be inserted 
 through the lower angle of the wound to the bottom of 
 the pelvis, and the patient put to bed in an exaggerated 
 Fowler's position. 
 
 When an abcess is drained and the appendix not re- 
 moved, the patient should be told that the operation was 
 not for appendicitis, but for an abcess which was the re- 
 sult of appendicitis. He should be made to understand, 
 that the appendix was not removed, advised of the possi- 
 bility of future trouble, and warned to apply promptly 
 for surgical relief if he suffered abdominal pain. 
 
 ii6 
 
THE MANAGEMENT OF APPENDICITIS 
 
 I have recently had correspondence with a number of 
 prominent surgeons to ascertain their views as to the 
 necessity for a second operation for the removal of the 
 appendix left in the abdomen at a first operation. I have 
 secured a large number of opinions, and find that while 
 all agree that the organ should be removed if it causes 
 symptoms, they are about equally divided as to the wis- 
 dom of operating on every case as a routine method. As 
 an example of the divergent views, I will cite Dr. J. 
 M. T. Finney, of Baltimore, who writes that in all cases 
 of abcess treated by simple incision and drainage, he ear- 
 nestly advises a secondary operation for the removal of 
 the appendix. He was forced to this opinion by seeing 
 three cases of death during secondary attacks of appendi- 
 citis after an appendiceal abcess had been drained and 
 the appendix left in. 
 
 On the other hand. Dr. Roswell Park, of Buffalo, 
 writes that he hardly ever advises a secondary operation 
 to remove an appendix which was not hunted up and 
 removed when an abcess was drained, unless it seems to 
 be producing occasional or persistent, even though mild, 
 symptoms or discomfort, i. e., so long as it remains inno- 
 cent and inoffensive, he does not feel like disturbing it, 
 but when it growls, he would urge its removal. 
 
 I have also written to twenty-three patients for whom 
 I had opened and drained abcesses without making an 
 attempt to remove the appendix. I found that all these 
 cases were in good health, that none of them had been 
 operated on a second time, that only two had had re- 
 currence of abdominal symptoms, and therefore, I am 
 disposed to agree with the opinion of Dr. Park, that a 
 second operation should not be done as a routine measure, 
 
 117 
 
THE MANAGEMENT OF APPENDICITIS 
 
 but only when called for by symptoms indicative of 
 trouble. 
 
 III. Appendicitis with Diffuse Peritonitis. — Cases in 
 which there is perforation of the appendix and free fluid 
 in the general peritoneal cavity have, until recently, been 
 the terror of the surgeon. The old method of opening 
 the abdomen, removing the appendix, washing out the 
 peritoneal cavity, and making counter incisions for multi- 
 ple drainage, was followed by a mortality of about eighty 
 per cent. There has been, to my mind, no recent advance 
 in surgery so brilliant in theory and so practical in results 
 as the new technique of treating diffuse suppurative peri- 
 tonitis. A short incision is made over the appendix, and 
 the diseased organ removed if it is readily accessible. A 
 second incision, not necessarily more than an inch in 
 length, is made in the mid-line over the pubes. A rubber 
 tube one-half inch in diameter, with openings on the side, 
 is introduced through the supra-pubic opening and car- 
 ried to the bottom of the pelvis. No irrigation of the 
 abdomen should be practiced, no effort even made to 
 sponge out the pus, but a voluminous dressing applied, 
 and the patient quickly put to bed in an exaggerated 
 Fowler's position. Saline solution should be slowly and 
 continuously given by rectum; the stomach irrigated if 
 vomiting is persistent; and the heart and kidneys stimu- 
 lated by the hypodermic use of sulphate of spartine. 
 Since the adoption of this method the mortality in this 
 class of cases has been reduced to about five per cent. 
 
 ii8 
 
Appendicostomy * 
 
 The operation of appendicostomy, though less than 
 four years old, has been firmly established as a rational 
 surgical procedure. It consists in bringing the appendix 
 through an abdominal incision, opening its tip and using 
 its lumen through which to irrigate the large intestine. 
 The value of the operation will be appreciated after a 
 consideration of the following facts: 
 
 1. Chronic diseases of the large bowel are frequent. 
 
 2. They are exceedingly rebellious to internal or local 
 treatment, as drugs by mouth are rendered inert in the 
 small intestines, and injections by rectum are not only 
 disagreeable, but often inefficient because of the difficulty 
 in reaching the upper portion of the tract. 
 
 3. The appendix is located at the very origin of the 
 large bowel ; hence fluids introduced through it reach 
 every part of the canal. 
 
 4. The operation of delivering, attaching and opening 
 the appendix is so simple that it can be safely done by 
 the average surgeon. 
 
 5. When an opening is once formed the irrigation 
 can be efficiently carried out by the patient without pain 
 or discomfort. 
 
 Experience has proved that the mechanical cleansing 
 which is accomplished, plus the therapeutic effect of the 
 antiseptic or astringent solutions employed, usually brings 
 
 * Read at the meeting of the Medical Society of Virginia, 
 October, 1906. 
 
 119 
 
APPENDICOSTOMY 
 
 quick relief to patients who have suffered many things 
 of many doctors without benefit. 
 
 Appendicostomy, like many other surgical procedures, 
 was first devised extemporaneously during the course of 
 another operation. In 1902, Dr. Robert F. Wier opened 
 an abdomen to do a valvular cecostomy in order to make 
 a fistula through which he could irrigate a colon, the 
 seat of chronic amebic dysentery. He saw the appendix 
 rise prominently into the wound and at once appreciated 
 the advantages of using the calibre of this organ for his 
 purpose. He stitched the tip of the appendix in the ab- 
 dominal wound and closed the latter around it. When 
 about to apply the dressings, the thought occurred to 
 him that the appendix might not be patulous and he there- 
 fore amputated its tip and introduced a No. 12 soft rub- 
 ber catheter through its lumen into the cecum. The 
 latter was drawn into the wound, anchored and a ligature 
 thrown around the stump of the appendix to prevent 
 leakage. The ligature was removed in twenty-four hours 
 and two days later irrigations of the colon were begun. 
 The result was eminently satisfactory. 
 
 The simplicity of the operation, its freedom from 
 danger and the ease and certainty of the ultimate closure 
 of the fistula appealed at once to the profession, and ap- 
 pendicostomy has been adopted as an acceptable sub- 
 stitute for cecostomy in all but a few selected cases. 
 
 The original technique has been so improved upon by 
 various surgeons, chiefly Meyer, Dawbarn and Tuttle, 
 that now a most acceptable method has been evolved. 
 
 Indications. 
 
 In general, the operation may be said to be indicated in 
 all cases of chronic, non-malignant diseases of the colon, 
 
 120 
 
APPENDICOSTOMY 
 
 which do not yield to medical treatment. It has been 
 chiefly employed in chronic amebic dysentery, muco- 
 membranous colitis and syphilitic and tuberculous ulcera- 
 tions of the colon. 
 
 Maunsell has employed it successfully to anchor the 
 cecum in a case of volvulus, and in another to prevent 
 gaseous distention after resection of the small intestine. 
 He also recommends it as a means of relieving tympanites 
 due to intestinal paresis from peritonitis. 
 
 Keitley has employed appendicostomy as a substitute 
 for cecal colostomy in a case of carcinoma of the tran- 
 verse colon ; in a case of intussusception of the ileum into 
 the ascending colon, and also in a case of obstinate consti- 
 pation. He recommends it to facilitate the introduction 
 of food when feeding by way of the bowel is necessary ; 
 and as a means of local treatment of the ulceration of 
 typhoid as suggested by Ewart. 
 
 Sir W. H. Bennett suggests the possibilities of the 
 operation as, first, a means of treating diseases of the 
 large and small intestines ; second, a means of relieving 
 or preventing intestinal distention ; third, a means of 
 artificial feeding; fourth, a substitute for cecal colostomy. 
 
 Technique. 
 
 The patient is prepared as for the ''interval operation" 
 of appendectomy. The abdomen is opened by the grid- 
 iron method through an incision large enough to admit 
 two fingers. The appendix is grasped and brought up 
 into the wound, the artery of its mesentery tied and the 
 organ freed to its base. The cecum is then fastened to 
 the parietal peritoneum at the lower angle of the wound 
 by sutures on either side and above the appendix, the 
 
 121 
 
APPENDICOSTOMY 
 
 last suture being continued to close the peritoneum. The 
 lesser appendiceal artery should not be included in the 
 side sutures. The abdominal incision is then closed in 
 layers by sutures of catgut, the appendix itself being 
 fastened in the lower angle of the skin wound by a suture 
 on either side. The protruding appendix is then wrapped 
 with thin rubber or gutta percha tissue and the dressings 
 applied. At the end of two days, the dressings are re- 
 moved. The appendix is usually found gangrenous at 
 its tip. It is amputated about one-quarter to three-eighths 
 of an inch from the skin and its lumen carefully dilated. 
 A catheter should then be introduced and secured by a 
 ligature tied firmly around the stump of the appendix. 
 The ligature serves the double purpose of preventing 
 leakage around the catheter, and at the same time by 
 constriction cuts off the stump of the appendix flush 
 with the skin. The catheter should be introduced about 
 two to four inches. If there is abdominal distention, its 
 lumen should be left open to allow escape of flatus. In 
 the absence of distention, the catheter should be bent on 
 itself and fastened with a safety pin to prevent leakage 
 into the dressings. On the third or fourth day irrigation 
 may be begun. 
 
 The question may arise whether it is advisable to at- 
 tempt appendicostomy in the presence of a small atrophied 
 appendix even though it be patulous. Will its calibre 
 admit a catheter large enough to serve the purposes of 
 irrigation ? Tuttle presents two cases in which the organ 
 was found easily dilatable and the results in these cases 
 were more satisfactory than in those with very large 
 appendices. This opinion is confirmed by C. B. Kietley, 
 who, in a case of carcinoma of the transverse colon with 
 
 122 
 
APPENDICOSTOMY 
 
 slender atrophied appendix, was able to dilate the latter 
 until he could introduce a small sized rectal tube, the 
 opening afterwards serving as an artificial anus. In my 
 own case herewith reported, no difficulty was encountered 
 in dilating an appendix greatly atrophied and adherent 
 as a result of previous inflammation. 
 
 Time for Opening the Appendix 
 If there is any doubt of the patency of the appendix 
 it should be opened before the bowel is fixed to the parie- 
 tal peritoneum in order that if its canal is obliterated 
 the operator may abandon appendicostomy and proceed 
 at once to a cecostomy. The surgeon, by rolling the ap- 
 pendix between his fingers, can usually determine whether 
 the organ is patulous. If it is permeable, he should not 
 take the risk of infecting the wound by opening the canal 
 until two or three days after the operation. This is 
 strongly insisted upon by Tuttle. Every case of post- 
 operative hernia noted by this observer has followed the 
 cases in which the appendix was opened at the time of 
 operation, and in all cases there has been subsequent if 
 not consequent infection. Of course such a practice is 
 not advisable in cases in which the operation is done for 
 intestinal obstruction or paralysis, for artificial feeding, 
 or any very acute conditions. In such cases, just as in 
 colostomy, a few hours delay is all that is necessary. 
 When opened early the appendix should be cut oflf fully 
 half an inch from the skin, a catheter introduced and a 
 thread tied around the stump to avoid leakage. 
 
 Solutions for Irrigation. 
 The selection of a fluid for irrigation will depend upon 
 the diseased condition. In amebic dysentery the consen- 
 
 123 
 
APPENDICOSTOMY 
 
 sus of opinion is largely in favor of quinine solutions. 
 Tuttle recommends normal saline solution at a tempera- 
 ture of 65 to 75 degrees F., and advises that care be 
 exercised to use normal salt solution and not brine. 
 
 In catarrhal colitis, with or without ulcerations, solu- 
 tions of nitrate of silver 1-5000, argyrol 5 per cent, to 
 25 per cent., peroxide of hydrogen 10 per cent, to 20 per 
 cent., and aqueous fluid extract of krameria 10 per cent., 
 have all been used with more or less satisfaction. Some 
 of these cases yield very promptly and others are very 
 obstinate. Ewart reports a case in which appendicostomy 
 was performed for colitis with diarrhea and profuse 
 bloody discharges. The hemorrhages continued in spite 
 of all the ordinary irrigations, but finally ceased after 
 injecting liquid paraffin into the colon. 
 
 When and How to Close the Opening. 
 
 The time at which the appendiscostomy fistula should 
 be closed depends upon the disease for which the opera- 
 tion has been performed, the history, condition and symp- 
 toms presented by the patient, and the amount of annoy- 
 ance the fistula gives. 
 
 In cases of amebic dysentery there is usually an ap- 
 parent cure in four weeks or less. It would not be wise, 
 however, to close the opening at this time as periods 
 of quiescence lasting some times months occur in the 
 disease even without treatment. These patients should 
 be advised to wait six or nine months, and if they are 
 to return to tropical regions the opening should be kept 
 open permanently to facilitate prompt and effectual 
 treatment in case of reinfection. 
 
 In cases of simple mucous colitis, the opening may be 
 
 124 
 
APPENDICOSTOMY 
 
 closed after mucous has been absent from the stools for 
 several weeks and the bowel movements have become 
 regular without irrigation or laxatives. 
 
 In cases of the various forms of ulcerative colitis too 
 much stress cannot be laid on the advisability of keeping 
 the fistual open for a considerable length of time. The 
 only disappointments from the operation, so far as known, 
 have followed too early closure. It is important in these 
 cases to aid the colonic flushings by proper internal medi- 
 cation and judiciously selected articles of diet. 
 
 In cases where the operation has been performed for 
 the relief of tuberculous ulceration, the fistula should be 
 kept open permanently. When made for the relief of 
 intestinal distention, caused by peritonitis or volvulus, 
 the fistula may be closed as soon as the primary condi- 
 tion has disappeared. In other conditions the time of 
 closure must be left to the judgment of the operator, as 
 there are no statistics upon which to base conclusions. 
 To close the fistula is usually simple and easy. The appli- 
 cation of nitric acid or the actual cautery to the mucous 
 lining has invariably and promptly been followed by 
 closure of the aperture. If, however, it is deemed advis- 
 able, the stump of the appendix may be dissected out and 
 the small abdominal wound sutured. 
 
 Results. 
 In forty-four cases of dysentery there were six deaths, 
 but none of them due to the operation. Two were from 
 unsuspected tuberculosis, two from extreme ulceration 
 of the bowel with chronic nephritis, one from exhaustion 
 before the appendix was opened, and one from cerebral 
 
 125 
 
APPENDICOSTOAIY 
 
 disease three months after the operation. The remainder 
 of the cases (38) are reported cured. 
 
 In sixteen cases of mucous colitis the reports are all 
 favorable. In some of them, however, it is difficult to 
 tell how much good was due to the removal of the appen- 
 dix and how much to the effect of appendicostomy. The 
 relationship between chronic appendicitis, with adhesions, 
 and chronic muco-membranous colitis is very close, and 
 the etiologic influence of the one on the other merits a 
 wider discussion than is permitted by the limits of this 
 paper. Suffice it to say that by appendicostomy we get 
 rid of the appendix, whether it be the cause or effect of 
 colitis, and at the same time give access to the parts for 
 local treatment. 
 
 In the cases reported, where the operation was done 
 for syphilitic ulceration, the patients appear to have been 
 greatly benefitted if not permanently cured. In the cases 
 of papilloma and carcinoma, the operation was performed 
 only as a palliative measure. In the cases of volvulus 
 and intussusception the operation was effectual. 
 
 REPORT OF AUTHOR'S CASE. 
 
 Mrs. X., aged 46, patient of Dr. W. S. Gordon, of Richmond, 
 Va., admitted to St. Luke's Hospital June 14, 1906. History of 
 typical attack of appendicitis about puberty. For thirty years 
 had suffered with occasional pain in right iliac region. Two 
 years ago had an attack of colitis. Recovered and remained 
 well for twelve months and then had recurrence. Disease grew 
 worse despite persistent and intelligent treatment. Was placed 
 at one of the hospitals of this city where diet, rest, astringent 
 and rectal irrigations were tried for some weeks without per- 
 manent benefit. During past six months had suffered constant 
 aodominal pain, attended by profuse diarrhea, with loss of 
 thirty-five pounds in weight. 
 
 126 
 
APPENDICOSTOMY 
 
 Operation of appendicostomy performed June 20, 1906. Appen- 
 dix was found atrophied and adherent, but was Hberated and 
 brought through the abdominal wound by the technique previ- 
 ously described. Two or three days later the appendix was 
 amputated, its calibre dilated, a catheter inserted and irriga- 
 tion of the colon begun. The patient was out of bed on the 
 fifteenth day and was discharged on the 22d day after operation. 
 
 As long as the patient was in the hospital she did admirably, 
 but shortly after her return home she had a sharp recurrence 
 of her old symptoms. This was partly due to the nature of her 
 disease, but largely accentuated by too heroic treatment. She 
 was a physician and the wife of a physician, and as I was in 
 Europe, they were left to their own resources, and, as is usual 
 in such cases, owing to over-anxiety, they tried too many reme- 
 dies. Finally, after correspondence with Dr. Tuttle, the patient 
 was put on sulpho-carbolate of zinc and oil of turpentine, and 
 the colon irrigated with a teaspoonful of salt and a teaspoonful 
 of bicarbonate of soda to a quart of hot water (120° F.) for 
 three days, followed by ly^ per cent, solution of ichthyol on 
 the fourth day. This resulted in controlling the diarrhea and a 
 gradual return to normal fecal movements. The appendicostomy 
 fistula was kept open for three weeks after the mucous dis- 
 appeared and then allowed to close. The patient has gained 
 more than fifteen pounds in weight and believes herself cured. 
 
 127 
 
Pylorospasm * 
 
 Twenty years ago the physician held undisputed sway 
 in the treatment of digestive disturbances, and the sug- 
 gestion that dyspepsia could be cured by surgery, when 
 medicinal, dietetic and hygienic measures had failed, 
 would have been regarded as an absurdity. 
 
 Ten years ago the surgeon took possession of the field, 
 and for a time the operation of gastro-enterostomy was 
 considered a panacea for all gastric disorders. It was 
 found, however, that while the operation in some cases 
 accomplished brilliant cures, in others it not only did not 
 relieve, but actually increased, the patient's distress. 
 
 Today it has been demonstrated that chronic and re- 
 curring indigestion is rarely, if ever, due to functional 
 causes, and cannot be cured by efforts to correct errors of 
 secretion. It is almost invariably caused by organic dis- 
 ease of the stomach or other organs, and can be corrected 
 only by operative intervention. In nine cases out of ten, 
 while the symptoms are gastric, the cause is appendicitis, 
 cholecystitis, pancreatitis, or duodenal ulcer: and while 
 the treatment is surgical, the operation is not done on the 
 stomach. A gastro-enterostomy will cure the symptoms 
 due to an organic obstruction of the pylorus such as re- 
 sult from cicatricial contraction of an ulcer, because it 
 relieves the condition by affording a new exit for the 
 stomach contents. The operation w^ill not cure, but will 
 
 * Read at meeting of the Southern Surgical and Gynecological 
 Association, Nashville, Tenn., December, 1910. 
 
 129 
 
PYLOROSPASM 
 
 aggravate, the symptoms due to a spasmodic obstruction 
 of the pylorus such as results reflexly from nervous stim- 
 ulation, because it overcomes t\ie effort being made by 
 nature to prevent the invasion of the intestines by irri- 
 tating stomach contents. Obstruction of the pylorus may 
 be organic or spasmodic. The first is mechanical and 
 should be relieved by making a new exit for the stomach 
 contents ; the second is nervous and should be relieved 
 by diagnosticating and correcting the cause which pro- 
 duces it. 
 
 Spasm of the pylorus, or pylorospasm as it is generally 
 called, is a very common trouble. It is not a disease, but 
 a symptom. It may be caused by rapid eating, by indi- 
 gestible food, by an ulcer or other lesion of the stomach, 
 but it is most frequently the expression of disease of some 
 remote abdominal structure. Plow appendicitis or cho- 
 lecystitis causes gastric symptoms has never been satis- 
 factorily explained. It is believed that irritation trans- 
 mitted to the stomach through the sympathetic nervous 
 system causes an excessive secretion of hydrochloric acid. 
 The resulting hyperchlorhydria causes spasm of the 
 pylorus ; the pylorospasm causes retention of food beyond 
 the physiologic limit, and finally there comes motor in- 
 sufficiency, food stagnation and dilation of the stomach. 
 
 The most prominent symptom of pylorospasm is a 
 cramping pain in the epigastrium, which may last only a 
 few minutes or may continue for several hours. In some 
 cases the spasm may relax suddenly; in others it may 
 terminate slowly and gradually. Some patients have at- 
 tacks several times a day ; others at intervals of weeks ; 
 and others still only once or twice a year. In the in- 
 terval between attacks, the digestion may be normal. 
 
 130 
 
PYLOROSPASM 
 
 During attacks peristalsis of the stomach is increased, but 
 food cannot pass through the pylorus, and often relief 
 comes only after vomiting. The patient usually diets 
 strictly, and loses flesh and strength steadily from star- 
 vation and autointoxication. 
 
 During the last few years I have recognized, treated 
 and cured a progressively increasing number of cases of 
 pylorospasm. In no other class of patients, with possibly 
 the exception of epileptics, is it necessary to be so 
 thorough in preliminary examination and so patient in 
 post-operative treatment. The real cause of the condition 
 must be found, and after it has been removed the patient 
 must be systematically treated until the hypersensitiveness 
 of the pyloric muscle is relieved, and its spasm habit is 
 overcome. This will be well illustrated by one of my 
 first cases. 
 
 Miss E., aged 32, a thin, anemic and nervous patient, gave a 
 history of chronic dyspepsia attended by frequent attacks of 
 violent pain in the upper abdomen. A diagnosis of gall-stones 
 was made and an operation advised. The abdomen was opened, 
 the gall-bladder exposed, and it was found to contain several 
 large gall-stones. They were removed, a drain was inserted, 
 and the incision was closed. No examination was made of other 
 abdominal organs. A week after the operation the patient had 
 a return of her old pain, and the paroxysms became so frequent 
 and distressing that her familj^ was told that it was probable 
 that a stone had been overlooked and it was advisable to re- 
 open the abdomen and try to remove it. At the second opera- 
 tion the gall-bladder and ducts were carefully palpated, with 
 negative results. The stomach was then delivered and ex- 
 amined. The pylorus was found hard and rigid, with a lumen 
 which would not admit the tip of the finger. While handling 
 it in search of evidences of ulceration, the spasm suddenly gave 
 way, the tissues became soft and elastic, and a finger could 
 readily be invaginated through the opening. Then, for the first 
 
 131 
 
PYLOROSPASM 
 
 time, the nature of the case was comprehended. The stomach 
 was normal; the gall-stones were an innocent coincidence; the 
 cause of the pylorospasm must be found elsewhere. The ap- 
 pendix, which, until then, had not been suspected of disease, 
 was brought into view. It was inflamed and contained several 
 enteroliths, and was removed. The patient recovered from the 
 operation, but for some months had recurrence of pain after 
 any imprudence in eating. She was carefully and intelligently 
 treated by her family physician and is now completely well. 
 
 This paper is intended only to be suggestive. Its pur- 
 poses are to impress : 
 
 First. — The necessity of differentiating between gastric 
 symptoms due to organic disease of the stomach and those 
 reflex from other organs. 
 
 Second. — The impropriety of performing a gastroenter- 
 ostomy for spasm of the pylorus. 
 
 Third. — The advisability, at the time of operation, of 
 examining all abdominal organs and correcting every ab- 
 normality, lest the obvious may not be the real cause of 
 the symptoms. 
 
 Fourth. — The importance of the post-operative and 
 post-hospital treatment of patients to overcome the spasm 
 habit of the pyloric sphincter. 
 
 132 
 
Etiology and Symptomatology of 
 Gall Stones * 
 
 The liver is the largest and one of the most important 
 organs of the abdomen. Its most obvious function is the 
 production of bile. One of its most essential duties, how- 
 ever, is the destruction of the bacteria coming to it from 
 the digestive tract through the portal system before the 
 blood enters the systemic circulation by way of the hepatic 
 vein. The liver secretes between 20 and 30 ounces of bile 
 every 24 hours. Healthy bile was at one time supposed 
 to be free from germ life and even to have mild apti- 
 septic properties : more recent and accurate investigations, 
 however, show that it always contains a moderate num- 
 ber of bacteria and that it is a good culture medium. 
 
 Most of the bile produced by the liver passes directly 
 to the duodenum through the hepatic and common ducts. 
 A small proportion passes up the cystic duct to the gall- 
 bladder where it is stored and somewhat modified by ab- 
 sorption and admixture with mucous. When stimulated 
 the gall-bladder contracts and forces its contents back 
 through the cystic duct to the general bile stream. Bile, 
 on reaching the intestinal tract, stimulates pancreatic 
 secretion, neutralizes the acid chyme of the stomach, 
 emulsifies fat present in food, and excites the peristaltic 
 action of the bowel. When bile reaches the cecum the 
 fluid element is absorbed and returned to the circulation 
 
 * Part of a Clinical Lecture delivered at the University College 
 of Medicine, Richmond, Va., November, 1912. 
 
 133 
 
ETIOLOGY AND SYMPTOMATOLOGY OF 
 
 while the pigments and waste products are excreted in the 
 feces. 
 
 The Gall-Bladder is a pear-shaped organ capable of 
 holding about one ounce af bile. Its function is unknown 
 and people seem to get along as well without it as they 
 do with it. The amount of bile it is capable of holding 
 is so small, compared with the total secretion of the liver, 
 that it cannot act in an important way as a reservoir. 
 Some think it acts as the air chamber to a fire engine, 
 regulating the flow of the stream, others that it secretes 
 mucous, which mixed with bile serves as a lubricant to 
 the ducts. At any rate the gall-gladder, like the appen- 
 dix, is a non-essential structure. 
 
 The Hepatic Duct begins at the transverse fissure of 
 the liver. It is about two inches in length and one-sixth 
 of an inch in diameter. It unites with the cystic duct to 
 form the common duct. 
 
 The Cystic Duct is about 13^^ inches long and ^ inch 
 in diameter. Its mucous lining is thrown in crescentic 
 folds which normally prevent the passage of a probe 
 from the gall bladder to the common duct. 
 
 The Common Duct is about three inches long. It emp- 
 ties into the duodenum together with the pancreatic duct 
 at the ampulla of Vater. The common duct is divided for 
 description into three portions. The supra-duodenal, the 
 retro-duodenal and the trans-duodenal. The supra-duod- 
 enal is about 13/2 inches long. It runs downward in the 
 free edge of the gastrohepatic omentum and forms the 
 anterior boundary of the foramen of Winslow. The 
 retro-duodenal portion of the duct is about one inch long 
 and, as its name implies, lies behind the duodenum. In 
 40% of cases it runs in a grove on the head of the pan- 
 
 134 
 
GALL STONES 
 
 creas. In 60% of cases it passes directly through the 
 pancreatic tissue. The trans-duodenal portion of the duct 
 is about Y2. inch long and passes obliquely through the 
 wall of the gut to open in common with the pancreatic 
 duct at the ampulla of Vater. The first portion of the 
 common duct is easily accessible to palpation and manipu- 
 lation as it can be raised by hooking the fingers in the 
 foramen of Winslow. The second and third portions 
 of the common duct are difficult of access and it is often 
 necessary to make an incision into the duodenum to ap- 
 proach them surgically. 
 
 The Pancreas is formed in the embryo by two buds. 
 It retains to a certain extent its primitive form and has 
 two lobes which are drained by two ducts having separate 
 openings into the duodenum. The duct of Wirsung is the 
 main drain of the pancreas in 83% of individuals. It 
 opens into the duodenum at the ampulla of Vater together 
 with the common duct. This has been termed an unfor- 
 tunate association of terminal facilities between the liver 
 and pancreas, as interference with traffic in one system 
 may block the service in the other. The duct of Santorini 
 is the main drain of the pancreas in 12% of indi- 
 viduals. When the other duct is obstructed it is capable 
 of acting as the main drain in' 54% of the cases. It may 
 open into the duodenum a short distance below the pylo- 
 rus. 
 
 Gail-Stones are concretions formed in the gall-bladder. 
 It is possible they may form in the hepatic or common 
 duct but such cases are extremely rare. Gall-stones are 
 not calcareous but fatty substances, as can be demon- 
 strated by subjecting one to the heat of an open flame 
 when it will soften and burn much like sealing wax. 
 Gallstones are composed of cholesterine, bile pigments 
 
 135 
 
ETIOLOGY AND SYMPTOMATOLOGY OF 
 
 and lime salts. The proportion of these elements are 
 not constant and as a result the color of the stone may 
 vary from light yellow to dark green or black. 
 
 Gall stones vary in size and number; they may be as 
 small as mustard seeds or as large as goose eggs. If 
 multiple they are often faceted from pressure one against 
 another. Numererous cases have been reported where 
 several thousands have been found in one patient. 
 
 Gall-stones are formed in from a few days to a few 
 weeks. They are usually all formed at the same time and 
 are symmetrical although cases are sometimes seen where 
 there are several crops of stones as shown by the entirely 
 different color, size, shape and proportion of chemical 
 constituents. 
 
 Gall-stones frequently migrate from the gall-bladder. 
 They often pass in the cystic, hepatic and common ducts. 
 They frequently reach the duodenum either by way of the 
 ducts or through a fistulous opening between the gall- 
 bladder and bowel. They are sometimes vomited and 
 often pass at stool. Occassionally they enter the appen- 
 dix and sometimes they lodge at the iliocecal valve or 
 some other portion of the intestinal canal producing ob- 
 struction. 
 
 The cause of the gall-stone formation has been a ques- 
 tion giving rise to much discussion. It is a fact that 
 50% of gall stones occur in patients over 40 years of age ; 
 that 75% of all gall stones occur in women and that 
 90% of these women have borne children. It is also a 
 fact that 33% of people with gall-stones give history of 
 typhoid fever and 25% give history of having had an 
 attack of appendicitis. Finally, it is a fact that gall- 
 stones are more common in people who lead sedentary 
 
 136 
 
GALL STONES 
 
 lives, eat and drink imprudently and suffer from consti- 
 pation and obesity. 
 
 The theory of the etiology of gall stone disease at 
 present accepted is that the condition is due to the com- 
 bination of predisposing and essential causes. The predis- 
 posing causes are supposed to be factors which produce 
 stagnation of the biliary current, under which must be 
 considered age, sex, pregnancy, tight lacing, obesity, con- 
 stipation, imprudence in eating and drinking, lack of exer- 
 cise and fresh air and other errors in the habits of living. 
 
 The essential cause is supposed to be the infection of 
 the gall-bladder and the production of chronic cholecysti- 
 tis. The microorganisms most often responsible for the 
 infection are of the colon group, including the typhoid 
 bacillus. Welsh has found the typhoid germ in the gall- 
 bladder seven years after an attack of typhoid fever, and 
 clumps of bacteria are frequently found in the nucleus 
 of gall-stones. Attempts to produce gall-stones artifi- 
 cially in animals by infection have usually failed because 
 the resulting inflammation has been so acute as to pro- 
 duce destruction of the mucous lining of the gall-bladder. 
 Success has only been secured when the germs em- 
 ployed were so attenuated as simply to produce irritation. 
 
 The avenue by which the bacteria reach the gall-blad- 
 der is a matter of dispute. Some authorities claim that 
 they pass directly from the intestinal tract through the 
 common duct. This theory is favored by the observation 
 of Bond that particles of indigo carmin placed in the 
 rectum were carried up by a reverse mucous current and 
 could be demonstrated after a certain time in the gall- 
 bladder; also by the observation that the bacillus prodi- 
 giosus introduced within the anus could be recovered in 
 
 137 
 
ETIOLOGY AND SYMPTOMATOLOGY OF 
 
 two hours from the animal's mouth. Opposed to this 
 theory are the facts that the duodenum is usually sterile 
 and that infection would travel with difficulty up the 
 common duct in opposition to the rapidly flowing stream 
 of bile. 
 
 Other authorities claim that the infection reaches the 
 liver through the portal blood and is conveyed to the gall- 
 bladder by the agency of the bile. In ordinary health the 
 blood going to the liver through the portal system con- 
 tains many bacteria picked up in the passage through 
 the digestive tract. The reason for its going through 
 the liver prior to return to the general circulation 
 is to permit the annihilation or attenuation of its in- 
 fection. If this infection be present in health it exists to 
 a much greater extent in disease. Proctitis, colitis, enter- 
 itis, appendicitis, typhoid fever, ulcer of the duodenum or 
 stomach, abcess of the spleen, inflammation of the pan- 
 creas or lesion of the liver itself, would all throw an 
 additional amount of infection in the blood stream. As 
 a result the bile would be infectious and chronic cholecy- 
 stitis with gall-stone result. This theory explains the 
 frequency with which gall-stones follow appendicitis, 
 typhoid fever, duodenal ulcer and other diseases of the 
 gastro-intestinal tract. 
 
 Post-mortem examinations made by pathologists of all 
 patients dying in large hospitals and the examination of 
 the upper abdomen by surgeons as a routine measure in 
 abdominal sections have shown the presence of gall-stones 
 in many cases where they were not suspected to exist. It 
 is stated by several reliable authorities that about one per- 
 son in ten has gall-stones. If this be true, the condition 
 should be constantly borne in mind when examining a 
 
 138 
 
GALL STONES 
 
 patient with abdominal trouble, and both physician and 
 surgeon should make a thorough study of the sympto- 
 matology of the disease in order that he may recognize it 
 early and treat it properly. 
 
 Indigestion is the earliest and most frequent symptom 
 of gall-stones. It is not produced by imprudence in eat- 
 ing, comes on without definite relation to taking food, and 
 is usually relieved by vomiting. 
 
 Pain located in the epigastrium and radiating to the 
 back is another fairly constant symptom. It is dull aching 
 in character and varies in intensity. It is increased when 
 the gall-bladder is distended and relieved when it is 
 emptied. 
 
 Tenderness over the gall-bladder can generally be eli- 
 cited by spreading the fingers of the left hand over the 
 patient's ribs and hooking the thumb under the costal 
 margin. When the patient takes a deep inspiration, the 
 diaphragm forces the liver down and the sensitive gall- 
 bladder coming in contact with the examiner's finger 
 causes a sudden catch in the patient's breath. 
 
 Colic is a familiar symptom. It is due to the sudden 
 blodkage of the duct and the muscular contraction of the 
 gall-bladder to overcome the obstruction. Colic is abrupt 
 in its onset and sudden in its relief. The patient is 
 doubled up in agony, and there is faintness, nausea and 
 vomiting. 
 
 Jaundice is not a very frequent symptom of gall-stones. 
 According to Murphy it only occurs in one out of seven 
 cases. Jaundice is due to obstruction of the common 
 duct. Bile, unable to escape into the duodenum, exerts a 
 back pressure on the liver and there is rupture of the 
 biliary radicles. Bile is taken up by the lymphatics and 
 
 130 
 
ETIOLOGY AND SYMPTOMATOLOGY OF 
 
 carried to the general circulation causing the characteris- 
 tic discoloration of the eyes and skin, and giving, sooner 
 or later, the symptoms of cholemia. 
 
 Obstruction of the common duct may be caused by it 
 being plugged by a stone from within or compressed by 
 a growth from without. Attention has been called to the 
 fact that the retro-duodenal portion of the common duct 
 lies in or on the head of the pancreas. Disease of the 
 pancreas, whether inflammatory or malignant, which 
 causes it to be enlarged, will by pressure obstruct the 
 common duct and produce jaundice. It is a fact which 
 cannot be too strongly impressed that most cases of gall- 
 stones are not attended by jaundice and most cases of 
 jaundice are not due to gall-stones. The differentiation 
 of jaundice due to gall-stones and jaundice due to malig- 
 nant disease is based on the fact that jaundice due to gall- 
 stones is usually preceded by colicky pain, while jaundice 
 due to cancer is not attended by pain. Also by the fact 
 that jaundice due to gall-stones varies in intensity, deep- 
 ening after an attack of pain and then clearing up, while 
 jaundice due to malignant disease gradually gets deeper 
 and deeper and never lessens. There is yet another fact, 
 first emphasized by Courvoisier namely, that in jaundice 
 due to a stone in the common duct the gall-bladder is con- 
 tracted and cannot be palpated, while in jaundice due to 
 malignant disease the gall-bladder is distended and can 
 usually be felt. 
 
