IMAGE EVALUATION TEST TARGET (MT-3) !^-^^ 4k 1.0 1.1 1.25 ■ 50 ""^~ us 124 1^ 2.5 ■2 2^ J.8 U ill 1.6 Hi& % Vi ^> c^m 0%. :> ''1^ ^>' y /^ Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4S03 Ki CIHM/ICMH Microfiche Series. CiHIVI/iCMH Collection de microfiches. Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques Tachnical and Bibliographic Notaa/Notaa tachniquos at bibliographiquaa Tha initituta hat attamptad to obtain tha baat original copy availabia for filming. Faaturoa of thia copy which may ba bibliographically uniqua, which may altar any of tha imagaa in tha raproduction. or which may aignificar>tly changa tha uaual mathod of filming, ara chackad balow. nColourad covara/ Couvartura da coulaur I — I Covara damagad/ D n n D n D Couvartura andommagia Covara raatorad and/or taminatad/ Couvartura raataurte at/ou palliculAa r~1 Covar titia miaaing/ La titra da couvartura manqua Coloured mapa/ Cartaa gAographiquaa 0n coulaur Colourad ink (i.a. othar than blua or black)/ Encra da coulaur (i.a. autra qua blaua ou noira) Colourad plataa and/or illuatrationa/ Planchaa at/ou illuatrationa wn coulaur Bound with othar matarial/ Ralii avac d'autraa documanta Tight binding may cauaa ahadowa or diatortion along intarior margin/ La re liura sarrie paut cauaar da I'ombra ou da la diatoraion la long de la marge int^riaure Blank laavaa added during restoration may appear within the text. Whenever possible, these have been omitted from filming/ II se peut que certainaa pages blanches ajoutiaa lore d'une restauration apparaiaaant dana la texte. mais, lorsqua cela Atait poaaibla, cea pagaa n'ont pas its filmiaa. Additional comments:/ Commentaires supplimentaires; L'Institut a microfllmi la meilleur exemplaire qu'il lui a M possible de se procurer. Les details de cot exemplaire qui sont peut-Atre uniques du point de vue bibllographiqua. qui peuvent modifier une image reproduite. ou qui peuvent exiger une modification dans la mithoda normale de filmaga aont indiquia ci-deasous. □ Coloured pagaa/ Pagaa D Pagaa da coulaur Pagaa damaged/ Pagaa andommagAea □ Pagaa restored and/or laminated/ Pagaa restaurAea at/ou peMiculAes Pagaa discoloured, stained or foxed/ Pages dicolories, tachaties ou piquies □Pagaa detached/ Pagaa ditachias 0Showthrough/ Tranaoarence Tranaparence Quality of prir Qualiti inAgale de I'impression Includes supplementary materit Comprend du material supplimentaire Only edition available/ Seule Mition disponible I I Quality of print variea/ I I Includes supplementary material/ I — I Only edition available/ d a b ri ri n Pagea whoHv or partially obscured by errata siipa, tissues, etc., have been refilmed to ensure the best possible image/ Lea pages totalement ou pertieliement obscurcies par un fauillet d'errata, une pelure, etc., ont M film^s A nouveau de faqon d obtanir la meilleure image possible. This item is filnisd at the reduction ratio checked below/ Ce document est filmi au taux de reduction indiquA ci-deasous. 10X 14X 18X 22X 26X 30X J 12X 16X 20X 24X 28X 32X Tht copy filmed h«r« hM bMn r«produe«d thanka to th« ganarosity of: Medical Library McGill University Montreal Tha imagaa appaaring hara ara tha baat quality poaaibia conaldaring tha condition and lagibillty of tha original copy and in kaaping with tha filming contract apaclficationa. L'axamplaira filmA fut raproduit grica i la g4n4roait4 da: Medical Library McGill University Montreal Laa Imagaa auhrantaa ont 4tA raproduitaa avac la plua grand aoin, compta tanu da la condition at da la nattat* da l'axamplaira film*, at an conformiti avac laa conditiona du contrat da filmaga. Original copiaa in printad papar covara ara filmad baginning with tha front covar and anding on tha laat paga with a printad or liluatratad impraa- •ion, or tha back covar whan appropriata. All othar original copiaa ara flimad baginning on tha first paga with a printad or liluatratad impraa- sion, and anding on tha iaat paga with a printad or liluatratad impraaaion. I.aa axamplairaa origlnaux dont la couvartura •» papiar aat Imprimto aont fiimto an commandant par la pramiar plat at an tarminant aoit par la darniAra paga qui comporta una amprainta d'impraaaion ou d'iiluatration. aoit par ia saeond plat, aaion la caa. Toua laa autraa axamplairaa originaux aont flimte an commandant par la pramiAra paga qui comporta una amprainta d'impraaaion ou d'iiluatration at an tarminant par la darnlAra paga qui comporta unc talla amprainta. Tha laat racordad frama on aach microficha shall contain tha symbol -^ (moaning "CON- TINUED"), or tha symbol y (moaning "END"), whichavar appliaa. Un daa symbolaa suivanta apparattra sur la darniira imaga da chaqua microficha, salon la caa: la symbola — »> signifia "A SUIVRE", la symboia y signifia "FIN". IMapa, piatas, charta, ate., may ba filmed at diffarant reduction ratioa. Thoaa too larga to ba entirely included in one expoaure are filmed beginning in the upper left hand comer, left to right and top to bottom, aa many framee aa required. The following diagrame illustrate the method: Lea cartea, planchea, tableeux, etc., peuvent Atre fiim4e A dee taux da rMuction diffArants. Lorsque le document est trop grand pour Atre reproduit en un seui clichA, II est film* A partir da I'angia supArieur gauche, do geuclie A droite, et do haut an baa. an prenent le nombre d'Imegea nAcaeaaira. Laa diagrammea suivanta iiluatrant le mithode. 