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is the duty of every brother in the profession to donate his "mite" to build up solid truth for the treatment of all diseased conditions.

On the 28th day of December, 1892, I was called to see Miss Maud M., aged 16, who had always enjoyed excellent health. She had a chill during the previous night, followed by a fever, and for some hours before my call had been suffering greatly with pain and cramps in the right lower corner of the abdomen. Temperature, 101; pulse, 103. Vomiting occasionally, and seemingly in great distress. Abdomen was not tympanitic, yet very tender over caecum, with a sensation of pressure, of tumefaction, extending nearly to the umbilicus, and from two inches below the border of the liver to Poupart's ligament. Other parts of the abdomen seemed normal.

I diagnosed appendicitis, and told the mother that her daughter had inflammation of a small, hollow tube, usually three inches long, about the size of a lead pencil, and attached to the lower end of the big bowel, but of no use in the make-up of a human being, that I know of, except to cause suffering.

Treatment: Gave subnitrate of bismuth after each effort at vomiting, and injected a 4 gr. of morphine into the skin. Ordered turpentine applied over the abdomen, every six hours, with constant applications of warm, wet flannel cloths. While lying over bed-pan, an enema of soap suds was given, as soon as morphia and hot cloths had quieted pain somewhat. Some gas and fecal matter passed and patient expressed herself as feeling much relieved. Ordered enemas to be given daily, or twice daily if in pain. No cathartics of any kind were given. Vomited occasionally for three or four days. No more morphia was given and no medicine except bismuth. When the hot flannels were neglected the pain returned, and upon their employment the pain subsided. This treatment was continued about eight days, at which time patient was greatly improved, and was well in two weeks. Only liquid food was given at first, and then other foods were gradually introduced.

The next attack occurred in February, 1893, after attending some entertainment at night. Chills, fever, pains and griping, with same treatment and same results. Other attacks took place in from three to four weeks. Often immediately after menstruation. Treatment the same and results the same until the sixth attack was safely passed.

At this time patient had been greatly reduced in flesh and strength, and the seventh attack was brought about after walking about a fourth of a mile when seemingly her appendicitic disease was well. Upon examining diseased region between the attacks, I sometimes persuaded myself I could feel an enlarged appendix through the walls of the abdomen, but was never THEI MEDICALI HERALD 190

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absolutely certain that I did, When the attack was on, the whole region felt stiff and doughy. Could never discover anything out of the normal per vaginam or rectum. I had expected every attack to be the last, but at this time I informed the parents that if she had another I would not be doing my duty to my patient unless I should open the abdomen and remove the offending organ. I explained the situation to patient and parents, also, the dangers of an operation, and was surprised to find that all were ready to have the trouble annihilated at once, and the young lady remarked that it would be better to die in an operation than to live as she had done. However, when I began to make preparations, the mother said wait for one more attack, and as it was about time for menstruation I thought it best to wait. Menstruation came and the attack came just as promptly and with more than usual violence, but with the same treatment it subsided just the same as others did. You ask, did I operate in the height of the attack? 1 answer, no; I waited till the inflammation had subsided and then operated. I fully expected to find some foreign body in the appendix, as the first cause of this inflammation.

On the 9th day of November, 1893, with the assistance of my son, Dr. H. C. Young, and Drs. Greenleaf, Duffield and Say, the operation was performed. I made the usual incision from the middle of Poupart's ligament, upward over the McBurney point. Found everything adherent; separated adhesions gently; found appendix pointing inward, and fast in all its length to the posterior peritoneum. Carefully loosened its adhesions and brought it out of the opening. Appendix was 34 of an inch in diameter and three inches long. Very firm; no perforation; and no pus in appendix or abdomen. Ligated appendix at junction with caecum, and amputated. Cauterized stump with carbolic acid carefully. Secured all bleeding points. Closed the abdomen in the usual manner with silkworm gut sutures. Usual

dressing and allowed stitches to remain fourteen days. Highest tempera. ture at any time 99% degrees. Recovery uneventful, and is now able to do light work about the house.

The appendix was split longitudinally and the lumen at junction with caecum was less than a line in diameter. And for one a half inches the cavity at its largest diameter was at least one half inch, containing only mucus and no foreign body. The mucous membrane and all tissues of this appendix had some of the general appearance of scar tissue, and by adhesions and thickening of walls bore evidence of the repeated inflammations. I am of the opinion that the opening into the appendix in this case had always been contracted; that the fluids from caecum would enter the appendix cavity and on account of the difficulty of exit would remain there

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until fermentation and the formation of ptomains became so abundant that inflammatory action resulted first in the mucous membrane, then in the adjacent tissues, to such an extent that local peritonitis spread to some of the adjoining organs. It might be that a microbe, similar in some respects to the streptococcus which produces erysipelas, had entered the tissues, and multiplying rapidly, producing its own ptomains, which destroyed the multitude thus formed, and inflammatory action subsides, as it does in erysipelas. We will leave this microbe for some microscopist to discover and describe.

During the last two years I have had, in my own practice, or have seen in consultation, eleven cases of appendicitis. Three of these cases have been operated on. All are now alive, except one, in which perforation took place, producing a local abscess in the peritoneum, hedged in by extensive adhesions. This case was seen by myself in consultation twenty days after the attack commenced. Half a gallon of pus and fecal matter was evacuated by a free opening near Poupart's ligament. Cavity gently. washed with warm boracic acid solution. No appendix could be discovered, but an opening in caecum large enough to admit the point of the index finger was found, through which gas and fecal matter escaped. The immense tympanitic condition subsided, pain was relieved, bowels moved naturally, and it was thought for a few days this patient would recover. Patient failed in strength gradually, and died of exhaustion on the thirtieth day after attack, but had no general peritonitis.

