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TWENTY-FIVE CASES OF ABDOMINAL SECTION WITH TWENTY RECOVERIES.
Crawfords V Road...! Dr. Eastman..
Dr. C. H. Abbett.
Dr. J. F. Smith.
Dr. A. J. Smith.
Dr. A. S. McMurray.
Dr. C. E. Wright.......
Dr. G. W. Vernon... 57
Dr. W. H. Brenton.. 46
In the accompanying table, cases 1, 2, 3 and 4 were reported in Transactions of Indiana State Society, for 1884.
Case 5 died from erysipelatous peritonitis, in the City Hospital, on the 5th day after the operation. The hospital had been built less than one year; still a case of erysipelas had been treated across the hall, only a few days before the operation. I was informed of this at the post-mortem examination of my patient.
Case 6 died in about twenty-four hours after our efforts, from shock. She had a violent attack of general peritonitis, in February preceding the operation, from which she came near losing her life. After this, the tumor grew rapidly, the operation being a last resort. The words yes, under the word recovery, renders comment unnecessary, except that cases 7, 8, and 9 were reported to the Indiana State Medical Society for 1885, and that my reports of work there have encouraged some practitioners to urge earlier operations, and stop tapping, thus insuring better success; and the success removes, to some extent, the fear heretofore felt by patients in this condition, that an ovariotomy was almost sure death. Others, heretofore silent on the subject of abdominal surgery, have presented the subject to State and county societies. This will aid in educating doctors and patients to the fact that the time for a successful ovariotomy is before the forces of death, plus the operation, are stronger than those of life.
Case No. 20 was really the subject of an exploratory incision to differentiate between a pelvic abcess and an encephaloid mass.. It proved to be the latter; the tumor sprang from the left ovary, filled the pelvis, and completely surrounded the rectum, making defecation extremely difficult. The growth was not disturbed, except to get a fragment for microscopic examination. It proved to be typical encephaloid cancer. The wound, five inches in length, healed perfectly. She recovered entirely from the operation; but the rectum completely closed, her death occurring two weeks from the date of the operation. I consider an exploratory incision worthy of record, as, in my opinion, it will, in expert hands, be a useful aid in diagnosis, and enable us occasionally to save a human life.
Case 25 is reported in the body of this paper.
This report includes all my abdominal sections. My statistics are like those of most operators, i. e., improved by increased personal experience. My experience has been supplemented by the increased experience of Miss Clementia M. Prough, the nurse who manages my private hospital, and has had charge of the aftertreatment of my last fifteen cases. True, I saw the operation many times before doing it myself, but it is like the juggler who keeps six balls in the air at a time-it looks simple. Try it; you'll let a few drop. Sufficient time has not yet elapsed to determine the cure in some of the cases where I removed small ovaries and tubes. I have, however, photographs and letters from some of them who were confirmed invalids, which are to me most gratifying, especially considering the fact that our text-books, written only a few years ago, consigned these sufferers to a life of incurable invalidism.
Dr. Sutton, of Pittsburgh, has recently given publication of all his abdominal sections including his death-roll. Dr. Goodell, of Philadelphia, comes out annually with his "year's work in ovariotomy" always including his death-roll. Dr. Wylie, of New York, is publishing his work with its necrology. Dr. John Homans, of Boston, is publishing his 260 odd operations which will include all fatal cases, with many other interesting features. I recently visited these men and saw them operate. They are specialists. They are doing for our American statistics what Wells, Kieth, Tate, Bantock, Martin, Shroeder, and others did for the statistics of the Old World.
Your honored President, Dr. Kemper, suggested to me yesterday, that the laity were not educated to the advantage of early operating, or to the danger of death from delay. I replied, that the published statistics of men specially equipped for the work, a larger experience by the few and fewer operations by the many, will in America, as in the Old World, show such a low rate of mortality that women will no longer defer an operation, but will accept it early, at the hand of the specialist. For despite reckless operating, and more reckless, almost criminal inexperience of those who conduct the after treatment of some cases, I predict that this century will draw to a close, honoring abdominal surgery for its marvelous achievements, not only as the crowning glory of all surgery, but of all science and of all art.
THE CARE OF THE BOWELS IN TYPHOID FEVER.
BY LEROY S. HENTHORNE, M. D., INDIANAPOLIS.
Typhoid fever is described as a specific fever in which the essential lesion is located in Peyer's and the solitary glands of the small intestine. There is but little doubt that the disease is caused by a specific germ, although it has not yet been positively demonstrated. If we were acquainted with the appearance, movements and habitat of this germ, there would yet remain to be discovered a remedy that would destroy it, without being at the same time harmful to the patient. Having discovered this we would still have the greatest task before us, that of learning to apply the remedy before serious pathological changes had taken place. We do not have patients come to us until they are sick. Then we must have time to make a diagnosis. Before this can be made with certainty in the case of typhoid fever our patient is suffering from inflamed or ulcerated intestinal glands. If we now proceed to destroy the germs, we have not cured the patient. He has remaining an inflammatory trouble for which rest and time must be factors in the cure. I do not see how any specific treatment will ever be discovered that can be made available in time to prevent the usual train of symptoms from following. This being the case, I think, in our present knowledge of the disease, we should disregard its specific character, and treat it on the same principles which we apply to the treatment of any other inflammatory disease.
The object of this paper is to advocate the attainment, as far as possible, of entire physiological rest for the diseased intestine, and to protest against the use of cathartics or laxatives at any stage of the disease.
The essential lesions being located in Peyer's and the solitary glands, it must be our object to give rest to these glands and the intestine where they are located. Before being able to accomplish this we must understand the physiology of digestion and absorption. I take it for granted that you all understand these subjects, but perhaps a review of them in connection with the subject will not be without some profit. When the food enters the mouth it is mixed with the alkaline secretions of the salivary glands. Starchy matters would be digested in this fluid if they remained long enough in contact with it. Practically this does not occur, as the food is rapidly taken to the stomach where the secretions are acid and starchy digestion ceases. When the food leaves the stomach and enters the intestine the mass becomes alkaline again from the secretions of the pancreas, the glands of Bruner and the follicles of Lieberkühn. When it leaves here and enters the large intestine it becomes acid again from the secretions of the large intestine and the matters excreted there, and in this acid condition the fœcal matter is discharged.
This sequence of acid and alkali is necessary to a healthy digestion and absorption. It is changed somewhere in typhoid fever, as the matters discharged in the diarrhoea of typhoid are alkaline or even ammoniacal. In the stomach we have the digestion of albuminoids carried on in an acid medium. The starch and fat go unchanged into the small intestine, and are digested and emulsified respectively in an alkaline medium. This alkaline medium is necessary, not only for their digestion but also for the absorption of the fat. Endosmosis of fatty matter can only take place from a fine emulsion in an alkaline medium. The digestion of the albuminoids, which begins in the stomach, and which requires an acid medium to begin with, may be completed in the intestine in an alkaline medium provided the secretion of the liver, the bile, is mixed with the mass in proper quantities. The function of bile is not thoroughly understood, but this much we know: It enables both kinds of digestion to proceed at the same time, in the same place, and prevents fermentation and putrefaction in the digesting mass. Now let us see how typhoid fever interferes with these pro
In the first place we usually have some congestion of the liver