 Fever is a frequent symptom of gall-stone disease, due 
 to an increase in the acuteness of infection. It is marked 
 by its rapid rise and abrupt termination. If the range of 
 the temperature be charted, it gives an appearance which 
 
 140 
 
GALL STONES 
 
 Moynihan calls "The Steeple Chart" and Murphy terms 
 "The Temperature Angle of Cholangic Infection." 
 Tumor of a movable pear-shaped mass which can be 
 palpated in the region of the gall-bladder indicates either 
 obstruction of the cystic duct with a stone and distention 
 of the viscus with mucous, or the obstruction of the com- 
 mon duct by cancer and the distention of the organ with 
 bile. 
 
 It sounds like a paradox, but it is a deplorable fact 
 that most cases of gall-stones are treated by the physi- 
 cian for indigestion, and that many cases of supposed gall- 
 stones operated on by surgeons are the victims of some 
 other disease. Mistakes in the diagnosis of gall-stones 
 are due to all the early symptoms being referred to the 
 stomach and the supposedly pathognomic symptom of 
 jaundice being most frequently due to cancer. 
 
 141 
 
Diagnosis and Treatment of 
 Gall Stones* 
 
 Cases of gall-stones have been recognized and treatec 
 for many centuries, but until Marion Sims did the first 
 premeditiated operation for the removal of a biliary con- 
 cretion, some twenty-six years ago, the disease was con- 
 sidered a medical one and not amenable to surgery. The 
 belief that gall-stones could be relieved bv diet, exercise, 
 mineral waters and drugs has been so long entertained 
 that the laity and many of the profession still think that 
 surgery should be resorted to only when continued jaun- 
 dice or profound sepsis threaten the life of the patient. 
 This fallacy is being dispelled and no stronger or more 
 conservative statement of the present concensus of 
 opinion can be cited than that of Kocher, who states in 
 his recent book that while he does not go to the length 
 of saying that gall-stones '"belong" to the surgeon, as 
 possession is nine points of law, and hence they are the 
 property of the patient ; still, 'Tf the patient prefers to 
 wait in suffering and pain for a stone to work its way 
 down per vias naturales he is but employing his personal 
 privileges. But in the present day a surgeon is certainly 
 justified in telling a patient with gall-stones that by an 
 operation he can be quickly and safely cured of his 
 trouble, and be saved from an eventual danger more rap- 
 idly and more easily than by any other treatment." 
 
 * Read at the meeting of the Tri-State Medical Association of 
 the Carolinas and Virginia, Danville, Va., February, 1904. 
 
 143 
 
DIAGNOSIS AND TREATMENT OF 
 
 The results of the work of Mayo, Kehr, Robson and 
 others show that early surgery in the biliary tract, like 
 early operation for appendicitis, is safe and easy; while 
 late surgery is difficult and desperate; and lead to the 
 inevitable conclusion that in all cases of gall-stones an 
 early effort should be made to restore health, rather than 
 a late effort to save life. 
 
 The importance of gall-stones can only be recognized 
 after an appreciation of the frequency with which the 
 disease exists. Naunyn, in post-mortem examinations of 
 a large number of bodies, found them in io% of all cases. 
 The reason why a diagnosis of the condition is not made 
 oftener is because in 85% of cases the stones are quiescent 
 and give rise to no trouble, and in the remaining 15% 
 of cases the symptoms originating from gall-stones are 
 frequently misinterpreted and attributed to gastritis, in- 
 testinal indigestion, chronic appendicitis, loose kidney or 
 other causes. 
 
 The surgeon who constantly bears in mind the possi- 
 bility of cholelithiasis in every patient with obscure 
 abdominal disease, will be the man to make the diagnosis 
 of gall-stones in the largest proportion of cases. Looking 
 for gall-stones will not give them to a patient, but finding 
 them will usually bring relief through an appropriate 
 operation. 
 
 Gall-stones are usually secondary to infection of the 
 gall-bladder with the colon bacillus or the germ of typhoid 
 fever. They are usually found at or after middle life, 
 are three times more common in women than in men, 
 and are most often observed in those who lead sedentary 
 lives, wear tight clothing or eat to excess. The symptoms 
 of gall-stones depend largely on the location of the 
 
 144 
 
GALL STONES 
 
 stone. If the calculus is in the gall-bladder or cystic duct 
 the symptoms are local, and consist of spasmodic pain, 
 attended by tenderness in the epigastrium, and frequently 
 distention of the gall-bladder sufficient to make it per- 
 ceptible on palpation. If the stone is lodged in the hepatic 
 or common duct in addition to the foregoing local symp- 
 toms there will be constitutional disturbances, such as 
 jaundice, due to the absorption of bile by the blood. 
 
 The diagnosis of gall-stones is easy when there is 
 characteristic colic, local tenderness, nausea and vomiting, 
 and more or less pronounced jaundice, but unfortunately 
 the co-existence of these classical symptoms is rare, and 
 the surgeon who hesitates to operate because one or even 
 two of them are absent will fail to give relief to many 
 patients. 
 
 In the record of a large number of cases where gall- 
 stones were found only one-half of the patients gave a 
 history of biliary colic and only one-fifth a history of 
 marked jaundice. 
 
 Ochsner, in describing the symptoms that will most 
 constantly lead to the correct diagnosis when gall-stones 
 are present, classifies them about as follows : 
 
 1st. Digestive disturbances such as weight and burn- 
 ing in the stomach, and distention of the abdomen, after 
 eating. 
 
 2nd. Dull pain, beginning in the epigastric region, ex- 
 tending to the right along the level of the tenth rib, and 
 distributed to the spine and right shoulder blade. 
 
 3rd. Tenderness upon pressure at a point between the 
 umbilicus and the ninth costal cartilage of the right side. 
 
 4th. History of having had one or more attacks of 
 typhoid fever or appendicitis. 
 
 5th. Slight yellow discoloration of the skin, not suffi- 
 
 145 
 
DIAGNOSIS AND TREATMENT OF 
 
 cient to be recognized as icterus, but still sufficient to be 
 perceptible upon close inspection. 
 
 6th. An increase in the area of liver dullness. 
 
 7th. A swelling of variable size sometimes seen op- 
 posite the end of the ninth rib. 
 
 In conclusion Ochsner says : *'Of course if we have 
 added to these symptoms the biliary colic, followed by 
 distinct jaundice, and possibly the passage of biliary cal- 
 culi, our diagnosis is still further confirmed, but even 
 without these three last conditions we must make the 
 diagnosis ordinarily, or we will miss the diagnosis in most 
 patients suffering from gall-stones." 
 
 It is obviously impossible in some cases to make an 
 absolute diagnosis, but the surgeon belongs to an un- 
 happy branch of the profession whose business it is to 
 look for trouble, and when a case is referred to him with 
 symptoms in the region of the liver that have defied 
 medical treatment, he should open the abdomen, ascer- 
 tain the nature of the disease and give relief by an appro- 
 priate operation. 
 
 In following the above practice I am free to admit I 
 have failed to find the suspected stone in about one-fourth 
 the cases operated on, but I have never failed to find 
 "trouble." If there was no stone there was cholecysti- 
 tis, flexon of the gall-bladder, cancer of the liver or some 
 other pathologic condition. If there was no operation to 
 be done for stone there was the equally important work 
 of draining the gall-bladder for infection, or suturing it 
 in a position to correct angulation and prevent residual 
 bile, or anastomosing it to the doudenum to overcome ir- 
 remediable obstruction of the common duct from malig- 
 nant deposit. 
 
 m6 
 
GALL STONES 
 
 Operations on the gall-tract have recently been 
 rendered easier and more accurate by an improved tech- 
 nique. Just as the method of exposing the kidney for 
 operative manipulation has improved so has the method 
 of exposing the liver. When surgeons first began to do 
 work on the kidney an incision was made and the work 
 done through it on the wabbling kidney beneath. Now 
 the kidney is delivered through the wound and the work 
 done on it while it is fixed in position and under actual 
 inspection. So, too, in hepatic surgery. Formerly the in- 
 cision was made and the work attempted in an inacces- 
 sible location. Now the patient is placed on the table in 
 a slightly reverse Trendelenburg position, with a sand 
 bag beneath the back, thus carrying movable viscera to- 
 wards the pelvis and making the liver itself more promi- 
 nent. An incision is made beginning near the ninth costal 
 cartilage of the right side and running vertically down- 
 ward through the outer border of the rectus muscle. If 
 complications are met with and more working space is 
 required the opening may be enlarged by a second incision 
 beginning at the upper angle of the first, and extending 
 obliquely upward and inward to the tip of the ensiform 
 cartilage. This last incision divides the skin and anterior 
 and posterior sheaths of the rectus muscle, but does not 
 sever the fibres of the rectus or the peritoneum, as these 
 structures can readily be stretched by a retracter. 
 
 The anterior border of the liver is grasped by the right 
 hand of the assistant and drawn first downward and then 
 outward until at least one-third of the organ is delivered 
 into the wound. This brings the gall-bladder practically 
 outside of the body and renders the ducts straight and 
 easily accessible. After opening the abdomen the gall- 
 
 147 
 
DIAGNOSIS AND TREATMENT OF 
 
 bladder should be carefully palpated for stones. If it 
 is tense with fluid it should be emptied before being in- 
 cised. If the ducts are open this can be accomplished by 
 gentle but firm pressure against the liver. If they are 
 closed the fluid must be removed with a canula or aspira- 
 tor. The gall-bladder should be opened whether stones 
 are found or not, as it may contain biliary sand, thick 
 tarry bile, or be chronically inflamed, and hence require 
 drainage. 
 
 Before making the incision into the gall-bladder the 
 general peritoneal cavity should be carefully protected 
 from contamination by a well placed coffer dam of gauze. 
 This can be effectively done by taking a piece of gauze 
 two yards long, folding it into a strip the width of the 
 hand and rolling it into a bandage. This is unrolled and 
 systematically packed in the abdomen, beginning at the 
 left side of the gall-bladder, then beneath it and finally 
 to its right. 
 
 The incision in the gall-bladder should be in the fun- 
 dus and of sufficient size to introduce the index finger. 
 Stones found in its cavity should be removed with a 
 scoop devised for the purpose or with a dull uterine 
 curette. 
 
 The question of the patency of the cystic, hepatic and 
 common ducts will next have to be determined. It is well 
 to bear in mind that they may contain a stone and still 
 be capable of transmitting bile, and again that they may 
 contain no stone but be temporarily occluded by swelling 
 of their mucosa. 
 
 There is no well determined procedure to settle this 
 important point. Some surgeons rely largely on the pa- 
 tient's previous history, but this is uncertain, as Kehr has 
 
 148 
 
GALL STONES 
 
 found stone in the common duct in a large number of 
 cases that had never manifested jaundice. Other opera- 
 tors endeavor to pass a probe through the ducts, but 
 this is a bad practice, as experiments in the dead house 
 show that a probe will not pass through the normal cystic 
 duct, owing to a valve like arrangement of the mucous 
 lining. Fergusson and Van Hook endeavor to inject 
 water or air through the ducts, but this method is time 
 consuming, requires special apparatus and endangers 
 sepsis. Weir adopts the plan of dropping a pellet of 
 methylene blue in the gall-bladder just as he completes 
 the operation, stating that if the ducts are open the 
 coloring agent passes into the intestines and stains the 
 feces, but if the ducts are closed the result is negative. 
 The method is safe and ingenious but does not help to 
 solve the problem while the patient is on the table. 
 
 Practically the best that can be done is to palpate the 
 ducts carefully and systematically from their origins in 
 the gall-bladder and liver to their termination in the 
 duodenum, which can be satisfactorily done by introduc- 
 ing two forefingers into the foramen of Winslow, behind 
 the ducts, and making pressure on them with the thumb 
 from the front. If a stone is found it should be removed 
 by incising the duct; if one can not be detected the duct 
 should be left intact. 
 
 Owing to the varying location of gall-stones and to the 
 many complications that result, a great number of opera- 
 tions have been devised to meet the different conditions 
 encountered. Gall-tract surgery is young compared with 
 surgery of the pelvis and of the appendix, and the indi- 
 cations for certain methods have not yet been definitely 
 settled. 
 
 149 
 
DIAGNOSIS AND TREATMENT OF 
 
 Cholecystotomy consists in the incision of the gall-blad- 
 der, the removal of its contents and the immediate closure 
 by suture of the opening in the viscus. The operation is 
 indicated for stones in a healthy gall-bladder with unob- 
 structed ducts. It is called the "ideal operation" by its 
 advocates and the same term is applied to it satirically by 
 its opponents. The cases in which it is safe to apply the 
 method are very exceptional. 
 
 Cholecystendesis consists in the steps described in the 
 operation of cholecystotomy, except that in place of drop- 
 ping the gall-bladder back in the abdomen, the fundus is 
 anchored by sutures to the abdominal incision. The ob- 
 ject is either to correct flexion or to place the organ in 
 such a position that it will be accessible in case it is found 
 necessary to open and drain it. 
 
 Cholecystostomy consists in the incision of the gall-blad- 
 der, the removal of its contents and the subsequent drain- 
 age of its cavity through the abdominal incision. The 
 fistulous opening may be formed either by sewing the cut 
 edge of the gall-bladder to the parietal peritoneum with 
 chromicised catgut, or preferably, by tying a tube in the 
 opening of the gall-bladder with a purse string suture and 
 bringing it through the abdominal incision, either trusting 
 to adhesions forming around the tube before its detach- 
 ment, or bringing the gall-bladder in contact with the 
 under surface of the wound by two suspension ligatures. 
 The operation of cholecystostomy is indicated in gall- 
 stones complicated by acute or chronic cholecystitis and is 
 the method applicable to the majority of cases. It pre- 
 vents accumulation of fluid in the diseased viscus, affords 
 exit for an overlooked stone, and cures inflammation of 
 
GALL STONES 
 
 the gall-bladder and ducts by providing free and pro- 
 longed drainage. 
 
 Cholecystectomy consists of the removal of the entire 
 gall-bladder. The operation can be done with compara- 
 tive ease if the cystic duct be first ligated and divided, and 
 the viscus freed from the attachment to the liver from 
 behind forwards. The indications for the operation are 
 yet unsettled. There is no doubt that it can be done with 
 low mortality, but the question is as to the ultimate re- 
 sults that follow it. Davis, of Omaha, and others claim 
 that it avoids a fistula with the attending long convales- 
 cence, removes a useless organ, prevents the possibility of 
 stones reforming, and gives the patient the best guaran- 
 tee of complete restoration to health. Richardson, of 
 Boston, at one time an enthusiastic advocate of the opera- 
 tion, now condemns it except in selected cases, as the re- 
 moval of the gall-bladder prevents its utilization as a 
 drainage tract, and patients after the operation frequent- 
 ly have a recurrence of symptoms which, owing to the ab- 
 sence of the gall-bladder, he is at a loss to know how to 
 re-relieve. A conservative statement of the present opin- 
 ion of the profession in regard to cholecystectomy is that 
 the operation should be limited to cases of irremedial 
 obstruction of the cystic duct, and to cases of gangrene 
 or malignant disease of the walls of the gall-bladder. 
 
 Choledochotomy consists in the incision of the common 
 duct for the removal of a stone. The term is also some- 
 times used to describe incision of the other bile ducts. 
 When the stone is lodged at the opening of the common 
 duct into the intestine it is best reached by ^IcBurney's 
 trans-duodenal route ; otherwise it is more accessible by 
 approaching the duct by the external route to the right 
 
 151 
 
GALL STONES 
 
 of the duodenum. An incision is made in the duct parallel 
 to its long axis and the stone removed either complete or 
 fragmented. Halstead and others advise suture of the 
 opening, but the majority of surgeons state that this pro- 
 cedure is unnecessary, and the present practice is sim- 
 ply to drain Morrison's pouch with a tube and gauze. 
 
 Cholecystenterostomy consists in the anastomosis of 
 the fundus of the gall-bladder to the duodenum, preferab- 
 ly by means of Murphy's button. The operation is in- 
 dicated for irremedial obstruction of the common duct 
 from cancer or other causes, and relieves jaundice by af- 
 fording a new avenue by which bile can pass from the 
 liver to the intestinal canal. 
 
 IS2 
 
Analysis of the 
 
 Last Fifty Cases of Goitre Operated On 
 
 at St. Luke's Hospital * 
 
 Nineteen years ago when the University College of 
 Medicine was established I was appointed assistant to 
 my father, and my principal duty was to provide material 
 for his weekly clinic. On two or three occasions I had 
 a case of goitre for him, but he always found some excuse 
 for not operating. Finally one night he called me into 
 his office and said : "Stuart, don't give me any more 
 cases of goitre in my clinic. I once operated on a case 
 and it was the most bloody, barbarous and unsurgical 
 procedure I ever attempted. Every man must be taught 
 by his own experience, but if there is one thing you can 
 learn from me it is not to operate for goitre." 
 
 This advice was good for its day and generation. The 
 great Kocher's mortality in his first seventy cases of 
 simple goitre was 40 per cent., and Charles H. Mayo's 
 mortality in his first sixteen cases of ex-ophthalmic goitre 
 was 25 per cent. It is no wonder that at one time the 
 operation was regarded as unwarranted by the majority 
 of surgeons, and it is not surprising that there are still 
 to-day some among the older practitioners who hesitate 
 to advise a patient with goitre to seek operative relief 
 except as a last resort. 
 
 Times have changed and the once formidable opera- 
 
 * Read at the meeting of the Medical Society of Virginia, 
 Richmond, Va., October, 191 1. 
 
 153 
 
CASES OF GOITRE OPERATED ON 
 
 tion has been rendered comparatively simple and safe in 
 experienced hands. Kocher, with a courage that seems 
 marvelous to the present generation of surgeons, per- 
 severed in his work until he finally established a tech- 
 nique that has reduced the mortality in his last one thou- 
 sand operations for goitre to four-tenths of one per cent. 
 This was accomplished by: 
 
 1. Early operations on more favorable cases. 
 
 2. Improved aseptic methods to prevent infection. 
 
 3. More skillful administration of anesthetics. 
 
 4. An exposure which gave ability to control hemor- 
 rhage and avoid injury to certain important structures 
 of the neck. 
 
 Six or seven years ago I became convinced from 
 Kocher's writings that the operation of partial thyroidec- 
 tomy was advisable in certain conditions. I have now 
 operated on more than one hundred cases of goitre, em- 
 bracing practically all types of the disease without a single 
 death and with most satisfactory symptomatic results. 
 
 Despite the low mortality of the operation, as reported 
 by numerous surgeons, I do not think a patient should 
 be treated surgically until medical measures have been 
 tried and proven to be inefficient. From personal obser- 
 vation I am satisfied that at least one-half of all patients 
 suflfering with both simple and ex-ophthalmic goitre will 
 get well without operation. Whether their recovery is 
 due to the remedies prescribed by the physician or to 
 the inherent tendency of the system to overcome an ab- 
 normality is not a material question. The practical fact 
 is that these patients should be treated along accepted 
 lines and given a reasonable time to see what Nature 
 will do for them before they are subjected to a surgical 
 
 154 
 
AT ST. LUKES HOSPITAL 
 
 risk. If, however, they fail to improve or their symp- 
 toms get worse, then an operation should be advised be- 
 fore complications develop, or incurable structural 
 changes occur in the heart, eyes or other organs. In 
 other words, the surgeon should not operate on a case 
 too soon, and the physician should not treat a case too 
 long. It is a pity that there is not a better understanding 
 between the physician and the surgeon in the treatment 
 of the disease, as each has a distinct and separate field 
 of work, and each accomplishes results the other could 
 not hope to secure. 
 
 The surgeon should not underestimate the value of 
 medical treatment. He should remember he sees only 
 the cases in which failure has resulted and is ignorant 
 of the cases in which cures have been effected. On the 
 other hand, the physician should not criticise the sur- 
 geon for operating on so many patients. He should re- 
 member that practically all his cases have been treated 
 medically without success and have been referred to him 
 because they could not be cured without the use of the 
 knife. 
 
 The medical treatment of simple goitre consists in plac- 
 ing the patient under the best possible hygienic conditions. 
 This is especially the case in the symmetrical enlarge- 
 ment of the thyroid gland which is frequently seen in 
 girls about the age of puberty. The patient should have 
 proper food, pure drinking water and an abundance of 
 fresh air. Regular hours of rest should be prescribed 
 and over-exertion and mental excitement carefully 
 guarded against. In the parenchymatous type of the dis- 
 ease the internal administration of an active preparation 
 
 155 
 
CASES OF GOITRE OPERATED ON 
 
 of thyroid extract does much good. If it fails, arsenic 
 and iodide of potash should be tried. The local use of 
 tincture of iodine, especially when applied with catapho- 
 resis, is a remedy of recognized value. As simple goitre 
 causes mechanical symptoms, the patient is often the best 
 judge as to when the disfigurement or discomfort it pro- 
 duces is sufficient to justify an operation. The danger 
 of malignant degeneration, however, must not be left 
 out of consideration. 
 
 The medical treatment of ex-ophthalmic goitre con- 
 sists primarily in rest. If possible, the patient should be 
 placed in a hospital and for a time confined to bed. An 
 ice-bag over the heart is often of temporary benefit. 
 Roger's and Beebee's serum gives good results in selected 
 cases and should be used where indicated. Forcheimer 
 reports cures from neutral preparation of hydro-bromate 
 of quinine. He advises that it be given four times a 
 day in five-grain doses. If there is no improvement in 
 forty-eight hours he adds one grain of ergotin to each 
 capsule. Belladonna given hypodermically in the form 
 of atropia is a remedy of recognized value. X-Ray 
 exposures sometimes result in marked benefit when every- 
 thing else fails. The local use of iodine and the internal 
 administration of thyroid extract are, of course, to be 
 avoided. 
 
 If medical treatment fails to effect a cure in a reason- 
 able time, then the case should be treated surgically. 
 Delay is more dangerous in exophthalmic than in simple 
 goitre as the symptoms are not due to pressure but to 
 poison, and if hyperthyroidism is permitted to continue 
 
 156 
 
AT ST. LUKES HOSPITAL 
 
 there will be both increased risk and less satisfactory 
 results from the operation. 
 
 If it is decided to do a partial thyroidectomy, it is not 
 well to tell the patient in advance the day and hour fixed 
 for the operation. In some cases where there is great 
 fear of the operation it may be proper to practice the 
 method of Crile which he calls "stealing the gland." 
 The patient is told that before resorting to an operation 
 it has been deemed best to try the "Inhalation Treatment." 
 Every day at a certain hour the anesthetist goes to the 
 patient's room, places a mask over his face and for ten 
 minutes allows him to inhale some one of the essential 
 oils, such as eucalyptus. The day set for the operation, 
 the relatives, of course, being informed of what is to 
 take place, the treatment is given as usual, only ether or 
 chloroform is slowly substituted for the oil and the 
 patient put to sleep without knowledge that the operation 
 will be done that day. 
 
 The operation is most conveniently and safely per- 
 formed with the table in a reverse Trendelenburg posi- 
 tion. The elevation of the patient's head causes a certain 
 degree of anaemia which reduces the tendency to bleed 
 and lessens the amount of the anesthetic necessary to pro- 
 duce unconsciousness. 
 
 A transverse collar incision is made through the skin 
 and platysma over the most prominent part of the goitre, 
 and these two structures reflected to expose the under- 
 lying muscles. The sterno-hyoids and sterno-thyroids 
 are separated in the middle line to expose the gland. This 
 may give sufficient room to permit the delivery of the 
 tumor, but often it is necessary to divide the muscles 
 
 157 
 
CASES OF GOITRE OPERATED ON 
 
 transversely near their upper insertion in order to give 
 a safe working field. 
 
 If the goitre is of the circumscribed variety, the en- 
 capsulated mass should be enucleated, the bleeding ar- 
 rested and the cavity closed by buried sutures. If the 
 goitre is of the diffuse variety, the affected lobe and 
 isthmus should be excised by ligating the superior and 
 inferior thyroid arteries and dissecting it from the pos- 
 terior capsule. 
 
 Hemorrhage should be minimized by catching vessels 
 before or immediately after division. Removal of the 
 parathyroids should be avoided by preservang the 
 posterior capsule which covers them. Injury to the recur- 
 rent laryngeal nerve should be guarded against by care- 
 fully exposing the inferior thyroid artery and ligating it 
 close to the pole. 
 
 After tying all bleeding points, drainage should be 
 inserted, the divided muscles sutured and the skin neatly 
 approximated. 
 
 In order to bring out some interesting and practical 
 facts with reference to goitre, I have made a brief analy- 
 sis of the last fifty cases operated on at St. Luke's Hos- 
 pital. As only white patients are admitted to the insti- 
 tution nothing with regard to the influence of race on 
 the occurrence of the disease can be deduced. I am 
 satisfied, however, from my experience in other hospitals 
 that goitre develops as frequently in the negro as in the 
 Caucasian. 
 
 The fifty cases came from six different states. The 
 number is so few and the territory covered so large that 
 no conclusions are possible with reference to the influence 
 
 158 
 
AT ST. LUKES HOSPITAL 
 
 of geographical location. Four-fifths of the cases came 
 from cities of 10,000 population, or over. 
 
 Of the patients, seven were men and forty-three were 
 women, showing that the disease is more frequent in the 
 female. The youngest patient was seventeen and the 
 oldest sixty-one, the average age being thirty, showing 
 that it is a disease of middle life. 
 
 Thirty-one cases were simple goitre, causing only 
 mechanical symptoms. Nineteen were of the ex-ophthal- 
 mic type attended by marked symptoms of hyperthy- 
 roidism. The proportion of the latter to the former is 
 much greater than usually reported and shows that the 
 profession in my territory is not yet educated to the 
 point of referring early and easy cases to the surgeon, 
 but as yet only send the patient whose need is urgent. 
 
 In thirty-six cases the operation was on the right lobe, 
 in seven on the left, and in seven on both lobes. 
 
 The greater frequency of the disease on the right side 
 of the thyroid as compared to the left is noted by all 
 observers, but so far no satisfactory explanation on either 
 anatomical or physiological lines has been given. 
 
 The anesthetic employed was cocaine in one case, chlo- 
 roform in thirty cases and ether in nineteen cases. 
 Cocaine was used in the one instance because the patient 
 was obese, had a bad heart and protested against taking 
 a general anesthetic. Chloroform and ether were used 
 in the other forty-nine cases. 
 
 From careful observation I am convinced that patients 
 with goitre take a general anesthetic as well as any other 
 class of cases and, as the operation can be done more 
 rapidly and thoroughly with less strain on the patient 
 and the surgeon, I advocate its use unless there be some 
 
 159 
 
CASES OF GOITRE OPERATED ON 
 
 special contraindication. Whether the agent employed 
 be chloroform or ether should be decided not by consid- 
 ering the anesthetic but the anesthetist. In the first of 
 the series reported I employed a man who had great 
 experience in giving chloroform. He left my service and 
 was replaced by a woman who had long training in the 
 administration of ether. In the hands of experts I found 
 both agents safe and satisfactory. 
 
 In the fifty cases reported, fourteen operations were 
 enucleations of circumscribed tumors, and thirty-six were 
 excisions of enlarged lobes. The amount of the gland 
 removed varied from a slightly enlarged lobe weighing 
 one or two ounces to a huge mass weighing seven pounds. 
 The average time taken to complete an operation was 
 thirty minutes. The average 9onfinement of the patient 
 to bed was seven days and the average stay in the hos- 
 pital was two weeks. 
 
 The Post-Operative Complications were as Follows : — 
 One patient had huskiness of the voice for a week or 
 ten days, showing I had irritated but not permanently 
 injured the recurrent laryngeal nerve. 
 
 One patient had infection of the wound due to the im- 
 perfect drainage of a large cavity left after the dislocation 
 of an intrathoracic goitre. 
 
 One patient had a severe hemorrhage shortly after re- 
 covery from the anesthetic, requiring the wound to be 
 reopened and the bleeding arrested. This accident was 
 probably due to including some muscular tissue in one 
 of the ligatlures, which contracted and pulled the suture 
 off. 
 
 Two patients had hyperthyroidism, one mildly, the 
 other severely. They both recovered in forty-eight hours 
 
 i6o 
 
AT ST. LUKES HOSPITAL 
 
 Whether the symptoms were due to absorption of the 
 thyroid juices from the wound or whether they were due 
 to ''psychic excitation," as claimed by Crile, I do not know 
 The surgeon should try to minimize the frequency and 
 severity of this complication by handling the gland gently 
 during the operation to avoid expressing its juices, and 
 also by endeavoring to allay the patient's fear before the 
 operation to avoid the possibility of hypersecretion from 
 psychic influences. If pain, fright or mental emotions 
 are capable of causing hyperthyroidism, it is an argu- 
 ment in the favor of the use of a general anesthetic. 
 
 Not long ago I had a case at the Virginia Hospital 
 which strongly substantiated Crile's theory. The patient 
 was a woman on whom I had operated two years before 
 for ex-ophthalmic goitre and had effected a symptomatic 
 cure. She came back to the hospital for the repair of the 
 perineum and the correction of a displacement. When 
 the time came for the operation she tried to back out, but 
 I urged her on, and she went to the anesthetizing room 
 in a bad state of fright. The operation was simple and 
 uncomplicated, but in a few hours she developed high 
 fever, was wildly delirious and her heart was so rapid 
 that her pulse could not be counted. Here was a clear 
 instance of hyperthyroidism developing from the exces- 
 sive secretion of the thyroid gland stimulated by the 
 patient's psychic condition. In this case there was no 
 possibility of thyroid juices being absorbed by fresh sur- 
 faces as the operation was not on the neck but in the 
 pelvis. 
 
 The final results of the operations were as follows: — 
 In thirty-one cases of simple goitre where the symptoms 
 
 i6i 
 
CASES OF GOITRE OPERATED ON 
 
 were due to mechanical pressure, there was complete 
 relief in every instance. 
 
 In the nineteen cases of ex-ophthalmic goitre where 
 the symptoms were due to hyperthyroidism, there was 
 symptomatic cure in sixteen cases, marked benefit in two 
 cases and failure to receive any benefit in one case. 
 
 In stating that a symptomatic cure was afifected in six- 
 teen cases, I mean that the patients were relieved of 
 nervousness, tremor, tachycardia, and digestive disturb- 
 ances and that they regained their usual weight, strength 
 and spirits. The ex-ophthalmos was improved in a few 
 of the early cases, but remained as a permanent disfigure- 
 ment in the majority of instances. All of the patients 
 still seem to have some irritability of the nervous 
 mechanism regulating the heart, for while the pulse rate 
 is normal under usual conditions it temporarily becomes 
 abnormally rapid on unusual excitement or exertion. 
 
 In the two cases reported improved but not cured, the 
 symptoms all continue but in much less intensity. Failure 
 to effect a cure was due to not removing enough of the 
 thyroid gland. If in the future the patients are not satis- 
 fied with their condition a second operation can be done. 
 
 The amount of the thyroid secretion is not dependent 
 on the anatomical bulk but on the physiological activity 
 of the glandular tissue ; hence, in every case it is a ques- 
 tion with the surgeon of how much to take out and how 
 much to leave in. If an error is made it had better be 
 on the side of conservatism as it is easy to take out more 
 and impossible to put back any of this tissue which has 
 such an important effect on the physical nutrition and ner- 
 vous equilibrium of the individual. Personally, however, 
 I must say that with increasing experience I find myself 
 
 162 
 
AT ST. LUKES HOSPITAL 
 
 taking out more and more of the gland and have never 
 seen any bad results. 
 
 In the one case reported where the patient received no 
 benefit, the fault was in the diagnosis, not in the treat- 
 ment, as the case was not one of hyperthyroidism but of 
 neurasthenia. The patient was a woman of thirty-two, 
 referred to me by a prominent specialist of this city. She 
 had very prominent eyes and a goitre the size of a lemon. 
 She was nervous, tremulous and suffered with tachycar- 
 dia on slight exertion. I operated on her and removed 
 the right lobe and the isthmus. My pathologist ex- 
 amined the specimen and reported that the tissue did not 
 show the cellular hyperplasia usually seen in hyperthy- 
 roidism, and he believed it was a case of simple goitre. A 
 more careful review of the patient's history and symp- 
 toms made it apparent that the woman was a victim of 
 neurasthenia and the goitre was but a coincident trouble. 
 Failure to secure the expected benefit from the opera- 
 tion was a further corroborative evidence. 
 
 163 
 
The Thyroid and Hyperthyroidism 
 
 A review of the history of surgery will show that at 
 certain periods special study has been concentrated on a 
 single organ. Disease of the pelvic organ, of the appendix 
 vermiformis, of the liver and gall-tract, of the stomach 
 and of the pancreas, have each in turn occupied the pro- 
 fessional mind. At present the thyroid gland is the or- 
 gan chiefly under consideration. 
 
 Much has been learned about its physiological func- 
 tion and pathological changes, but much is yet unknown. 
 Brilliant results have been achieved in treating patients 
 the victims of its diseases, but they have been obtained 
 by relieving the symptoms rather than by removing the 
 cause, or at the cost of a mutilating operation. The day 
 will come when a satisfactory knowledge of the etiology 
 of thyroid disease will enable us either to prevent its oc- 
 currence or to cure it by some less heroic measure than 
 the violence of surgery, but the time is not yet. 
 
 From the conception of Claude Bernard of subtle 
 agents known as internal secretions, down to the demon- 
 stration of the existence and composition of iodothyrin, 
 the history of the thyroid gland has received many valu- 
 able, and some dramatic, contributions. 
 
 Paracelsus, in the seventeenth century, recognized the 
 relationship between goitre and cretinism. 
 
 Schiff, in 1856, showed that complete thyroidectomy 
 was followed by the death of the animal. 
 
 * Oration on Surgery delivered at the meeting of the Southern 
 Medical Association, Jacksonville, Fla., November, 1912. 
 
 i6s 
 
THE THYROID AND HYPERTHYROIDISM 
 
 Gull, in 1873, described the symptoms of myxedema. 
 Sandstroem, in 1880, discovered the parathyroid 
 glands, but did not distinguish their physiological impor- 
 tance. 
 
 Kocher, in 1882, demonstrated the fact that myxede- 
 ma would develop after removal of the thyroid. 
 
 Moebius, in 1886, crystallized the work of Parry, 
 Graves and Basedow, and proved that the syndrome pre- 
 viously described by them and believed to be a disease 
 of the nervous system, was really caused by excessive 
 thyroid secretion. 
 
 Gley, in 1891, separated the functions of the thyroid 
 and parathyroids and proved that tetany following an 
 operation was due to the loss of the parathyroids. 
 
 Baumann, in 1896, isolated a body containing iodine, 
 possessing the physiological characteristics of the thyroid. 
 To this substance he gave the name iodothyrin. 
 
 McCallum and Voegtlin, in 1908, proved the import- 
 ance of the parathyroids in the control of calcium meta- 
 bolism. 
 
 Such, in brief, are the more profound and epoch- 
 making advances made in the study of the gland. They 
 constitute a series, beautiful in its logical evolution, pro- 
 found in its import to human welfare. 
 
 The function of the thyroid is carried out by an in- 
 ternal secretion. It reaches the general system of lym- 
 phatics, and its most important element has been demon- 
 strated in the blood. The colloid material found in the 
 follicles is regarded by some of the best authorities as 
 peculiar to this gland. Chemically it is made up of iodo- 
 
 166 
 
THE THYROID AND HYPERTHYROIDISM 
 
 thyrin and thyro-albumin, the latter a nucleo-proteid con- 
 taining no iodine, but rich in phosphorous. 
 
 lodothyrin is a combination of a globuHn with iodine. 
 The compound is not found elsewhere save in the blood, 
 where it may be regarded as directly derived from the 
 gland. It is not at all certain that iodothyrin represents 
 the total of the active principles of the thyroid, but it is 
 at least true that its administration produces much the 
 same effect as does the extract of the gland in the treat- 
 ment of myxedema. 
 
 The thyroid gland is essential to life. Whatever be 
 the nature of its control over body metabolism, it is a 
 vital one. Kocher states that an individual deprived of 
 the thyroid may live seven years. So quietly and modest- 
 ly does this important organ do its work that the exact 
 part it plays is still hidden. But it naturally lies some- 
 where between the two extremes, hypo and hyper-thyroid- 
 ism. The former is seen upon removing the gland, leav- 
 ing the parathyroids, the latter by feeding thyroid ex- 
 tract. 
 
 Thyroidectomy produces symptoms of a chronic cach- 
 exia. The metabolism of the body is depressed, heat 
 regulation and gaseous interchange are at a low ebb. In 
 the young growth is lessened and the skeletal system is 
 dwarfed. The cells fail to reach their proper develop- 
 ment and the connective tissue remains myxomatous, giv- 
 ing to the skin a dry, massive, elephantile appearance. 
 The hair is coarse and shows deficient nourishment. The 
 nervous system halts in development, and mentality does 
 not rise above the level of the infant. Physically and in- 
 tellectually the victim of thyroid poverty is less a man, 
 more a beast. 
 
