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acter of the disease before its manifestations have reached the point of danger. He will also be better prepared to attack the case at the proper moment; in fact, he can choose his own time for interference. It is hardly possible to attach too much importance to this point. If the symptoms do not show marked amelioration by the third day, further counsel should be sought, not that an operation may be demanded at once, but that due preparations may be made, and that no time may be lost when time is important.
3. A patient has a moderate attack of appendicitis. He is to all appearances improving, when without any definite the symptoms are aggravated. He has a relapse, and has to make another start in his convalescence, only to experience the same chain of events sooner or later to prevent his recovery. The patient, and oftentimes the physician, is inclined to attribute these relapses to over-exertion, an error in diet, catching cold, etc. While these factors may occasionally act as exciting causes, yet the essential feature to be borne in mind is a damaged appen
Every exacerbation means an extension of the morbid process, and leaves the patient a little weaker and a little worse off than he was before. The time may come when he fails to rally, and he then becomes an invalid from chronic appendicitis.
These cases are not quite free from danger, and sound judg ment is required to decide the proper period for interference. Each case must be managed according to its condition and peculiarities, yet it may be said, that, as a rule, or at most, three or four relapses, according to the severity, are sufficient to call for removal of the appendix. I presume that every surgeon feels that he has delayed action too long in occasional instances, but I have yet to meet one who has cause to regret a premature operation under these circumstances. It is better to err on the side of safety.
4. No variety of appendicitis is more embarrassing to the attending physician, or to the consultant, than the following: A man is seized with a sharp attack of pain in the umbilical region, accompanied by tenderness. It knocks him out, so to speak, doubles him up, and sends him to bed. The symptoms may be severe enough to produce a moderate collapse. An opiate under
the skin gives him complete relief for several hours. Seen for the first time during this period, the patient seems to have little or nothing the matter with him. No pain or tenderness, no disturbance of pulse or temperature. Everything is quiet under the sway of the "divine poppy." In many instances this lull in the symptoms is deceptive, as in from twelve to twenty-four hours with increased violence. This is usually the signal for calling the surgeon, and it goes without saying, that he should be prepared to operate at once if necessary.
5. And, finally, we have the recurring cases of appendicitis to consider, which differ from the relapsing variety in the fact that patients are apparently well between the attacks. Recently a gentleman consulted the writer for the following symptoms: Five or six times during the past year, after a hearty meal he has been suddenly seized with a severe pain in the umbilical region, which gradually worked down into the vicinity of the appendix. The pain is accompanied by marked local tenderness and inability to stand erect. It lasts about twelve hours, but the tenderness persists for three or four days or even longer. He is weak and exhausted for several days-much more so than would be expected after an ordinary attack of colic or indigestiod. This man is strong, robust, and is entirely well between these attacks. In the writer's opinion he is suffering from a mild form of recurring catarrhal appendicitis.
Now comes the important question of treatment. Is an operation necessary, and if so, when shall it be performed? The temperament of the surgeon and of the patient is a factor in deciding these questions. If the attacks are increasing in frequency and severity, there can be little doubt as to the necessity of an operation; and the sooner it is done the safer and better for the patient. On the contrary, if the intervals are increasing in length, and the symptoms becoming less severe and of shorter duration with each attack, it might be well to wait a while before resorting to a radical cure, as a certain number of these cases do eventually wear themselves out, so to speak, and entirely disappear, thus coming under the head of "appendicitis obliterans." In the opinion of the writer six attacks of appendicitis in one year, even if mild, are quite sufficient to justify an operation for the removal of the exciting cause.
Not a few physicians entertain the idea that there is no occasion for calling the surgeon until a tumor has formed, indicating that the inflammatory process is limited in extent and has ceased spreading. That this idea is erroneous and misleading, is abundantly proven by the fact that in very many cases no tumor is ever found, and yet the convalescence dates from the moment of operation. It is often impossible to detect a tumor, even when present, by reason of its depth in the pelvis, its shape and size, as well as the the thickness and rigidity of the abdominal walls. The presence of a tumor does not of itself indicate an operation, nor does its absence preclude it. In fact, the indications for treatment are influenced very little by this symptom. A tumor shows the variety of the inflammatory processes going on in the peritoneal cavity, and also indicates the site of the incision. The plan of treatment is based upon other and more important factors in the condition of the patient. If he is growing steadily worse, radical means are called for, and the more rapid is the progress of the symptoms, the earlier are effective measures demanded.
