Part 3

Another important subject was the question of treatment of Tubercular fistula. For a number of years Dr. Tuttle said he was most discouraged in his results and had almost abandoned any attempt to cure this class of infections, but of late he had obtained most excellent results by introducing his soft flexible probe and following this tract with a grooved director; opening this throughout its entire extent, and then completely cauterizing at dull red heat with the actual cautery. This is then packed with iodoform gauze, and since using the cautery, his results have been decidedly better. Under the direction of his assistant, Dr. J. M. Lynch, a class of three was formed, with regular work and instructions in the dispensary of St. Bartholomew's Clinic, where we were given cases to diagnose and treat. This course consisted in introduction of proctoscope and sigmoidscope diagnosis of ulcerations specific and benign, and local treatment through this instrument. To the inexperienced the results and probabilities gained through the use of this pneumatic instrument of Tuttle's, which is a modification of the Laws proctoscope, are surprising. By the electric illumination with which it is equipped one is able to introduce the instrument with absolute safety to the patient for a distance of 10 to 14 inches, exploring the entire circumference from the anus up through the sigmoid.

My next course of instructions was under the direction of Prof. Samuel Gant at the New York Post-Graduate Medical School. Dr. Gant likewise was most cordial in his reception, and on several occasions honored me by entertainments, including letters of membership to his club, and at his home with his family. Dr. Gant, also a master of his art, has made a reputation of renown, and is a most successful operator. While of an entirely different character from that of Dr. Tuttle he is equally attractive. Dr. Gant argues that the majority of cases of cancer when seen by the specialist are too far advanced to offer any hope by radical operation, and generally limits his attempts at relief to a colostomy. As to the merits of this procedure, I am not sufficiently versed to offer criticism further than to say that the results of Dr. Tuttle are certainly encouraging to the surgeon who will undertake this ordeal of extirpation in hopes of eradicating the disease, while Dr. Gant's operation of colostomy, of course, is only palliative, he making no claims of a cure, except when the growth is seen very early and is freely movable; then he will extirpate.

As to the operation for hemorrhoids, Dr. Gant uses ligature and sterile water anesthesia in nearly every case, and the patient is thereby cured without the administration of a general anesthetic. The difference in the time of recovery is a question to be always considered, in my own judgment, and is as follows: Dr. Tuttle uses the clamp and cautery almost universally, and the patient is discharged within the period of one week, while the ligature method requires local treatments to the ulcerations produced by the sluffing of the linen threads, and takes from 10 days to three weeks.

Constipation and Obstipation are treated surgically by both of these gentlemen by the operation of Sigmoidopexy or Colopexy, which consists in anchoring the gut to the abdominal parietes after having first stripped back the peritoneum over the area covered by their sutures.

Chronic diarrheas and Amœbic Dysentery are likewise treated by Appendicostomy and Caecostomy. The difference in this operation being that the former consists in delivering the appendix upon the abdomen and fixing the same with catgut sutures until the peritoneal cavity is walled off by adhesions, and then amputating later, so that the stump may be dilated to permit of regular colonic irrigations.

Dr. Gant performs a similar operation, to which he has applied the name of Caecostomy, and having devised an ingenious director consisting of one metal rod within a tube of slightly larger calibre, he is able to pass the obturator through the ileo-caecal valve, and then, by withdrawing the rod or obturator, is able to pass a rubber catheter into the small intestine. The metal tube is then withdrawn and a shorter catheter is placed parallel with the long one, which necessarily is in the caput, and after placing clips upon each tube to prevent leakage, he is able to flush out both large and small bowel at desired intervals.

As to the irrigations through these newly-made openings, it is a matter of choice with different operators, those in greatest favor, I think, being Ice Water, Aq. Ext Krameria and Quinine Solution.

A very interesting case brought before us by Dr. Tuttle was one of Specific Stricture of the Rectum, and the treatment anticipated is as follows: He performed a Maydl-Reclus Colostomy in the transverse colon, in order first to treat the ulcerations and infected area locally, and, secondly, so that he would have sufficient gut above the stricture to do a Perineal extirpation later and bring down new healthy intestine from the upper Sigmoid for a new permanent anus; then later he would close the artificial anus in the transverse colon, and his patient should have a perfect result. The period required for these three operations would cover a period of not less than nine months; and if after this there is not perfect Sphincteric action, Dr. Tuttle does a plastic operation to repair his sphincter.

Before continuing with a brief description of the technique of Extirpation as above referred to, I wish to herewith express my sincere gratitude and appreciation of the many honors and courtesies extended to me by these gentlemen, and am quite sure that the same was not all personal, but honor to the University of Maryland's Faculty of Physic, who have aided so materially this younger specialty by such men as Hemmeter, Pennington and Earle, who are constantly quoted by all intestinal and rectal surgeons.