One of the cases, that of a young man aged 19, had violent appendicitis, followed by diffused peritonitis. We kept everything ready for laparotomy one week, but finally the inflammation subsided aad the patient got on his feet again. This patient had two other attacks, all within three months in other towns in lowa, from which he recovered, and for one year and a half from last attack has been able to attend to his business, that of a drug clerk, without any sign of a relapse.

Last spring I was called in consultation to see a young man in a neighboring town, suffering with a violent attack of appendicitis. Called, in fact, to open his abdomen and remove appendix, and cleanse peritoneum, as we supposed there was perforation and discharge of bowel contents into the peritoneum. Found three physicians in attendance and the patient at this time (three days from initial symptoms) with general peritonitis. Temperature scarcely normal. Pulse, 120. Pinched features and anxious expression. Great tympanitis. But easier than he had been, on account of a large hypodermic injection of morphine before my arrival. The general verdict was that he would die. I was requested to operate. I asked one of the doctors how long he would live if we made a laparotomy. Said he, the

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patient will die in less than two hours. All gave the same opinion. I suggested to give him an enema of warm soap suds. Patient passed off gas and some watery green fluid. Had them renew the hot flannel pack, with turpentine over the bowels, Gave him no medicine except enough morphine to relieve pain. In due time he recovered, and is now a lively dry goods clerk in Coatesville, Mo. The other cases I attended or saw in consultation had but one attack, with recovery in all up to the present time.

My treatment has always been the same. No cathartics or other medicines, except opium in some form, and but little of that. Hot applications over the abdonien and enemas of soap suds. I will not say there is no condition in which I would not open the abdomen during the height of an attack. If I am sure there is a large amount of pus, either encysted by adhesions or free in the abdomen, I think it is best to evacuate and cleanse the peritoneum at once. Dr. Christian Fenger, of Chicago, always operates if he has a violent case, in the midst of an attack, but his record shows a high rate of mortality. Dr. Joseph Price, of Philadelphia, says operate at once in all violent cases, and has a much better showing. Dr. Price must have greater skill in cleansing the peritoneum, as his losses are few. I would say, if I were sure, from the extent of shock and other signs, such as we find in gunshot wounds of the abdomen in which the bowel contents are being poured out, operate at once, if the contents of the caecum were escaping from a perforation, as they sometimes do, nothing else is left to do. In general, I shall adhere to my present line of treatment of appendicitis in all its forms, while my per cent of recoveries remains as good as it now appears to be. Rest, moist heat, enemas and opium-but will operate when a large amount of pus is known to exist, or free escape of contents of bowels occurs through a perforation.

It will, no doubt, amuse some of you gentlemen who operate in a well equipped hospital, with a corps of skilled assistants and trained nurses, to know just how a country doctor performs laparotomy at a country farmhouse, with picked-up assistants and train-your-own nurses. You must understand I am not a specialist, but do a little of any kind of surgery that presents. I will give you a few of the details of the operation in the case presented. My son and myself do business together, and have the ordinary equipments of country surgeons. Two days before the operation I took a three gallon tin bucket with lid and drove six miles to the farm-house of my patient. Ordered the carpets and all furniture removed from their so-called parlor, walls and ceiling well brushed down and floor scrubbed and room well aired. Had an operating table made of deal boards. Ordered a folding bed which was in the house, prepared and put in one corner of the

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room, ready for patient. Had them hunt up some fruit jars for hot water bottles. I shaved the abdomen and pubes of patient. Ordered the mother to give the daughter as good a bath as possible, and make her as clean as ever she was in her life. Patient to have next day no food after breakfast, except a little broth at noon meal. No supper that evening and no breakfast on the morning of operation. But a good dose of castor oil with turpentine at 4 P.M, next day. Ordered mother to rub into a folded wet towel strong soap and place it over the daughter's abdomen and have her wear it all night, and until we came next morning to operate. Ordered my tin bucket filled with pure strained water and boiled one hour, and set by to cool, the evening before the operation. We invited the three physicians named to be present at 10 A.M. and assist. My son and myself with our outfit, arrived one hour earlier than the rest. Set my operating table in good light, with folded comforter and clean sheet over all. Common dining table was placed convenient with clean sheet over it. Our other three gallon tin bucket was placed on the stove nearly full of clean water, with a dozen clean towels in the water, also, three dozen napkins, of cheese cloth, each a foot square, to be used instead of sponges. These last had a safety pin put through all, to prevent them getting scattered. Instruments, silk, needles, glass drainage tubes were placed in square tin pans, alongside of the tin bucket of towels and napkins, and boiled for nearly an hour. Our flushing apparatus was sterilized in the same manner. Of course my son and myself had rendered ourselves as aseptic as possible, by bathing and clean clothes before leaving home. When the doctors arrived they were asked to take off their coats and scrub hands all around. In due time, instruments and the usual dressings were prepared and arranged on the table in about as good shape as you will find in any operating amphitheatre. And when everything was ready the patient was given chloroform and carried to and placed on the table. The cheese cloth napkins were wrung out of the hot water by clean hands and were used as sponges to cover the edges of the incision and to hold back intestines, and also to absorb all blood in the peritoneum. After patient was placed on the table, the soaped towel was removed and abdomen washed with warm water. Then washed with a solution of bichloride of mercury, one to five hundred, which solution was also used as last cleansing for my hands. The operation was completed without accident and with coolness, and some of my associates, who had seen our best operators, were supprised that everything should be in such good order in a farm-house operation. After the usual dressings were all on, the folding bed was let down, the patient was placed on it in good condition, with fruit jars of warm water around her and was soon comfort

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