 167 
 
THE THYROID AND HYPERTHYROIDISM 
 
 At the other end of the scale stands the exophthalmic. 
 Excessive feeding with thyroid extract produces symp- 
 toms of metabolic riot. Heat production and gaseous 
 interchange are rapid. The body tissues are stimulated 
 to a course of wasting dissipation. There are seen trem- 
 or, sweating, tachycardia, muscular weakness, loss of 
 weight and feverish mental activity. The evidence of 
 thyroid excess suggests the entrance of tragedy into the 
 life of its subject. 
 
 The thyroid gland, then, has a special influence on the 
 nervous system, the muscular system, the skin and epi- 
 thelial structures, the osseous system, and on the sexual 
 functions. It exercises a general influence on the meta- 
 bolism of the body. Of the various hypotheses that have 
 been advanced to explain its action, it is impossible at 
 this time to say which is the true one. It may be that 
 each contains an element of truth; it is not likely that 
 all are wide of the mark. But, either as a neutralizer of 
 endogenous toxins, or as a hormone stimulating other or- 
 gans and tissues to activity, or by some other obscure but 
 potent influence the thyroid is a pace-maker for the body. 
 
 It is a temptation to speculate as to what the future 
 may have to tell of the thyroid and other ductless glands. 
 Who can say how far the influence of these organs may 
 be shown to parallel the lines of the great social hier- 
 archy? Who can say that the dullard, the drone and the 
 vast army of the inefficient and dependent are not, after 
 all, but close cousins to the cretin or can deny that iodo- 
 thyrin represents in some measure the baser ore, which 
 worked in the fires of experience, is seen and known in 
 that gift of the gods which we call genius ? What is there 
 in the history of science to make us doubt that some day 
 
 i68 
 
THE THYROID AND HYPERTHYROIDISM 
 
 we will be able to read backward the broader history of 
 the world, finding in the correlation of physiological prin- 
 ciples the gall of Napoleon's ambition and the iron of 
 Caesar's hand? 
 
 Less than a generation ago, Billroth, Reverdin, Miku- 
 licz and Kochcr, blazing the trail for those who were to 
 come after them, had one out of every four patients 
 operated on for goitre develop tetany. A description of 
 the symptoms given by one of the old authorities reads 
 as follows : 
 
 ''Some days after thyroidectomy, ordinarily on the third 
 or sixth day, sometimes a little earlier or later, the pa- 
 tient was seized with convulsions of the extrcmeties, more 
 often the superior, which were sometimes preceded by 
 tingling in the fingers or twitching of the muscles. Usu- 
 ally chronic contractions appeared ; the hands closed with 
 such violence that the nails often penetrated the skin. The 
 limbs were sometimes contracted so that it seemed that 
 they were going to break; even the diaphragm was at 
 times involved." 
 
 It is now well Iknown that tetany is not due to removal 
 of the thyroid but of the parathyroid glands. Mayo 
 states that the danger of tetany in thyroidectomy under a 
 proper technique is no greater than that of pulmonary 
 eml)olism following abdominal surgery. Thyroidectomy 
 alone docs not produce tetany ; removal of the parathy- 
 roids alone does cause it. The symptoms of tetany are 
 not relieved by giving thyroid extract ; on the other hand 
 parathyroid feeding does control them. Permanent cure 
 may be affected by transplanting parathyroid glands, but 
 a successful graft cannot be made unless there be a para- 
 thyroid poverty. 
 
 169 
 
THE THYROID AND HYPERTHYROIDISM 
 
 The parathyroid glands have been studied in the cat, 
 dog, monkey, guinea-pig, rabbit, rat, horse, sheep, goat, 
 ox, birds and man. Forsyth alone examined forty-two 
 species of mammals and thirty-five species of birds. In 
 man they are normally four in number, small, flat, soft, 
 yellowish-brown bodies, lying along the posterior margin 
 of the thyroid. McCallum states that their arrangement 
 is so inconstant that a composite picture of many dissec- 
 tions shows them occupying every point in a band from 
 top to bottom of the thyroid. Enlargements of the thy- 
 roid displace them out of all recognition in operation. 
 
 Chemically no predominating feature is found, such as 
 the iodine of the thyroid gland. Berkeley and Beebe, 
 however, obtained a nucleo-proteid and a globulin. The 
 globulin is of no value in relieving tetany. But according 
 to these observers, the nucleo-proteid will relieve tetany, 
 when given by mouth, subcutaneously or intraperi- 
 toneally. 
 
 Before the role of the parathyroids in tetany was 
 known, acute observers had recognized the low calcium 
 content of the body in tetany and the efficacy of these 
 salts in the control of the condition. Only recently 
 McCallum and Voegtlin were able to line the metabolic 
 perversion with its anatomical origin. 
 
 In contrast with the dramatic phenomena following 
 sudden loss of the parathyroids, their slow destruction 
 brings on gradual nutritional disturbances. These may 
 terminate in death without symptoms of tetany, and this 
 phase of parathyroid deficiency must be given due consid- 
 eration in the physiology of these glands. 
 
 Much promising work is now being done to determine 
 the relation of the thyroid gland with other organs, es- 
 
 170 
 
THE THYROID AND HYPERTHYROIDISM 
 
 pecially with other ductless glands. The association be- 
 tween the thyroid and the sexual organs, the pituitary 
 body, the ardrenals, the thymus, the pancreas, and the 
 parathyroids is substantiated by numerous facts. 
 
 The relation of the thyroid to the sexual function is 
 shown by its congestion following coitus, at puberty and 
 the menopause, in menstruation, pregnancy and lactation. 
 The thyroid tends to atrophy with the decline of sexual 
 power ; and the cretin is marked by sexual blight. 
 
 The pituitary body seems to be in close alliance with 
 the thyroid. In hypothyroidism it undergoes hyper- 
 trophy, apparently compensatory; while in acromegaly 
 the thyroid is usually enlarged. 
 
 The adrenals are stimulated by the thyroid. In Addi- 
 son's disease the thyroid is frequently atrophied, though it 
 may be enlarged. 
 
 The thymus gland undergoes hypertrophy so frequently 
 in exophthalmic goitre that it is regarded by some as a 
 part of the essential pathology. 
 
 The pancreas is inhibited by the thyroid. In hyperthy- 
 roidism degenerative changes are frequently seen in it, 
 and often sugar appears in the urine. On the other hand, 
 primary pancreatic insufficiency is at times followed by 
 marked alterations in the thyroid. 
 
 Such a collection of facts, inperfectly linked and but 
 poorly understood, is more suggestive than practical. But 
 it is prophetic of a better understanding of the subject. 
 
 At this time we are not able to say how the ductless 
 glands are controlled. Though they respond to nervous 
 influences, the functional results seen in grafts cut off 
 from all demonstrable nervous connection would tend to 
 show that they react to chemical stimuli contained in the 
 
 171 
 
THE THYROID AND HYPERTHYROIDISM 
 
 blood, known as hormones. The word "hormone" is de- 
 rived from a Greek verb meaning to awake or excite. 
 Their composition is largely unknown. They act by sti- 
 mulating organs to activity and are not nutritive material 
 to body cells. A very small quantity, therefore, is suffi- 
 cient for the exercise of their function. The evidence 
 seems to indicate that the correlation of the organs of in- 
 ternal secretion is accomplished through their medium. 
 Responsive to the call of these quick messengers, the in- 
 ternal secretions are seen in a silent but ceaseless con- 
 cert of action. It is probable that the ductless glands are 
 grouped about the thyroid as the director of the phy- 
 siological synergy. It brings to mind the words of Goethe 
 in his tribute to Nature: "She is the unique artificer, 
 from the simplest substances to the greatest contrasts, 
 without appearance of exertion to the greatest perfection; 
 to the most accurate precision, ever suffused with some- 
 what of delicacy." 
 
 The histological unit of the thyroid is a closed follicle 
 lined with a single layer of columnar epithelium, elaborat- 
 ing a secretion. It is surrounded by lymph channels and 
 blood-vessels lying in a connective tissue septum derived 
 from the capsule of the gland. Some of the follicles 
 have a lumen, others have none. Those with a lumen 
 are filled with colloid material. The difference in histolo- 
 gical structure of a normal thyroid and the thyroid of ex- 
 ophthalmic goitre is about the same as the difference ob- 
 served in the resting and the lactating breast. The change 
 is best represented by the term "hypertrophic parenchy- 
 matous thyroid." There is an increase in the number of 
 active cells in the follicles or increase in the number of 
 follicles, or both. For symptoms of hyperthyroidism to 
 
 172 
 
THE THYROID AND HYPERTHYROIDISM 
 
 arise, this increase must be sufficiently general to out- 
 weigh any retrogressive changes that may be going on 
 in other parts of the gland. There must also be ab- 
 sorption of the secretion at a rate corresponding to the 
 hyperplasia. Otherwise there follows retention of se- 
 cretion, enlargement of the gland, and development of 
 colloid goitre, with a subsidence of symptoms. Thus 
 it is seen that exophthalmic and simple goitre are not 
 separate entities, but stages of one process. Wilson says 
 that a large percentage of cases of simple goitre will re- 
 veal a history of definite signs of hyperthyroidism if in- 
 quired into, and that every case of exophthalmic goitre 
 is hypothetically destined, in order of pathological de- 
 generation, to become a case of simple goitre. Having 
 reached the colloid stage, one of the three possibilities 
 may occur: either the condition may persist as simple 
 goitre, or active hyperplasia and absorption may again 
 arise with return of exophthalmic symptoms ; or atrophic 
 and degenerative changes may occur resulting in myxe- 
 dema. In many cases of untreated hyperplastic thyroid, 
 secretion ceases before retention has occurred. These 
 cases show clinically either a return to normal or shade 
 into myxedema with atrophy of the gland. 
 
 Seen in proper perspective then, changes undergone by 
 the thyroid represent a series at first progressive, later 
 'degressive, but never assuredly resting. So closely do the 
 symptoms follow the changes described that the history 
 of the patient can be written by the pathologist in more 
 than 80 per cent of cases. 
 
 Wilson summarizes the pathology about as follows : 
 Very early acute cases show hyperemia and cellular 
 hyperplasia, at least in much of the gland. The recently 
 
 173 
 
THE THYROID AND HYPERTHYROIDISM 
 
 developed very mild, or moderately mild, cases of long 
 standing almost always show some total parenchyma in- 
 crease, but apparently not greatly increased functionating 
 power. Later acute, moderate, severe and very severe 
 cases show greater parenchyma increase, and in many 
 cases, greater absorbable secretion. Cases which clini- 
 cally are showing any remission of toxic symptoms, show 
 somewhere within the gland more or less evidence of de- 
 creased function. Patients who have recovered from 
 their toxic symptoms and are now sufifering from long, 
 previously acquired heart or nerve lesions show degenera- 
 tive changes and large quantities of colloid that is probab- 
 ly not absorbable. 
 
 Outside of the thyroid gland itself, other tissue changes 
 should be regarded as secondary. Any attempt to in- 
 clude as primary, functional and degenerative changes in 
 the nervous, vascular and sympathetic systems will lead 
 only to confusion. 
 
 Goitre was at one time thought to be a disease more or 
 less limited to mountainous countries. It is now known 
 to be widely disseminated. Goitrous districts were 
 thought to be peculiarly free from exophthalmic goitre. 
 This idea also had to be abandoned. There have always 
 been many cases of goitre in our Southern States. Only 
 recently, however, have patients with goitre been referred 
 to the surgeon, owing to the fact that no promise of re- 
 lief was offered them, and they remained under the care 
 of their family physicians. Now that the results of sur- 
 gery are more generally known, patients are coming to 
 the hospital in such numbers as to add a new specialty to 
 operative work. 
 
 Hyperthyroidism is seen most often in the third de- 
 
 174 
 
THE THYROID AND HYPERTHYROIDISM 
 
 cade of life. It is comparatively rare at either extreme, 
 though Mayo has performed thyroidectomy for its cure 
 in a child of seven. Females are more liable than males. 
 According to Kocher, the disease is less common in the 
 laboring class. 
 
 Through all the range of disease, physiology and etiol- 
 ogy are inseparably interwoven and in exophthalmic 
 goitre the cause must remain more or less obscure until 
 we reach a better understanding of the function. Just as 
 the whole truth is probably not embodied in any one of 
 the present theories as to function, so it is likely that the 
 cause is a complex one. The water and the soil, social 
 circumstances and racial development may each contri- 
 bute a factor. 
 
 Beebe distinguishes the following groups according to 
 etiology- : First, those following infectious diseases ; sec- 
 ond, those associated with pregnancy or disturbed men- 
 strual function ; third, those arising in the course of sim- 
 ple goitre ; fourth, those following a period of physical or 
 mental overwork, and fifth, those due to severe emotional 
 disturbance or nervous shock of some kind. 
 
 McCarty assumes that the thyroid has retrogressed. 
 The thyro-glossal duct formerly opened into the alimen- 
 tary canal, and the thyroid may at one time have had 
 a more extensive function than at present. He regards 
 hyperplasia and hyperthyroidism as a reversion of the 
 gland to its former type, though no attempt is made to 
 point out the stimulus to reversion. Analogous processes 
 are seen in supernumerary mammary glands. 
 
 Crile has pointed out that the thyroid plays a leading 
 role in stimulating the emotions. This is shown by their 
 increase upon feeding an extract of the gland, and by 
 
 1/5 
 
THE THYROID AND HYPERTHYROIDISM 
 
 dimunution on removal of part of the hyperplastic thy- 
 roid. The symptoms of exophthalmic goitre closely re- 
 semble those of fear. They have in common increased 
 heart-beat, rapid respiration, rise in temperature, muscu- 
 lar tremor, protruding eyes and loss of weight. Crile 
 believes that in exophthalmic goitre there is a reciprocal 
 relation between the brain and the thyroid gland. The 
 nerve supply of the gland enters along the walls of the 
 blood vessels and maintains the connection between the 
 gland and the brain. According to Crile's theory ligation 
 is effective through breaking this nerve connection. 
 
 A clear conception of hyperthyroidism as a form of 
 toxicosis will explain all the more important symptoms. 
 Recalling the tendency of any toxemia to produce in time 
 degenerative changes in various organs, a wide range of 
 late and secondary characteristics are readily understood. 
 When the enlargement of the gland is present, there may 
 be introduced another factor, namely, pressure upon the 
 neighboring structures. This may occur even though uo 
 external enlargement is apparent. 
 
 Tachycardia is probably the earliest, most constant and 
 most reliable of any single symptom or sign. The pulse 
 varies from 90 to 120, but may reach a much higher rate. 
 It is usually over 100. It is the best index to the severity 
 of the disease, and the best criterion of improvement or 
 failure under any plan of treatment. The patient may 
 or may not be aware of the abnormal heart action ; usual- 
 ly, however, he is conscious of it. Murmurs, both cardiac 
 and vascular, are frequently heard, but endocarditic 
 changes are not themselves a component part of the thy- 
 roid heart. Examination of the blood reveals only a 
 
 176 
 
THE THYROID AND HYPERTHYROIDISM 
 
 relative lymphocytosis, not peculiar to hyperthyroidism. 
 Blood pressure is an unreliable sign. 
 
 Exophthalmos is a comparatively late symptom. It is 
 less constant than the rapid pulse. It occurs in about 
 three-fourths of all cases. Numerous explanations have 
 been advanced for the development of this symptom. It 
 is not unlikely that the true cause has been located in the 
 recent demonstration by Landstroem of another muscle 
 in the orbital space. This investigator has described a 
 cylindrical band of plain muscle arising from the septum 
 of the orbit, inserted into the superior aspect of the bulb 
 just posterior to the equator. Stimulation of this muscle 
 through the sympathetic system would cause a widening 
 of the lid slit (Stellwag's sign). As a consequence there 
 arises incoordination of the movements of the lid and ball 
 (Von Graefe's sign). A spastic condition of this muscle 
 would also tend to overcome the normal tone of the rectus 
 internus and thus upset the mechanism of convergence 
 (Moebius' sign). Corneal anesthesia, inflammation and 
 nystagmus are all seen at times, and are the results of the 
 foregoing changes in the eye. Thus, if Landstroems 
 muscle, stimulated by the sympathetic, proves to be the 
 cause of this series of phenomena, they are associated di- 
 rectly with the toxicosis underlying sympathetic stimula- 
 tion. 
 
 Goitre or enlargement of the thyroid gland occurs in 
 about 80 per cent of cases. The size of the enlargement 
 bears no relation to the severity of the toxic symptoms. 
 Tachycardia and nervousness, on the contrary, are more 
 liable to be exaggerated in association with the smaller 
 tumors. Owing to the fibrous attachments to the trachea 
 and esophagous, the tumor rises and falls with degluti- 
 tion. Mobility is greater in the lateral than in the vertical 
 
 177 
 
THE THYROID AND HYPERTHYROIDISM 
 
 direction. Both lobes are enlarged but the right is usu- 
 ally larger than the left. Pressure on the trachea may 
 cause dyspnoea and pressure on the blood vessels may 
 produce headache, vertigo, engorgement of the jugular 
 and edema of the face. As a result of either toxicosis or 
 pressure, nearly every patient will describe sensations 
 about the head, varying in graphic force with his powers 
 of expression. Pressure on the recurrent nerve may 
 cause paralysis of the laryngeal muscles. The resultant 
 hoarseness is rarely permanent, as only one nerve is af- 
 fected, and the laryngeal muscles in time accommodate 
 themselves to compensate for the injury. Dysphagia is not 
 common, nor is pain often a symptom of goitre, coming 
 late even in malignant degeneration. 
 
 Tremor, especially of the fingers, is almost as charac- 
 teristic, if not quite as constant, as any of the foregoing 
 symptoms. It may vary considerably in degree. There 
 is a fine rhythmic movement with from eight to ten vibra- 
 tions to the second. 
 
 "Nervousness" is an early and frequent complaint. Too 
 often it is passed by with pity or contempt. Irritability, 
 excitability, restlessness and insomnia, parasthesia, verti- 
 go and faintness, mental fatigue and loss of memory, de- 
 pression, apprehension and morbid fears, are common 
 mental states. Fortunately less common are hallucina- 
 tions, confusion of ideas, delirum and suicidal or homi- 
 cidal mania. 
 
 Alimentary disturbances are common, due to function- 
 al and degenerative changes the result of toxemia. The 
 occurrence in spite of a good appetite of rapid emacia- 
 tion is as peculiar here as in diabetes. Abdominal criscis 
 may occur simulating those of tabes. A diarrhea is seen 
 
 178 
 
THE THYROID AND HYPERTHYROIDISM 
 
 in about one-third of the cases, due to subacidity of the 
 gastric contents. 
 
 Body weight may be lost from ten to thirty or even 
 sixty pounds in a short while. It may be regained almost 
 as rapidly. The skin is warm, moist and relaxed. The 
 patient complains of a sensation of subjective warmth. 
 Sweating is profuse to a characteristic degree. Vaso- 
 motor instability is shown in mottling of the skin. Pig- 
 mentation of the skin is common. Fever is present in 
 the severe acute cases, and, according to Stern, is even 
 more common in the mild types. 
 
 The pathological changes in the thyroid gland and the 
 clinical course of exophthalmic goitre closely parallel each 
 other. Rogers describes the course of the disease in four 
 stages, as follows : 
 
 First — In the incipent stage, the patient may notice 
 fatigue too readily induced. Loss of appetite, insomnia, 
 irritability and slight dyspnoea may ensue. If tachycar- 
 dia appears the disease is progressing. Throughout this 
 early stage are seen symptoms of a vague but distinct 
 coupling of the emotions and the central nervous system, 
 the heart and vaso-motor apparatus, the digestive and 
 muscular systems. All alike seem to feel the whip of 
 insidious toxins stinging their several systems into fev- 
 erish activity, sapping stamina and disorganizing order- 
 ly co-operation. The picture is strikingly suggestive of 
 the intoxication of a chronic infection such as tuberculo- 
 sis, or a more dangerous pitfall yet, these vague com- 
 plaints might be classed as neurasthenic. 
 
 If the disease remains untreated it usually progresses to 
 the second stage of distinct hyperthyroidism. Plummer 
 states that on an average patients appear at the Mayo 
 
 179 
 
THE THYROID AND HYPERTHYROIDISM 
 
 clinic for treatment three years after the first evidence 
 of intoxication. This stage is apt to show one, two, or 
 all of the classical triad : tachycardia, exophthalmos and 
 goitre, and it is at this time that the picture is most 
 typical. 
 
 The third stage is that of chronic exophthalmic goitre. 
 When the disease has lasted a long time, and particularly 
 after treatment has been applied, the gland may harden 
 and the vascular phenomena diminish. The symptoms 
 can be demonstrated at once, however, by any excitment. 
 Remissions of greater or less duration are quite charac- 
 teristic, and there is a tendency to relapse or exacerba- 
 tions. It is in this chronic stage that both exophthalmos 
 and goitre are likely to be pronounced. The various psy- 
 choses are then more apt to appear. 
 
 Coincident with the atrophic and degenerative changes 
 in the thyroid, the typical case progresses to the final or 
 myxedematous stage. With the goitre of the same size 
 or enlarging, the weakness is progressive, the skin be- 
 comes pale and shows increased puflfiness about the eyes 
 and face, with dense edema of the lower extremeties, 
 mental torpor, slow pulse and anemia. 
 
 The diagnosis of exophthalmic goitre is often difficult 
 in the early stages, but this is the period the disease should 
 be recognized, as treatment is then much more efficient 
 than later. The name of the disease is misleading, as fre- 
 quently the eyes are not prominent and the thyroid is not 
 appreciably enlarged. Tachycardia is the most constant 
 symptom, and when it persists without obvious cause, 
 such as hysteria, cardiac disease, tobacco, whisky or drug 
 addiction, hyperthyroidism should be suspected ; and a 
 postive diagnosis is justified if either goitre or exophthal- 
 
 j8o 
 
THE THYROID AND HYPERTHYROIDISM 
 
 mos is found to co-exist. The presence of tremor, sweat- 
 ing, muscular weakness, nervous excitability, digestive 
 disturbances, emaciation and characteristic blood changes 
 leave no question as to the nature of the disease. Not 
 looking is a more frequent source of error in the diagnosis 
 than not knowing. 
 
 The symptoms of hyperthyroidism are increased by 
 excitement or exertion. The tendency to remissions or 
 exacerbations must be borne in mind. At one observa- 
 tion the patient may have an enlarged, pulsating goitre, 
 prominent eyes and rapid pulse ; and at another the gland 
 may be smaller, the eyes nearly normal and the pulse com- 
 paratively slow and regular. This fact is believed to be 
 due to thyroid secretion accumulating in the gland until, 
 from some apparent or unknown cause, it suddenly 
 throws its contents into the circulation. 
 
 The differential diagnosis of hyperthyroidism from hys- 
 teria is sometimes difficult. In both diseases the patient 
 often dates the onset from some mental or physical shock. 
 In both there are tachycardia, nervousness and muscular 
 weakness, and in both there is often some difficulty in 
 swallowing, caused by the goitre in the one case and the 
 globus hysterica in the other. 
 
 Early tuberculosis may closely simulate hyperthyroid- 
 ism. Tachycardia, slight fever, nervousness, emaciation 
 and weakness are common to both. In incipient tuber- 
 culosis the patient is usually in good spirits, while thyroid 
 intoxication, as a rule, causes despondency Physicnl ex- 
 amine tjon of the chest and X-ray piceure should serve to 
 distinguish the two in most cases. The therapeutic test 
 of the administration of thyroid extract over a short 
 
 i8i 
 
THE THYROID AND HYPERTHYROIDISM 
 
 period may be useful, for if hyperthroidism exists the 
 symptoms are made worse. 
 
 Despite the low mortality as now reported in the hands 
 of numerous surgeons, a patient should not be treated 
 surgically until medical measures have been tried and 
 proved inefficient, as from one-fourth to one-half of all 
 patients suffering with exophthalmic goitre will get well 
 without operation. Whether their recovery is due to the 
 remedies prescribed by the physician or the inherent tend- 
 ency of the system to overcome an abnormality, is not a 
 material question. The practical fact is that these pa- 
 tients should be treated along accepted lines and given 
 reasonable time to see what nature will do for them, be- 
 fore they are subjected to surgical risk. If, however, 
 they fail to improve or their symptoms get worse, then 
 an operation should be advised before complications de- 
 velop or incurable structural changes take place in the 
 heart, eyes and other organs. In other words, the sur- 
 geon should not operate on a case too soon, and the phy- 
 sician should not treat a case too long. 
 
 The medical treatment of hyperthyroidism consists pri- 
 marily in rest. If possible the patient should be placed 
 in a hospital for a time and confined to bed. An ice bag 
 over the heart is often of temporary benefit. Various 
 drugs have been advocated by different authorities, but no 
 two seem able to get the same results in either experimen- 
 tal or clinical work. All agree that iodine and thyroid 
 extract should not be employed. As myxedema and ex- 
 ophthalmic goitre are the antithesis one of the other, one 
 of the earliest treatments consisted in injecting the serum 
 of the blood of a patient suffering with myxedema into 
 the circulation of the victim of hyperthyroidism. Some 
 
 182 
 
THE THYROID AND HYPERTHYROIDISM 
 
 temporary good resulted. The next effort in this direc- 
 tion was the use of a serum called antithyroidin, obtained 
 from the blood of a thyroidectomized sheep. Theoretical- 
 ly, the blood of an animal whose thyroid had been re- 
 moved should contain the toxin which would combine 
 with and neutralize thyroglobulin ; but the remedy failed 
 to prove of therapeutic value. Several years ago a cyto- 
 lytic and antitoxic serum was introduced by Rogers and 
 Beebe. The reputation of the originators and the good 
 results reported by those who first used it encouraged the 
 profession to hope that a specific for the disease had at 
 last been found. This expectation has not been realized. 
 In a recent personal communication, Dr. Rogers states 
 that he regards the serum as very valuable in the treat- 
 ment of toxemic patients, but it is merely an adjuvant for 
 helping out a small number of cases. He regards as the 
 rational treatment of hyperthyroidal disturbances the liga- 
 tion of arteries or the extirpation of limited foci of dis- 
 ease, which, by pressure upon the sound parts of the 
 gland, may interfere with nutrition of the organ. 
 
 While as yet serum therapy has been unsuccessful, the 
 work of men like Rogers and Beebe will eventually tri- 
 umph. The day will come when some specific of ani- 
 mal origin will be discovered that will act as beneficially 
 in exophthalmic goitre as thyroid extract does in myxe- 
 dema. 
 
 Electricity, that mysterious agent which has promised 
 so much and accomplished so little in the treatment of va- 
 rious diseases, has, of course, been tried for hyperthy- 
 riodism. Faradism has a few advocates. Galvanism, es- 
 pecially in the form of electrolysis and cataphoresis, has 
 been extensively employed. The X-ray seemed at one 
 
 183 
 
THE THYROID AND HYPERTHYROIDISM 
 
 time to have established a place for itself. Beck reports 
 good results in the treatment of small goitres. Mayo still 
 uses it in certain cases as preliminary to operation, claim- 
 ing it produces sclerosis of the gland. Von Eiselsberg, 
 Deaver and others after extensive trial, say it has pos- 
 tively no beneficial effect. 
 
 Injections into the gland of alcohol, iodine carbolic acid 
 and iodoform emulsion have been tried and abandoned. 
 Abbey has used radium and reports £:ood results. Porter 
 has published a number of cases markedly improved by 
 the injection of boiling water, the technique being the 
 same as that employed by Wyeth in the treatment of an- 
 gioma. This treatment causes a coagulation of the blood 
 and acts on the principle of a ligation operation. There 
 would seem to be little to commend it. 
 
 Statistics showing the results of non-operative treat- 
 ment are meager. White followed up the histories of 
 102 cases admitted to Guy's Hospital between 1888 and 
 1907. In White's series 60 per cent recovered, 20 per 
 cent were improved, 5 per cent had not done well, and 
 15 per cent had died. 
 
 The surgical treatment of hyperthyroidism owes its 
 conception to the accidental observation that patients 
 operated on to relieve them of the mechanical or pressure 
 symptoms of goitre, were also cured of their toxic symp- 
 toms, such as tachycardia, tremor, nervous irritability, 
 muscular weakness and loss of weight. 
 
 The development of the surgical treatment is largely 
 due to the work of Theodor Kocher of Berne, Switzer- 
 land. A generation ago the operation of thyroidectomy 
 was considered one of the most dangerous in surgery. 
 Kocher's mortality in his first seventy cases of simple 
 
 184 
 
THE THYROID AND HYPERTHYROIDISM 
 
 goitre was 40 per cent; Charles H. Mayo's mortality in 
 his first sixteen cases of exophthalmic goitre was 25 per 
 cent. It is no wonder that at one time the operation was 
 regarded by the majority of the surgeons as unwarranted, 
 and it is not surprising that there are still today, some 
 among the older practitioners who hesitate to advise a 
 patient with goitre to seek operative relief except as a 
 last resort. Times have changed, however, and the op- 
 eration has been rendered comparatively simple and safe 
 in experienced hands. Kocher with a courage that seemed 
 man^elous to the present generation of surgeons, per- 
 sisted in his work until he finally established a technique 
 that has reduced the mortality in his last one thousand 
 cases of goitre to three-tenths of one per cent. This was 
 accomplished by : 
 
 T. Early operations on more favorable cases. 
 
 2. Improved aseptic methods to prevent infection. 
 
 3. Better methods of anesthesia. 
 
 4. An exposure which gave ability to control hemor- 
 rhage and avoid injury to certain structures of the neck. 
 
 All operations have for their object the diminution of 
 thyroid secretion. This is accomplished in one or two 
 ways : either by lessening the amount of the blood going 
 to the gland by ligation of one or more of the principal 
 arteries, or by reducing the amount of secreting structure 
 by excision of part of the gland. Crile thinks in both 
 ligation and excision the benefit results not only from les- 
 sening the blood supply and diminishing the secreting 
 structure, but also from cutting oflf the nerve supply. 
 
 Ligations are indicated in very mild cases where this 
 operation may be all that is necessary to effect a cure; 
 and in verv bad cases as a preliminary to a more radical 
 
 185 
 
THE THYROID AND HYPERTHYROIDISM 
 
 operation when the condition of the patient improves 
 sufficiently to make it safe. 
 
 The operation of excision usually consists in the re- 
 moval of one lobe and the isthmus. The difficult and im- 
 portant question that confronts the surgeon in every case 
 is how much thyroid tissue he should take out. If he 
 removes too little, the symptoms of hyperthyroidism con- 
 tinue ; if he removes too much, the symptoms of hypo- 
 thyroidism develop. Rogers has impressed the fact that 
 operations which give brilliant immediate results are of- 
 ten followed by remote difficulties and complications. A 
 compensatory hyperthrophy of the remaining lobe may 
 develop with persistence of exophthalmic goitre symp- 
 toms, or degenerative changes may take place in the tissue 
 left, with the development of myxedema. Until we know 
 more, surgery should not be too radical. If an error is 
 made, it had better be on the side of conservatism, as it 
 is easy to take out more, but impossible to put back any, 
 of the tissue which has such an important effect on the 
 physical nutrition and nervous equilibrium of the 
 individual. 
 
 Mayo states that the thyroid gland has a ''factor of 
 safety" of six; in other words, that one-sixth of the 
 gland can carry on its work. The removal of one lobe 
 and the isthmus means the excision of about three-fifths 
 of the gland, and this is the common practice of most 
 surgeons. 
 
 The dangers attending the operation of partial thyriod- 
 ectomy were formerly discussed under numerous heads. 
 Infection, hemorrhage and shock have been so minimized 
 by modern methods that they are not more likely to oc- 
 cur than during other major operations. Injury to the 
 
THE THYROID AND HYPERTHYROIDISM 
 
 recurrent larg}ngeal nerve can be avoided by care in 
 ligating the inferior thyroid artery, and is an accident 
 less frequent than cutting the ureter in hysterectomy. Te- 
 tany can be prevented by leaving the posterior capsule of 
 the gland, thus assuring the preservation of the parathy- 
 roids. Myxedema can be guarded against by leaving 
 enough active thyroid tissue to carry on the function of 
 the gland. 
 
 The danger of the anesthetic has been much discussed. 
 Kocher, Tinker, and others operate almost exclusively 
 with local anesthesia, and attribute their low mortality 
 largely to its use. Mayo, Ochsner and others use a gen- 
 eral anesthetic and get just as good results. 
 
 The one and only special danger in the surgical treat- 
 ment of exophthalmic goitre is acute hyperthyroidism. 
 When this condition develops the symptoms come on 
 shortly after the patient is removed from the table, and 
 consist in rapid pulse, high fever, great restlessness, and 
 often wild delirium. Acute hyperthyriodism after an 
 operation was formerly thought to be due to squeezing 
 the gland and the absorption of its juices by the raw 
 surfaces of the wound. This theory has been discredited 
 on the ground that the thyroid in exophthalmic goitre has 
 been repeatedly and thoroughly massaged by osteopaths 
 without producing marked increase in the symptoms. 
 Kocher as a routine measure crushes a zone of the gland 
 with a heavy forcep prior to its ligation and division, 
 and no increase of hyperthyroidism has been noted. A 
 number of surgeons who at one time cauterized the wound 
 or painted it with Harrington's solution, to prevent ab- 
 sorption, have now abandoned the practice because it did 
 no good. 
 
 187 
 
THE THYROID AND HYPERTHYROIDISM 
 
 Crile believes that acute hyperthyroidism after an op- 
 eration is due to excessive secretion of the gland caused 
 by psychic and traumatic stimuli. The psychic 
 factor is excitement and fear. This may be independent 
 of mechanical injury to the thyroid as shown by the fact 
 that the symptoms often develop in susceptible patients 
 after operations on other parts of the body. The method 
 used by Crile to eliminate this factor is to inspire the pa- 
 tient with confidence and keep him in ignorance of the 
 time of operation. 
 
 The traumatic factor consists in the impulses that pass 
 from the field of operation to the central nervous system. 
 Crile claims that a general anesthetic does not prevent in- 
 jurious impulses reaching the brain and causing exhaus- 
 tion and shock. The use of a local anesthetic, however, 
 temporarily disconnects the part being operated on from 
 the brain. He therefore, cocainizes the field of operation 
 as thoroughly as if no general anesthetic were employed. 
 With these two precautions, he states, ligation or excision 
 may be done in desperate cases without fear of acute hy- 
 perthyroidism. The method is very valuable in certain 
 cases, but it is too elaborate and time-consuming to be 
 adopted as a routine practice by many surgeons in all 
 cases. 
 
 When a patient with exophthalmic goitre comes to a 
 surgeon, the case ought to be kept under observation and 
 carefully studied for some days before deciding on the 
 character of the operation best suited to the individual, 
 and the safest time to perform it. Tinker impresses the 
 fact that an examination of a patient who has been kept at 
 rest for some days may give an erroneous impression of 
 the safety of the operation. On the other hand, a patient 
 
 i88 
 
THE THYROID AND HYPERTHYROIDISM 
 
 coming from a distance, fatigued and frightened, may 
 give the impression of a worse operative risk than is 
 really the case. 
 
 Mayo states that the operation for exophthalmic goitre 
 is not one of emergency, nor is it to be called life-saving 
 in extreme cases, and it should not be undertaken except 
 at a proper time. He calls attention to the exacerbations 
 and remissions in the intensity of the symptoms, which 
 he attributes to the accumulation and discharge of toxic 
 substances in the gland. He believes that if the patient is 
 carefully watched, these periods can be predicted, and the 
 most favorable time for the operation is not when the 
 patient's symptoms are at the best, but shortly after the 
 gland has dumped its load and before it again becomes 
 laden with toxic material. 
 
 Some cases can safely be operated on after one or two 
 day's study; others require weeks of rest and medical 
 treatment preliminary to the operation. Some cases re- 
 quire ligation of one or more arteries before it is safe 
 to excise a portion of the gland ; other cases should have 
 one lobe and the isthmus removed without preliminary 
 ligation. Tinker describes a desperate case Avhich was 
 saved by a graduated operation divided into five separate 
 stages at intervals varying from a few days to several 
 weeks. 
 