In closing I can but repeat what has already been said, that from a surgical standpoint it seems wise and prudent that every case of appendicitis of any severity or duration should be seen in the early stages by one accustomed to operating for this affection, as well as to deciding the many difficult questions which are constantly arising throughout its course.
If the initiary were severe; if they are steadily growing worse; if they relapse, or come to a stand-still; if the patient is sick, weak, irritable, impatient, restless; and especially if he cannot pass wind, or is inclined to nausea, vomiting, hiccough or delirium, then I urge you to be vigilant and prompt in calling for surgical aid, for reasons already mentioned. You will never be criticised for calling it too early or too often. The serious character of the affection, the sudden onset, the insidious course, the rapid and unexpected variations, the startling collapses and excruciating pain liable to occur in this affection, as in almost no other, will protect you from these charges. And should the result be unfortunate, you and the friends will have the lasting satisfaction of knowing that you have done your whole duty in the matter, and are in no way responsible for the disastrous termination.-Boston Med. and Surg. Jour.
Extracts from Home and Foreign Journals.
TECHNIC OF ALEXANDER'S OPERATION.
Calmann (Centralblatt für Gynäkologie, 1897, No. 4) describes the following ingenious procedure: after drawing out the ligament as far as necessary on both sides, it is kept on the stretch by an assistant while two sutures of fine catgut are passed through it and the pillar of the external ring on either side. Then sutures are passed on both sides through the aponeurosis, then through half of the ligament parallel with its long axis, and out through the aponeurosis again near the point of entrance. When tied, these unite the ligament firmly to the aponeurosis without constricting the former. Finally the redundant portion of the ligament is excised and the distal end is sutured to the stump of the ligament. The wound in the skin is closed with a continuous catgut suture.-Amer. Jour. of the Med. Sciences.
INTESTINAL ANASTOMOSIS BY SUTURE.
The prevalence of the use of plates or buttons for the performance of anastomosis in intestinal operations makes prominent the results obtained by Taylor (Birmingham Med. Review, Feb. 1897) in two cases which he reports, where a double row of glover's sutures were employed in the performance of a lateral posterior gastro-enterostomy and an end-to-end intestinal anastomosis.
The intestinal anastomosis was performed for a tubercular
tublar growth to the cæcum, which involved the entire coat and circumference of the bowel and caused stenosis, with recurring symptoms of intestinal obstruction and some of recurrent appendicitis. The entire growth was excised and the dilated ileum united to the lower proximal end of the ascending colon. The recovery was complete, with no sign as yet of returning tubercular disease.
The posterior gastro-enterostomy was performed for pyloric stenosis in a case in which digital dilatation had been previously employed with a relief of symptoms extending over two years. The posterior opening was employed to prevent the accumulation of undigested food in the dilated stomach and give free exit to the food.
The method of operation was that described by Doyen, and consisted of a continuous glover's suture, which embraced all the coats of the intestine, the mucous the least, and united the cut margins of each wound to that of the other, forming a continuous mucous canal free from the scar-tissue which results after the sloughing out of a button and which occasionally gives rise to cicatrical contraction and stenosis. After the approximation of the edges of the wound by the first glover's suture, a second suture united the serous surfaces a little distance from the wound.
The author believes that the Murphy button and other similar means are useful in emergency cases, better results can be obtained in an operation au froid by the use of the suture, which he inserts with a round curved needle with no cuttingedge. Amer. Jour. of the Med. Sciences.
WHY FASHIONS IN SURGERY CHANGE.
Lawson Tait says that the only way an operation can be esti mated justly is to ascertain its remote results. "It would matter very little if an operation had no primary mortality at all if it left the majority of its subjects mained, halt, or insane, at the end of two years. The absence of injury in secondary results is the cause of so much change of fashion in surgery, to say nothing of medicine."-Med. News.