32X 1 2 3 1 2 3 4 5 6 /4£. £^e,f>^atc/j F'.J, REPRINTED FROM THE " MONTREAL MEDICAL JOURNAL." FEB . 1890. -J^-^ r.-W'W- APPENDICITIS— LAPAROTOMY— RECOVERS. By Francis J. Shepherd, M.D., Surgeon to the Montreal General Hospital. WITH REMARKS ON CASE BT DR. R. L. MACDONNBLL. The following notes of the case have been furnished me by Dr. R. L. MacDonnell, under whose care the patient was up to the time of operation : — " Julia B., aet. 20, was admitted into the medical wards of the Montreal General Hospital on September 13th, 1889, complain- ing of severe pain in the abdomen. For the last twelve months she has frequently suffered from occasional pain and tenderness in the right iliac region, but the first really severe attack which resembled the present one occurred five months ago, and was very severe. She remained in bed for three weeks, and thought that recovery was complete, but after being up three weeks a second attack occurred, which was more severe than the first. She was taken to the Notre Dame Hospital, where she remained some three or four weeks, leaving the institution some time in June. Since then she has never been free from some degree of pain in the right iliac fossa. The present attack began nine days ago. She awoke in the night with a very severe pain in the right side of the abdomen, which was almost immediately followed by vomiting. The pain next day was more intense. Five days before entering hospital she had a severe rigor. She was under treatment evidently by opium until day of admission. At the time of visit she presented the following appearance : A strong, muscular girl, with bright complexion ; dorsal de- cubitus ; legs drawn up ; face pinched and expressive of the greaiest suifering ; great tenderness and pain over right iliac fossa, which extends towards the right breast and up the back of the chest ; pulse 120, small and hard ; respirations hurried and shallow (30) ; temperature, morning 99.4*', evening 100.8°. The bowels have not moved for several days. On admission an enema had been administered, opium was given, and fomentations applied. Next day the condition was much worse. Pain and tender- ness general over the whole abdomen. Dr. Shepherd was now called in." I saw the patient, at Dr. MacDonnell's request, at mid-day, September 14th, 1889. She was suiTering from well-marked symptoms of appendicitis. We both decided it was a case for operation, and without further loss of time the patient was put under ether. On examination, no tumor could be made out in the right iliac fossa, but there was a distinct sense of resist- ance. After thoroughly cleansing the abdominal walls, an in- cision was made in the right iliac region some four inches m length. The incision made was the usual curved one, the centre being a little internal to the anterior superior spinous process of the ilium. After cutting through the abdominal wall, the peri- toneum could not be distinguished, but a mass of inflammatory tissue and omentum appeared ; this was carefully pulled aside, and in doing so a small stinking abscess containing a few drachms of pus was evacuated. The appendix was now searched for, and was somewhat difficult to And. The first structures that came into view were some coils of small intestine and the rght Fallopian tube. After some little search, which was complicated by the condition of the parts, the appendix was found, somewhat larger than normal, coiled up beneath the Caecum and imbedded in a mass of inflammatory tissue. Cautiously separating it pre- paratory to applying a ligature, an abscess behind the caecum containing several ounces of stinking pus was evacuated, a por- tion of which escaped into the general peritoneal cavity. On 8 examining the appendix, quite close to its junction mth the caecum a gangrenous ulcer was seen, which almost severed the appendix from the bowel. The appendix was with diflScult' ligated above the ulcer, a piece of the caecum being pinched up to make the ligature hold ; it was then removed at the site of the ulcer. The cavity of the peritoneum was now washed out with boiled water and the wound closed, except at the lower end, through which was introduced a large rubber tube to the bottom of the abscess cavity. Dressing consisted of iodoform and cotton wool, held in place by a couple of strips of rubber plaster. After the operation the patient had a very restless night, with considerable vomiting and pain. Next day the dressings were changed, being soaked through with the oozing of a bloody serum, and also some bloody serum was withdrawn from the wouiid by means of a syringe having a piece of tubing attached. Two days after the operation the bowels moved freely. At the end of a week patient was doing well, had very little pain, and no rise of temperature. The discharge from the wound had a distinctly foecal odor, and was yet in some quantity. The stitches were taken out, and near where the drainage tube was the wound gaped considerably, so it was packed with sticky iodoform gauze from the bottom. From this time the case progressed favorably, a slough the size of a five-cent piece coming away at the end of the second week. The patient was placed on plain full diet at the end of the