 Surgery of the thyroid is still in its developmental stage. 
 In reading the literature one is impressed by the fact 
 that each author, at one time, attributed his good results 
 to some special feature of his operation which he has 
 since found unnecessary or injurious and has abandoned. 
 Fads are fast disappearing, and the work is rapidly ap- 
 
 189 
 
THE THYROID AND HYPERTHYROIDISM 
 
 preaching the practice of basic principles underlying es- 
 tablished surgery. 
 
 In the hands of men like Mayo, Kocher, Ochsner, Crile, 
 Tinker and others, the mortality of operations for hyper- 
 thyroidism is now from two to five per cent, and 85 per 
 cent of those who recover may be said to be symptoma- 
 tic cures. It is neither honest nor expedient, however, to 
 make light of the operation or to belittle its difficulties 
 and dangers. The figures quoted are from the statistics 
 of master surgeons, and by no means represent the results 
 of the average operator. 
 
 After a successful operation for hyperthyroidism, the 
 improvement in the patient is immediate and marked. In 
 fact, no operation in surgery produces such quick and 
 brilliant results. Tremor disappears, the pulse falls to 
 normal, the eyes become less wild, and restlessness and 
 irritability are replaced by quiet and composure. The 
 wound, as a rule, heals rapidly, and the patient is able 
 to leave the hospital in from ten to fourteen days. 
 
 Because the patient is well from the operation, and 
 because the acute symptoms are relieved, is not ground 
 for immediate return to the ordinary activities of Hfe. 
 Crile very properly states that it requires approximately 
 the same time to recover from exophthalmic goitre as 
 from a nervous breakdown from other causes. A suc- 
 cessful operation should be followed by an adequate rest 
 cure. 
 
 190 
 
The Diagnosis and Treatment of 
 Hypothyroidism.* 
 
 The thyroid gland is in many respects the most won- 
 derful organ of the body. Through its internal secretion 
 it influences the physical development of the child, and 
 the psychic condition and mental activity of the adult. 
 It regulates the growth of bone, the formation and dis- 
 tribution of fat, and the nutrition of the skin, teeth, hair 
 end nails. It plays an important part in menstruation 
 and parturition, and has much to do with sexual desire 
 and power. It influences the rate of heart beat, the char- 
 acter of the peripheral circulation, and hence markedly 
 affects the general blood pressure. It presides over the 
 nitrogenous metabolism of the body and in other known, 
 and perhaps unsuspected ways, plays an important 
 part in the human economy. 
 
 Many theories have been advanced to explain the pro- 
 tean action of thyroid secretion, but at this time it is 
 impossible to say which is the true one. Either as a neu- 
 tralizer of endogenous toxins, or as a hormone stimulat- 
 ing other organs and tissues to activity, or by some other 
 obscure but potent influence, it is the pace maker for the 
 body. Thyroid secretion seems to act as the gasoline for 
 the human automobile. If the lever controlling its supply 
 is advanced then the engine races, the gears grind and the 
 whole machine throbs and vibrates. If the lever is re- 
 
 *Read before the North Carolina Medical Society, June i8, 
 
 191 
 
THE DIAGNOSIS AND TREATMENT OF 
 
 tarded then the engine knocks, the pistons hang, and the 
 halting machinery momentarily threatens to come to a 
 standstill. 
 
 If thyroid secretion is excessive there are symptoms 
 of metabolic riot. Heat production and gaseous inter- 
 change are rapid. The body tissues are stimulated to a 
 course of wasting dissipation. There are seen tremor, 
 sweating, tachycardia, muscular weakness, loss of weight 
 and feverish mental activity. 
 
 If thyroid secretion is deficient the metabolism of the 
 body is depressed and heat production and gaseous in- 
 terchange are at a low ebb. In the young, growth is 
 lessened and the skeletal system is dwarfed. Connective 
 tissue cells remain myxomatous. The skin is dry and 
 thick and the hair is coarse and shows deficient nourish- 
 ment. The nervous system halts in development and 
 mentality does not rise above the level of the infant. 
 
 My interest in the thyroid gland was first attracted by 
 the cases of exopthalmic goitre that came to me for sur- 
 gical treatment. The symptoms in the advanced type of 
 this disease were so dramatic and the results of opera- 
 tions directed to reducing the supply of thyroid secretion 
 to the system so immediate and remarkable that I was 
 tremendously impressed with the important role the thy- 
 roid gland played in the physiology of the human or- 
 ganism. 
 
 The study of hyperthyroidism as seen in exopthalmic 
 goitre naturally led me to the study of hypothyroidism 
 as seen in myxedema, and the increasing number of cases 
 coming under my observation where the symptoms were 
 demonstrated to be due to excess of thyroid activity led 
 me to wonder if there were not an equal number of 
 
 192 
 
HYPOTHYROIDISM 
 
 patients who suffered from symptoms due to deficient 
 thyroid secretion. 
 
 Any diagnostician will of course recognize at once a 
 fully developed case of exopthalmic goitre with its star- 
 ing eyes, bulging throat, tachycardia, tremor, sweating, 
 nervous irritability and loss of weight, or a marked case 
 of infantile myxedema such as has been so graphically 
 described by Osier. The stunted statue and squat figure ; 
 the blubber lips, sunken nose, lolling tongue and half 
 closed eyes, the expressionless face, thick skin and coarse 
 hair make a picture that cannot be mistaken. 
 
 But there are other cases where the symptoms due to 
 perverted thyroid secretion are not so clear and well 
 defined, and cases of mild hyperthyroidism have often 
 been treated for hysteria or neurasthenia, and cases of 
 mild hypothyroidism have often been treated for anemia 
 or malaria. 
 
 Surgeons in recent years have learned to be constantly 
 on the watch for symptoms of hyperthyroidism and many 
 cases of the disease are diagnosticated and treated in the 
 incipient stage, but physicians as a rule have not yet been 
 trained to the same vigilance in the detection of the early 
 symptoms of hypothyroidism, a condition of equal fre- 
 quency and importance and one much more easily treated. 
 
 From observation and study I am satisfied there are 
 a large number of patients who suffer from thyroid pov- 
 erty and who drift from physician to physician without 
 the cause of their symptoms being suspected. 
 
 A proper diagnosis in this class of cases must be based 
 on a thorough knowledge of the physiological action of 
 the thyroid gland and a study of the symptoms that follow 
 its perverted function. In doubtful cases thyroid extract 
 
 193 
 
THE DIAGNOSIS AND TREATMENT OF 
 
 may be given in small doses as a therapeutic test, and 
 continued if it does good and discontinued if it does 
 harm. 
 
 Thyroid extract should never be given in cases of 
 heart lesion, albuminuria or glycosuria. In other cases 
 if it produces dizziness, intoxication or cardiac disturb- 
 ances it need not be discontinued at once as the untoward 
 symptoms can be relieved by the administration of Fow- 
 ler's solution of arsenic. The dose of thyroid extract 
 should be a small one, not over two grains three times 
 a day and the common mistake should not be made in 
 acting on the belief that if a little is good more will be 
 better. A small dose long continued is safer and more 
 efficient than a large dose given for a short time. It 
 must also be remembered that many of the thyroid prepa- 
 rations on the market are absolutely inert and the phy- 
 sician should either prescribe a standardized tablet made 
 by a reliable manufacturer or else activate the tablet of 
 unknown efficiency by combining with it several grains of 
 iodide of soda. 
 
 Thyroid extract has been recommended as almost a 
 specific in a long list of diseases, but the indiscriminate 
 use of the drug is to be condemned, as large doses are 
 dangerous and small doses frequently repeated may per- 
 manently impair the patient's health. It is a poison and 
 should never be prescribed unless the case is kept under 
 observation while it is being administered. 
 
 I would like to report a number of cases suffering from 
 widely varying symptoms that I have treated and relieved 
 by the use of thyroid extract, but the time at my disposal 
 for the preparation of this paper has been too limited 
 to allow me to look up their histories and records. I must 
 
 194 
 
HYPOTHYROIDISM 
 
 content myself, therefore, in being suggestive rather than 
 explicit and simply state that I have personally found 
 the substitution thyroid treatment of unquestioned benefit 
 in selected cases embraced in the following heads : 
 
 1. Cretinism. 
 
 2. Myxedema (spontaneous and post-operative). 
 
 3. Parenchymatous goitre — especially in girls about 
 the age of puberty. 
 
 4. Amenorrhoea and chlorosis. 
 
 5. Absence or failure of sexual desire or power. 
 
 6. Obesity. 
 
 7. Eczema of the dry or scaly type. 
 
 8. Delayed union of fractures. 
 
 9. Certain neuropathic conditions where the patient 
 is apathetic and drowsy with slow pulse and cold skin. 
 
 195 
 
The Influence of the General Condition 
 
 of the Patient on the Result of a 
 
 Surgical Operation* 
 
 There are some operations, such as for the relief of a 
 strangulated hernia or the removal of a gangrenous ap- 
 pendix, which are so urgently demanded for the imme- 
 diate purpose of saving life, that the surgeon has no 
 choice, and nothing is considered but the one great need. 
 These are imperative operations, and must be done re- 
 gardless of risk. There are other operations, such as for 
 the correction of deformities or the relief of some 
 chronic ailment, which, however desirable, are not essen- 
 tial to the life of the patient. These are elective opera- 
 tions, and should not be undertaken without carefully 
 considering the danger to be incurred on the one hand 
 and the benefit to be hoped for on the other. 
 
 In estimating the risk of an operation, the modern 
 surgeon is too apt to base his opinion on the statistics 
 contained in text-books and encyclopedise. Figures are 
 proverbially unreliable. Thus, for instance, the statistics 
 of old operations, such as ligations and amputations, are 
 usually a record of pre-antiseptic surgery, and do not 
 represent the work of today ; while the statistics of more 
 recent operations, such as thyroidectomy or gastroenter- 
 ostomy, are usually the record of master-workmen 
 like Kocher and the Mayos, and do not represent the 
 
 * Read at a meeting of the Rochester Surgical Club, Rochester, 
 Minn., August, 1907. 
 
 197 
 
INFLUENCE OF THE GENERAL CONDITION 
 
 danger of these operations in the hands of the average 
 surgeon. 
 
 In deciding whether or not to advise a patient to 
 undergo an elective operation, the following factors 
 should be considered : 
 
 First, the gravity of the operation and the relief to he 
 expected from its successful issue. There is no operation 
 devoid of risk, and some are attended by great danger. 
 Patients are occasionally unreasonable, and insist on hav- 
 ing a serious operation done to rid themselves of a more 
 or less fancied ailment. Unless the operation is safe and 
 there is a reasonable assurance of the patient being ma- 
 terially benefited, he should not be subjected to an elec- 
 tive surgical ordeal. 
 
 Second, the ability and experience of the operator. No 
 courageous doctor should fail to undertake an opera- 
 tion if the patient's condition is argent, if delay means 
 death, and if no more experienced surgeon is available. 
 Competency is a relative term, and the man on the 
 ground should endeavor to afford relief, or else he fails 
 to measure up to his responsibility. It is different, how- 
 ever, when the disease is a chronic one, and the patient 
 could be safely moved to a hospital, or await the arrival 
 of a surgeon from a neighboring city. A patient is en- 
 titled to the best possible prospect for prolonged life or 
 restored health that his resources permit. No con- 
 scientious surgeon should undertake an operation with- 
 out asking himself whether he has the skill to do the 
 work satisfactorily. In many cases he can honestly 
 answer the question in the affirmative. In some cases, 
 while there may be a doubt in his mind, he is justified 
 in operating by the fact that the patient has not the phy- 
 
 198 
 
OF PATIENT ON RESULT OF OPERATION 
 
 sical strength to bear transportation, or the financial 
 means to bring a surgeon from a distance. In other cases, 
 however, the surgeon must recognize his inferiority to 
 other men in the profession who devote their lives to 
 special lines of work, and when the patient has the physi- 
 cal and the pecuniary power to secure their services it is 
 his duty to place the case in their hands. This obliga- 
 tion is so universally recognized that the sacrifice it en- 
 tails is not often appreciated by the laity, and sometimes 
 not by the class of the profession which is benefited. 
 
 Third, the general condition of the patient, or the con- 
 sideration of the personal factors in the individual case 
 which influence the result of the operation. It is often 
 said — sometimes seriously, sometimes satirically and 
 sometimes truly — that the operation was a success, but 
 the patient died. In such a case the indications for the 
 operation may have been plain, but the contraindications 
 were either overlooked or disregarded. The operation 
 may have completely corrected the condition from which 
 the patient suffered ; it may have been perfect in its tech- 
 nique and brilliant in its execution, but the patient may 
 have lost his life from some complication which could 
 have been foreseen by more careful preliminary investi- 
 gation. Many surgeons have had uncontrollable hemor- 
 rhage to follow the removal of a small tumor, owing to 
 the patient having hemophilia, or have had gangrene de- 
 velop in a wound, owing to the existence of diabetes, or 
 have had suppression of urine to follow, owing to the 
 presence of nephritis. 
 
 Sir James Paget, in one of his classical lectures, says : 
 ''Never decide upon an operation, even of trivial kind, 
 without first examining the patient as to the risk of his 
 
 199 
 
INFLUENCE OF THE GENERAL CONDITION 
 
 life. You should examine him with at least as much care 
 as you would for life insurance. It is surely at least as 
 important that a man should not die or suffer serious 
 damage after an operation, as that his life should be safe- 
 ly insured for a few hundred pounds." 
 
 Two separate and independent examinations should be 
 made of every surgical patient — the first for the purpose 
 of diagnosis and the determination of the condition to 
 be corrected; and the second for the purpose of prog- 
 nosis, or the determination of the safety of the operation. 
 In forming an estimate of the latter many factors have 
 to be taken into consideration, such as age, sex, race, 
 habits of life, constitutional diseases and visceral dis- 
 orders. In discussing these under separate headings much 
 use has been made of an article by Sir Frederick Treves, 
 who acknowledges a similar indebtedness to the writings 
 of Sir James Paget. 
 
 Age. As a general proposition it may be stated that 
 patients at either extreme of life are poor subjects for 
 surgery. 
 
 Children under five years of age take anesthetics badly, 
 often suffer severe shock from only moderate loss of 
 blood, and are difficult to manage during convalescence. 
 They are liable to gastro-intestinal disturbances, especially 
 in hot weather, and frequently are the victims of chicken- 
 pox, measles, or other infectious diseases to which they 
 are susceptible. On the other hand, owing to the ener- 
 getic cell activity of the period of growth, their tissues 
 heal rapidly and are not prone to suppuration. In operat- 
 ing on children avoid, if possible, the period of first 
 dentition, as they are liable to digestive disturbances and 
 to convulsions, and apt to develop a high temperature 
 
 200 
 
OF PATIENT ON RESULT OF OPERATION 
 
 from slight provocation. Use chloroform as an anes- 
 thetic, and avoid the infliction of long-continued pain. 
 Especial care should be taken to prevent loss of blood or 
 body heat. Dressings should be carefully watched and 
 changed as often as soiled. Usually no attempt should be 
 made to keep the child in bed, but, from the first, it 
 should be permitted to lie on the mother's lap or be car- 
 ried about in her arms. 
 
 The period from the fifth to the fifteenth year is the 
 golden age of surgery. Hence the mortality is least and 
 the results best from operations of almost every kind. 
 This is due to the fact that metabolic processes are ac- 
 tive and resistance to infection vigorous ; that the various 
 organs of the body are normal and perform their func- 
 tions satisfactory ; that the nervous system is stable and 
 uninfluenced by regrets for the past or fears for the 
 future ; and finally, that the reason and will of the patient 
 have developed sufficiently for the surgeon to secure their 
 acquiescence and co-operation. 
 
 Between the twentieth and fortieth years the mor- 
 tality of operations greatly increases. This is due to 
 sexual development, attended by the possibility of ex- 
 cesses, abnormalities and diseases; also, to the cares and 
 responsibilities of maturity, often leading to neurasthenia 
 from excessive work and worry. And finally there may 
 be superadded the injurious results of addiction to to- 
 bacco, whiskey or other drugs, and of other forms of 
 dissipation. 
 
 In patients past forty years of age the mortality from 
 operations is nearly three times as great as in patients 
 under twenty. As a rule, old people are severely 
 shocked by loss of blood or body heat ; their wounds heal 
 
 201 
 
INFLUENCE OF THE GENERAL CONDITION 
 
 slowly, and their tissues have little power to resist in- 
 fection. They are head-strong and rebellious, and in- 
 tolerant to confinement. Their organs of assimilation 
 and excretion are impaired, and their stomachs and kid- 
 neys liable to break down. Taken all in all, old age is 
 a greater bar to surgery than any other complication, 
 unless it be chronic alcoholism. It must be remembered, 
 however, that senility is not measured in years. Sur- 
 gically speaking, a man is as old as his arteries. In im- 
 pressing this point Sir James Paget says : "They that 
 are fat and bloated, flabby of texture, torpid, wheezy, 
 and incapable of exercises, looking older than their years, 
 are very bad. 
 
 "They that are fat, florid and plethoric, firm skinned, 
 and with good muscular power, clear-headed, and willing 
 to work like younger men, are not, indeed, good sub- 
 jects for operation, but they are scarcely bad. 
 
 "The old people that are thin and dry and tough, 
 clear-voiced and bright-eyed, with good stomachs and 
 strong wills, muscular and active, are not bad ; they bear 
 all but the largest operations very well." 
 
 The brilliant results of Young and others in operat- 
 ing on old men for prostatic enlargement show that 
 modern surgery, with its short period of anesthesia, 
 diminished loss of blood, freedom from infection, and pro- 
 visions for adequate drainage, has made it safe to do 
 operations on the aged which, only a short time ago would 
 have been unjustifiable. 
 
 Sex. Other things being equal, women bear opera- 
 tions better than men. This is due to the fact that they 
 are designed for maternity and are naturally endowed 
 w^'th more passive endurance; that they are more con- 
 
 202 
 
OF PATIENT ON RESULT OF OPERATION 
 
 fiding and trustful and place greater confidence in the 
 assurances of the surgeon; that they are more tolerant 
 to confinement to bed, because they are not accustomed 
 to active out-door life; and finally, they are* more tem- 
 perate and regular in their lives, and not as frequently 
 the victims of excesses in food and drink. 
 
 On the other hand, menstruation, pregnancy, lactation 
 and the phenomena of the menopause give to the sex the 
 possibility of complications to which the male is not sub- 
 ject. As a rule, operations should be avoided during men- 
 struation, as the period is frequently attended with ner- 
 vous and digestive disturbances. The time of election, 
 especially in gynecological work, is the two weeks midway 
 between the completion of one period and the beginning 
 of the next. In emergencies, however, an operation may 
 be done during menstruation without misgivings, as usu- 
 ally no ill effects result. 
 
 It is also undesirable to do an operation of election 
 during pregnancy, as it entails the possibility of miscar- 
 riage and of kidney break-down. The danger is more 
 theoretical than real, however, as hundreds of abdomi- 
 nal sections have been done on pregnant women, for 
 appendicitis and other abdominal diseases without inter- 
 ference with gestation. 
 
 It is also inadvisable to operate during lactation, be- 
 cause the woman's strength and resistance are below 
 par, and if she continues to nurse the child she will have 
 an undue tax upon her; while if she ceases to do so, 
 there will be the danger of trouble with her breast. 
 
 Race. The influence of race on the result of an opera- 
 tion is a question of interest, but not of great practical 
 value. It is stated that a Chinaman makes the best 
 
 203 
 
INFLUENCE OF THE GENERAL CONDITION 
 
 patient on earth. In America, especially in the Southern 
 States, there is good opportunity to contrast the respec- 
 tive resistence of the Caucasian and the Negro. Sur- 
 geons of large experience in operating on both races are 
 practically unanimous in the opinion that the black man 
 is a better subject than the white man. This does not 
 apply to the mulatto, for he follows the rule of the mon- 
 grel, and has the vices of both parents and the virtues of 
 neither. It is obvious even in the life of an individual 
 that the pure negro is losing the immunity formerly en- 
 joyed to certain diseases, and is developing predisposi- 
 tions which render him a less favorable subject for opera- 
 tion. Before the Civil War insanity was almost unknown 
 in the race; tuberculosis was not common, and venereal 
 diseases of rare occurrence. With education and syphili- 
 zation he is now the victim of various nervous disorders ; 
 with unhygienic surroundings and scant clothing he is a 
 frequent victim of the Great White Plague, and with im- 
 proper food, eaten at irregular intervals, his digestion 
 has become impaired, and he is suffering more and more 
 frequently from gall-stones, appendicitis, and diseases of 
 the kidneys. The day will come when the degeneration 
 of the whole race will have reached a point to make it an 
 accepted fact that they are poor subjects for surgical 
 work. 
 
 Vigor and Weakness. — Paradoxical as it may sound, 
 the strong, robust man frequently does not make as good 
 a surgical patient as one who is feeble and wasted by 
 disease. He may have huge limbs and mighty strength ; 
 he may never have had an illness in his life, and boast 
 the constitution of an ox, but he is a poor subject for the 
 surgeon's knife. He is accustomed to fresh air and an 
 
 204 
 
OF PATIENT ON RESULT OF OPERATION 
 
 active life ; his blood vessels are full and oxygenation of 
 the tissues is rapid. His food has been large in quantity 
 and gross in quality. When misfortune overtakes him 
 there is no time to accommodate himself to new condi- 
 tions, and the whole habit of his life is suddenly changed. 
 To this is added the shock of his accident, the horror of 
 an operation, and the dread of the future. Just the con- 
 trary is true with the chronic invalid, who has been accli- 
 mated to bed life by long weeks of invalidism, whose cir- 
 culation, respiration, and digestion have become adjusted 
 to his condition, and who has been brought to view the 
 approaching operation as a means of relief and pain and 
 restoration to health. Of the two types described the last 
 will be well first. 
 
 Obesity. — As a rule, a fat patient is a bad patient. 
 If the obesity is hereditary and the general health good, 
 it is not as bad as when the fat is due to gluttony, in- 
 dolence, or beer-drinking. An obese patient is an ele- 
 phant on your hands. He usually breathes with difficulty 
 and cannot assume a recumbent position. It is hard to 
 move him in bed, and difficult to prevent the formation 
 of bed-sores. The skin is usually thin from pressure, and 
 its edges difficult to approximate. The subcutaneous fat 
 has little vitality and readily breaks down and liquefies. 
 Infection once taking place, pus burrows far and wide, 
 and is drained with great difficulty. Sometimes such 
 patients die suddenly from fat embolism; again, they be- 
 come exhausted and prove an easy victim to intercurrent 
 diseases. If recovery takes place, convalescence is always 
 tedious and prolonged. 
 
 Alcoholism. — The most unpromising patient who ever 
 comes to a surgeon is the chronic alcoholic. Constant 
 
 205 
 
INFLUENCE OF THE GENERAL CONDITION 
 
 drinkers who are never drunk, and yet who are never 
 sober, are worse subjects than those who get on periodic 
 sprees. The gravity of the risk in the individual case will 
 depend on the length of time the individual has taken sti- 
 mulant; the average amount consumed daily; the pres- 
 ence or absence of tremor of the hand or alteration of 
 the knee-jerk; the existence of gastritis, as indicated by 
 anorexia, nausea or vomiting; and the condition of the 
 liver, kidneys, heart, and blood vessels. No operation 
 except the most imperative should be done on the alco- 
 holic, because of the danger of administration of the 
 anesthetic, because of the depraved condition of the tis- 
 sues and consequent lack of resistance to infection, be- 
 cause of the liability of the kidneys to stall or the heart 
 to run away, and because of the danger of the develop- 
 ment of wild and uncontrollable delirium. When an 
 operation is unavoidable, but not immediately necessary, 
 the patient should be prepared for it by diminishing or 
 withdrawing the stimulant. When an immediate opera- 
 tion is necessary, it is better to continue the alcohol until 
 the period of greatest danger is passed. 
 
 Affections of the Nervous System. — Hysterical patients 
 usually give a great deal of trouble before the operation, 
 but do very well after the ordeal is over. A nervous wo- 
 man who wishes to tell of the surgical adventures of her 
 friends, who desires to discuss every step and detail of 
 her own operation and tell how she wishes her case 
 managed, and who is possessed of exaggerated fears as to 
 the complications which may develop or the ultimate re- 
 sult which may follow, usually, after the operation, be- 
 comes a model patient. Her imagination enters upon 
 
 206 
 
OF PATIENT ON RESULT OF OPERATION 
 
 fresh fields and she becomes hopeful and courageous, and 
 at once begins to plan a new life of activity. 
 
 The neurasthentic, however, is a different subject, and 
 woe betide the incautious surgeon who operates on one. 
 Occasionally neurasthenia may be due to chronic appendi- 
 citis, uterine displacement, or some other cause which 
 can be corrected and the patient cured. But in a large 
 majority of cases the neurasthenia is due to a disturbance 
 of the general body nutrition, and no operation will 
 prove of benefit. The victim of neurasthenia wears out 
 the patience of his family and friends, and in order to 
 secure a sympathetic listener, and in order to demonstrate 
 to the community the serious nature of his disease, he 
 goes from surgeon to surgeon and from hospital to hospi- 
 tal, offering himself as a bloody sacrifice to his curious 
 form of egotism, and glorying in his martyrdom. Sur- 
 gery does this class of patients no good, but deepens, 
 rather than relieves, the neurasthenia. 
 
 The insane are usually good subjects for surgical opera- 
 tion. The regular life of an asylum is conducive to good 
 health, and the absence of mental anxiety on the part of 
 the patient is a favorable factor. Mayo, who has done 
 a great deal of work on this class of cases, states that 
 they are entitled to just the same surgical treatment as 
 the sane — no more, no less. In other words, insane peo- 
 ple should be operated on to relieve them of hernia, gall- 
 stones, and abdominal tumors, but hernia, gall-stones, and 
 abdominal tumors should not be operated on to cure the 
 patient of insanity. 
 
 Syphilis does not usually increase the risk of a surgical 
 operation. Wounds made during the full bloom of the 
 secondary stage heal kindly, and operations done on ter- 
 
 207 
 
INFLUENCE OF THE GENERAL CONDITION 
 
 tiary lesions usually do well. The danger in operating in 
 the early stages of syphilis is rather one to the surgeon 
 than to the patient, as the blood is infectious. 
 
 Gout has no effect upon the result of an operation, un- 
 less it has existed sufficiently long to produce cardiac or 
 renal changes. It is, of course, not wise to operate during 
 an acute attack of the disease, and it must also be remem- 
 bered that an operation sometimes precipitates an attack 
 in a person predisposed to the disease. 
 
 Hemophilia contraindicates a surgical operation, un- 
 less urgent and required to save life. Fortunately, the 
 subjects of hemophilia do not always bleed. A case is 
 in mind where a man was brought to the hospital with 
 gangrenous appendicitis, and who gave a history of hav- 
 ing suffered repeatedly from almost fatal hemorrhage 
 after trivial injuries. After consultation a section was 
 determined on as the only hope for life. It was per- 
 formed with less than the usual loss of blood. 
 
 Anemia, or a deficiency of either hemoglobin or red 
 blood cells, is often a contraindication to an operation. 
 Mikulicz states that a hemoglobin percentage below 30, 
 or a red blood count below 3,500,000 should postpone 
 operative intervention until the blood is enriched by medi- 
 cal treatment. While this is a safe rule to follow, it has 
 its exceptions. The lives of women have often been 
 saved by hysterectomies, whose blood findings were be- 
 low this minimum, owing to profuse and uncontrollable 
 uterine hemorrhage. 
 
 Malaria and an injury or operation have a reciprocal 
 relation one with the other. Malaria may cause pain, 
 hemorrage or inflammatory changes at the site of injury, 
 which assumes an intermittent type and yield to adminis- 
 
 208 
 
OF PATIENT ON RESULT OF OPERATION 
 
 tration of quinine. Again, an injury or operation in- 
 flicted on a person the victim of malaria may markedly 
 aggravate the disease, or induce a fresh onset of ague , or 
 again, it will make active symptoms in a person who is 
 not known to be infected. 
 
 Diabetes is a contraindication to an operation of elec- 
 tion. The tissues of a diabetic patient possess little power 
 of regeneration, and have so little resistance to infection 
 that inflammation, suppuration, and gangrene are almost 
 certain to develop. Surgery on diabetics should only be 
 done when most imperatively demanded, as often, when 
 the sugar in the urine has been decreased to an insignifi- 
 cant amount by weeks of dietetic treatment, it will reap- 
 pear in large quantities immediately after the operation, 
 and the patient die in diabetic coma. 
 
 Cardiac Disease. — Valvular disease of the heart is be- 
 lieved by the laity and by most of the profession to add 
 greatly to the risk of the anesthetic and to the danger of 
 death from complications following the operation. This 
 does not seem substantiated by facts. Many thousands 
 of patients with valvular heart disease are operated upon 
 every year, and it is exceedingly rare that any bad effect 
 is produced ; and but a very small proportion of the pa- 
 tients who die from chloroform or ether are found to 
 have been the victim of organic heart disease. So far as 
 convalescence after the operation is concerned, patients 
 with heart trouble are usually markedly improved by the 
 enforced rest and confinement to bed. A dilated or fatty 
 heart is much more to be feared than one with valvular 
 lesion, especially if there is adequate compensation. 
 
 Renal Diseases. — It was formerly thought that the 
 presence of albumen or casts in the urine indicated grave 
 
 2C9 
 
INFLUENCE OF THE GENERAL CONDITION 
 
 organic change in the kidney, and was a bar to surgery. 
 This may have been the case with the crude tests of the 
 older pathologists, but it is certainly not so today, for the 
 modern laboratory man finds albumen and casts in a 
 great proportion of the specimens submitted to him. Dr. 
 Osier has emphasized this in a recent article entitled, 
 *'The Advantages of Having a Few Casts in the Urine 
 After a Man Reaches Sixty Years of Age." Certain 
 forms of nephritis, however, add greatly to the danger of 
 an operation, and all surgeons occasionally lose patients 
 from suppression of urine followed by uremic convul- 
 sions. No operation of election should be done on a pa- 
 tient suffering with advanced Bright's, and when the ur- 
 gency of the case is such that an operation has to be done, 
 the patient should be carefully prepared by dietetic and 
 eliminative treatment before the operation, and the kid- 
 neys kept active afterwards by the use of spartine and the 
 administration of large quantities of water by mouth or 
 rectum. 
 
 Respiratory Tract. — Bronchitis, pneumonitis, and 
 phthisis pulmonalis are serious bars to surgery, inasmuch 
 as they make the administration of the anesthetic difficult 
 and dangerous, and complicate the after-treatment by 
 coughing, embarrased breathing, and imperfect oxygena- 
 tion. In acute inflammation of the lungs operations 
 should be postponed, and in chronic trouble they should 
 not be done except to meet real indications. 
 
 Alimentary Tract. — Gastric dyspepsia, intestinal indi- 
 gestion, diarrhea, and constipation are all conditions to 
 be corrected prior to an operation. The prognosis is bad 
 when, to the toxins of disease, is added the poison pro- 
 duced by putrefaction of gastric and intestinal contents. 
 
 210 
 
OF PATIENT ON RESULT OF OPERATION 
 
 In correcting the conditions named food should be steri- 
 lized, the mouth should be repeatedly disinfected, the 
 stomach should be properly irrigated, and intestinal anti- 
 septics, together with purgatives, should be judiciously 
 administered. 
 
 In disease of the liver, especially when the patient is 
 jaundiced, the danger of hemorrhage should be deter- 
 mined by testing the coagulability of the blood, and, ex- 
 cept in cases of great urgency, operations should be post- 
 poned until the cholemia subsides, or until, by the ad- 
 ministration of calcium chloride or other remedies, the 
 danger of uncontrollable bleeding can be removed. 
 
 211 
 
Surgical Shock * 
 
 It has long been known that patients who met with 
 accidents or underwent operations, not of themselves 
 necessarily fatal, frequently died without apparent cause. 
 It is only within the last century that it has been known 
 that these cases died of shock. As soon as the condition 
 was recognized it was studied both clinically and experi- 
 mentally by the leading men of the profession, and the 
 literature of the subject is now large. 
 
 The writers of the past generation had a clear concep- 
 tion of the causes and symptoms of shock, but they did 
 not understand its nature, and hence the methods of pre- 
 vention and cure were inefficient and unscientific. With- 
 in the past decade Crile, of Cleveland, a leader in the 
 new school of surgical physiology, has done much to work 
 out its pathology, and the publication of his recent ar- 
 ticles has revolutionized the practice of the profession in 
 dealing with the condition. There are yet some appar- 
 ently contradictory facts to be explained and certain prob- 
 lems to be more fully elucidated, and, consequently, it will 
 probably be best to introduce the subject by giving a 
 clinical picture of a typical case. 
 
 Typical Case. 
 A patient who has been subjected to a mutilating and 
 perhaps bloody, operation is carried to the ward. When 
 placed in bed he m^es no effort to move or speak, but 
 
 * Lecture reprinted from the Bulletin of the University College 
 of Medicine, August, 1908. 
 
 213 
 
SURGICAL SHOCK 
 
 lies staring at the attendants. His face is white and pal- 
 Hd, his features pinched, and his eyes are sunken in their 
 sockets and encircled by black discoloration. He com- 
 plains of no pain, expresses no anxiety, and his mental 
 attitude is one of complete indifference. His skin is cold 
 and bathed in a clammy sweat. His lips and nails are 
 blue, his pulse is rapid and thread-like, or may be im- 
 perceptible at the wrist. His respiration is shallow, sigh- 
 ing and irregular. A thermometer placed in the rectum 
 shows his temperature to be subnormal. There is no 
 muscular paralysis, but the patient lies perfectly still and 
 is disinclined to move. There is no unconsciousness, but 
 he does not speak unless spoken to, and then answers 
 questions in slow monosyllables. If reaction does not 
 follow, the pulse gets weaker and finally disappears ; the 
 respiration becomes more shallow, and the skin clammy 
 and colder, and ''this momentary pause in the act of death 
 is soon followed by the grim reality." A post mortem 
 examination shows no pathologic change to explain the 
 symptoms. 
 
 Causes of Shock. 
 
 Loss of Blood. — This is by far the most frequent cause 
 of shock. In fact, a sudden hemorrhage produces symp- 
 toms so identical with shock that it is difficult to distin- 
 guish the two. The more rapid the loss of blood the 
 more severe the shock, and the less the chance of 
 recovery. 
 
 Loss of Heat. — The abstraction of body heat by operat- 
 ing in a cold room, exposing the abdominal or other vis- 
 cera to the air, or wetting the clothing of the patient with 
 
 214 
 
SURGICAL SHOCK 
 
 solutions which, while warm at the time, soon become 
 cold, all strongly tend to produce shock. 
 
 Loss of Time. — An operation which, if quickly done, 
 would produce no appreciable degree of shock, if unduly 
 prolonged, frequently is followed by alarming symptoms. 
 This is partially due to the fatigue, exposure, and pro- 
 longed anesthesia to which the patient is subjected, but 
 is also due to the continued irritation of the brain and 
 spinal cord by stimuli from the field of operation. Ether 
 and chloroform prevent the appreciation of pain, but 
 they do not protect the nerve centers whose exhaustion 
 causes shock. 
 
 Mechanical Injuries. — These vary in degree from 
 rough-handling of tissues by the surgeon to a compound 
 dislocation or crushing injury of a limb by an accident. 
 The various tissues and organs of the body have a shock- 
 producing power in proportion to their nerve supply, 
 and, consequently, the degree of shock will depend not 
 only on the severity of the trauma, but also on the sen- 
 sory innervation of the part. Injuries to certain regions 
 of the body are especially likely to be followed by shock, 
 such as a blow on the testicle, in the pit of the stomach, 
 or at the angle of the jaw. 
 
 Burns. — The action of intense heat on the nerve termi- 
 nals of the skin often produces profound shock. Mum- 
 mery has pointed out that burns of the first and second 
 degree produce more shock than burns of the third de- 
 gree. This is due to the fact that, in the first case, the 
 nerve terminals are exposed and irritated, whereas, in the 
 second, they are destroyed. A burn involving more than 
 one-half of the surface of the body usually causes death 
 from shodk. 
 
 2T5 
 
SURGICAL SHOCK 
 
 Perforating Injuries. — Rupture of the gall bladder, 
 perforation of a gastric, duodenal or typhoid ulcer, or 
 a rapidly fulminating case of appendicitis, resulting in 
 the discharge of irritating fluids into the peritoneal cavity, 
 frequently causes sudden and profound shock. It is sup- 
 posed that the pus, gastric juices, or intestinal contents 
 act on the peritoneum as heat would act on the skin. 
 