EXTIRPATION OF RECTUM.

The operation of removing the rectum is now almost two centuries old. Faget performed it in 1739, but Listfrane first successfully extirpated the rectum for cancer in 1826. The results of the operation in nine cases were embodied in a thesis by one of his students (Penault, Thesis, Paris, 1829), and in 1833 the great surgeon himself gave to the world a complete account of his operation and method, thus establishing the procedure as a surgical measure. The results in these cases were not calculated to create any great enthusiasm, for the mortality was high owing to the lack of aseptic technique. The methods described in older books give us five varieties of operation for extirpation--the perineal, the sacral, the vaginal, the abdominal and the combined. In this paper I shall only endeavor to describe briefly the two methods used by Dr. Tuttle. Before describing these methods in detail it may be well to consider the preparation of the patient, which is practically the same in each. In order to obtain the best results, it is necessary to increase the patient's strength as far as possible by forced feeding for a time, to empty the intestinal tract of all hard and putrifying faecal masses, to establish as far as we may intestinal antisepsis and to check, in a measure, the purulent secretion from the growth. It requires from 7 to 10 days, or longer, to properly prepare a patient for this operation. The diet best calculated to obtain a proper condition of the intestinal tract is generally conceded to be a nitrogenous one. The absolute milk diet is not so satisfactory as a mixed diet composed of meat, strong broth, milk and a small quantity of bread and refined cereals. The patient should be fed at frequent intervals, and as much as he can digest. Along with this forced feeding one should administer daily a saline laxative which will produce two or three thin movements, and to disinfect the intestinal canal one should give through the stomach three or four times a day sulpho-carbolate of zinc, grs. iiss., in form of an enteric pill. On the day previous to the operation the perinaeum, sacral region and pubis should be shaved, dressed with a soap poultice for two hours, then washed and dressed with bichloride dressing, which should be retained until patient is anesthetized. Notwithstanding all of these preparations, it is impossible to obtain absolute asepsis of the affected area, and so many fatalities occur from infection that it is deemed wise by many surgeons to make an artificial inguinal anus as a preliminary procedure in all extirpations of the rectum.

PERINEAL METHOD.

Under this method may be included certain operations for small epitheliomas low down in the rectum done through the anus. The patient having been properly prepared, the sphincter is thoroughly dilated; a circular incision through the entire wall of the gut is made, and the segment is caught with traction forceps and dragged by an assistant while the operator frees, by scissors and blunt dissection, to a point at least one-half inch above the cancer. The free end of the gut is then tied with strong tape, as the temptation is very great to put your finger in the bowel as a guide, and thereby invite infection. A deep dorsal incision is then made, going down to the right of the coccyx through the post-rectal tissue. The hand is then placed in the sacral fossa and the structures lifted out into the pelvis, after which this space is thoroughly packed with gauze to control the bleeding and hold the structures out of the fossa. The edges of the wound, including each half of the sphincter which has been cut posteriorly, are held by flat retractors, while the operator proceeds to dissect the anterior portion of the rectum loose from its attachments. A sound should be held in the urethra in men and an assistant's finger in the vagina in women to prevent wounding these organs. After the gut has been dissected out well above the tumor, it is caught by clamps and cut off below these. Bleeding is controlled by ligatures and equal parts of hot water and alcohol. This newly-exposed gut is then sterilized by pure carbolic acid and alcohol, or may be seared with cautery. Sometimes the peritoneum can be stripped off from the rectum and its cavity need not be opened; it is better, however, to open the cavity at once when the growth extends above this point. The peritoneum is incised, cut loose from its attachments close to the rectum, back to the mesorectum, which should be cut close to the sacrum, in order to avoid the inferior mesenteric artery. When the gut has been loosened sufficiently above the tumor, it may be still fastened by two lateral peritoneal reflections, which are the lateral rectal ligaments, and should be cut at once. The gut is then brought down and sutured to the anus, and the operator should proceed to close the peritoneum and restore the planes of the pelvic floor down to the levator ani by fine catgut sutures. After this has been accomplished, the anus, which is now well outside the operative field, should be reopened, the gauze removed, and the gut flushed with a solution of bichloride or peroxide of hydrogen. Quenu advises that in amputating each layer should be cut separately, in order to avoid hemorrhage, but there appears to be no advantage in this; in fact, we are more likely to meet with deficient blood supply, causing subsequent sloughing of the gut, than with hemorrhage. The posterior and anterior portions of the perineal wound are packed with gauze and left open to assure drainage, and the parts are covered with aseptic pads, held in position by a well-fitting "T" bandage. A large drainage tube is passed well up into the rectum, its lower end extending outside of the dressings, in order to convey the discharges and gases beyond the operative wound.