fourth week, and was then seized with severe colicky pains without rise of temperature. On enquiry it was found that she was constipated, so salines were ordered, but these not relieving the pain she was placed on milk diet, which in a couple of days restored her to her normal condition. Patient was discharged from hospital on the 4th of November ; she still had a small sinus at the site of the drainage-tube. I saw her on Wednesday, December 18th, and she had then been back to her work for three weeks ; she looked strong and fat, and said she had not the slightest pain. There was still a small shallow sinus at the lower end of the abdominal wound. In laparotomy for appendicitis the lateral incision is much the most convenient, especially in cases where the diagnosis is as plain as in the one just related ; besides being the most suitable for examining the condition of the caecum and appendix, the lateral incision is much the most favorable for after drainage. Some surgeons advise that in excision of the appendix the peri- toneum should be dissected away and sewed over the end of the cut tube. I see no special advantage in this procedure, and, besides, it is only practicable in a few cases ; when the peri- toneum is so altered by inflammatory action, as is usually the case, no such plan could be carried out. In this case the ap< pendix was removed so close up to the caecum that even if the peritoneum had been normal a flap of it could not have been removed. Omental grafting, as recommended by Dr. Senn in wounds of the intestines, might be a useful and practicable pro- ceeding. The situation of the ulcer in this case was unusual ; it is generally situated at some distance from the caecal junction, most frequently near the apex. No concretion was found. This case was successful because early operation was per- formed and symptoms of general peritonitis were not waited for. In fact, to treat such cases on the expectant plan is obsolete and bad surgery ; a very few may get well, but the great ma- jority will perish, and perish rapidly. Again, this case, from its history of repeated previous attacks and its not very rapid course, was one which was eminently favorable to operation. Where the appendix is curled up beneath the caecum, the dis- eased area is usually separated from the general peritoneal cavity by a boundary of inflammatory tissue, and this is the time operation should be undertaken. Should the disease go on, the abscess may either present in the iliac fossa, rupture into the peritoneal cavity, or, if the pus be pent up, it may cause death by septicasmia. The cases which have a previous history of attacks of appendicitis should be operated on without hesita- tion early ; the danger of early operation is not great, and the patient is permanently relieved from a condition which will, sooner or later, cause his death. Such cases arc advised to be operated on between the attacks and the appendix removed. Mr. Treves of London and Dr. McBurney of New York have \ I' successfully operated in such cases. These oases differ much from those others where the appendix hangs freely over the brim of the pelvis and perforation occurs almost without previous warning, and is not preceded by a limiting inflammation. In such cases there is a sudden lighting up of a general peritonitis of a most virulent type, which in spite of any operation rapidly proceeds to a fatal termination. I have operated on several such cases always with the same result. Death has not been averted by the operation, but pain and vomiting have been relieved. There is no doubt in my mind that the degree and virulence of the inflammation of the peritoneum caused by perforation of the appendix varies considerably in different cases, depending on the condition of the individual and the quality of the poisonous matter extruded from the perforated appendix. I believe in some cases operation, even if performed at a very early stage, would be of no avail. Those cases where an abscess has burst into the peritoneal cavity, unless operation be immediately per- formed, are always fatal. A general suppurative peritonitis is lighted up — no amount of washing will cleanse the many nooks and corners of the peritoneal cavity from its infective material. Remarks by Dr. MacDonnell. — Did the prognosis warrant an operation so formidable as laparotomy ? (1) There were three distinct attacks of pain in the right iliac region, each worse than the preceding one. (2) The suddenness of the onset is characteristic of disease of the appendix. Sudden, severe ab- dominal pain was present in 216 out of 287 cases collected by Dr. Fitz of Boston (84jper cent.) (3) In the intervals between the attacks of acute pain the patient still suffered, though not severely. It would therefore be unlikely that even ii tae present aoute symptoms were to pass off she would regain her health. (4) The symptoms pointed to a change from a local to a general peritonitis, though after operation there were no indications of general peritonitis observed. Appendicular peritonitis has a special tendency to become general, and when general the result is almost invariably fatal. I therefore felt that in handing my patient over to the surgeons I was giving her the best chance for life which circumstances afforded.