 Mental Emotions. — The psychic condition of the pa- 
 tient undoubtedly influences the occurrence of shock. 
 There is no reason to doubt that violent emotions, such 
 as intense fear or terror, can exhaust the nervous power 
 and produce the same results as a physical injury. A 
 case is on record where a man who had been sentenced 
 to death by bleeding actually died on hearing water 
 trickle into a basin, which he supposed to be blood issuing 
 from his veins. Another case is quoted where a man 
 fainted and died, under the impression that an operation 
 was in progress when the surgeon was, in fact, only trac- 
 ing with his nail the line of incision on his perineum. 
 Brunton quotes the case of a janitor of a college who had 
 rendered himself obnoxious to the students. One night 
 they carried him to a lonely place, and having dressed 
 themselves in black, tried him for his life. He at first 
 affected to treat the incindent as a joke, but was assured 
 by the students that they meant it in real earnest. He 
 was found guilty and was told to prepare himself for 
 death. He was blind-folded and made to kneel before a 
 block, and was struck on the back of the neck with a wet 
 towel. He fell to the ground, and, to the astonishment 
 and horror of the students, they found that he was dead. 
 
 In addition to the foregoing exciting causes of shock 
 there is considerable influence exerted on its production 
 
 216 
 
SURGICAL SHOCK 
 
 by the age, sex, temperament, mental condition, and gen- 
 eral health of the individual. The young and the old are 
 more likely to suffer from shock than those of middle 
 years. Women, as a rule, stand injuries and operations 
 better than men. Those of sanguine or nervous tempera- 
 ment suffer more from shock than the lymphatic. The 
 chronic invalid usually stands surgery better than a ro- 
 bust man, and a patient who comes to the operating table 
 confident and hopeful is less likely to develop shock than 
 one possessed with gloomy forebodings as to the future. 
 
 Pathology of Shock. 
 
 Shock is stated by Crile to be due essentially to an ab- 
 normally low blood pressure. The normal blood pres- 
 sure is dependent on three factors : First, a proper force 
 of heart beat; second, a proper rate of heart beat; and 
 third, a proper peripheral resistance. The effect of varia- 
 tion of these factors may be stated in several definite 
 laws: 
 
 1. The blood pressure must vary with the rate of the 
 heart, if the heart strength and peripheral resistance re- 
 main constant. 
 
 2. The blood pressure must vary with the strength of 
 the heart, if the heart rate and peripheral resistance re- 
 main constant. 
 
 3. The blood pressure must vary with peripheral resis- 
 tance, if the heart strength and heart rate remain constant. 
 
 4. The blood pressure may be normal if one or two 
 factors increase, while one or two factors decrease. 
 
 5. If all three factors increase, we must have a pro- 
 portionate increase in blood pressure. 
 
 217 
 
SURGICAL SHOCK 
 
 6. If all decrease, we must have a proportionate de- 
 crease in blood pressure. 
 
 7. All three factors are controlled by the nervous 
 system. 
 
 Shock is due to irritating or painful impulses which 
 are produced by accidents or operations. These impulses 
 act on the centers of the brain and cord, first causing sti- 
 mulation, but later resulting in exhaustion or paralysis. 
 They may be of such degree as at once to overwhelm the 
 centers, or they may produce the same result slowly, by 
 acting continuously for a considerable period of time. 
 Crile believes that shock is invariably due to paralysis of 
 the, vaso-motor centers and a consequent loss of periphe- 
 ral resistance. Howell believes that it may also be due to 
 feeble heart action. Accepting the latter conclusion, as 
 seems borne out by clinical facts, shock may be defined as 
 a condition characterized by long continued low blood 
 pressure, due either to partial or complete paralysis of the 
 vaso-constrictor centers and consequent lack of periphe- 
 ral resistance (vascular shock), or to alterations in the 
 rate and force of the heart beat, due to partial or com- 
 plete loss of activity of the cardio-inhibitory center (car- 
 diac shock). 
 
 Whether the low blood pressure be due to vascular or 
 cardiac causes, the result is the same. The face becomes 
 blanched, the skin pallid, the temperature subnormal, the 
 pulse weak and thread-like, the respiration shallow and 
 sighing, the muscular power impaired, and cerebration 
 blunted. These changes are due to lack of sufficient cir- 
 culation to maintain normal physiological function. The 
 blood does not flow freely through the arterial system, 
 but accumulates in the dilated venous trunks, especially 
 
 218 
 
SURGICAL SHOCK 
 
 in the abdominal region. In other words, the arterial 
 system bleeds into the dilated venous system, and, as the 
 old writers put it. the patient may bleed to death into his 
 own vessels. 
 
 Symptoms of Shock. 
 
 Facial. — The expression of the face is frequently so 
 altered that it is difficult to recognize the individual. The 
 pupils are but slightly changed, but the eyes are sunken 
 in their sockets, the lids half closed, and the areolar 
 around them darkened. The nose is small and shriveled, 
 and the lips are thin, pale, and usually parted. 
 
 Cutaneous. — The skin has a sickly pallor, and the sur- 
 face of the body is cold and bathed in clammy sweat. 
 The fingers and nails are of a bluish color, and the skin 
 on the palmar aspect of the hands lies in loose folds. 
 
 Mental. — The patient is not unconscious, but the men- 
 tal faculties are less acute than normal. He complains 
 of no pain, expresses no anxiety as to his future, and 
 shows no interest in what is being done for him. If 
 asked a question, he will reply intelligently, but slowly 
 and with effort. 
 
 Miiscidar. — There is no paralysis, but reflexes are di- 
 minished, and the voluntary and involuntary muscular 
 systems are greatly relaxed. The patient lies in the pos- 
 ture in which he is put, and does not voluntarily change 
 his position or move his limbs. There is frequently loss 
 of control of the sphincters, with involuntary discharge 
 of urine and feces. 
 
 Respiratory. — Respirations are, as a rule, quickened, 
 irregular, and shallow. In grave cases there is gasping 
 
 219 
 
SURGICAL SHOCK 
 
 although air hunger is never as marked as in pure 
 hemorrhage. 
 
 Circulatory. — The condition of the pulse varies with 
 the degree of shock. It is usually small, thread-like, and 
 at times imperceptible. The strength of the pulse is an 
 important guide to the surgeon in making a prognosis. 
 
 Temperature. — The temperature is subnormal, a ther- 
 mometer placed in the rectum frequently registering as 
 low as 95° or 96° F. Much lower temperatures are re- 
 ported from observations taken in the axilla, but these are 
 not reliable. 
 
 Terminations. 
 
 Shock may terminate in either of two ways : 
 Reaction. — If recovery ensues, the patient begins to 
 move about in bed, turns on his side, and perhaps vomits. 
 The pulse gets fuller and slower; the respiration deeper 
 and more regular; the skin warmer and dryer, until fin- 
 ally there is a return of the system to its normal condition. 
 Death. — In fatal cases of shock, the pulse grows weak- 
 er and finally disappears. Respiration becomes shallow 
 and irregular. The skin grows colder ; the patient gradu- 
 ally becomes unconscious ; the sphincters relax, and he 
 slowly expires. 
 
 Diagnosis of Shock. 
 
 The diagnosis of shock, at the present time, cannot be 
 made with scientific accuracy, and must be based on the 
 personal experience of the surgeon. It is made on the 
 symptoms above described, especially the weak, rapid 
 pulse, the cold, pallid skin, the subnormal temperature 
 and the curious condition of the mental faculties. 
 
 220 
 
SURGICAL SHOCK 
 
 The differential diagnosis between traumatic shock and 
 hemorrhage, syncope, fat embohsm, hysteria, and other 
 conditions with which it may be confused, is sometimes 
 difficult. In hemorrhage, the symptoms are usually grad- 
 ual in onset and progressive. The patient often faints, re- 
 covers, and faints again; and is usually restless, tossing 
 from side to side in bed, and expressing great anxiety 
 about his condition. In syncope there is usually prelimi- 
 nary nausea, ringing in the ears and dizziness, and when 
 the actual attack ensues the patient becomes completely 
 unconscious. In fat embolism, the symptoms usually de- 
 velop twenty-four to forty-eight hours after the injury, 
 when there is sudden pallor, irregular heart action, diffi- 
 cult breathing, and perhaps convulsions. This occurs 
 chiefly after fractures or operations on bone. Fat will 
 be found in the urine. In hysteria there are usually the 
 characteristic stigmata of the disease, the temperature re- 
 mains normal, and careful observation will usually de- 
 tect a flaw in the symptom complex. 
 
 Prognosis of Shock. 
 
 This depends on the degree of the injury, the severity 
 of the symptoms, the general condition of the patient, and 
 the presence or absence of complications like septic in- 
 fection. Shock may prove instantly fatal, as in death 
 from a blow over the solar plexus ; or the patient may 
 live one or two days and finally die ; or recovery may 
 take place when hope has been practically abandoned. 
 Shock, the result of profuse hemorrhage, is more dan- 
 gerous than shock from other causes. 
 
 221 
 
SURGICAL SHOCK 
 
 Treatment of Shock. 
 
 While much difference exists among surgeons as to 
 the treatment of shock when it develops there is great 
 unanimity of opinion as to the necessity of using certain 
 measures to prevent its occurrence. Shock is rarely 
 seen in a hospital where well-conducted operations are 
 skillfully performed on properly prepared patients. The 
 call for curative treatment of shock is now principally 
 seen in cases injured in railway accidents or other 
 catastrophes. 
 
 Preventive Treatment. 
 
 I. Avoid fright by gaining the patient's confidence, in- 
 spiring him with hope, and sending him to the operating 
 room in good mental condition. If the operation be one 
 of election, the surgeon should be absolutely frank in dis- 
 cussing the dangers of the proceedure at the time the 
 patient is considering whether or not to have it done. If, 
 however, it is decided to do the operation, the surgeon 
 should no longer refer to the possibility of disaster or 
 death, but should become optimistic and dwell on the 
 relief and benefits to be expected. If, at the time of the 
 operation, the patient is nervous, it is often wise to give a 
 hypodermic of morphine. In the case of a child, when 
 possible, it is well to fix the hour of the operation so that 
 the anesthetic may be begun while the patient is asleep. 
 
 Sometimes an adult is met with who is so panic- 
 stricken at the thought of an operation that it may be 
 necessary to adopt the following method suggested by 
 Crile, which, of course, should only be carried out with 
 the full consent of near relatives or friends: The sur- 
 
SURGICAL SHOCK 
 
 geon tells the patient on his admission to the hospital 
 that he does not know whether or not it will be necessary 
 to operate on him, and that he will only undertake the 
 case with the distinct agreement that he is to do what- 
 ever he thinks best. The consent of the patient having 
 been obtained, he is subjected to considerable prelimi- 
 nary examination, and linally told that he will be given 
 the 'inhalation treatment." An anaesthetizer goes to the 
 bed at a certain hour each day, places a mask over his 
 face and lets him inhale alcohol, disguised with some 
 aromatic agent. At the same hour on the day set for the 
 operation the alcohol is given as usual, with the slow 
 addition of an anesthetic, until unconsciousness is pro- 
 duced and the patient can be transported to the operatmg 
 room. This expedient has, in Crile's opinion, enabled 
 him to save several lives which would otherwise have 
 been lost. 
 
 2. Avoid loss of blood during the operation by the use 
 of Esmarch's bandages and constictors in amputations, 
 by angulation of the table in work on the head and neck, 
 and by carefully and quickly catching and tying all bleed- 
 ing vessels. Bloodgood says that a long bloodless opera- 
 tion is less likely to produce shock than a short bloody 
 one. 
 
 3. Avoid loss of heat by operating in a warm room, 
 keeping exposed viscera and raw surfaces protected with 
 hot moist towels, and seeing that the patient does not be- 
 come wet with solutions. It is also wise not to have the 
 patient in actual contact with the surface of a glass or 
 iron table, but to interpose some non-conductor, if not 
 actually to put him on a hot-water pad. 
 
 4. Avoid loss of time, not by breathless haste, which 
 
 223 
 
SURGICAL SHOCK 
 
 might lead to imperfect work, but by having a distinct 
 plan of the operation in mind and executing its various 
 steps speedily. Occasionally, in extremely difficult and 
 tedious operations, requiring more than an hour for their 
 execution, it is well, if circumstances permit, to do part 
 of the work one .day and complete it one or two days 
 later. Victor Horsley advocates this being regularly done 
 in cerebral surgery, trephining and exposing the dura one 
 day, and subsequently dividing it and doing the work in 
 the brain structure. 
 
 5. Avoid bruising and tearing tissue, roughly handling 
 or pulling on viscera. Dissection should not be made 
 bluntly, and all manipulations should be gently carried 
 out. The fact that the patient is under an anaesthetic 
 and his sensory centers unable to appreciate pain does 
 not mean that his vaso-motor and cardiac centers are 
 equally protected and he cannot develop shock. 
 
 6. Avoid division of large nerves, especially in weak 
 patients, until these have been blocked by the intra-neural 
 injection of cocaine. Crile says: ''As no impulses of any 
 kind can pass either upward or downward, there is no 
 more shock in dividing tissues — even the nerve trunks 
 themselves, thus blocked — than in dividing the sleeve of 
 the patient's coat." In operations on the lower extremity 
 and pelvis this principle can be more extensively applied 
 by injecting the cocaine into the spinal canal at or near 
 the fourth lumbar vertebra. 
 
 Curative Treatment. 
 
 When shock is actually present, active treatment is of 
 little use, and in using remedies the surgeon should be 
 careful that, if he do no good, at least he do no harm. 
 
 224 
 
SURGICAL SHOCK 
 
 Senn says that it is as important to know what not to do 
 as to 'know what to do, and Warren emphasizes the fact 
 that it should be clearly remembered that the condition 
 is one of exhaustion, and rest is needed for repair. As 
 the symptoms of shock are those of profound weakness 
 and prostration, it was long a practice to give stimulants, 
 such as alcohol, digitalis or strychnine. According to the 
 modern pathology, which is undoubtedly correct, these 
 remedies do harm. The centers are already partly or 
 completely paralyzed from over-stimulation, and the ad- 
 ministration of strychnine, according to Mummery, "is 
 like beating a tired horse — it may call forth an effort if 
 we beat hard enough, but it hastens the end." Or, to 
 quote Crile, **It would be just as logical to treat strych- 
 nine poisoning with traumatic shock as to treat trau- 
 matic shock with strychnine." 
 
 The only rational remedy would be one which would 
 act not on the centers, but on the dilated vessels, restor- 
 ing the peripheral resistance. Unfortunately, we have 
 no satisfactory means to accomplish this end. The fol- 
 lowing is a brief description of the present accepted mode 
 of treatment : 
 
 1. Secure physiological rest by placing the patient in 
 a quiet room, excluding all friends and relatives, and 
 giving a moderate dose of morphine. The surgeon and 
 attendants should be calm and confident in their manner, 
 and the patient should not be allowed to infer that his 
 condition is unusual or alarming. 
 
 2. Apply external heat by placing the patient between 
 warm blankets, putting hot-water bags to the feet, thighs, 
 and body, and in some cases injecting hot fluids into the 
 rectum. 
 
 225 
 
SURGICAL SHOCK 
 
 3. Support the circulation mechanically by posture, by 
 bandaging, or by the pneumatic suit. In mild cases of 
 shock all that may be necessary is to lower the head, thus 
 gravitating the blood to the anemic brain. In graver 
 cases the limbs should be enveloped in elastic, non-ab- 
 sorbent cotton, and firmly bandaged from extremity to 
 body. A compress may also be applied over the abdomen. 
 Crile's pneumatic suit is an appliance by which the entire 
 surface of the body is subjected to pressure by com- 
 pressed air. Unfortunately, however, it is rarely at hand 
 when needed. 
 
 4. Transfusion with warm saline solution by rectum, 
 beneath the skin, or into a vein. In cases of shock due 
 to hemorrhage this is the most logical and efficient method 
 of treatment. In cases of shock from other causes, how- 
 ever, it is not so valuable. The average individual can 
 only take up about two quarts of the solution. After 
 this amount has been given an interval must elapse, and 
 then only two or three ounces given at a time. If this 
 precaution is disregarded, fatal complications may ensue 
 from edema of the pulmonary or abdominal regions. 
 
 5. The administration of adrenalin chloride, which is 
 usually effected by combining it with the saline solution 
 used in transfusion, one drachm of the i-iooo commercial 
 solution being added to one quart of normal salt solution 
 and introduced slowly, but continuously, the rate regu- 
 lated by the character of the symptoms or the record of 
 a sphygmomanometer. 
 
 Question of Operating During Shock. 
 
 In accident cases the surgeon is confronted with the 
 question whether to operate at once or wait for reaction ; 
 
 226 
 
SURGICAL SHOCK 
 
 whether he had better add the shock of an operation to 
 the shock of the injury, with danger of death of the 
 patient, or whether he had better wait, hoping for im- 
 provement, but possibly sacrificing the patient's only 
 chance for life. There is no rule, although most authori- 
 ties advise waiting, unless the mutilation causes great 
 pain, or unless hemorrhage is actually in existence. On 
 ihe other hand, Wainwright says: "To remove the nerve 
 impulses after trauma an immediate repair of injury is 
 very important. Leaving a mangled, oozing limb, with 
 crushed and exposed nerves, with the hope that it will 
 give more favorable opportunity for intervention, will, 
 in many cases, by allowing the cause continually to act, 
 only drive the patient into a condition beyond all hope." 
 
 227 
 
Sulphate of Spartine in Surgical 
 Practice * 
 
 Like most surgeons, I devote little time to the study 
 of the therapeutic action of drugs. Patients who are re- 
 ferred to me have usually exhausted the resources of 
 materia medica, and in my practice I rarely have occasion 
 to employ medicinal agents other than the well-known 
 anaesthetics, antiseptics, purgatives and tonics. I believe, 
 however, I have accidentally discovered in sulphate of 
 spartine a valuable remedy for the prevention and treat- 
 ment of post-operative suppression of urine. 
 
 I do not know whether or not my experience coincides 
 with that of other surgeons, but it is a fact that in the 
 last five years I have lost more cases from post-operative 
 suppression of urine than from all other causes com- 
 bined, and this despite the almost routine use of chlro- 
 form as an anaesthetic. 
 
 The cases have usually been those with pre-existing 
 nephritis from sepsis or cholemia. Shock has not ap- 
 parently been a factor, for the condition would not de- 
 velop for twenty-four or thirty-six hours. A patient 
 operated upon for retention of urine, or for jaundice 
 due to obstruction of the common duct, would do well 
 for one or two days, and just as he was thought to be 
 out of danger, there would come the news that he was 
 passing no urine. He would become restless, then list- 
 less, would develop a stupor which would rapidly deepen 
 
 * Read before the Southern Surgical and Gynecological Asso- 
 ciation, December, 1906. 
 
 229 
 
SULPHATE OF SPARTINE IN 
 
 into coma, and would die with all the symptoms charac- 
 teristic of uremia. In the treatment of this condition I 
 tried water by mouth, under the skin and in the rectum ; 
 hot packs and vapor baths; cups and counter-irritants; 
 strychnine, digitalis and nitro-glycerin ; calomel and saline 
 purgatives ; and in one case stripping the kidney capsules, 
 with uniformly bad results. 
 
 Two years ago I began empirically the use of sulphate 
 of spartine, and now I have the record of six cases in 
 which I am sure the drug was the means of saving the 
 patient's life. 
 
 I will not occupy the time of the Association by read- 
 ing a dissertation on spartine which I would, of course, 
 have to copy from a text book. Its therapeutic effect 
 is to increase the blood pressure, make the pulse slower 
 and stronger, and act as a powerful diuretic. Its action 
 is manifest in thirty minutes after administration and 
 lasts for four to six hours. 
 
 I believe the reason why the value of sulphate of spar- 
 tine is not more widely recognized is because authorities 
 advise its use in doses so small as to be worthless. To 
 get results, it must be given hypodermatically in doses 
 of from one to two grains, repeated every three to six 
 hours. When so employed, I have repeatedly seen it 
 pull up a run-a-way heart and set in motion a pair of 
 stalled kidneys. Its use should not be delayed until sup- 
 pression of urine is already in existence, but it should be 
 prescribed as a prophylactic as well as a curative agent. 
 
 I do not mean to claim that it is specific, or that it 
 should be employed to the exclusion of other measures, 
 such as purgatives, transfusions and hot packs. I do 
 
 230 
 
SURGICAL PRACTICE 
 
 believe, however, from actual experience, that it is pre- 
 ferable to the drugs of the digitalis type in rapidity of 
 action, ease of administration, and, what is more impor- 
 tant — results. 
 
 231 
 
The After Care of a Surgical Patient * 
 
 When the operation is concluded, the dressings ap- 
 plied, and the gown, if soiled or wet, changed, the patient 
 is ready to be taken to his room. To accomplish this 
 would seem a simple procedure, yet from the lack of 
 definite plan it is often the occasion of much confusion 
 and delay. The litter consists of a light frame of metal 
 tubing resting on a rolling carriage. The frame is short 
 enough to fit lengthwise in the patient's bed. The litter 
 is covered with a warm dry blanket. It is rolled up 
 beside the operating table. Two assistants on the opposite 
 side of the table now lift the patient vertically upward 
 while two others slip the frame beneath him. The blanket 
 worn around the limbs during the operation is now re- 
 moved and the blanket on the litter wrapped about him. 
 The frame is put back on the carriage and the patient 
 quickly rolled to his room. The frame is put on the bed, 
 the patient lifted up and the frame slipped out. The 
 transfer is complete and there has been no pulling or 
 hauling, which might slip a ligature or disarrange the 
 dressings. Some one must now sit with the patient until 
 the effects of the anesthetic have worn off and reaction 
 has taken place. 
 
 Shock is rarely seen in an alarming degree after opera- 
 tions on properly prepared patients, planned and executed 
 so as to avoid unnecessary loss of heat, blood and time. 
 
 * Printed in the Charlotte Medical Journal, December, 1905. 
 
 22,2, 
 
THE AFTER-CARE OF A SURGICAL PATIENT 
 
 It is frequently seen, however, in accident cases espe- 
 cially if there has been hemorrhage or mutilation. 
 
 The operating room is not the place to treat shock. 
 Only in rare cases should intravenous or subcutaneous 
 transfusion be practiced while the patient is on the table. 
 The unavoidable delay in the operation, the danger of 
 infection and the manipulations of unskilled assistants 
 which attend the procedure, render it more productive of 
 harm than of good. All that should usually be done is 
 to give a hypodermic of a small dose of morphine and 
 bend every energy to the rapid completion of the opera- 
 tive work and the early removal of the case from the 
 table. The patient should be put to bed between warm 
 blankets. Additional heat should also be applied by 
 means of hot water bags, due precautions being observed 
 to prevent accidental burns. The foot of the bed should 
 be elevated to gravitate blood to the anemic brain. The 
 half empty blood vessels should be filled by the intro- 
 duction into the system of as much normal saline solution 
 as it will take up. This can best be effected by low press- 
 ure continuous rectal injection. By this method many 
 quarts of fluid can be introduced without discomfort or 
 traumatism. 
 
 While the use of small doses of morphine has a decided 
 effect for good, the confidence formerly placed in strych- 
 nine seems misplaced. If shock is due to paralysis of the 
 vaso-motor system then stimulation of the exhausted 
 centers will result in more harm than good. Of all drugs 
 employed to produce re-action the solution of chloride of 
 adrenalin seems the most logical. As its effect is evanes- 
 cent the dose must be repeated at frequent intervals. 
 In addition to the measures recommended it is of the 
 
 234 
 
THE AFTER-CARE OF A SURGICAL PATIENT 
 
 utmost importance to exclude all relatives from the room, 
 thus removing injurious excitement. The patient should 
 not be encouraged by hysterical reassurance, but made 
 to feel that everything is being done for him by the quiet 
 self confidence exhibited in the deportment of the doctor 
 and nurses. 
 
 Pain. — The first, and to the patient, the most important 
 symptom after an operation to demand prompt and ade- 
 quate treatment is pain. It is often a difficult question 
 for the surgeon to decide how much the patient really 
 suffers, and what measures are really demanded. Some 
 patients make a great outcry when really they are more 
 scared than hurt, and the pain will do them less harm 
 than the drug which brings relief. Again, other patients 
 invested with a sort of old fashioned doctrine of predesti- 
 nation will make no complaint, and it is only by seeing 
 the set face, the compressed lips and clinched hands and 
 noting the cold and clammy skin, that a knowledge is 
 derived of the necessity for giving an opiate. When pain 
 is moderate the patient should be encouraged to bear it, 
 but when it is excessive the patient should be relieved 
 by the hypodermic use of morphine. The bromides and 
 coal tar preparations are worse than useless. Morphine 
 in small, and if necessary repeated doses, is what is de- 
 manded. It is true the drug may mask symptoms, cause 
 nausea and produce constipation, but it is the lesser horn 
 of the dilemma. In the old days morphine was first abused, 
 and then not used. Even now some well known authori- 
 ties decry its employment. The majority of modern sur- 
 geons, however, believe that when administered judic- 
 iously it not only brings temporary relief, but frequently 
 saves life. 
 
 235 
 
THE AFTER-CARE OF A SURGICAL PATIENT 
 
 Nausea. — Another frequent and distressing symptom 
 from which the patient suffers after an operation is 
 nausea and vomiting, primarily due to the anesthetic, but 
 sometimes continued by sepsis and the presence of blood 
 and bile in the stomach. When the patient retches on 
 the operating table, and it is evident there is fluid in the 
 stomach, then much after distress will be avoided if the 
 stomach contents are washed out before he is taken to his 
 room. This procedure is a routine practice with some sur- 
 geons, but is not necessary or advisable in all cases. When 
 nausea and vomiting continue it is at first treated ten- 
 tatively by putting ice cloths to the forehead and throat, 
 applying a mustard plaster to the pit of the stomach, and 
 giving cracked ice or a few sips of water. If the symp- 
 toms are unrelieved the patient is given two glasses of 
 tepid water. It is always taken with relish. If retained 
 it reestablishes peristalsis in the proper direction, and 
 if rejected it washes out the stomach contents almost as 
 effectually as could be done by lavage. Drugs, such as 
 creosote, oxalate of cerium, ingluvin, bismuth, hydro- 
 cyanic acid, etc., have been found useless, and efferves- 
 cent drinks such as ginger ale and champagne are inju- 
 rious. In the vast majority of cases the nausea will cease 
 spontaneously as soon as the chloroform or ether is elimi- 
 nated from the blood. Time is the only panacea and 
 unless symptoms of danger are evident the less that is 
 done by the surgeon the sooner the patient will experience 
 relief. 
 
 In a few cases the vomiting, instead of getting better, 
 gets worse. At first the patient strains violently and 
 ejects a clear or yellow fluid. Later without muscular 
 effort there is the constant regurgitation of a green or 
 
 236 
 
THE AFTER-CARE OF A SURGICAL PATIENT 
 
 black fluid. There is little or no nausea, but at frequent 
 intervals the patient gives a little gulp and spits out a 
 mouthful of what is popularly supposed to be bile. A 
 chemical examination will show that it is not bile but 
 blood. The patholog}^ of this condition is a disputed 
 question, but it is generally believed that a low grade of 
 septicemia has so weakened the gastric blood vessels as 
 to permit the hemorrhagic transudation. The practical 
 fact is that if these patients are let alone most of them 
 will die. The introduction of a stomach tube will show 
 the presence of a quart or more of black fluid in the 
 stomach. What is spit up is merely the overflow. If 
 the material remains in the stomach the patient may die 
 from exhaustion. If the material passes into the intes- 
 tines the patient may die from toxemia. The prompt use 
 of the stomach tube at the first symptom of black vomit, 
 the emptying of the viscus and the irrigation of its cavity 
 with normal saline or a weak adrenalin solution gives the 
 only chance for life. 
 
 Position in Bed. — In the early days of abdominal sur- 
 gery patients were kept on their backs and not allowed 
 to turn on the side for the first seven days. It was found, 
 however, that in addition to the suffering entailed there 
 was an increase in the liability to complications. After an 
 ovariotomy or hysterectomy it is well to keep the patient 
 in one position for the first twenty-four hours to lessen 
 the danger of a ligature slipping, but in operations like 
 appendicitis the patient should be encouraged to lie first 
 on one side and then on the other. In cases of opera- 
 tions on the stomach or where there is a vaginal drain, 
 the patient should be put in an exaggerated Fowler's 
 position in order to carry fluids in the desired direction 
 
 237 
 
THE AFTER-CARE OF A SURGICAL PATIENT 
 
 by gravity. Some surgeons go so far as to put all lapa- 
 rotomies in a sitting position from the first, claiming not 
 only better drainage, but increased freedom of respira- 
 tion from the removal of the pressure of the liver on 
 the diaphragm. The position of the patient in bed is one 
 of the essential features of the Fowler-Murphy method of 
 treating cases of diffuse peritonitis, hence hospitals 
 should have facilities and nurses experience, to enable 
 them to handle such cases. 
 
 Bladder and Kidneys. — During the first few days after 
 an operation the bladder and kidneys require careful 
 watching to see that they properly perform their func- 
 tions. If the patient does not voluntarily pass urine he 
 should be urged to make every effort to do so. A cathe- 
 ter should not be employed if it is possible to avoid it, as 
 its use always entails some danger of infection, and makes 
 the patient more or less dependent on it in future. Some- 
 times, however, it has to be employed to prevent undue 
 distention of the bladder. The quantity of urine should 
 be carefully recorded and if any abnormality is noted a 
 specimen should be sent to the laboratory for examination. 
 
 In cases of chronic interstitial nephritis and in cases 
 of acute septicemia and cholemia there is often sudden 
 suppression of urine which may result in death. After 
 operations on patients with jaundice more cases die from 
 uremia than from any other one cause. At St. Luke's 
 Hospital the old treatment of transfusion, sweating, cups 
 over the kidneys, administration of infusion of digitalis, 
 etc., has given very poor results. Recently a new line 
 has been followed, and while the number of cases is yet 
 too few to justify an unqualified statement, still it is be- 
 lieved that a distinct improvement has been made. As 
 
 238 
 
THE AFTER-CARE OF A SURGICAL PATIENT 
 
 soon as any inadequacy of kidney activity is noted sul- 
 phate of spartine is given hypodermically in one to two 
 grain doses; repeated according to effects at four or six 
 hour intervals. In six cases where there w^as complete 
 suppression there has been prompt response to the drug, 
 with ultimate recovery. 
 
 Bowels. — When peritonitis, either local or general, was 
 more the rule than the exception after abdominal sec- 
 tions, it was the practice to give calomel in large doses 
 as soon as the stomach w^ould retain it. In fact the sur- 
 geon was not happy until the patient was freely purged. 
 
 That early purgation is a prophylactic against inflam- 
 matory conditions is undeniably true, but that it depletes 
 the patient, retards recovery, and is not necessary under 
 modern methods has been proved to the satisfaction of 
 most operators. In a case which runs smoothly, in other 
 words when the abdomen is not distended and the pulse 
 and temperature are practically normal, there is no hurry 
 to purge. Usually a soap suds enema is given 36 or 48 
 hours after the operation and the bowels afterwards regu- 
 lated if necessary by the administration of some mild 
 laxative such as cascara or senna. Occasionally, how- 
 ever, symptoms quickly develop 'which forbode evil, and 
 then broken doses of calomel should be at once prescribed. 
 Should the drug be rejected, or fail to act, it should be 
 followed by enemata. When the abdomen becomes 
 swollen and tympanitic the administration of purgatives 
 by the mouth should be withheld. The bowels are paraly- 
 tic from distention, and stimulation is ineffective and 
 harmful. In this condition enemata are the sole reliance. 
 Many authorities recommend high injections through a 
 long rectal tube, but this method has not given the results 
 
 239 
 
THE AFTER-CARE OF A SURGICAL PATIENT 
 
 that were claimed for it. In the hands of the average 
 nurse the tube simply coils up in the rectum, and the 
 surgeon himself usually fails in his efforts to pass it 
 through the sigmoid flexure. Fortunately the elevation 
 of the hips on pillows and the slow injection into the 
 rectum with an ordinary syringe gives about as good re- 
 sults, and does not entail as much manipulation or cause 
 as much discomfort. The formula of the enemata used 
 varies, the most common combination consisting of gly- 
 cerine, turpentine, sulphate of magnesia and water. Har- 
 don, of Atlanta, is enthusiastic in advocating a mixture 
 of one ounce of powdered alum to one quart of water, 
 and at St. Luke's Hospital human bile is sometimes used 
 with good effect. This is only possible when a case of 
 gall-bladder drainage is in the house to supply the needed 
 material. For the past ten years efforts have been made 
 by many experimenters to find a drug which would pro- 
 duce purgation when administered hypodermically, but 
 so far without success. If such an agent is ever dis- 
 covered it will prove one of the most valuable additions 
 that could be made to our present resources. 
 
 Water. — As an empty stomach is one of the best safe- 
 guards against vomiting, water should be withheld from a 
 patient for several hours after recovery from anesthesia. 
 If at the end of this time no nausea exists it may be given 
 in small quantities at half hour intervals, and if it be 
 well borne by the stomach the quantity increased until 
 thirst is relieved. The water may be acidulated with 
 lemon juice, or cold or hot tea without sweetening sub- 
 stituted for it. Should vomiting prevent the patient from 
 retaining fluid, thirst may be relieved by allowing the 
 patient to rinse out the mouth with water to get the taste, 
 
 240 
 
THE AFTER-CARE OF A SURGICAL PATIENT 
 
 and injecting a pint of saline solution in the rectum to 
 produce the effect. 
 
 Nourishment. — If the patient is very weak nutritive 
 enemata may be used from the first. In employing this 
 method of feeding it must be remembered that while the 
 rectum can absorb it cannot digest, hence nutriment must 
 be in an assimilable form. As good a mixture as any other 
 consists of two ounces of Peptohoids or Predigested Beef 
 and four ounces of saline solution. If deemed necessary 
 one ounce of whiskey may be added. Nutritive enemata 
 should not be given oftener than every six hours, and 
 the rectum should be irrigated once daily to remove resi- 
 duum or other irritating material. The average patient 
 does not require any nourishment for the first twenty- 
 four or thirty-six hours. In fact many may safely and 
 advantageously be allowed to go without food for two 
 or three days. Dr. Tanner has taught the profession 
 that starvation is not an immediate danger. The case, 
 whose death is attributed to exhaustion, usually dies 
 of some form of sepsis. 
 
 The first nourishment given a patient by mouth should 
 be liquid, easily digested and not likely to cause gas 
 in the stomach and intestines. Egg albumen, chicken 
 broth, beef tea and buttermilk fulfill these conditions. 
 After the third day, if everything is going well, soft 
 boiled eggs, milk toast and other semi-solid articles of 
 diet may be added. At the end of the first week the 
 patient may be allowed the ordinary hospital bill of fare. 
 
 Tonics. — But little medicine as a rule is given in a sur- 
 gical hospital. If the patient's appetite flags a table- 
 spoonful of whiskey before meals or a glass of wine or 
 beer with meals is usually more productive of results 
 
 241 
 
THE AFTER-CARE OF A SURGICAL PATIENT 
 
 than distasteful drugs. If the patient feels he is being 
 neglected he should be given tincture of nux vomica or 
 some harmless placebo, with which the market is well 
 supplied. 
 
 General Hygiene. — The efficiency of the modem 
 trained nurse leaves but little for the surgeon to suggest 
 in regard to changing bed linen, giving baths, rubbing 
 the back, etc. If there is one point occasionally neglected 
 it is the toilet of the mouth. The proper use of the tooth 
 brush and the employment of antiseptic washes will not 
 only add to the patient's comfort, but prevent fermen- 
 tation of food by the reduction in the number of bacteria 
 taken into the digestive tract. 
 
