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wards and downwards. The corpora cavernosa are divided with one sweep of the knife at the base of the flap. The arteries are secured and the urethra dissected out of the inferior flap. An opening is made in the dorsal flap, the urethra drawn through it, and sutured to the opening. The upper and under flaps are then united with sutures. A flexible catheter is passed into the bladder, and the urine allowed to pass off through a tube connected to it into a receptacle beside the bed. The catheter will be dispensed with in forty-eight hours, the patient then passing his urine naturally. Care should be taken to keep the wound thoroughly clean.
(The patient made an exceptionally good and rapid recovery. The wounds healed rapidly. The stitches were removed from the flaps in four days, and the patient allowed to go home on the sixth day. Microscopic examination of sections made of the specimen shows it to be unmistakably epithelioma.)
THE PROPER MANAGEMENT OF APPENDICITIS.
The medical world has not yet arrived at a uniform method of treating appendicitis. It would seem, when taking into account the voluminous literature upon this subject and the great mass of facts that have been collected, that the wide differences of opinion in this direction should not obtain.
There are able men who would operate on every case at the earliest possible moment after making sure of the diagnosis. Again, there are among our best surgeons those who would wait until there has been pus-formation, or at least an appreciable tumor. There are equally good surgeons who hold a middle ground and call it conservative. The position of the latter would be impregnable were they able to diagnosticate the catarrhal from the suppurative form of the ailment. The one does not always require operation, the other does.
It cannot be denied that operation in every case as soon as the diagnosis is satisfactorily made will, in skilled hands, give results almost, if not entirely, free from a death-rate. Nor can it be denied, either, that by this rule some cases will be operated upon that would get well and stay well without operation. The central query here is this: What percentage of catarrhal appendicitis will be followed by a recurrence, and what percentage of recurrent appendicitis will forever remain free from pusformation? I have seen no statistics that will satisfactorily answer these questions. I have recorded in my note-book details of a case that occurred five years ago. The attack was a typical one; the symptoms were all severe; the patient was confined to bed for ten days, and during the week following there was a readily perceptible tumor, tender to moderate pressure. This
case was preceded by constipation, and it is recorded that the cause "was acute indigestion." There was no recurrence till one year ago, and then a very light attack, which disappeared after the exhibition of a saline cathartic. Since then the patient has been well.
I have a little patient of twelve years who has an attack of appendicitis whenever she becomes even slightly constipated. The temperature rises to 100° F.; the pulse ranges from 100 to 120; colicky pains appear in the abdomen, with tenderness at the McBurney point and rigidity of the right rectus muscle; sometimes there is a little vomiting. This whole condition clears up as soon as the bowels have been thoroughly acted upon by sulphate of magnesia. She has had seven attacks within the last year; they do not increase in severity, and the condition is just as easily relieved as the first one was. I have seen several cases in which there has been no recurrence for one, two, and three years. Whether it is possible to have one attack and never have a recurrence, is a point I am not sure of. I do, however, feel sure that a recurrence is the rule; and I also feel sure that, sooner or later, an operation will be demanded in most cases, either because life is in jeopardy or because the patient will get tired of being confined to bed for several days at varying intervals. I have also observed that an operation is usually more difficult on account of adhesions in patients who have had several recurrent attacks of catarrhal appendicitis; especially have I found this to be true when the appendix has been located posteriorly, pointing backward and upward. I have often wished in such cases that I had operated at the beginning of previous attacks.
Just as soon as we are able to differentiate those cases in which there will never be an abscess, and in which there will not be adhesions that will cripple portions of the bowel and thus interfere with its function, there will be a better reason to condemn those who operate in every case they see. At present it is not possible to do this. A more carefully conducted observation of all cases of appendicitis and more accurately-kept records will contribute much to this end. All cases of appendicitis are not alike, either in their morbid anatomy or their subjective and objective symptoms. It is, therefore, desirable to study each case
with as judicial a mind as possible. This course and less of dogmatic assertion will lead medical men to more rational conclusions.
It is certain that an operation will cure appendicitis and forever prevent a recurrence. Now, is it equally certain that therapeutic measures other than this can accomplish as much? Operation furnishes the only possible means of saving life in a suppu. rative case. I must make a single exception that will include but a very small percentage of cases, namely: where adhesions are strong and the pus finds its exit either at the surface of the body directly or via one of the abdominal viscera. Will any medical man tell us how to make a differential diagnosis between the catarrhal and suppurative form of the disease before an abscess has actually occurred? It will not be enough to reply that the suppurative form may be recognized by the severity of symp. toms either subjective or objective. Such a test is not a guide at the bedside. No one, so far as I know, has yet claimed to be able to separate the two prior to pus-formation. The surgeon who operates indiscriminately on all cases will operate on a certain percentage of cases where no immediate necessity for operation exists. Suppose he does; if he be competent to operate at all, what risks are run by his patient? But one; namely: ventral hernia in the future. By a short incision, by a careful approximation of divided surfaces, and an accurately fitting bandage for a year, the percentage of hernia will be small, much smaller indeed than the death-rate resulting from an indiscriminate dependence upon purgatives and expectancy.
A few years ago I saw a case of apendicitis in a patient with advanced pulmonary tuberculosis. Owing to the latter condition no operation was advised. The symptoms were not more severe than I have observed scores of times in catarrhal cases, nor, so far as I could observe, were they different. A small tumor could be felt. At 5 P. M., of the fifth day he was suddenly seized with terrific pain shooting through the abdomen in every direction, and at midnight he was dead. The necropsy revealed the usual ragged hole at the base of the appendix, which had been enclosed by some weak adhesions, and the peritoneal cavity was full of pus.
My note-book contains records of another case interesting in this connection, and particularly interesting in another connec
tion, viz. to illustrate a point made above, that all case are not marked by the same symptoms. This patient was attending to his business as usual when, with as abrupt suddenness as ever marks the entering of a duct by a calculus, he was stricken with abdominal pain of a most violent character. The pulse was rapid; temperature at first scarcely elevated. There was frequent vomiting; tenderness over the abdomen, not more marked in one place than another; marked tympany; in short, the case was, so far as could be made out, one of peritonitis. Twelve hours later the patient was in collapse, and about thirty hours from the beginning he was dead. Again the necropsy revealed the small, jagged opening at the base of the apdendix, and the belly full of pus, but this time no trace of adhesions anywhere.
The first case, as I have said, was not seemingly very severe, in fact, was just such a case as many an able practitioner would have treated expectantly. Though it was a suppurative case it wore no peculiar livery that would separate it from a catarrhal case of the same severity, so far as the physicians in attendance were able to abserve; yet it must be admitted that no remedial resource save an operation would avail anything in such a case. In the latter case, had the belly been opened immediately, it is possible, though I admit not very probable, the patient's life might have been saved.
Since beginning this paper I have operated on a case, the main points of which I shall mention very briefly. The patient, a telegraph operator, had been suffering for ten days when I first saw him, and had during most of this time attended to his work. At the time of my visit I found a tumor at the usual site, temperature was 100°, pulse 90, and there was not much pain, nor was the tenderness excessive. I operated at the earliest possible moment, and found an appendix covered in by the omentum, thickened to the extent of three-quarters of an inch, just as a handkerchief might be made to cover in a finger. Upon separating the omentum from the appendix, I found three or four drams of stinking pus and two ragged holes in the appendix. A large piece of omentum had to be removed. There were no other adhesions than between the appendix proper and the overlying omentum. Externally to the base of the appendix there was seen a gangrenous patch of cecal wall about the size of a dime.