TUTTLE'S BONE FLAP OPERATION.

"The Kraske Operation" is applied to various methods in which access to the rectum is obtained by removing the coccyx or cutting off certain portions of the lower end of the sacrum. They are all modifications of Kraske's original method, with which we are all familiar. Dr. Tuttle has modified this plan, as it furnishes a rapid and adequate approach to the rectum; it facilitates the control of hemorrhage and restores the bony floor of pelvis and attachment of the anal muscles, and involves injury of the sacral nerves and lateral sacral arteries on one side only. The technique which he employs is as follows:

The patient is previously prepared as heretofore described, and an artificial anus established or not, as the conditions indicate; before the final scrubbing the sphincter should be dilated and the rectum irrigated with bichloride 1-2000 or hydrogen peroxide. It should then be packed with absorbent gauze, so that the finger cannot be introduced. The patient is then placed in the prone position on the left side, with the hips elevated on a hard pillow or sandbag; an oblique incision is made from the level of the third foramen on right side of sacrum down to the tip of the coccyx, and extending half-way between this point and the posterior margin of the anus.

This incision should be made boldly with one stroke through the skin, muscles and ligaments into the cellular tissue posterior to the rectum; the rectum is then rapidly separated by the fingers from the sacrum, and the space thus formed and the wound should be firmly packed with sterile gauze. A transverse incision down to the bone is then made at a level of the 4th sacral foramen, the bone is rapidly chiseled off in this line, and the triangular flap is pulled down to the left side and held by retractor. At this point it is usually necessary to catch and tie the right lateral and middle sacral arteries. Frequently these are the only vessels that need to be tied during the entire operation, although if one cuts too far away from the sacrum, the right sciatic may be severed. The first step in the actual extirpation of the rectum consists in isolating the organ below the level of the resected sacrum, so that a ligature can be thrown around it, or a long clamp applied to control any bleeding from its walls. If the neoplasm extends above this level and it is necessary to open the peritoneal cavity to extirpate it, one should do this at once, as it will be found much easier to dissect the rectum out by following the course of the peritoneal folds. By opening the peritoneum and incising its lateral folds close to the rectum, the danger of wounding the ureters is greatly decreased and the gut is much more easily dragged down.

When the posterior peritoneal folds or meso-rectum is reached, the incision should be carried as far away from the rectum, or, rather, as close to the sacrum, as possible in order to avoid wounding the superior hemorrhoids artery, and to remove all the sacral glands. The gut should be loosened and dragged down until its healthy portion easily reaches the anus or healthy segment below the growth. A strong clamp should then be placed upon the intestine about one inch above the neoplasm, but should never be placed in the area involved by it; for in so doing the friable walls may rupture and the contents of the intestine be poured out into the wound. As soon as the gut has been sufficiently liberated and dragged down, the peritoneal cavity should be cleansed by wiping with dry sterilized gauze and closed by sutures which attach the membrane to the gut. By this procedure the entire intraperitoneal part of the operation is completed and this cavity closed before the intestine is incised. After this is done the gut should be cut across between two clamps or ligatures above the tumor, the ends being cauterized with carbolic acid and covered with rubber protective tissue. The lower segment containing the neoplasm may then be dissected from above downward in an almost bloodless manner until the lowest portion is reached. It is much more easily removed in this direction than from below upward, and there is less danger of wounding the other pelvic organs. If the neoplasm extends within one inch of the anus, it will be necessary to remove the entire lower portion of the rectum. If, however, more than one inch of perfectly healthy tissue remains below, this should always be preserved. Having removed the neoplasm, if one inch or more of healthy gut remains above anus, one should unite the proximal and distal ends either by Murphy button or end-to-end suture.

All oozing is checked by hot compresses, and the concavity of the sacrum is packed with a large mass of sterilized gauze, the end of which protrudes from the lower angle of the wound. This serves to check the oozing, and also furnishes a support to the bone-flap after it has been restored to position. Finally the flap is fastened in its original position by silk-worm gut sutures, which pass deeply through the skin and periosternum on each side of the transverse incision. Suturing the bone itself is not necessary. The lateral portion of the wound is closed by similar sutures down to the level of the sacro-coccygeal articulation; below this it is left open for drainage (Tuttle, Diseases of Rectum, Page 829-1903).

REPORT OF A CASE OF GANGRENOUS APPENDICITIS, FROM THE SERVICE OF PROF. R. WINSLOW.

BY C. C. SMINK, '09, _Senior Medical Student_.

In selecting a case I have not taken one that is a surgical curiosity, or at all an unusual one, but I have taken this because it is just in these cases that a doubt sometimes exists as to the treatment when diagnosed, and often the condition of the appendix and surrounding peritoneum is in doubt, even if a diagnosis of trouble originating in the appendix is made.