 Length of Confinement to Bed. — It is of course im- 
 possible to have any hard and fast rule as to how long 
 it is necessary to keep a patient in bed after an operation. 
 Each case must be considered on its special indications. 
 A prudent patient may be allowed to sit up sooner than 
 a reckless one. A lean individual will secure a firm 
 cicatrix quicker than a fat one. A wound that unites 
 by primary intention does not necessitate the same length 
 of confinment as one that suppurates. Still there ought 
 to be some consensus of opinion among surgeons of ex- 
 perience as to how long an uncomplicated abdominal case 
 should retain the recumbent position. Unfortunately 
 the beginner who consults literature for the answer to 
 this question will find the expression of very dififerent 
 views. Some surgeons put their appendicitis cases up 
 on the seventh day and send them home on the ninth. 
 Others keep them in bed three or four weeks and dis- 
 charge them, with many injunctions as to prudence, a 
 week or ten days later. The tendency is to make the 
 
 242 
 
THE AFTER-CARE OF A SURGICAL PATIENT 
 
 patient's stay in the hospital shorter and shorter. This 
 is partly due to improved results, but also influenced by 
 a desire to advertise the surgeon, to make the patient 
 more willing to consent to an operation, to increase the 
 number of cases cared for by a ward of limited capacity, 
 and finally to lessen the money paid to the hospital so 
 there may be more left for professional services. Be- 
 tween too great conservatism on the one hand, with the 
 attendant loss of time and money, and too great radi- 
 calism on the other, with the danger of hernia and other 
 complications, there must eventually be derived the happy 
 mean. At present the average surgeon keeps an appendi- 
 citis case in bed about two weeks and discharges him in 
 three. An operation necessitating greater weakening of 
 the abdominal wall such as a hysterectomy confines the 
 patient to bed three weeks and to the hospital four. Ex- 
 perience has proved that incisions in the upper abdomen, 
 for liver and stomach work, do not entail the same lia- 
 bility to hernia as openings in the lower abdomen for 
 pelvic tumors, hence the time in bed after the former 
 may safely be less than after the latter. The use of 
 abdominal belts after operations is not advisable unless 
 the abdomen is pendulous, or in cases where the cicatrix 
 is weak owing to the employment of drainage. This last 
 indication for the use of an irksome prophylactic measure 
 has been materially lessened by the present practice of 
 inserting drains, when needed, through stab incisions and 
 closing the operative wound as if no drain had been 
 employed. 
 
 The After Care of Wounds. — Clean wounds, without 
 drainage, need not usually be dressed until the eighth 
 or ninth day, when the stitches are removed and a second 
 
 243 
 
THE AFTER-CARE OF A SURGICAL PATIENT 
 
 dressing applied. The three indications for an earlier 
 dressing are pain, fever, or saturation of dressings with 
 wound secretion. Should the wound be uncomfortable 
 when there is no rise of temperature it is probably due 
 to stiffening of the dressings with blood or serum, and 
 redressing will give immediate relief. Should there be 
 a tight stitch with a read area about it, it should be 
 clipped or removed as soon as discovered in order to 
 prevent the formation of an abcess. 
 
 244 
 
Past, Present and Future of Cancer * 
 
 Cancer has been a constant subject of study in all ages 
 and in all nations; but the mystery of its origin has yet 
 been unsolved, resistance to its progress has yet proved 
 unsuccessful, and the symbolic crab continues to sink its 
 claws slowly but relentlessly into the flesh of its victim. 
 The disease, at first local, becomes regional and consti- 
 tutional, recurring when removed, disseminating when 
 left ; undergoing degeneration, intractable ulceration, deep 
 spreading excavation, and is usually followed by cachexia 
 and death. 
 
 It is the object of this paper to review the history of 
 cancer, to call attention to the recent view^s of the etiology 
 of the disease, to state the present accepted principles 
 of its treatment, and to suggest the possible developments 
 of the future — a scope admittedly too broad to be prop- 
 erly covered in the time at the writer's disposal for prep- 
 aration, or of the Society's programme for reading. 
 
 History and Etiology of Cancer. 
 The earliest medical writings contained descriptions of 
 tumors, and their origin was attributed to the influence 
 of maHgn or evil spirits. Hippocrates taught that the 
 body was composed of four humors — blood, phlegm, black 
 bile and yellow bile; and Galen believed that tumors re- 
 sulted from the accumulation of one of these humors. 
 Harvey, by the discovery of the circulation of the blood, 
 
 * Read at a meeting of the Medical Society of Virginia, Lynch- 
 burg, Va., November, 1901. 
 
 245 
 
THE PAST, PRESENT AND 
 
 overturned preconceived views of pathology, and the 
 blood was next regarded as the source of disease, and its 
 organization the origin of tumor formation. Boerhaave, 
 some years later, ascribed tumors to the newly discovered 
 lymph, the vitiated or degenerated variety being supposed 
 to produce cancer. Hunter was the first to recognize the 
 similarity in structure between tumors and normal tis- 
 sues, and to maintain that they originated by a modifi- 
 cation of formative processes. Broussais, early in the 
 nineteenth century, claimed that all tumors, including 
 cancer, were forms of chronic inflammation consequent on 
 organic irritation. This view, owing to its simplicity 
 and comprehensiveness, at once became accepted, but its 
 supremacy was short-lived. Schleiden, with the aid of 
 the then recently-perfected microscope, discovered the 
 cellular structure of plants. Schwann demonstrated the 
 analogy in animals; Muller established the fact that tu- 
 mors were formed of cells, but believed the cells were 
 derived from the blood. Virchow accepted the cellular 
 structure of tumors, but denied the blastodermal origin of 
 the cells. He proved that cells could not develop de novo, 
 but followed biological laws, and were always the result 
 of the division of pre-existing cells. He believed in meta- 
 plasia, and taught that a given cell under some conditions 
 might become an epithelial cell, and, under other condi- 
 tions, a connective tissue cell. Cohnheim controverted 
 the existence of metaplasia, and established the law of 
 the legitimate succession of cells. He classified tumors 
 by referring each to the embryonic layer, from which 
 its cell had origin, and advanced a novel and ingenious 
 theory to explain their development. He claimed that 
 during the progress of cell diflferentiation in the embryo 
 
 246 
 
FUTURE OF CANCER 
 
 more cells were produced at a certain point than were 
 necessary for the formation of that particular region. 
 He believed that these left-over cells — not utilized by 
 the growth of the organism — were arrested in their fur- 
 ther development and remained in a dormant condition. 
 He claimed that if the energy of these detached and 
 slumbering islets of embryonal cells were reawakened 
 later by internal or external stimulation, they would 
 undergo rapid proliferation and form a tumor, whose 
 histologic type and clinical behavior would depend on the 
 epiblastic, mesoblastic, or hypoblastic source of the parent 
 cells. The physiologic analogue of this hypothetic patho- 
 logic process is seen in the changes which occur in the 
 human body at the age of puberty, when cells that have 
 slept for years with latent energy are re-awakened, and, 
 multiplying rapidly, produce the development of the sex- 
 ual organs and the other changes characteristic of that 
 period. 
 
 Based on Cohnheim's theory, which is almost univer- 
 sally accepted, the term tumor is now used in a much 
 more restricted sense than formerly. At one time the 
 word was employed to designate all kinds of swellings ; 
 now a sharp line of separation is drawn between tumors 
 supposed to be the result of the proliferation of embryo- 
 nal cells occurring independently of microbic cause, and 
 inflammatory swellings demonstrated to be the result of 
 the proliferation of mature cells produced by the action 
 of pathogenic organisms. 
 
 Bacteriologists have accepted this division, but have 
 patiently and persistently endeavored to prove that many 
 of the growths supposed to be tumors or neoplasms, due 
 to the proliferation of embryonal cells, were really in- 
 
 247 
 
THE PAST, PRESENT AND 
 
 flammatory swellings, due to the action of hitherto un- 
 known but recently-discovered micro-organisms. 
 
 In the past few years lupus, syphilis, leprosy, tuber- 
 culosis, actinomycocis, and other diseases have been 
 proved either by direct demonstration or by argument 
 from analogy, to be due to a germ, and one by one have 
 been transferred from the slowly diminishing list of tu- 
 mors to the gradually increasing list of infective gran- 
 ulomata. At this time a vigorous and well-directed effort 
 is being made to prove that cancer is due to a parasite, 
 but the claim is resisted by the adherents of the cellular 
 theory of the origin of the growth. Two papers read 
 a few months ago at the same meeting of the American 
 Medical Association, one by Dr. Nicholas Senn, of Chi- 
 cago, and the other by Dr. Rosewell Park, of Buffalo, 
 ably and forcibly present the two sides of the question. 
 
 Senn, perhaps, the greatest surgical philosopher of the 
 day, presents his views with citations of authorities so 
 voluminous that while the article will remain as a per- 
 manent encyclopedia of reference to the literature of 
 the subject, it is almost impossible to make an abstract 
 of it that does justice to the author. Senn adheres to the 
 cellular theory of the origin of cancer and claims that 
 from an etiologic standpoint very little has been added 
 to our knowledge of the disease since the epoch-making 
 labors of Virchow, Cohnheim, and Waldeyer. He says 
 that after the demonstration of the fact that all inflam- 
 matory processes were caused by micro-organisms, it 
 was natural that by reasoning from analogy the con- 
 clusion was reached that cancer was also a parasitic dis- 
 ease. Earnest workers in all parts of the civilized world 
 have investigated the subject; various methods of tissue 
 
 248 
 
FUTURE OF CANCER 
 
 staining, cultivation, and inoculation have been utilized ; 
 numerous intra-cellular and extra-cellular bodies have 
 been discovered and described; but the numerous claims 
 of having isolated the essential cause of cancer have 
 never yet been substantiated. Searching criticisms from 
 different reliable sources have shown almost conclusively 
 that these bodies are not living organisms, but the pro- 
 ducts of degeneration of the cell protoplasm of a non- 
 parasitic nature. 
 
 Senn claims that the histology and histogenesis of can- 
 cer speak against a parasitic origin of the disease, be- 
 cause of the difference in the histologic structure of the 
 cells which constitute the mass in carcinoma and in in- 
 flammatory products. Carcinoma differs morphologically 
 according to the structures in which it originates, while 
 inflammatory products present the same structure inde- 
 pendent of their anatomic location or character of the 
 tissue involved. In other words, carcinoma of the breast 
 when transported by metastasis to the liver produces 
 typical breast cancer in the liver, while inflammation of 
 the breast transported to the liver produces ordinary 
 hepatitis. 
 
 Senn states that the results of implanation and inocula- 
 tion experiments have so far failed in establishing the 
 parasitic theory of carcinoma. The two objections to the 
 validity of the claim are: 
 
 1st. The variety of microbes and bodies which have 
 been found in carcinoma tissue by different experimenters 
 and for all of which — at different times and by different 
 authors — the same specific pathogenic qualities have been 
 claimed. 
 
 2d. The histologic structure of the products of im- 
 
 249 
 
THE PAST, PRESENT AND 
 
 planation of carcinoma tissue — or inoculation with the 
 supposed cancer germs — does not correspond with the 
 structure of a true carcinoma. 
 
 Senn states that no well-authenticated case of inocu- 
 lation carcinoma has occurred among surgeons who have 
 frequently injured their fingers and hands during opera- 
 tions for carcinoma, while inoculation tuberculosis from 
 the same cause has been frequently observed. The same 
 can be said of persons who take care of carcinoma pa- 
 tients, or who live in the same room with them. In the 
 case of an inoperable carcinoma of the leg, Senn im- 
 planted subcutaneously fragments of aseptic carcinoma 
 tissue at two points on the affected limb. During the 
 first two weeks little nodules formed at the point of 
 inoculation, but then gradually disappeared. 
 
 On May 4, 1901, Senn inoculated himself with car- 
 cinoma tissue immediately after he had completed a radi- 
 cal operation for advanced carcinoma of the lower lip. The 
 patient from whom the malignant graft was obtained was 
 an Irishman sixty years of age. The submental and 
 submaxillary lymphatic glands were involved. The glands 
 were immersed in warm saline solutions, and from one 
 of them a fragment the size of a split pea was used for 
 implantation. A small incision was made about the mid- 
 dle of the forearm, under strict aseptic precautions. One 
 of the margins of the wound was undermined sufficiently 
 to make a pocket large enough to receive the graft. After 
 implantation, the wound was closed with a horse-hair 
 suture and iodoform collodion. The carcinomatous na- 
 ture of the glandular affection was proved by micro- 
 scopic examination of the gland from which the graft 
 was taken. In the course of a week a nodule the size 
 
 250 
 
FUTURE OF CANCER 
 
 of a pea made its appearance, which remained stationary 
 for two weeks, and then gradually disappeared. 
 
 Dr. Roswell Park, to whose enthusiasm and inde- 
 fatigable industry was due the establishment of the New 
 York State Pathological Laboratory for the Study of 
 Cancer, takes the opposite view. He claims that the 
 infectiousness of cancer has been proved, but admits 
 that the exact nature of the organism has not been demon- 
 strated. He says that it is not now believed that cancer 
 is due to a bacterium, but to a parasite, perhaps similar 
 to the Plasmodium of malaria. Little is known of these 
 lowly forms of animal life, and it has not yet been de- 
 termined whether Koch's laws for the determination of 
 the infectious nature of a given disease are valid when 
 applied to them. In the Buffalo Laboratory, these organ- 
 isms have been found whenever conditions were favor- 
 able, and the introduction of cultures made from them 
 has produced fatal results in animals, although the inocu- 
 lations have not invariably produced distinct carcinomata. 
 Park states that Cohnheim's theory explains the presence 
 of certain cells in unusual localities, but offers nothing 
 to explain the peculiar behavior of these cells, which 
 constitute the essential feature of malignant growth. He 
 claims that the parasitic theory is much more satisfac- 
 tory than the cellular theory, and substantiates his views 
 with arguments by analogy, by comparative pathology, 
 by miscroscopic findings, and by clinical obsen^ations. 
 He states that the study of tumor formations in the 
 vegetable kingdom shows a striking analogy between the 
 proposed parasitic theory of the origin of cancer in ani- 
 mals and the known relation of insect infection in plants. 
 Botanists have shown that tumors occur in trees. They 
 
 251 
 
THE PAST, PRESENT AND 
 
 vary in size from a trifling gall to a large woody mass, 
 and are frequently spoken of as "tree cancers." The 
 infectious agent or parasite is a minute insect, which dis- 
 turbs cell growth and produces cell proliferation. Usually 
 there is a traumatism of the bark with infection of the 
 growing wood beneath. A combination of etiologic 
 factors is necessary — the infection atrium and the 
 infectious agent. Without the atrium the insect could 
 not enter; without the agent the breach would be healed 
 without pathologic change. 
 
 Park states that the comparative pathology of tumor 
 formations in the lower animals furnishes an equally 
 strong argument in favor of the parasitic theory of can- 
 cer in the human race. Various tumors occurring in in- 
 sects and invertebrates have been demonstrated to be 
 due to protoza. The higher we go in the animal scale 
 the more closely do these tumors resemble those in the 
 human being, until the histologic characteristics are almost 
 exactly similar. One cannot avoid the conclusion that 
 tumors in animals and man are due to the same general 
 cause. If, then, their existence in animals can be proved 
 to be of parasitic origin, it strengthens the conclusion in 
 favor of a similar origin for such lesions in man. 
 
 Park states that metastasis is regarded as the principal 
 evidence of infectiousness in all infective diseases — from 
 the most acute of the septic and pyemic type to the slower 
 manifestations of tuberculosis. The similar manifes- 
 tion in cancer is a like evidence of its infectious- 
 ness; if it means anything in the one case, it has exactly 
 the same meaning in the other. As the surgeon watches 
 a case of melanotic sarcoma of the leg and sees the 
 gradual transmission of the disease up the limb, and 
 
 252 
 
FUTURE OF CANCER 
 
 becomes still later aware of the involvement of the liver, 
 then of the lungs, and then of the various other parts of 
 the body, how can he help but say that this is a disease 
 which travels along the same paths and after the same 
 fashion as does tuberculosis ; or, when he sees cancer eji 
 ciiirasse following an operation for cancer of the breast, 
 how can he avoid the conviction that he has here to deal 
 with a slowly creeping infection which is gradually ex- 
 tending and travelling as only an infection can? 
 
 On the microscopic appearance of cancer, Park says 
 that it is a well-known fact that in and between cells of 
 cancer growth are seen peculiar forms or particles, which 
 have been regarded by some as parasites, by others as 
 a product of cell degeneration. No such appearances are 
 noted in healthy tissue, or in the infectious granulomata, 
 or in the truly benign tumors. They must be either cell 
 degenerations or parasites. Exactly similar appearances 
 have been produced in large numbers after inoculation 
 with cancer material, but no one has been able to produce 
 such degenerations under other circumstances. 
 
 Under clinical observations confirmatory to the para- 
 sitic theory of the cause of cancer. Park reports the case 
 of a woman with epithelioma of the chest wall following 
 a burn. As a result of the cicatrix her arm was bound 
 down to her side, and a cancerous ulcer appeared on its 
 under surface. He states that numerous instances in 
 which cancerous infection has followed the track of in- 
 struments, such as the trocar, afford other evidence whose 
 value is undeniable. In regard to the objection raised to 
 the infectiousness of cancer, based on the fact of the 
 almost constant failure of investigators to reproduce the 
 disease by inoculation or implantation, he says that the 
 
 253 
 
THE PAST, PRESENT AND 
 
 failures were due to ignorance in regard to the condi- 
 tions which favor the life of minute organisms. By 
 observing certain conditions at the Buffalo Laboratory, 
 carcinoma has been produced in a number of animals 
 by inoculation, and one positive demonstration of the 
 infectiousness of the disease is worth more than one 
 hundred negative experiments. 
 
 Leaving the discussion of the essential cause of can- 
 cer, and withholding judgment as to the merits of the 
 rival claims of the intrinsic cell and extrinsic parasite, 
 the writer wishes briefly to discuss some of the existing 
 factors which clinical experience clearly prove to bear 
 an important relation to the actual development of the 
 disease. 
 
 Heredity. — The mysterious influence of heredity, a 
 force transmitted by a single cell to the entire organism, 
 by which physical attributes, intellectual powers, moral 
 qualities, and pathologic tendencies are perpetrated from 
 parents to offspring, markedly influence the occurrence 
 of cancer. Twist the facts as you please, the inevitable 
 conclusion cannot be avoided that cancer runs in fami- 
 lies. Here, as in the following sections, the explanation 
 may be made compatible with either of the two theories of 
 the essential cause of the disease. If the cellular theory 
 be correct, then there is diminished physiologic resist- 
 ance to the growth of the matrix of embryonal cells, 
 and they assume active tissue proliferation. If, on the 
 contrary, the parasitic theory be true, then it is an in- 
 creased susceptibility of tissue from diminished physio- 
 logic resistance to action of the micro-organism, and they 
 effect localization and produce their characteristic results. 
 
 Age. — So constant a factor is age in the development 
 
 254 
 
FUTURE OF CANCER 
 
 of cancer that it is used as a practical diagnostic sign in 
 doubtful cases. Cancer is a disease of middle and ad- 
 vanced life. While the forces of growth and reproductive 
 activity are greatest the tendency to cancer is least. When 
 cancer develops in opposition to these forces the prog- 
 nosis is gravest. A well-known surgeon once said with 
 reference to the relation of age to the probability of cure, 
 "The older the better." 
 
 Sex. — The influence of sex on the occurrence of can- 
 cer is demonstrated by the fact that the disease occurs 
 nearly twice as often in women as in men. This is prob- 
 ably due to the functional activity of the breast and uterus 
 in the one sex and the functional inactivity of the analo- 
 gous organs in the other. 
 
 Race. — The bearing of the race on cancer is evident, 
 as it is stated that in the United States cancer rarely af- 
 fects the Indian, and the negro is attacked less frequently 
 than are the whites. As a rule, the higher the civilization 
 the more prevalent the disease. 
 
 Diet. — It is supposed by some authorities that diet 
 plays an important role in the development of cancer, 
 but its influence is denied by others. It is claimed that 
 the disease is less frequent in the vegetarian than in the 
 flesh-eaters — the statement being supported by statistics 
 apparently proving that nations living on rice are less 
 susceptible than those living on animal food, and that 
 in any country the portion of the population which, 
 either through taste or necessity, lives on vegetables, is 
 more immune than their fellows whose diet contains a 
 large proportion of meat. 
 
 General Health. — The constitutional condition has an 
 uncertain influence on the development of cancer; but it 
 
 255 
 
THE PAST, PRESENT AND 
 
 is stated that cancer is a disease of persons whose pre- 
 vious hfe has been healthy, and whose nutritive vigor 
 gives them otherwise a prospect of long life. 
 
 Traumatism. — Traumatism is an important factor in 
 cancer, for in at least 20 per cent, of all cases of the 
 disease the patient will give a history of local injury to 
 the part affected. The injuries are usually of trivial 
 nature, and the explanation offered is that serious in- 
 juries cause vigorous reaction, with complete restoration 
 of the part, while minor injuries are often followed by 
 incomplete reaction, and the tissues are left with di- 
 minished pathologic resistance. 
 
 Local Irritation. — It is a well-accepted fact that local 
 irritation acts as an exciting cause of cancer, as mani- 
 fested by the frequency with which the disease attacks 
 parts and organs most often the seat of repeated and pro- 
 longed irritation. As examples may be cited the lip can- 
 cer of smokers, the scrotal cancer of chimney-sweepers 
 and the close association between gall-bladder and cancer 
 of the liver. 
 
 Geographical. — The habitat of the individual increases 
 or diminishes the probability of cancer. The disease is rare 
 in the arctic and tropical regions, and frequent in the 
 temperate zone. It is almost unknown in Iceland, Green- 
 land, and Africa, and common in America, Europe, Asia, 
 and Australia. 
 
 Topographical. — The influence of topographic location 
 is demonstrated by the difference in mortality lecords in 
 lural communities and in manufacturing centres. As a 
 general proposition, it may be stated that the rate of 
 
 2s6 
 
FUTURE OF CANCER 
 
 cancer is highest where the struggle for existence is hard- 
 est and the density of population greatest. 
 
 Dismissing the subject of the etilogy of cancer, and 
 omitting for lack of space all reference to the histology, 
 symptomalogy and diagnosis of the disease, the question 
 of its treatment will next be considered. 
 
 Treatment of Cancer. 
 
 The great and vital importance of the proper manage- 
 ment of carcinoma can only properly be appreciated after 
 a recognition, first of the frequency of the disease; 
 second, the apparent rapid increase of the disease, and 
 third, the improvement in results that has followed the 
 modern methods of radical surgical extirpation of the 
 disease. 
 
 The following figures are gathered from a recent ar- 
 ticle of Dr. Frederick S. Dennis, of New York. In 
 1890 the death rate from cancer for the United States 
 was 53 per 100,000 population; for England, 67; for 
 Scotland, 60 ; for Austria, 52 ; for Ireland, 45 ; for Prus- 
 sia, 43 ; for Italy, 42. In England there are 7,000 deaths an- 
 nually from cancer and 30,000 patients suffer at all times 
 from the disease. In the United States, by the census, 
 there were 18,000 deaths from cancer in 1890 and conser- 
 vative estimates now place the death-rate at over 25,000 
 per annum. Based on the proportion of deaths to cases, 
 as calculated for England, there are to-day over 100,000 
 cases of cancer in the United States. Statistics also show 
 an apparent alarming and rapid increase in the number 
 of cases of cancer. It has been calculated that in recent 
 years cancer of the breast alone has increased 12 per 
 
 257 
 
THE PAST, PRESENT AND 
 
 cent, in Connecticut ; 50 per cent, in the District of Colum- 
 bia; 115 per cent, in Rhode Island, and 179 per cent, in 
 Philadelphia. Roswell Park makes the startling state- 
 ment that if cancer continues to increase during the next 
 ten years as it has done in the past ten, at the end of a 
 decade more people will die in the State of New York 
 from cancer than will die from small-pox, typhoid fever, 
 and tuberculosis combined. 
 
 It is but fair to state that Senn and others claim that 
 this increase is more apparent than real, and is due to 
 more accurate diagnosis, more frequent post-mortems, 
 more general resort to operative intervention, and to in- 
 creased longevity. 
 
 Statistics in regard to the improvement in the perma- 
 nent results of operation for cancer are prolific, but not 
 easily concentrated to comparative figures. Dennis re- 
 ports eighty-seven cases of malignant growths operated 
 upon and cured; the nature of the disease in each in- 
 stance being demonstrated by microscopic examination, 
 and the permanency of the result tested by careful sub- 
 sequent observations for a period, in no instance less than 
 three, and in some of over twenty-years. 
 
 While Dennis' results are no better than those attained 
 by many other surgeons, yet he deserves the thanks of 
 the profession for the arduous labor he has performed in 
 tracing his cases and proving the fallacy of the views of 
 many of the laity that cancer is incurable. 
 
 In actual practice almost every conceivable treatment 
 has been applied to cancer, and while the dearly-earned 
 experience has united the profession in the conclusion 
 that at the present time there is but one possibility of 
 
 258 
 
FUTURE OF CANCER 
 
 cure — namely, early and radical surgical intervention — it 
 will be well to review other methods which have been 
 tried and failed. 
 
 Electricity. — Electricity, which has promised so much 
 in so many different fields of medicine, and which has 
 practically yielded so little of postive therapeutic value, 
 has been long, faithfully, and variously employed in the 
 treatment of cancer. Constant and interrupted currents 
 have been applied, electrylosis and cataphoresis used, and 
 lastly, the influence of the X-ray tested, all with practi- 
 cally negative results. 
 
 Drugs. — The local application of methylene blue, for- 
 maldehyde, and similar antiseptics, has resulted in no 
 good except to diminish the offensiveness of discharge in 
 ulcerative cases. The parenchymatous injection of alco- 
 hol, acetic acid, and other sclerotics has accomplished 
 nothing save in a few cases where they have temporarily 
 arrested the local extension by impairing the blood sup- 
 ply through cicatrization of adjacent tissue. The internal 
 administration of iodide of potassium, arsenic, cunduran- 
 go, turpentine, cinnamon, clover tea, and a host of others 
 has served no purpose, unless it has been to keep alive 
 the flickering hope of poor unfortunates painfully con- 
 scious of their doom. 
 
 Toxins and Serums. — The injection of the combined 
 toxins of the streptococcus erysipelatus and of the bacillus 
 prodigiosus, which for a time excited so much attention, 
 has ceased to be seriously considered. Even its origina- 
 tor, Coley, states that it has only an inhibitory influence 
 on carcinoma, and is but rarely curative. Cancroin, a 
 toxic product derived from cancerous tissue by Adam- 
 
 259 
 
THE PAST, PRESENT AND 
 
 kiewiez, has been extensively tried, but has proved to be 
 without specific virtue. Blood serum, obtained from hor- 
 ses, goats, and sheep, injected with cancer juice, or the 
 toxins of the supposed cancer protozoon, have likewise 
 failed. Despite these facts, the serum therapy of can- 
 cer offers a promising and fascinating field for investi- 
 gation. If cancer be due to a parasite, if it can be iso- 
 lated and cultivated, if its pecuHarities can be studied and 
 its idiosyncrasies noted, in the words of Dr. Park, "It is 
 not too much to hope that some agent, be it either vege- 
 table or mineral drug, or animal antitoxin, may yet be 
 discovered by which the ravages of the disease may be 
 checked or prevented." 
 
 Caustics. — Chemical escharotics were once largely used 
 by the profession in the treatment of superficial forms of 
 cancer, but they have now been practically abandoned, 
 and are only of interest owing to their frequent revival 
 by quacks and charlatans, who reintroduce them as new 
 discoveries, cloaked in mystery and vested with mar- 
 vellous properties. A caustic causes coagulation of the 
 protoplasm of the cells with which it comes in contact. 
 It acts chemically, has no selectivity, and destroys heal- 
 thy and diseased tissue alike. It produces the formation 
 of a sphacelus which separates from adjacent structures 
 by ulceration. Its action is slow and the pain produced 
 prolonged and extreme. Its destruction of tissue is un- 
 certain in extent, and the carcinoma is frequently not re- 
 moved, and sometimes healthy tissue is unnecessarily 
 sacrificed. It leaves an open, suppurating wound, which 
 entails a long period of convalescence, and exposes the 
 
 260 
 
FUTURE OF CANCER 
 
 patient to the dangers of secondary hemorrhage and 
 pyemic infection. 
 
 When it is remembered that the only object in the 
 use of a caustic is to remove the diseased tissue, and when 
 it is known that this can be done much more speedily, 
 accurately, and painlessly by the knife, with shorter 
 period of convalescence, less resulting deformity, and di- 
 minished risk to life, it is at first a matter of surprise 
 that cancer quacks prosper. Competition with them, 
 however, will soon supply the explanation — competition, 
 not in a pecuniary sense, for they have consistency in 
 their effrontery, and their charges are in proportion to 
 their promises — ^but competition in a higher sense; con- 
 tention for a case, not a fee ; effort to save a patient from 
 what is believed to be a sacrifice of the one and only 
 chance of recovery — namely, radical surgical removal be- 
 fore regional and general infection make the case inoper- 
 able. Quacks have apparently no professional restric- 
 tions, no moral obligations, and no legal responsibihties. 
 Free from the provisions of the Code of Ethics of the 
 regular profession, they advertise extensively in all the 
 popular publications of the day, offering hope and promis- 
 ing cure to despairing individuals ready to grasp at 
 straws. Communication once established, the victim is 
 bombarded with reprints of histories of cases successfully 
 treated, copies of eulogistic editorials from venal religi- 
 ous papers, and sweeping letters of endorsation from ig- 
 norant and credulous ministers of the Gospel. The pa- 
 tient secured, the lotion or paste is applied. If the di- 
 sease be a warty excrescence, or a benign tumor, or a 
 syphilitic sore, the case is cured and the result recorded. 
 
 261 
 
THE PAST, PRESENT AND 
 
 If it be cancer, the case dies, and the profit is pocketed. 
 Yet, the public, which has organized a Society for the 
 Prevention of Cruelty to Animals, and the Legislature, 
 which has passed laws to prevent money being obtained 
 under false pretences, stand idly by, and the medical pro- 
 fession, when it attempts to expose outrages being com- 
 mitted, is charged with being actuated by unworthy 
 motives. 
 
 Operative Treatment. — The early and radical use of 
 the knife offers the only possible cure for cancer. The 
 theory that cancer is a local manifestation of a consti- 
 tutional dyscrasia has been abandoned. The fact that 
 cancer is at first a strictly local disease and becomes 
 regional and general later by extension and metastasis, 
 has been accepted. If the diagnosis of cancer can be 
 made early while the disease is yet local, and if its anato- 
 mical position is such as to permit of its complete re- 
 moval, the prognosis is good. If the diagnosis of cancer 
 is delayed until the disease has become regional by ex- 
 tension through the lymphatics, the prognosis is bad. If 
 the diagnosis of cancer is postponed until the disease has 
 become general by dissemination through the veins the 
 prognosis is hopeless. It will thus be seen that the cases 
 early diagnosticated are the ones that give the cures, 
 and the cases only recognized late in their pathologic life 
 give the failures. Authorities state that after the disease 
 has been in existence for more than six months removal, 
 no matter how complete, is almost certain to be followed 
 by recurrence. 
 
 Second only in importance to early diagnosis is the 
 completeness of the operation for the removal of the in- 
 
 262 
 
FUTURE OF CANCER 
 
 fected tissue. Heidenheim, by exhaustive research, has 
 shown the direction of the regional extension of cancer, 
 and taught the surgeon the necessity of not only remov- 
 ing the organ in which the disease originated, but 
 the adjacent lymphatics as well. In cancer of the 
 breast not only should the mammary gland be amputated, 
 but the axillary and possibly the supra-clavicular space 
 opened and cleared of all fat fascia and lymphatics. In 
 cancer of the cervix, not only should the uterus, but the 
 retro-peritoneal glands of the pelvis, be removed. In 
 cancer of the penis, not only should the organ be sacri- 
 ficed, but the inguinal glands of both groins should be 
 removed. As operations for cancer have become more 
 radical, the ultimate results have become more favorable. 
 
 263 
 
Methods to Hasten Epidermization, 
 
 With Special Reference to 
 
 Skin Grafting * 
 
 Every practitioner is frequently called on to treat loss 
 of cutaneous surface due either to injury or disease. If 
 the area is small, repair is usually rapid and complete, but 
 if it is large, repair often progresses to a certain point, 
 and then ceases. In the one case the capacity of the ger- 
 minal cells is sufficient to meet the demands made upon 
 them; in the other the amount of material required is 
 more than they can produce. 
 
 It is the object of this paper to discuss methods to 
 hasten healing in cases where the process is slow or at 
 a stand still. No effort will be made to review the litera- 
 ture of the subject, and only the results of practical ex- 
 perience will be given. 
 
 To secure epidermization the first step should be to 
 stop suppuration. The second should be to stimulate nor- 
 mal regeneration and to protect the embryonal cells re- 
 sulting. The third, in case the first two are insufficient, 
 should be to augment nature's reparative forces by graft- 
 ing the bare area with epithelial tissue of sufficient vitality 
 not only to live, but to grow. 
 
 These three indications for treatment must be followed 
 in the management of every granulating wound, whether 
 it be a small ulcer or an extensive burn. They cannot 
 
 * Read at a meeting of the Medical Society of Virginia, 
 Roanoke, Va., September, 1904. 
 
 265 
 
METHODS TO HASTEN EPIDERMIZATION 
 
 be carried out independently, but must be combined. They 
 will not be discussed separately, but collectively under 
 the different dressings commonly employed. 
 
 Moist Dressings. — After the preliminary cleaning of 
 the wound and adjacent surfaces, the tirst treatment 
 usually tried is the moist dressing, the character varying 
 from the cold water dressing of our forefathers to the 
 moist corrosive dressing of the antiseptic extremist of 
 the present day. The method of application consists in 
 saturating a pad of absorbent cotton with the fluid se- 
 lected, applying it to the raw surface, and preventing 
 rapid evaporation by covering it with a layer of oil silk. 
 The cotton should be wet as often as it becomes dry, and 
 should be changed as often as it becomes soiled. The 
 solution employed should not be a strong antiseptic, as 
 it would kill cells as well as germs, but it should have 
 an inhibitory action on microbic life. The three that will 
 be found most satisfactory are chloral hydrate solution 
 (chloral hydrate gr Ixiv; water oij) ; Thiersch's solution 
 (salicylic acid gr xxx, boric acid drams iij, water oij) ; 
 and acetate of aluminum solution (alum drams vj, acetate 
 lead drams ixss, water oij ) . They may be used either hot 
 or cold, and should be employed in conjunction with rest 
 and elevation. I have had many a swollen and rebellious 
 leg ulcer come to me, scarred with caustics, gritty with 
 antiseptic powders, or filthy with greasy ointments, but 
 not one that did not yield readily when the patient was 
 put to bed, the limb elevated, and the part treated with hot 
 chloral dressings. 
 
 Dry Dressings. — The treatment of granulating surfaces 
 by dusting them with antiseptic powders has been made 
 undeservedly popular by the advertisements of firms that 
 
 266 
 
ESPECIALLY SKIN GRAFTING 
 
 had proprietary preparations to sell. The powders most 
 frequently employed are iodoform, aristol, dermatol, bis- 
 muth, boric acid and oxide of zinc. In some cases they 
 do good, but in most instances they do harm. Chemically 
 they destroy germs and lessen suppuration ; mechanically 
 they destroy embryonal cells and retard healing. When 
 first applied to a wound decided improvement is seen, 
 but continued use is followed by irritation due to absorp- 
 tion of serum and the formation of crystalline concre- 
 tions that act as foreign bodies, or broad incrustations 
 that prevent the escape of pus or other wound secretions. 
 I am free to say that I do not use dusting powders. There 
 has not been a grain of iodoform in my private hospital 
 for the last three years, and its banishment has not proved 
 detrimental to patients, but exceeding beneficial to the 
 atmosphere of the institution. 
 
 Oleaginous Dressings. — The use of salves and oint- 
 ments in the treatment of superficial wounds has fallen 
 into unmerited disfavor. Because, before the day of anti- 
 septic surgery, they were abused is no reason why they 
 should now no longer be used. Some preparations quickly 
 become rancid and should be avoided ; others remain sterile 
 indefinitely, and may safely be employed. Vaseline, lano- 
 line and castor oil, plain or medicated, will give better 
 results in some cases than any other application. They 
 exert a feeble antiseptic action, thus lessening suppura- 
 tion ; they exclude the air, thus relieving pain ; and they 
 prevent the adhesion of overlying dressings, thus saving 
 the embryonal cells from mechanical injury. In exten- 
 sive burns I have found nothing better in the early stages 
 than a 5 per cent, mixture of ichthyol and vaseline, and in 
 sluggish granulations, especially of a tuberculous char- 
 
 267 
 
METHODS TO HASTEN EPIDERMIZATION 
 
 acter, I have never failed to see good come from the 
 appHcation of a combination of i per cent. carboHc acid, 
 5 per cent. Balsam Peru, and 94 per cent, castor oil. 
 
 Nutritive Dressings. — Considerable benefit will some- 
 times be derived in the treatment of a granulating wound 
 by the use of a dressing that supplies food directly to 
 the germinal cells and their offspring. Proliferation is 
 often arrested by starvation, and feeding is the logical 
 remedy. The agent employed should be aseptic, non- 
 irritating, and should contain nutritive material in an 
 easily absorbable form. The preparation that in my 
 opinion most nearly meets these requirements is Valen- 
 tine's Meat Juice. It is sterile, contains no alcohol, is rich 
 in food stuff, and has practically the same percentage 
 of sodium chloride as the normal serum of the blood. It 
 should be diluted with three parts of water, warmed to 
 the temperature of the body, and applied on cotton in 
 the form of a moist dressing. My experience has been 
 that it does a great deal of good for a short while, but 
 then loses its effect. As soon as pale granulations be- 
 come pink and healthy is has fulfilled its function, and 
 should give place to some other dressing. 
 
 Alterative Dressings. — Cells, like individuals, some- 
 times without assignable reason, develop disturbances of 
 nutrition requiring alterative treatment. In the manage- 
 ment of a granulating wound there is often call for local 
 medication. Experience alone can teach the surgeon the 
 agent to employ and the time and method of its appli- 
 cation. Nitrate of silver, mercurial ointment, chloride 
 of zinc and sulphate of copper are all useful and time- 
 honored remedies. Among newer preparations must be 
 mentioned proto-nuclein. I have several times seen in- 
 
 268 
 
ESPECIALLY SKIN GRAFTING 
 
 dolent or foul granulating areas that had detied a half 
 dozen other lines of treatment improve under its use 
 as if by magic. 
 
 Protective Dressings. — In direct contrast to granulat- 
 ing surfaces that need stimulating or alterative treat- 
 ment are those that are doing well and only require pro- 
 tection. When the wound is healthy and healing pro- 
 gressing satisfactorily, nothing is more mischievous than 
 meddlesome interference. All that should be done is to 
 prevent infection by cleanliness, and to avoid injury to 
 the newly formed cells by mechanical protection. Clean- 
 liness is secured by changing the dressings as frequently 
 as they become soiled and bathing the wound with nor- 
 mal salt solution. Protection is best accomplished by in- 
 terposing some impervious material between the granula- 
 tions and the meshes of the overlying gauze, into which 
 they would otherwise become entangled. In my exper- 
 ience, the best results follow the use of strips of rubber 
 dam, collodion tilm, or cargile membrane placed lattice- 
 wise so as to afford drainage. Rubber dam is the material 
 used by dentists, and can be sterilized by boiling. Col- 
 lodion film can be prepared by pouring collodion on an 
 aseptic sheet of glass, allowing it to harden and then 
 cutting it in strips. Cargile membrane is made from the 
 peritoneum of an ox, and can be bought on the market 
 in germ proof envelopes. 
 
 Proliferating Dressings. — When the destruction of 
 skin is so extensive that the normal reparative power 
 is insufficient to cover the granulating area with epithelial 
 cells, recourse must be made to skin grafting. It has 
 long been known that bits of cuticle properly planted 
 on fresh wounds or healthy granulating surfaces would 
 
 260 
 
METHODS TO HASTEN EPIDERMIZATION 
 
 become adherent and grow, thus protecting underlying 
 structures and acting as independent foci of epidermiza- 
 tion for adjacent tissue. The application of this fact with 
 epithelial cells secured from different sources and ap- 
 plied by various methods has enabled the surgeon to heal 
 wounds quickly and certainly which otherwise would be 
 slow to close, or perhaps become permanent ulcers. 
 
 Skin grafting, when practiced on newly made wounds, 
 is called primary grafting. When practiced on granulat- 
 ing surfaces it is called secondary grafting. If the sur- 
 face be a fresh one, care must be taken perfectly to arrest 
 hemorrhage before applying the grafts, otherwise bleed- 
 ing will detach them. If the surface be an old one, care 
 must be taken to stop suppuration before applying the 
 grafts ; otherwise pus germs will devitalize them. 
 
 Skin grafts may be obtained from the patient, and 
 then they are called autografts; they may be cut from 
 another person, and then they are called heterograf ts ; or 
 they may be secured from an animal of a different species, 
 and then are called zoografts. 
 
 There are three recognized methods of skin grafting. 
 Reverdins', consisting in cutting small particles from 
 the superficial layers of the skin with scissors and plant- 
 ing them at intervals over the surface to be covered ; 
 Thiersch's, consisting in cutting broad strips from the 
 superficial layers of the skin with a razor and placing 
 them so as completely to cover the wound area ; and 
 Wolfe's, consisting in the dissection of a piece of skin 
 the entire thickness of the structure and fitting it to the 
 defect to be remedied. 
 
 The dressing after any of the above methods consists 
 of a lattice work of protective strips over which is placed 
 
 270 
 
ESPECIALLY SKIN GRAFTING 
 
 a pad of gauze wet with normal salt solution. This 
 should be removed and replaced at the end of the third 
 day, and the subsequent management of the case carried 
 out on general surgical principles. 
 
 The instruments required for skin grafting are so few, 
 the operation itself so simple, and the results secured so 
 immediate and satisfactory, that the surgeon who does 
 not avail himself of it in suitable cases does an injustice 
 both to himself and his patient. 
 
 Primary skin grafting should be employed after the 
 removal of an epithelioma or other superficial growth, 
 provided, infection can be prevented, hemorrhage ar- 
 rested, and ligatures and sutures avoided. The depres- 
 sion due to the removal of tissue will fill up beneath the 
 grafts and the deformity will be less than anticipated. 
 I have removed a growth the size of a silver dollar from 
 a nose, grafted it at once with skin from the arm, 
 and discharged the patient with a perfectly healed wound 
 in ten days from the operation. 
 
 Secondary skin grafting should be employed when liga- 
 tures are used to arrest bleeding, or sutures to secure 
 partial coaptation ; where infection is likely or already 
 exists, or where the excavation is deep and a large amount 
 of granulation tissue is necessary to fill it. In operating 
 for cancer of the breast, where the approximation of the 
 margins of the wound is secondary to extirpation of the 
 diseased tissue, I remove the malignant growth as com- 
 pletely as possible, bring the cut edges of the skin to- 
 gether as nearly as practicable, apply a protective dress- 
 ing, and a week or ten days later remove the stitches and 
 skin graft the granulating area. 
 
 Reverdins' method should be employed where the area 
 
 271 
 
METHODS TO HASTEN EPIDERMIZATION 
 
 to be covered is small, and where the administration of 
 a general anesthetic is contraindicated. The surface to 
 be grafted and the site from which the grafts are to be 
 taken should both be prepared. The skin is then elevated 
 into a cone by means of a sharp tenaculum and a small 
 piece snipped from its superficial layer by means of a pair 
 of curved scissors. The fragment is at once transferred 
 to the area to be grafted and carefully seated on the gran- 
 ulations, care being taken to prevent the edges curling 
 inward, thus preventing apposition of raw surfaces. This 
 is repeated until a sufficient number of grafts have been 
 planted quickly to stud the bare area. The operation of 
 cutting the grafts can be made painless by the use of the 
 chloride of ethyl spray. I have found the above method 
 very satisfactory, especially in weak, nervous patients, 
 where a more formidable operation would have a bad 
 effect. The space between the grafts is rapidly covered 
 and the resulting scar is good. 
 
 Thiersch's method should be used when the surface to 
 be covered is large, and when the patient is either under 
 an anesthetic or its administration will be compensated 
 for by the more rapid recovery it promises. The grafts 
 are obtained by making the skin tense and fat, either man- 
 ually or by special hooks, and cuttings off the superficial 
 layers by a to and fro sawing motion of a sharp razor. 
 The larger the size of the grafts the better. Usually they 
 are an inch wide and four or five inches in length. Care 
 should be taken to remove only the upper layer of the 
 skin, otherwise the wound inflicted may prove as difficult 
 to cure as the wound the surgeon is endeavoring to 
 remedy. As the grafts are cut they are dropped into 
 a basin of warm saline solution. Afterwards they are 
 
 272 
 
ESPECIALLY SKIN GRAFTING 
 
 carefully placed on the area to be grafted, the edge of 
 one graft overlapping that of the adjacent one. Thiersch's 
 method of skin grafting is the one most frequently prac- 
 ticed, and the one that gives the most brilliant results. 
 The objections to it are that it necessitates the use of an 
 anesthetic and the site from which the grafts are cut 
 is painful and takes some days to heal. 
 
 Wolfe's method should only be employed in exceptional 
 cases. The surface of the area to be grafted should be 
 thoroughly revivified and the margins made fresh and 
 vertical. All bleeding should be completely arrested. The 
 new skin to be used as a graft must be dissected from 
 some other site. The entire thickness of the skin should 
 be removed, but no subcutaneous fat taken with it. The 
 outline of the incision should preferably be an ellipse 
 to permit of closure of the defect by sutures. The skin 
 removed should be one-third larger than the defect to 
 be covered to allow for shrinkage. The graft after hav- 
 ing been placed in its new position may be retained by 
 sutures or reliance placed on overlying dressings. The 
 method is uncertain in results, but may sometimes be 
 used with advantage. I remember one case where I 
 planted a single piece of skin, having an area of some 
 1 6 square inches. The graft was obtained in retrench- 
 ing the scrotum of a man for varicocele, and was planted 
 on a woman who had been operated on some days pre- 
 viously for cancer. 
 
 In addition to the recognized methods of skin graft- 
 ing just described, occasional reference will be found to 
 grafting wounds with the skin of an egg, with the pellicle 
 of a blister, and with dry epidermal scales, such as scrap- 
 ings from callosities or dandruff from the head. I have 
 
 273 
 
METHODS TO HASTEN EPIDERMIZATION 
 
 tried all these expedients with unsatisfactory results. The 
 only reasonable sources from which to obtain vital epithe- 
 lial tissues are the skin of the patient, autografts ; the 
 skin of another individual, heterograf ts ; and the skin 
 of a lower animal, zoografts. 
 
 Autografts are usually cut from the patient's thigh or 
 shoulder. They furnish the material most likely to prove 
 successful, and should be employed except in cases where 
 the patient's general condition is bad or where the area 
 to be grafted is very extensive. The practice, however, 
 is not free from annoyance or distressing complications. 
 A woman came to me not long ago with an epithelioma 
 of long standing on the vertex of her head. It originated 
 in an old scar and was about four inches in diameter. 
 I shaved her head, made an incision around the growth, 
 and scalped her. The wound was treated with a moist 
 antiseptic dressing until it had filled with healthy granula- 
 tions to the level of the margins. I then skin grafted 
 the bare surface by Thiersch's method, cutting the grafts 
 from the deltoid region. The grafts took beautifully, and 
 in two weeks she was apparently well. Several months 
 later she came back to the hospital. Her head looked 
 like a tonsured monk, and the skin on the bald area was 
 perfect, but the shoulder from which the grafts had been 
 cut gave her much pain. On examination it was found 
 to be the seat of a keloid growth the size of a man's 
 hand. I had cured her of cancer only to give her keloids. 
 
 Heterografts are obtained from another individual, 
 from amputated extremities, or from fresh cadavers. 
 They usually grow well, and should be employed when 
 they can be secured from a satisfactory source. They 
 entail the danger of infecting the patient with syphilis, 
 tuberculosis, and other diseases, which must be carefully 
 
 274 
 
ESPECIALLY SKIN GRAFTING 
 
 guarded against. The question of the necessity of the 
 grafts being the same color as the skin of the patient 
 on which they are planted is still unsettled. It is claimed 
 that a negro skin grafted on a white person will lose 
 its pigment, and that white skin grafted on a negro will 
 become pigmented. A few years ago I had an oppor- 
 tunity to test the question. A negro man as black as the 
 ace of spades had his leg crushed. It w^as amputated, 
 but the flaps sloughed, leaving a granulated area three or 
 four inches in diameter. It was determined to graft skin 
 and my assistants were directed to prepare the man 
 for the operation at the next clinic. When the patient 
 was brought into the amphitheatre I had just finished 
 amputating the leg of a white man. On the spur of 
 the moment I decided to cut the grafts from the white 
 leg and plant them on the black one. The operation 
 was done by Thiersch's method with satisfactory results, 
 the patient being discharged as cured in three weeks' 
 time. Two years afterwards the man came back to the 
 clinic on account of some other trouble. xAn examina- 
 tion of the grafted stump showed that the grafts were 
 as white as they were on the day they were planted. 
 While one case proves little, the result is significant. It 
 has for obvious reasons deterred me from reversing the 
 experiment and grafting a negro's skin on a white patient. 
 Zoografts are obtained from one of the lower animals, 
 the frog, chicken, pig, dog, cat, rabbit or guinea pig 
 being most commonly used. They do not grow as readily 
 as grafts from the skin of a human oeing, and they should 
 not be employed when other sources of supply are avail- 
 able. Still there are certain conditions where they are not 
 only useful, but are the only means by which the patient 
 can be cured. 
 
 275 
 
METHODS TO HASTEN EPIDERMIZATIOX 
 
 A small negro child was brought to the clinic last 
 winter, who had been severely scalded several months 
 before. Some healing had occurred at the margins of 
 the burns, but effort at repair had ceased, and there was 
 a granulating surface on the body covering an area of 
 over one hundred square inches. The child was treated 
 until the granulations were healthy, and then came the 
 question of where to get the skin with which to graft 
 it. The child was too small and its condition too feeble 
 to furnish the grafts from its own person. The mother, 
 relations and friends all declined to make the necessary 
 sacrifice, no jail bird would volunteer as a victim even 
 at the promise of liberty, and applications at all the hos- 
 pitals in the city seemed to show that for the time at 
 least surgeons had stopped amputating limbs. As a last 
 resort, recourse was made to zoografts. A healthy six 
 weeks' pig of chocolate color was purchased. It was 
 carefully shaved and given frequent scribbings and anti- 
 septic baths. The day before the operation the belly was 
 prepared as if for abdominal section. The grafting was 
 done before the class of the University College of Medi- 
 cine. The pig was brought in on one table, the pickaninny 
 on another. Grafts were cut from the belly of the pig 
 and planted on the back of the child. The usual dress- 
 ings were applied, and for two weeks everything went 
 well, and it was thought the operation had been com- 
 pletely successful. The wound itched, however, and one 
 night the child got its hands beneath the dressing and 
 scratched off a large portion of the new and tender skin. 
 While the result was a partial failure, enough of grafts 
 remained to demonstrate that pig skin would grow. More 
 recently I have had other cases that were perfectly cured 
 by this method. 
 
 2/6 
 
To Cut or Crush In Stone of the 
 Urinary Bladder? * 
 
 The question whether to cut or crush in cases of stone 
 in the urinary bladder is no new one, as Uthotomy and 
 lithotrity have both been practiced for over a tliousand 
 years. The opinion of the profession, as to the relative 
 value of the two methods has varied, first one and then 
 the other gaining ascendency. 
 
 In the first century Celsus wrote a clear description of 
 lithotomy, and the operation was frequently performed. 
 In the tenth century. Albueasis described an instrument 
 which could be passed along the urethra, ''seize the stone, 
 crush it, if soft, and remove it." In the seventeenth 
 century Beaulieu, a Franciscan monk, performed several 
 thousand perineal lithotomies and is reported to have 
 operated on thirty-eight consecutive cases in Versailles 
 without a death. 
 
 In 1818 Civiale invented his litholabe and some years 
 afterwards reported seventy-eight cases in which he had 
 crushed and removed stone, with five deaths. In 1878 
 Gross advocated the cutting operation and reported 163 
 lithotomies, with fourteen deaths. In the same year 
 Bigelow invented his evacuator, and the possibility of 
 doing lithotrity at one sitting (or litholapaxy, as it was 
 then called) created great enthusiasm. In 1884 Henry 
 Thompson reported 116 cases of lithotrity, with six 
 
 * Read at a meeting of the Tri-State Medical Association, 
 Richmond, Va., February, 1901. 
 
 277 
 
TO CUT OR CRUSH IN STONE OF 
 
 deaths. In 1890 Hunter McGuire reported twenty-six 
 cases of supra-pubic cystotomy for stone, with one death. 
 In 1893 Chismore reported fifty-four cases of lithotrity, 
 done by a series of short sittings under cocaine, with no 
 deaths. 
 
 Having attempted to show the curious vacillation of 
 surgical opinion as to the relative merits of the two opera- 
 tions in the past, I will now try to find expression for 
 the accepted views of the present. I believe it can be 
 most fairly done by quoting from new and standard text- 
 books, which treat of the subject. 
 
 White and Martin. — "The two received methods of 
 treatment are litholapaxy and cystotomy. Lithclapaxy 
 is in both adults and children the method of choice." 
 
 Lydston. — "The supra-pubic operation is so safe in 
 favorable cases that it is preferable to litholapaxy unless 
 the surgeon is expert in its performance." 
 
 An American Text-Book of Surgery. — "The possible 
 methods of removing a given stone from the male blad- 
 der are perineal lithotomy, supra-pubic lithotomy and 
 litholapaxy. The remarkable changes brought about by 
 the introduction of the last named method has greatly 
 reduced the field of the first two." 
 
 Wyeth. — "The conditions in which lithotrity is to be 
 preferred to lithotomy are rare." 
 
 Treves. — "Litholapaxy is now the recognized opera- 
 tion for all cases of vesical calculus in males." 
 
 Moullin. — "Calculi must be removed from the bladder 
 by crushing or cutting. The former is more common 
 and has to a great extent superseded the latter." 
 
 Wharton and Curtis. — "Lithotomy is indicated m cases 
 not suited for crushing, although the recent improve- 
 
 278 
 
THE URINARY BLADDER 
 
 ments in supra-pubic cystotomy bid fair to make it the 
 rival of the method by crushing in all cases." 
 
 From the extracts given it will be seen that both 
 methods are advised, but the surgeon is taught by the 
 majority of the authorities to perform lithotrity as the 
 operation of election and lithotomy as the operation of 
 compulsion. In other words, that the cutting operation 
 should only be done when the crushing operation is im- 
 possible. I believe this teaching is a survival of the pre- 
 antiseptic era and does not accord with the practice of 
 the modern surgeon. Twenty years ago, when the use 
 of the knife was attended by danger to life, from septi- 
 cemia, or slow and complicated convalescense from sup- 
 puration, it was undoubtedly sound, but to-day — with the 
 aseptic and antiseptic technique and the perfection of the 
 supra-pubic operation — it is false and misleading. From 
 a limited personal experience with both operations, and 
 a careful study of the literature of the subject, I believe 
 lithotomy should be the operation most frequently per- 
 formed and lithotrity reserved for a few carefully se- 
 lected cases. The demonstration of the truth of this 
 statement can best be made by a comparison of the ad- 
 vantages and disadvantages of the two operations under 
 separate headings. 
 
 Mortality. — Figures seem to bhow that lithotrity is 
 safer than lithotomy. But in making a deduction from 
 statistics it must be remembered that they are based 
 largely upon work done before the introduction of anti- 
 septics ; that simple and easy cases were crushed and 
 difficult and complicated cases cut ; and, finally, that the 
 results of a few expert lithotritists are compared with 
 those secured by a number of average lithotomists. 
 
 279 
 
TO CUT OR CRUSH IN STONE OF 
 
 Requisite Skill and Experience. — Lithotrity is un- 
 doubtedly a more delicate and difficult operation than 
 lithotomy. It is blind surgery, liable to be attended by 
 annoying complications or dangerous accidents, and 
 should not be undertaken by one not thoroughly familiar 
 with the manipulation of instruments in the urethra and 
 bladder. Lithotomy, especially if done by the supra- 
 pubic route, is one of the simplest operations in surgery 
 and may safely be attempted by any one of fair exper- 
 ience in general operative work. 
 
 Injury to the Soft Parts and Septic Sequences. — It is 
 claimed that lithotrity creates no breach of continuity of 
 tissue, while lithotomy leaves a wound of considerable 
 gravity, and therefore, the former operation is followed 
 by more rapid recovery. This is true in selected cases 
 in the hands of expert operators, but in many instances, 
 where the stone is large and hard, and the surgeon less 
 experienced, manipulations are prolonged and rough, and 
 there is considerable bruising and laceration of the 
 mucous lining of the urethra and bladder. Copious 
 hemorrhage is not uncommon and the bleeding points 
 are inaccessible to direct hemostasis. There is practi- 
 cally no drainage, and the septic sequences sometimes 
 follow, manifested by urethral fever, urethritis, cystitis, 
 p''0statitis, epidydimitis or phlebitis. 
 
 In lithotomy, especially if done by the supra-pubic 
 method, there is no contusion of the mucosa of the uri- 
 nary tract, but simply a clean cut incision through unim- 
 portant structures. There is practically no bleeding, and 
 if it does occur from complications, it can be con- 
 trolled by the ligation of vessels or direct tamponade of 
 the bladder. If sepsis follows, which is unlikely, owing 
 
 280 
 
THE URINARY BLADDER 
 
 to the free drainage afforded, it can be combated by irri- 
 gation of the wound, bladder and urethra with antiseptic 
 solutions. The duration of convalescence after lithotrity 
 is uncertain. It may be shorter than lithotomy — it may 
 be longer. 
 
 Ability to Diagnosticate and Treat Other Pathologic 
 Conditions. — Stone in the bladder is usually found at the 
 two extremes of life. In the young it is usually uncom- 
 plicated ; in the old it is often associated with enlargement 
 of the prostate, severe cystitis, or vesical tumors. Litho- 
 tomy has the advantage in both instances, as it avoids 
 the dilatation of the undeveloped penis and small urethra 
 of the one — with the danger of incontinence and impo- 
 tency ; and affords direct examination of the interior of 
 the bladder in the other, making accessible to surgical 
 correction any co-existing disease present, and affording 
 subsequently the necessary drainage of the cavity of the 
 viscus. 
 
 Permanency of Results. — There is certainly more lia- 
 bility to the recurrence of stone after lithotrity than 
 after lithotomy. In old men, with enlarged prostates, it 
 is impossible to be sure of removing all fragments after 
 crushing, and it is also possible to overlook a small stone 
 in cases of multiple calculi. If a single particle is re- 
 tained in the bladder it will act as an exciting cause to 
 the predisposing diathesis and result in the production 
 of a new stone. I recall the case of an old man with 
 a sacculated bladder, in whom stone was twice crushed. 
 On his third return to the hospital I did a supra-pubic 
 lithotomy and removed five small calculi. Since then 
 he has remained well. 
 
 Simplicity and Freedom from Mechanical Complica- 
 
 281 
 
TO CUT OR CRUSH IN STONE OF 
 
 tions. — While questions of economy of instruments have 
 no place in surgery, and the fact that lithotrites and evacu- 
 ators are expensive and perishable, is no argument against 
 lithotrity, the simplicity and freedom from dependence on 
 the mechanical action of complicated instruments is a 
 strong point in favor of lithotomy. Many cases are report- 
 ed where surgeons had clogging, bending or breaking of 
 the blades of a lithotrite to occur in the bladder, and 
 were forced to resort to the knife to complete the opera- 
 tion. Only recently I found myself in a predicament 
 which would have been ludicrous if it had not been 
 dangerous. I was crushing a soft stone of medium size 
 in the bladder of a boy, aged seventeen, who weighed 
 nearly three hundred pounds ; the operation of lithotrity 
 being selected on account of the patient's obesity. The 
 stone was readily seized and crumbled at the first turn 
 of the screw. The instrument was opened and several 
 of the fragments caught and broken. It was then observed 
 that the blades would not close. Every known expedient 
 was tried to free the impaction, but failed. A supra- 
 pubic cystotomy was finally done, a sticky, gummy mass 
 cleared from the jaws of the lithotrite and the instrument 
 closed and withdrawn. A subsequent interrogation of the 
 boy secured the confession that some time before his ad- 
 mission to the hospital he had introduced a bolus of 
 chewing-gum into his urethra, which had slipped from 
 his grasp and passed into th^ bladder, doubtless forming 
 the nucleus of the stone. 
 
 Range of Application. — Lithotomy may be done in 
 any case and has no limitations other than those of gen- 
 eral surgery. Lithotrity is admitted by its advocates to 
 be contra-indicated in the following conditions 
 
 282 
 
\. 
 
 ^'^-»- 
 
 FlG. 7 — Specimens of Stone showing Foreign Bodies as Nuclei. 
 
THE URINARY BLADDER 
 
 1st. When the stone is hard and cannot be crushed 
 by instruments capable of being used through the urethra. 
 
 2d. When the stone is large and cannot be grasped 
 by reasonable separation of the jaws of the lithotrite. 
 
 3d. When the stone is brittle and the resulting frag- 
 ments sharp and irregular. 
 
 4th. When the stone is fixed or encysted. 
 
 5th. When the stone has a foreign body as a nucleus 
 which cannot be crushed and removed. 
 
 6th. When the prostate is enlarged, or the bladder 
 contracted, making it difficult to seize the stone. 
 
 7th. When there is a tight or impassable urethral 
 stricture, requiring a long operation to relieve. 
 
 8th. When there is ankylosis of the hip joint in a 
 position embarrassing the movements of the lithotrite. 
 
 9th. When the general condition of the patient is such 
 as to make shock dangerous and rapid work necessary. 
 
 In corroboration of the above I wish to exhibit some 
 specimens of stone with foreign bodies as nuclei, re- 
 moved by my father. Dr. Hunter McGuire, by lithotomy. 
 It is obvious that an effort to operate by lithotrity would 
 have resulted in failure. 
 
 In the history of the cases on which he operated for 
 vesical calculi there are nine instances of stones with 
 foreign bodies as nuclei, as follows: four hairpins, two 
 bullets, one piece of bone, one piece of gum catheter, 
 and one section of a silver catheter. One of these speci- 
 mens has been lost, one was destroyed by the patient, 
 three are now in the Army and Navy Medical Museum, 
 and the other four are herewith presented. 
 
 I also wish to report a case in which I acted as his 
 assistant. As soon as the stone was caught in the blades 
 
 283 
 
THE URINARY BLADDER 
 
 of the lithotrite and subjected to pressure, it flew to 
 pieces as if it were glass. The operation of lithotrity 
 was at once abandoned and the bladder opened above the 
 pubes. The fragments of the stone were gently removed 
 with the finger and were found to have razor-like edges, 
 which would undoubtedly have seriously injured the walls 
 of the viscus had the first operation been continued. 
 
 Conclusion. — For fear of being misunderstood, per- 
 mit me to repeat the views I maintain in regard to the 
 two operations. I do not condemn the crushing opera- 
 tion, for I believe it is the best method to employ in cer- 
 tain cases. What I do condemn is the abuse of the 
 operation by the efforts of its advocates to substitute 
 it for the cutting operation in cases for which it is not 
 suited. As previously stated, I believe that lithotomy 
 should be the operation most frequently employed, and 
 lithotrity reserved for a few carefully selected cases. 
 
 284 
 
Extra-Peritoneal Implantation of the 
 
 Ureters Into the Rectum in a Case 
 
 of Exstrophy of the Bladder * 
 
 Exstrophy of the bladder is a congenital abnormality 
 due to failure of the ventral plates forming the anterior 
 abdominal wall to unite in the median line. As a result 
 the front wall and roof of the bladder are absent, and 
 its posterior wall, presents through a defect in the ab- 
 dominal parietes. 
 
 The irritation of the exposed mucous membrane, and 
 the constant saturation of the person and clothing with 
 urine makes the condition of the patient one of the great- 
 est distress. Fortunately the abnormality is not very 
 common. Spooner reports only four cases in 116,500 
 births. From 80 to 90 per cent .of the cases occur in 
 males. 
 
 Various operations have been proposed and executed 
 for the relief of the condition. They may be divided into 
 two classes : first, those which attempt to restore the 
 anterior portion of the abdominal wall and bladder by 
 plastic work, and second, those w^hich attempt to divert 
 the urine from the bladder to some other organ by trans- 
 plantation of the ureters. Plastic operations on the 
 bladder are notoriously inefficient in relieving the con- 
 dition. Flaps artfully obtained from adjacent structures 
 may replace the missing anterior wall, but there is yet 
 
 * Old Dominion Journal of Medicine and Surgery, August, 
 1909. 
 
 28s 
 
EXTRA-PERITOXEAL IMPLANTATION 
 
 no possibility of forming a competent sphincter muscle, 
 which is so absolutely necessary to restoration of func- 
 tion. As a rule, the more successful the plastic operation, 
 the more distressing the condition of the- patient, for the 
 leakage of urine continues unabated, and there are added 
 symptoms due to phosphatic deposits and putrefactive 
 changes in the newly formed closed cavity. Usually the 
 space has subsequently to be opened in order to give 
 drainage and expose its interior to disinfection. 
 
 Transplantation of the ureters, so that the urine will 
 be diverted into the sigmoid or rectum was done many 
 years ago, but for a time was practically abandoned, be- 
 cause in both clinical and experimental work, the patient 
 or animal invariably died from ascending infection and 
 resulting pyelitis and pyelonephritis. 
 
 Tuffier, in 1890, concluded from a careful study of the 
 subject that the secondary involvement of the kidneys 
 was not essentially the result of the implantation of the 
 ureters into the bowel, but was due to the division of the 
 ureter (which up to that time had been practiced), and 
 the loss of the normal mechanism of the ureteral valves. 
 The open end of the cut ureter predisposed to the en- 
 trance of septic material, and the inevitable cicatricial 
 contraction of the new orifices produced obstruction to 
 the escape of urine and consequent congestion of the 
 kidneys. 
 
 Maydl, in 1892, made practical application of this 
 theory and introduced his operation, which consisted in 
 dissecting out the ureters, leaving a goodly portion of 
 bladder mucous membrane around their terminations ; 
 then opening the abdomen and implanting the u/eteral 
 valves into the sigmoid flexure of the colon. 
 
 286 
 
Fig. 8 Catheterization of the Ureters and Beginning 
 Separation of the Bladder. (Annals of Surgery.) 
 
OF THE URETERS IXTO THE RECTUM 
 
 Bergerhem later modified the operation so that it ac- 
 complished the same object without opening the peritoneal 
 cavity. He makes an incision around each ureteral open- 
 ing and pushes aside the adjacent tissue until an inch 
 or more of the ureter hangs free with a rosette of mucous 
 membrane at its tip. He next introduces a finger into 
 the rectum and presses it upward and forward. He 
 then dissects through the openings made in the bladder 
 by the excision of the ureteral orifices until he reaches 
 the anterior wall of the rectum and this is now opened. 
 A forceps is carried through the anus and its point pushed 
 through the incision in the bladder. The ends of the 
 ureters are caught, drawn gently downward into the 
 rectum and fastened with one or two stitches. 
 
 Buchanan publishes a valuable paper on the "Remote 
 Results of Implantation of the Ureters into the Bowel 
 for Exbtrophy," in which he tabulates all recorded opera- 
 tions. Maydl's operations has been done 80 times with 
 2^ deaths, a mortality of 28.'/ per cent. ; and Bergen- 
 hem's operation has been done 26 times with 3 deaths, 
 a mortality of 11.5 per cent., the striking difference being 
 largely due to the extra-peritoneal nature of the latter 
 method. 
 
 Buchanan's investigation with reference to the remote 
 mortality from ascending urinary infection in cases sur- 
 viving intestinal implantation of intact ureters with part 
 of the bladder wall attached, shows that in 98 instances 
 there have been only 11 deaths. 
 
 Berger has traced the histories of 74 cases of exstrophy 
 of the bladder not operated on and of these, 49 died be- 
 fore the twentieth year from renal infection. In compar- 
 ing the remote death rate from pyelo-nephritis after oper- 
 
 287 
 
EXTRA-PERITOXEAL IMPLANTATION 
 
 ation, (ii.2%) with deaths from the same cause in cases 
 not operated on (66.2%), it must be remembered that 
 many of the operative cases suffered with infection be- 
 fore operation, and hence surgery should not always be 
 charged with the development of fatal complications. 
 
 Moynihan reports an operation for exstrophy done on 
 a youth 19 years of age, in which he transplanted practi- 
 cally the entire bladder into the rectum without opening 
 the peritoneum. The object of grafting such a large 
 area of bladder was to increase the capacity of the rectum, 
 and to form a cloaca or pouch in its anterior wall to act 
 as a reservoir for urine. The operation appears so logical 
 and the results reported were so satisfactory that I de- 
 termined to try the method at the first opportunity. I 
 herewith report a recent case, illustrating the steps of 
 operation with the cuts from Mr. Moynihan's original 
 article made available by the courtesy of the publisher 
 of The Annals of Surgery. 
 
 F. H., male, 4^/2 years, from Winston-Salem, N. C, was ad- 
 mitted to the Virginia Hospital, January 5, 1909. The boy was 
 bright and intelligent, but poorly developed physically. He had 
 a typical case of. exstrophy, the trigone and posterior walls of 
 the bladder protruding as a red area of mucous membrane 
 through a deficiency in the hypogastric region about twice the 
 size of a silver dollar. The ureteral orifices showed on well 
 marked papillae. They contracted rhythmically and ejected 
 characteristic spurts of urine. The lining of the bladder was 
 red and engorged, and the surrounding skin irritated and in- 
 flamed from the leakage of urine. The penis was dwarfed and 
 grooved on its upper surface, and the symphysis pubis and 
 umbilicus were absent. The testicles were both present in the 
 scrotum. After a week's preparation the operation to be de- 
 scribed was performed in a clinic before the students of the 
 University College of Medicine. 
 
 288 
 
Fig. 8— The Bladder Separated and Rectum Exposed. 
 (Annals of Surgery.) 
 
OF THE URETERS INTO THE RECTUM 
 
 The boy was anesthetized with chloroform and placed in the 
 Trendelenburg- position. Ureteral catheters were inserted into 
 each ureter for a distance of four inches. A circular incision 
 was made around the bladder at its junction with the skin, and 
 it was dissected from the underlying tissue until it hung free 
 except for the two ureters. The peritoneum was not opened. 
 The bladder was wrapped in moist gauze, placed to one side, 
 and all bleeding carefully arrested in the cavity from which it 
 had been removed. The sphincter ani was stretched, an assist- 
 ant's finger introduced into the rectum, and the anterior wall 
 made to bulge into the wound. A longitudinal incision was then 
 made into the rectum and the edges of the incision caught with 
 Volsella forceps and separated. The bladder was then rotated 
 so that its upper margin became its lower, and its mucus sur- 
 face faced the cavity of the rectum. The ends of the ureteral 
 catheters were drawn into the rectum and out of the anus. The 
 margin of the bladder was then carefully sutured with catgut 
 to the edges of the incision in the rectum. The abdominal 
 wound was lightly packed with gauze, and the patient returned 
 to bed in good condition. Within two hours after the operation, 
 urine was draining from both ureteral catheters. The next day 
 the patient pulled one of the catheters out, and after this urine 
 was passed both from the rectum and from the remaining 
 catheter until the latter was removed. The boy did well until 
 the fifth day, when he developed broncho-pneumonia and was 
 seriously ill. His recovery from this complication was due to 
 the skillful and untiring care of my colleague. Dr. McGuire 
 Newton. 
 
 At no time was there any perceptible leakage of urine or feces 
 into the abdominal wound. It rapidly filled with granulation 
 tissue and in three weeks was completely healed and the patient 
 well. 
 
 Owing to the dilation of the sphincter ani, there was inconti- 
 nence of faeces for some days; soon, however, the muscle 
 regained its tonicity. Six weeks after the operation, the patient's 
 mother wrote me that he was able to retain his urine for a 
 period of three hours during the day and five hours during the 
 night. Six months after the operation she reports that there 
 
 289 
 
EXTRA-PERITONEAL IMPLANTATION 
 
 was continued improvement in urinary control, together with a 
 most decided change for the better in his general health. 
 
 Note. — Five years after operation father reports that the 
 patient is strong and well. He goes to school regularly, and is 
 able to retain urine without leakage as long in his rectum as 
 other children do in their bladders. 
 
 290 
 
Intestinal Obstruction from Meckel's 
 Diverticulum * 
 
 Whether admitted or not, there is undoubtedly a gen- 
 eral belief among surgeons that cases occur in groups ; 
 and I confess the superstition has been brought home to 
 me by three cases of intestinal obstruction, due to 
 Meckel's diverticulum, that have recently occurred in my 
 practice. The symptoms, pathologic conditions and final 
 results were so similar in all that it is unnecessary to 
 give a separate history of each. All were men between 
 twenty and thirty years of age; all were taken with sud- 
 den abdominal pain, followed by obstruction, distention 
 and peritonitis ; all were brought to the hospital practi- 
 cally moribund from sepsis; all were diagnosticated as 
 fulminating appendicitis; all were operated upon, and all 
 died. 
 
 In each case, when the abdomen was opened, there 
 was the escape of a quart or more of bloody serum; in 
 each the bowels were inflamed and distended with gas, 
 and in each a gangrenous diverticulum was found, origi- 
 nating from the ileum, extending upward and inward to 
 be attached by its tip to the mesentery, and having be- 
 neath it an incarcerated coil of small intestine. The 
 specimen I exhibit was removed from the last case. 
 It is 7 inches in length, one inch in its smallest diameter 
 and is expanded at its tip into a sacculated cavity. 
 