_History of Case_--Patient, a boy, L. W., age 9 years, schoolboy; admitted December 26, 1908, with a diagnosis of appendicitis.

_Family History_--Parents well; one brother died in infancy, cause unknown; two brothers living and well; only history of any family disease is tuberculosis in one uncle; no rheumatism, syphilis, gout, haemophilia or other disease bearing on the case.

_Past History_--Measles at 5 years, with uneventful recovery; whooping-cough at 6, no complications; badly burned two years ago; has had "indigestion" (?) since he was 3 years old; pain but no tenderness during these attacks; treated by different physicians and got better for a time; no history of scarlet fever, influenza, pneumonia, typhoid or other disease of childhood.

_Habits_--A normal child.

_Present Illness_--On 20th of December, 1908, patient came home from church complaining of pains in the right side. This was Sunday. Next day he complained of severe pain all over abdomen, but on Tuesday these became localized in the right lower quadrant of the abdomen. Had some fever. Bowels constipated. No nausea or vomiting. There was a localized tenderness in the right lower quadrant from the start. Pains got better on Friday, but temperature and pulse still stayed up, and patient came into hospital on Saturday, December 26. The unusual feature was that there was no nausea or vomiting. It is also to be noted that the pain subsided suddenly on the 24th. The child entered hospital on the 26th, and on entrance the whole right side was rigid, while the left side was comparatively soft. A lump could be felt in the appendical region, the centre of which was above McBurney's point. Temperature was 99 and pulse 78. The leucocyte count, however, was 30,200; urine negative.

Child was put to bed; an ice cap placed on the abdomen. Liquid diet. The next day, December 27th, leucocytes stood at 35,200. Temperature unchanged, but the pulse had risen to 110 beats. A hypodermic of morphine and atropine was given, and patient taken to the operating room, anesthetized, and abdomen cleaned for an aseptic (if possible) operation.

Prof. Winslow made an incision in the abdominal wall, well out toward the crest of the ilium, using the gridiron incision. The caecum was found and pulled over toward the middle line, and in looking for the appendix, which was supposed to be behind the caecum, a great quantity of pus was found. This nasty smelling, grayish pus welled up into the wound and was sponged away. Several pieces of mucous membrane and presumably the tip of the appendix were found in the pus. Also several faecal secretions. The pus was sponged away and carefully a search was made for the appendix, or rather what remained of it. It was found tied down by adhesions and dissected loose. It broke away in pieces, and it was unnecessary to ligate any of the arteries of the meso appendix. The stump of the appendix close to the caecum was crushed, cauterized and ligated. No attempt was made to invert it, as the tissues would not stand it. The pus cavity was found to extend up behind the caecum and over toward the median line for some distance. The puncture, which I will refer to later, was then made in the right lumbar region, and two cigarette drains were introduced extending clear back into the bottom of the abscess cavity. Then a gauze drain was introduced into the anterior wound, and this sutured up. The wound was then dressed and the patient taken to the ward. Recovery from anesthetic without ill effects.

The next morning the patient was unable to pass his water, and had to be catheterized. Aside from this no ill effects were seen, and his temperature and pulse remained practically at the same place. At the end of 48 hours the drains and dressings were changed and the patient was doing well and the wound draining profusely. At no time was the bed elevated and at no time was a stimulant administered, with the exception of a hot normal salt enema on the day following the operation. Several times during his stay a dose of castor oil was given, but no other medication was necessary. As the dressings were reapplied and drains introduced daily the wounds were found to be granulating up, and gradually these closed, first the one in the lumbar region and then the one in the abdomen. By the tenth day a normal temperature was present, and he sat up on the twelfth.

The child went on to an uneventful recovery, and went home on January 21st fully cured.

This was undoubtedly one of those cases of gangrenous appendicitis where, owing either to the intensity of the infection or to a thrombosis of the vessels supplying the appendix, the vitality of the tissues is lost and gangrene results. Now, "even in this, the gravest form of appendicitis, the general peritoneal cavity is often protected against infection by walling off the pus, and the appendix, detached in the form of a slough, is often found on opening the localized abscess." But "in other cases there is from the beginning the symptoms of peritoneal sepsis and peritonitis."

Now, it seems to me that a great deal depends on the kind of infection--or, rather, the kind of organism infecting--and often the difference between a localized abscess and a general peritonitis is really the difference between a colon and a streptococcus infection. Again, should a general peritonitis develop, I have noticed from a number of cases in the wards that the prognosis practically depends on the organism, although we all know that a general peritonitis is a mighty grave condition, no matter what it is due to.

Another point in favor of the child was the fact that the gangrenous process seemed to start in the tip of the appendix, and it seems that when it starts there, there is greater likelihood of localization, and when it starts in the base a greater likelihood of general peritonitis.