 * Read at meeting of the Richmond Academy of Medicine 
 and Surgery, January 12, 1904. 
 
 291 
 
INTESTINAL OBSTRUCTION 
 
 The rapidity with which a strangulated diverticulum 
 kills, and the necessity of surgical intervention even more 
 prompt than in appendicitis, has led me to study the 
 available literature on the subject and to report the rather 
 unsatisfactory result. 
 
 In early fetal development the intestinal canal com- 
 municates with the vitelline sac by means of the vitelline 
 or omphalo-mesenteric duct. This duct begins at the 
 lower part of the ileum and passes through the abdominal 
 wall at the site of the future umbilicus. It usually be- 
 comes obliterated at the end of the sixth week. If it 
 does not undergo atrophy a diverticulum results shaped 
 like a glove finger, with its base opening into the bowel 
 and its tip either floating free in the abdominal cavity 
 or attached by a fibrous cord to the umbilicus. Meckel's 
 diverticulum varies in length from one to ten inches, and 
 in diameter from a scarcely permeable tube to a pro- 
 trusion the caliber of the small intestine. It is usually 
 cylindrical in shape, but may be sacculated or expanded 
 into cavities. The distal extremity may be smooth and 
 tapering or it may be rough and bulbous. It is usually 
 located about three feet above the ileo-cecal valve on the 
 convex side of the intestine opposite the insertion of its 
 mesentery. 
 
 If free, the distal end may become adherent to any place 
 within the abdominal cavity which its length permits it to 
 reach. Its most frequent point of attachment is the mes- 
 entery, although a case is reported where it was fastened 
 to the bladder. 
 
 When Meckel's diverticulum is connected with the um- 
 bilicus by a fibrous cord it may cause intestinal obstruc- 
 tion by a loop of bowel becoming twisted around it. When 
 
 292 
 
Fig. 10 Rectum Opened Ready for the Transplantation of 
 the Bladder. (Annals of Surgery.) 
 
FROM MECKEL'S DIVERTICULUM 
 
 it floats free in the abdominal cavity it may cause ob- 
 struction either by encircUng a bowel and becoming me- 
 chanically locked by its club shaped extremity, or by the 
 free end becoming attached to a fixed point by inflamma- 
 tory adhesions and a loop of intestines being caught be- 
 neath it. 
 
 Meckel's diverticulum is said to exist in about 2 per 
 cent, of all bodies examined. I have accidentally ob- 
 served its presence several times while operating for 
 other abdominal troubles. As the victim of the abnor- 
 mality usually goes through life unconscious of its exist- 
 ence, and as only a small per cent, have intestinal ob- 
 struction, the number of cases reported is not large. 
 
 The symptoms due to strangulation by the diverticulum 
 are sudden in onset. Pain is severe and persistent and 
 referred chiefly to the region of the umbilicus. Vomiting 
 appears early and may become stercoraceous ; tenesmus 
 and discharge of blood from the rectum are absent ; con- 
 stipation is as a rule absolute ; the abdominal wall is not 
 rigid but later becomes tense from distension ; fever and 
 the attending symptoms of sepsis begin wath the develop- 
 ment of peritonitis, and sometimes there is tenderness 
 or a perceptible swelling near the umbilicus. 
 
 All writers admit that it is impossible to make a posi- 
 tive diagnosis in a case of intestinal obstruction due to 
 the diverticulum, or to differentiate it from intestinal 
 paresis due to peritonitis of appendicular origin ; hence 
 the importance of early operative intervention in doubtful 
 cases. 
 
 Ochsner's method of treatment of peritonitis would 
 prove uniformly fatal in mechanical obstruction. 
 The abdomen should be opened in the middle line 
 
 293 
 
INTESTINAL OBSTRUCTION 
 
 and the lower right quadrant first examined. If 
 there is a large quantity of bloody serum free from 
 the admixture of pus a strangulated diverticulum 
 will most likely be found. As soon as it is located 
 the tip should be separated from the tissue to which it 
 has become adherent and the obstruction relieved. The 
 patency of the bowel should then be demonstrated and 
 its walls carefully examined to see if they are damaged 
 sufficiently to necessitate resection. Finally the diver- 
 ticulum should be removed. If it is small, it may be tied 
 and amputated like an appendix, the stump being buried 
 or covered with peritoneum. If it is large it would be 
 unsafe to trust to a ligature, as it might cut through and 
 cause death from peritonitis at a time when the patient 
 was regarded as out of danger. If the size of the diver- 
 ticulum approaches that of the ileum, from which it 
 originates, it should be amputated and the opening closed 
 with the same care and by the same methods as an in- 
 testinal wound of the same size from other causes. 
 
 294 
 
Fig. 11 -The Transplantation Completed. 
 (Annals of Surgery.) 
 
Obstruction of the Esophagus, With 
 Report of Illustrative Cases* 
 
 Obstruction of the esophagus from accident or disease 
 is sufficiently common to make the subject one of interest 
 to every physician and surgeon. The cause of obstruction 
 may usually be classified under one of the following head- 
 ings : I, Foreign bodies, 2, Spasm, 3, Stricture, 4, Angu- 
 lation, 5, Carcinoma. The diagnosis in an individual case 
 is based on the history and symptoms of the patient ; the 
 use of sounds, bougies and the esophagoscope ; and last 
 but not least on the result of an X-ray examination. I 
 desire briefly to report eight cases of esophageal obstruc- 
 tion that have occurred in my practice. They have been 
 selected from a fairly large series because they illustrate 
 various types of the condition and different methods of 
 treatment. 
 
 I. Obstruction from Foreign Bodies. — The first three 
 cases represent obstruction due to the impaction of a 
 foreign body. This accident is most frequently met with 
 in the very young and in the insane. The foreign bodies 
 are usually pins, coins, buttons, pieces of bone or arti- 
 ficial teeth. The points of impaction correspond to the 
 level of the upper border of the cricoid cartilage, or 
 where the esophagus is crossed by the left bronchus, or 
 where it passes through the diaphragm. 
 
 The symptoms are nausea, sensation of obstruction, 
 
 *Read at Tri-State Medical Association, Charleston, S. C, 
 February 17, 191 5. 
 
 295 ... 
 
OBSTRUCTION OF THE ESOPHAGUS 
 
 pain and difficulty on swallowing, eructation of food 
 and mucous, sometimes hemorrhage, and occasionally 
 a reflex cough. In regard to prognosis the size of 
 the foreign body is not as important as the shape. If 
 large it may produce complete obstruction, but this con- 
 dition forces the patient to seek prompt reUef. If ir- 
 regular or sharp pointed the patient may be able to swal- 
 low soft food and hence not recognize the urgency of 
 the condition until ulceration of the esophageal wall leads 
 to perforation and the involment of the pleura or medi- 
 astinum. 
 
 The character and location of the foreign body being 
 determined, the practical question is how best to remove 
 it. The hypodermic injection of apomorphia has been 
 successful in some cases, but vomiting usually wedges the 
 foreign body in more tightly and the use of emetics in 
 this class of cases is as dangerous and unsurgical as the 
 use of purgatives in intestinal obstruction. 
 
 If the foreign body is round or smooth, efforts should 
 be made to extract it through the esophagoscope by means 
 of forceps or probangs. If the body is soft, and there 
 is no stricture in the esophagus, it may be practicable to 
 push it into the stomach. Neither of these expedients 
 should be tried, however, if the foreign body is pointed, 
 sharp or angular. Here under modern surgical technique 
 an open operation is the safest procedure. 
 
 There are two methods of approach : by an external 
 esophagotomy or by a gastrotomy, and the selection of 
 the route will depend on the location of the impaction. 
 If it is opposite the cricoid cartilage an esophagotomy 
 should be done. If it is below the level of the supra- 
 clavicular notch a gastrotomy should be performed. 
 
 296 
 
WITH REPORT OF ILLUSTRATIVE CASES 
 
 Case I, D. C, male, aged sixteen years, was a patient at the 
 Virginia Hospital. Five days before admission, the boy sneaked 
 into a kitchen and grabbed a hunk of meat. He was pursued by 
 the cook, crammed the meat into his mouth and attempted to 
 swallow it. The bolus lodged in his esophagus and the obstruc- 
 tion could be located with a bougie just above the cardiac open- 
 ing of the stomach. The patient had been unable to take either 
 liquids or solids and was suffering horribly from thirst. As 
 there was no stricture of the esophagus, and as the impacted 
 body was soft, a stiff bougie was inserted and steady pressure 
 made, when the bolus was felt to pass into the stomach. The 
 patient was given a glass of water, but was at first incredulous 
 as to his ability to swallow. When the first gulp went down his 
 expression of pleasure was ludicrous, and he drank glass after 
 glass until he had swallowed a quart or more. 
 
 Case 2, M. S., female, aged ten years, patient at St. Luke's 
 Hospital, gave history of putting the glass stopper of a cologne 
 bottle in her mouth and swallowing it. The stopper lodged in 
 the esophagus opposite the cricoid cartilage and produced com- 
 plete obstruction. Eight days later she was brought to the hos- 
 pital in a pitiable condition from thirst and starvation. A throat 
 specialist was called in consultation, but despite patient and skill- 
 ful efforts he failed to remove it. It was then decided to do an 
 external esophagotomy. The patient was anesthetized and a 
 three inch incision was made on the left side of the neck parallel 
 with the anterior border of the sterno-mastoid muscle. The 
 deep cervical fascia was exposed and divided. The thyroid, 
 larynx and trachea were pulled forward and the large vessels 
 and the nerves backward, thus exposing the esophagus. A large 
 bougie was then passed to the point of obstruction and the 
 esophagus incised on its tip. The glass stopper at once came 
 into view and was easily removed. 
 
 Case 3, L. K., baby, aged seven months, was a patient at the 
 Virginia Hospital. The baby while being dressed had seized an 
 open safety pin and put it in his mouth. The mother in her 
 endeavor to remove it, pushed it first into the fauces and then 
 into the esophagus. The family physician and later a throat 
 specialist made unsuccessful efforts to remove it with probangs. 
 
 297 
 
OBSTRUCTION OF THE ESOPHAGUS 
 
 Five weeks after the accident the child was brought to the Vir- 
 ginia Hospital. He was feverish, emaciated and evidently in 
 constant pain. A skiagram located the pin in the esophagus 
 immediately behind the heart. The safety pin was open with 
 the point up and it was evidently impossible to remove it from 
 above. It was therefore determined to do a gastrotomy and 
 extract it from below. The patient was anesthetized and the 
 abdomen opened. The stomach was incised and a finger inserted 
 and carried through the cardiac opening. At first the pin could 
 not be reached, but by the use of an esophageal bougie passed 
 from above it was pushed into a position to be easily removed. 
 
 II. Obstruction from Spasm. — The next case illus- 
 trates obstruction of the esophagus from spasm. By this 
 is not meant esophagismus but cardiospasm. Esopha- 
 gismus is a paroxysmal contraction of the upper part of 
 the esophagus, seen in smokers, drinkers and hysterical 
 individuals, which is a functional disease and unattended 
 by organic changes. Cardiospasm is a more or less con- 
 stant contraction of the cardiac opening of the stomach 
 producing an obstruction which results in organic changes 
 such as hypertrophy of muscles, dilatation and saccula- 
 tion of the esophagus and inflammation and ulceration 
 of the mucous membrane. The term cardiospasm is an 
 unfortunate one, for when seen or heard for the first 
 time it is often thought to refer to some disease of the 
 heart. The true significance of the term will be im- 
 pressed if it is remembered that the stomach has two 
 openings, the pyloric and the cardiac, and that pyloro- 
 spasm is spasm of the one and cardiospasm is spasm of 
 the other. 
 
 The etiology of pylorospasm has been settled and it 
 is known that it is a protective effort on the part of nature 
 to prevent the passage of irritating gastric contents into 
 
 298 
 
WITH REPORT OF ILLUSTRATIVE CASES 
 
 the intestinal canal. It is a symptom and not a disease 
 and is commonly seen in cases of chronic appendicitis, 
 cholecystitis and ulcer of the duodenum. 
 
 The etiology of cardiospasm is undetermined. There 
 are many theories but it would not be profitable to discuss 
 them here, as they are unsubstantiated and contradictory. 
 The condition was formerly thought to be rare, but it is 
 now being recognized with increasing frequency, the ac- 
 curacy of the diagnosis being demonstrated by the result 
 of treatment. 
 
 Patients with cardiospasm are usually thought to suf- 
 fer from some disease of the stomach. The symptoms 
 often cover a period of many years but vary in intensity 
 at diflFerent times. They consist of a sensation of press- 
 ure and fullness after eating relieved by vomiting. The 
 regurgitation of food is accomplished with little effort 
 and without nausea. The material spit up may be one 
 or two pints in quantity, and consists of mucous and un- 
 digested food without trace of hydrochloric acid or pep- 
 sin. If a stomach tube is introduced a short way into the 
 esophagus there is the escape of fluid through its lumen 
 and along its sides. When the tube reaches the cardiac 
 opening of the stomach an obstruction is met which is 
 overcome by moderate pressure continued for a short 
 time. If after emptying the esophagus the patient will 
 drink a mixture of bismuth and buttermilk a skiagram of 
 the chest will show the shadow of the dilated esophagus 
 with perhaps a small stream of bismuth mixture trickling 
 into the stomach through the spasmodic stricture at the 
 cardia. 
 
 The treatment of this condition was formerly very un- 
 satisfactory. Its cure is now simple, safe, prompt and 
 
 299 
 
OBSTRUCTION OF THE ESOPHAGUS 
 
 permanent. At first antispasmodics and other drugs were 
 tried without success. Then resort was Had to surgery. 
 MikuHcz operated on and cured six patients by opening 
 the abdomen, incising the stomach and forcibly dilating 
 the cardiac opening. The result in this series established 
 the principle for successful treatment and future effort 
 was made to devise a means by which the spasmodic 
 stricture could be efficiently stretched without opening 
 the abdomen. 
 
 This problem has been satisfactorily met by Plummer's 
 Hydrostatic Dilator which consists essentially of an eso- 
 phageal bougie with a collapsible rubber bag at its tip. 
 After the bougie has been passed through the stricture the 
 bag is distended with water and the desired degree of 
 dilatation exerted by slowly increasing the amount of 
 fluid until the attached metre shows the requisite number 
 of pounds pressure. After one or two treatments the 
 spasm* disappears, the symptoms are relieved and the 
 patient gains weight and strength in a marvelous way. 
 
 Case 4, S. H., male, aged sixty-one, was a patient at St. Luke's 
 Hospital. He stated that for the last ten or twelve years he had 
 had trouble in swallowing. His appetite was normal but food 
 would not go into the stomach. After eating he suffered pain 
 and oppression and then the food either slowly entered the 
 stomach or was vomited. His trouble had recently grown much 
 worse and he now spit up practically all the food he took. He 
 had lost twenty-five pounds in weight and had become more or 
 less nervous and despondent. A stomach tube was inserted and 
 readily pased down the esophagus until it reached the cardiac 
 end where it met an obstruction. Gentle pressure was made and 
 in a few moments the obstruction yielded and the tube entered 
 the stomach. An X-ray examination after a bismuth meal showed 
 the esophagus full of fluid which was trickling drop by drop 
 through the cardiac opening into the stomach. A diagnosis of 
 cardiospasm was made, and the patient was treated with Plum- 
 mer's hydrostatic dilators. After being dilated three or four 
 
 300 
 
Fig. 12— Obstruction of Esophagus Caused by Cardiospasm. 
 
WITH REPORT OF ILLUSTRATIVE CASES 
 
 times he was able to swallow without diffifficulty, and one year 
 later reported that he had gained thirty pounds in weight and 
 was perfectly well. 
 
 III. Obstruction from Stricture. — The next two cases 
 illustrate obstruction of the esophagus from organic 
 stricture, one the result of swallowing concentrated lye, 
 the other the result of a severe attack of typhoid fever. 
 The most common causes of stricture of the esophagus 
 are syphilis, the local action of mechanical, chemical or 
 thermal irritants and the remote resuhs of certain acute 
 infectious diseases such as typhoid fever, scarlet fever, 
 diphtheria and smallpox. 
 
 When due to syphilis, the stricture is usually in the 
 upper part of the esophagus and is of large calibre. The 
 diagnosis is based on the history, presence of other lesions 
 and on the Wasserman test. Stricture due to local irri- 
 tants or toxic diseases are usually located near the car- 
 dia, and are diagnosed by the history and symptoms of 
 the patient, and the use of the bougie, esophagoscope 
 and X-ray. The treatment of esophageal stricture con- 
 sists in either bloodless or operative dilatation. The ex- 
 pedients which have been employed to correct the con- 
 dition are ingenious and interesting, but too varied and 
 numerous to be described. If the case is seen sufficiently 
 early it is usually possible to effect a cure by gradual 
 dilatation with bougies or sounds. The treatment re- 
 quires skill and patience and has to be kept up for months 
 or years. In some cases where the stricture is found 
 impermeable, or where the patient's condition requires 
 prompt reUef, the abdomen has to be opened, a gastro- 
 tomy performed and the stricture divided by Abbe's or 
 some other method. 
 
 301 
 
OBSTRUCTION OF THE ESOPHAGUS 
 
 Case 5, A. B., male, aged two years, was a patient at St. Luke's 
 Hospital. Some months before, the child in crawling about the 
 floor found a saucer containing concentrated lye that had been 
 used to remove grease spots, and as babies usually do when in- 
 vestigating new objects, he put some of the lye in his mouth and 
 swallowed it. The symptoms of stricture soon followed. On 
 admission the patient could only take a few drops of milk 
 at a time and was nearly dead from starvation. After long 
 effort under chloroform anesthesia a very small bougie was 
 finally passed through the stricture. A progressively larger sized 
 bougie was introduced at intervals of several days and this treat- 
 ment continued for some weeks. The child was then sent home 
 with instruction to bring him back at stated intervals for obser- 
 vation and treatment. This was faithfully done by the parents 
 who fortunately did not live at a great distance. When the 
 patient was about six years old the father was told that it was 
 unnecessary to continue the administration of choloform in order 
 to pass the bougie. He hesitated a moment and then said "Please 
 give it to him twice more as that will be one hundred times he 
 will have taken it and some day he will be proud to tell about 
 it." The boy is now ten years old and is apparently completely 
 well. 
 
 Case 6, H. B. R., male, aged 22, was a patient at St Luke's 
 Hospital. Four months before admission he was taken with 
 typhoid fever and confined to bed for seven weeks. During the 
 last ten days he was in bed he noticed a progressively increas- 
 ing difficulty in swallowing liquids, and when he was finally 
 given permission to eat solid food he found that the food would 
 not pass into the stomach, but lodged in the esophagus, where it 
 remained until he either vomited or gulped it up. An esophageal 
 bougie showed an obstruction three or four inches above the 
 stomach. An X-ray plate made after drinking a mixture of 
 bismuth and buttermilk showed a stricture of small calibre and 
 about three inches in length at the lower end of the esophagus. 
 Efforts at dilatation on three successive days failed, but finally 
 a small bougie was passed. The stricture was slowly but steadily 
 dilated. The patient remained in the Hospital eighteen days and 
 
 302 
 
Fig. 13— Obstruction of the Esophagus Due to Stricture the 
 Result of Typhoid Fever. 
 
WITH REPORT OF ILLUSTRATIVE CASES 
 
 gained eighteen pounds in weight. He was then sent home to 
 hii family physician to have the treatment continued. 
 
 IV. Obstruction from Angulation. — The next case 
 illustrates obstruction of the esophagus from angulation 
 due to diaphragmatic hernia. 
 
 Case 7, B. D., male, aged nineteen, was a patient at St. Luke's 
 Hospital. He stated that four months before his admission he 
 had been struck in the abdomen and knocked down. His antag- 
 onist then jumped on him and cut him with a pocket knife on 
 the neck and outer side of the arm, and finally stabbed him in 
 the left side of the chest. For three days he was unconscious 
 and for three weeks he could take no food by mouth and had 
 to be sustained by nutritive anemas. He then began to swallow 
 liquids, but if he attempted to eat solids he experienced the sen- 
 sation as though the food stopped before it reached the stomach, 
 and he would spit or vomit it up shortly afterwards. An at- 
 tempt was made to pass a stomach tube, but it met with com- 
 plete block 17% inches from the incisor teeth, A mixture of 
 bismuth and buttermilk was given slowly by mouth and after 
 eight ounces had passed into the stomach a skiagram was made, 
 when it was found that the man had diaphragmatic hernia, and 
 that the stomach was in the left thoracic cavity. The obstruc- 
 tion in the esophagus was obviously due to angulation. The 
 patient's thorax was opened by raising a rectangular flap con- 
 sisting of the entire thickness of the chest wall and containing 
 sections of the eighth and ninth ribs. Adhesions between the her- 
 niated stomach and the heart, lung and pleura were separated, 
 the stomach was returned to the abdominal cavity and the rupture 
 of the diaphragm sutured. The patient made a rapid recovery 
 and was completely relieved of his previous difficulty in swallow- 
 ing. 
 
 V. Obstruction from Carcinoma. — The last case illus- 
 trates obstruction of the esophagus from carcinoma. 
 
 Case 8, J. A., male, aged fifty-nine, was a patient at St. Luke's 
 Hospital. The man's previous history was negative. The present 
 
 303 
 
OBSTRUCTION OF THE ESOPHAGUS 
 
 symptoms had begun two months before his admission and con- 
 sisted of difficulty in taking food. If he swallowed any solid 
 material it caused pain in his chest and then in a few minutes 
 he could feel it enter the stomach and the pain was relieved. 
 During the last few weeks he had been unable to swallow any 
 solid foods and even liquids remained in the esophagus and 
 were regurgitated several hours after being swallowed. For the 
 past week he had been sustained by nutritive enemata. There 
 was no history of syphilis, of acute infectious disease or of 
 swallowing a caustic. X-ray showed a stricture at the cardiac 
 end of the stomach. An esophageal bougie could not be passed 
 and hence an abdominal section was decided on in order to 
 demonstrate the nature of the lesion. The abdomen was opened, 
 and after delivering and palpating the stomach, a hard, annular 
 growth was found completely obstructing the cardiac orifice. 
 As the disease was unquestionably malignant, a gastrostomy was 
 done by Senn's method, and the patient was afterwards fed 
 through the tube by means of a funnel. He gained weight and 
 strength in a most satisfactory way, and was sent home in good 
 shape. Three months later he was found dead in bed and it 
 was thought it was probable he had committed suicide. 
 
 304 
 
Fig. 14— Obstruction of Esophagus Caused by Cancer of the Cardia. 
 
Diaphragmatic Hernia, With Report 
 
 of a Case* 
 
 Diaphragmatic hernia is the protrusion of one or more 
 of the abdominal viscera into the pleural cavity through 
 an opening in the diaphragm. 
 
 The opening may be a defect in development, a dila- 
 tation of a normal aperture, or a rupture due to trauma- 
 tism. Therefore diaphragmatic hernias may be either 
 congenital or acquired. 
 
 In ten per cent, of cases the herniated mass is enclosed 
 in a peritoneal sac, but in ninety per cent, of cases the 
 viscera lie bare in the pleural cavity, hence in a strict 
 sense these hernias may be divided into true and false. 
 
 According to statistics diaphragmatic hernia occurs on 
 the right side in eight per cent, of cases, and on the left 
 in ninety-two per cent, of cases. The relative immunity 
 of the right side is largely due to the presence of the 
 liver which acts as a buffer and protects the diaphragm 
 on that side from the effects of increased abdominal press- 
 ure and closses effectively any rupture that may occur 
 
 The abdominal organs most frequently found in a 
 diaphragmatic hernia are the stomach, colon, small in- 
 testines and omentum in the order named. Almost every 
 abdominal organ, however, except the rectum and pelvic 
 viscera has been found in one or more of the cases that 
 have been recorded. 
 
 * Read at a meeting of the North Carolina State Medical As- 
 sociation, Raleigh, N. C, June, 1914. 
 
 305 
 
DIAPHRAGMATIC HERNIA, 
 
 Diaphragmatic hernias are not common, but they occur 
 with sufficient frequency to make it necessary to bear 
 the condition in mind when making a diagnosis in an 
 obscure case. At the time of the pubHcation of Giffin's 
 paper in the Annals of Surgery for March, 1912, six 
 hundred and fifty cases had been reported, but most of 
 these were either congenital hernias occurring in babies 
 or symptomless hernias discovered at autopsy. Accord- 
 ing to Giffin, only fifteen cases of diaphragmatic hernia 
 had been correctly diagnosed during life. 
 
 The recognition of the condition is based on a careful 
 inquiry into the patient's previous history, especially with 
 reference to injuries, on a thorough physical examination 
 of the chest, and on radiographic and fluoroscopic exami- 
 nations after the ingestion of a bismuth meal. The con- 
 ditions most difficult to exclude in making a differential 
 diagnosis are pneumothorax and eventration of the dia- 
 phragm. 
 
 The treatment of diaphragmatic hernia is essentially 
 surgical. While patients with the trouble have been 
 known to live for years, sooner or later they all develop 
 obstructive symptoms, inflammatory complications or 
 strangulation with gangrene. 
 
 Two exploratory routes have been recommended to 
 reduce the hernia and repair the tear in the diaphragm — 
 the thoracic and the abdominal. Those who favor the 
 thoracic route claim that the adhesions can be more 
 safely separated, that the diaphragmatic opening can be 
 more easily sutured and that by the entrance of air 
 into the pleural cavity the negative pressure or suction 
 power of the thorax is abolished so that replacement of 
 
 the viscera is less difficult. 
 
 306 
 

 •oi^ 
 
WITH REPORT OF A CASE 
 
 Those who favor the abdominal route claim that a 
 considerable number of hernias can be reduced without 
 opening the thorax, and that it is not wise to collapse 
 the lung if it can be avoided ; also that the viscera in- 
 jured from strangulation are the abdominal organs and 
 that they can be better repaired through an abdominaJ 
 incision. 
 
 The following brief quotations from various authors 
 will show the evolution of surgical opinion on the sub- 
 ject of diaphragmatic hernia during the last twenty-five 
 years. 
 
 Holmes' System of Surgery, published in 1881, con- 
 tains the following: "We are silent on the subject of 
 treatment. We can not hope to close the aperture in the 
 diaphragm by any measures which science or mechanical 
 surgery would justify ; could we accurately detect the 
 existence of a protrustion it were in vain to attempt its 
 reduction with any benefit to the patient or credit to 
 ourselves." 
 
 Von Bergmann's Surgery, publislied in 1904, states : 
 "Up to this time no radical operation has ever been per- 
 formed for non-strangulated hernia in this region, 
 although an operation is indicated provided the diagnosis 
 is certain." 
 
 Fergusson in his book. Modern Operations for Hernia- 
 published in 1907, says : "The presence of diaphragmatic 
 hernia is seldom discovered during life. In but seven 
 of the two hundred and sixty-six cases review^ed by Lach- 
 ner was the diagnosis made ante-mortem. If the hernia 
 is incarcerated I believe the thoracic route the preferable 
 one, but in a case where the hernia is inflamed, ulcerated, 
 strangulated or gangrenous when a resection of the bowel 
 
 307 
 
DIAPHRAGMATIC HERNIA, 
 
 must be done the thoracic insures less tendency to infect 
 the peritoneal cavity." 
 
 Ochsner in his Clinical Surgery, published in 191 1, 
 says : "Diaphragmatic hernias are very rare, and when 
 they do exist are seldom discovered before the abdomen 
 is opened. The majority of cases that have been reported 
 have been found at post-mortem. Diaphragmatic hernia 
 may be congenital or acquired. The congenital variety 
 is rarely amenable to surgical treatment because so great 
 a portion of the diaphragm is absent that it is impossible 
 to close the large opening. The acquired variety may 
 frequently be benefited by operation." 
 
 Mumford in his book on Practice of Surgery, published 
 in 191 1, says: "The treatment of strangulated diaphrag- 
 matic hernia is obviously to open the abdomen and treat 
 the viscera as the conditions indicate. Hitherto no 
 operation is reported as performed upon a non-strangu- 
 lated diaphragmatic hernia." 
 
 Binnie in his Operative Surgery, published in 1914, 
 says: "Of the cases of strangulated diaphragmatic her- 
 nia collected by Neugebauer all those operated on through 
 the abdominal route died ; one out of the two operated 
 on the thorax lived. The only two cases of non-strangu- 
 lated diaphragmatic hernia submitted to radical cure 
 (Llobet's and Cranwell's) lived after a trans-thoracic 
 operation." 
 
 Doubtless some cases of diaphragmatic hernia have 
 been operated on and not reported, and other cases have 
 been operated on and recorded since the statistics quoted 
 were compiled, still the total number of operations is so 
 small that I feel justified in reporting the following case: 
 
 308 
 
Fig. 16— X-Ray of Second Case, Before Operation, 
 Showing Stomach in Left Thoracic Cavity 
 
WITH REPORT OF A CASE 
 
 B. D., male, aged 19; entered St. Luke's Hospital April 10. 
 1914, referred by Dr. J. B. Catlett, of Staunton, Va. Patient 
 stated that four months ago as he came out of a pool room 
 he met a man with whom he had quarreled earlier in the day, 
 who struck him with great force in the epigastrium with a bottle. 
 The blow knocked him down and his antagonist jumped on 
 him and cut him on the left side of the neck, on the outer side 
 of the left arm, and finally stabbed him in the posterior axillary 
 line about the third intercosal space on the left side of the 
 chest. The patient bled profusely from the wounds, vomited 
 blood and later passed much blood by bowel. The incisions were 
 sutured without an anesthetic and the patient put to bed. For 
 three days he was unconscious. He finally began slowly to im- 
 prove, but for three weeks he could take no food by mouth 
 and had to be sustained by nutritive enemata. He then became 
 able to swallow and retain liquids. If he attempted to eat solids. 
 however, he experienced a sensation as though the food stopped 
 before it reached the stomach, and he would spit or vomit it 
 up shortly after swallowing it. 
 
 When the patient was brought to Richmond he was very weak 
 and anemic and had lost about fifty pounds in weight. Physical 
 examination of the chest showed the heart markedly displaced 
 to the right and a tympanitic percussion note with absence of 
 breath sounds from the fifth rib down on the left side. An at- 
 tempt was made to pass a stomach tube, but it met with a 
 complete block lyy^ inches from the incisor teeth. 
 
 A mixture of bismuth and buttermilk was given slowly and 
 after about eight ounces were introduced into the stomach sev- 
 eral radiograms of the abdomen were made by Dr. A. L. Gray. 
 The history, symptoms, physical examination and X-ray findings 
 all pointed to diaphragmatic hernia, with escape of practically 
 the entire stomach into the left thoratic cavity. 
 
 An operation was advised and agreed to. It was determined 
 to adopt the transpleural rather than the abdominal route, as 
 the hernia had been in existence for four months, and it was 
 believed that the adhesions between the stomach and the viscera 
 of the chest were so strong and numerous that they could not 
 be safely separated except under direct inspection. 
 
 309 
 
DIAPHRAGMATIC HERNIA, 
 
 The patient was placed on the table in the reverse Trendelen- 
 burg position in order to minimize the possible shock from the 
 sudden admission of air into the pleural cavity. 
 
 The incision was made after the method suggested by Cran- 
 well. The lower and lateral part of the thorax was opened 
 by a flap having its base above, consisting of the whole thick- 
 ness of the chest wall and containing about five inches of the 
 eighth and ninth ribs. As soon as the parietal pleura was opened 
 the stomach presented itself. There were numerous adhesions 
 between it and the pericardium and collapsed left lung. These 
 were carefully separated, several attachments requiring prelimi- 
 nary ligature. 
 
 A very dense and firm adhesion was found between the car- 
 diac end of the stomach and the postero-lateral surface of the 
 chest wall just opposite the stab wound. This was peeled loose 
 after considerable efifort and there was at once the escape of 
 some stomach contents. The stomach was delivered through 
 the opening into the thorax and an incision three inches long 
 found on its anterior surface beginning near the esophageal 
 opening and extending in the direction of its greater curvature. 
 The edges of this incision did not bleed and showed evidences 
 of cicatrization, hence it seems reasonable to believe that the 
 rupture of the diaphragm and hernia of the stomach resulted 
 from the blow and injury inflicted on the abdomen prior to 
 the cutting, and that when the stab wound was made in the 
 third intercostal space the vulnerating instrument cut the stomach 
 which was already in the left thoracic cavity. 
 
 The opening just described in the stomach was sutured in 
 the usual way, and then the adhesions to the stomach where 
 it passed through the diaphragm were separated, and the stomach 
 replaced in the abdomen. 
 
 The rupture in the diaphragm was about four inches in length, 
 beginning near the esophageal opening and extending through 
 the left leaf toward the sternum. The tear was repaired with 
 two tiers of chromic catgut sutures. A rubber drain was then 
 placed in the pleural cavity and the opening in the chest wall 
 closed. The operation while spectacular was not difficult and 
 was completed in fifty-five minutes. There was little bleeding 
 
 310 
 
Fig. 17- Incision in Operation by Thoracic Route. 
 (Copied from Binnie)) 
 
WITH REPORT OF A CASE 
 
 and no appreciable shock. The patient did not suffer from 
 nausea, and begged for a cigarette as soon as he became con- 
 scious. Liquid nourishment was given the following day. At 
 the end of a week the, patient was placed on general diet and 
 from the first swallowed and retained solid food without 
 difficulty. 
 
 He gained weight at the rate of a pound a day and left the 
 hospital in four weeks after the operation. A radiogram taken 
 just before the patient was dismissed showed the stomach in 
 its normal position, the heart almost back in its proper place, 
 but the collapsed lung not yet fully expanded. 
 
 Second Case of Diaphragmatic Hernia operated on 
 after the above was published. 
 
 R. M., male, aged 34, entered St. Luke's Hospital November 
 27, 1914, referred by Dr. W. N. Thomas, of Oxford, N. C. 
 Patient stated that seven months ago while working on the roof 
 of a house a rope broke and he fell a distance of thirty-four 
 feet. He was unconscious for two hours. On examination it 
 was found that he had fractured both bones of his forearm, in- 
 jured his left hip and received numerous cuts and bruises. He 
 suffered with pain and soreness in the epigastrium and hic- 
 coughed for three days. There was nausea but no vomiting. 
 Patient was confined to bed for six weeks. He had little ap- 
 petite and what he ate caused distress. When he finally got up 
 and began to walk, he noticed a gurgling sound in his left chest 
 similar to what he had frequently heard and felt in his abdomen 
 before the accident. 
 
 In July he came to Richmond and entered a hospital in order 
 to have the bones of his arm reset. The surgeon in making 
 his general examination, recognized the presence of a diaphrag- 
 matic hernia, and confirmed his diagnosis by an X-ray plate. 
 The patient was operated on for the vicious union of the bones 
 of the forearm but declined to have anything done for the 
 rupture of his diaphragm. He returned home, but suffered so 
 much from indigestion and shortness of breath that he was 
 finally persuaded to come to me for surgical relief. 
 
 311 
 
DIAPHRAGMATIC HERNIA, 
 
 Physical examination showed the left chest larger than the 
 right. There was hyperresonance from the fourth rib down, 
 and peristaltic sounds were plainly audible. An X-ray plate 
 made after a bismuth meal showed practically the entire stomach 
 in the left pleural cavity. The patient had lost twenty pounds 
 in weight, but was otherwise in good general condition. 
 
 The patient was placed on the table in the reverse Trendelen- 
 burg position and the left thoracic cavity opened by Cranwell's 
 incision. As soon as the pleura was opened and the negative 
 pressure relieved, the stomach and other herniated viscera re- 
 turned to the abdomen. The left lung was completely collapsed. 
 There was a tear in the diaphragm about five inches long, ex- 
 tending from the left margin to the esophageal opening. The 
 liver, spleen and other abdominal organs could plainly be seen. 
 There were no adhesions except between the margins of the 
 hernial opening and the great omentum, and these were easily 
 separated. 
 
 The tear in the diaphragm was repaired with chromicized cat- 
 gut sutures, and the incision in the chest wall closed without 
 drainage. 
 
 The patient lost little blood, showed no appreciable shock, and 
 at this writing, one week after the operation, has had no symp- 
 toms to cause discomfort or give anxiety. The patient is now 
 on general diet and states that he is completely relieved of his 
 former digestive disturbance, and also that "it is a great satis- 
 faction to feel the food go to the proper place." 
 
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