believe in many cases after complete abla-
tion of the uterus and appendages for
purulent disease, the subsequent abdom-
inal pain and tenderness are not so com-
monly dependent upon adhesions gi has
: upon aahesions as has
Digitized by VjOOQIC
434
PELVIC DISEASES-PETERSON.
Jour. M.S. M.S.
been supposed. Rather in many cases it
is due to the presence of a diseased ap-
pendix. I know that my symptomatic
cures have increased since I began sys-
tematically to remove the appendix when
the abdomen was opened for other pur-
poses. This alone is enough to warrant
my continuation of the. practice.
As I stated at the outset of- this paper
there may be contraindications to the re-
moval of the appendix. However firmly
the surgeon may believe it his duty to
remove every appendix, he would not
prolong the operation for five minutes if
thereby he would seriously jeopardize his
patients' chances of recovery. Neither
would he remove the uterus in a case of
bilateral pus tubes nor resect an ovary
after removal of one pus tube, nor correct
a retrodisplaced uterus in addition to
other pelvic procedures, if thereby he
thought he was diminishmg his patients'
chances of life. Yet rarely in his routine
work does he have to decide against such
additional procedures. I cannot see the
force of the time argument against the
removal of the appendix as applied to the
large majority of cases. In my opinion,
as before stated, the removal of the ap-
pendix as a concomitant operation when
opening the abdomen for other purposes
should not and does not in the hands of
the trained surgeon add to the mortality
of the abdominal section. Nor do I be-
lieve it prolongs the convalescence. These
last two statements are individual
opinions and possibly are of value merely
as applied to my own work. But if they
be universally true the only reason for the
non-removal of every appendix where no
contraindications exist is eliminated and
the operator is logically compelled to re-
move the organ in every case, otherwise
in nearly 50 per cent, of cases he will be
leaving behind a diseased appendix. His
operations will be incomplete and his pa-
tients will suffer correspondingly.
Another argument in favor of removal
of the appendix as a concomitant to pelvic
operations by the abdominal route is the
occasional presence of malignant disease
of the appendix. The cases of primary-
carcinoma of the appendix are multiply-
ing since the latter has been more sys-
tematically subjected to microscopic ex-
amination. Clark has reported recently a
case of primary carcinoma of the appen-
dix in a series of 120 laparotomies for
pelvic disease with coincident removal of
the appendix. One year later there had
been no return of the disease. A. O.
J. Kelly in 1900 reported three cases
of prijuary carcinoma of the appendix
in an examination of 706 appendices
removed by Deaver. There was a fourth
case but it may have been secondary to a
carcinoma elsewhere in the body. In the
three undoubted cases the tumors were
of microscopic size and were not detected
by the ordinary microscopic examination.
In my case also the true nature of the dis-
ease was not discovered until the syste-
matic laboratory examination had been
made. Although removed nearly a year
ago there has been no sign of a recur-
rence. Here are five cases of primary
carcinoma of the appendix in 1026 ap-
pendectomies all unrecognized macro-
scopically. All the appendices were re-
moved so early that the chances of non-
recurrences are very good.
Purposely I have passed over with few
comments that portion of our subject
which I believe has been settled beyond
doubt. Deaver, Ochsner, Kelly, and the
testimony of other equally good surgeons,
have proved that the appendix often be-
comes diseased through it$ close prox-
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October, 1904.
PEIyVIC DISEASES— PETERSON.
435
imity to diseased appendages and vice
versa. Baldy is of a different opinion,
but his statements lack proof. Micro-
scopic sections in quite a few of the 200
cases in my series showed progressive in-
volvement of the different layers of the
wall of the appendix, beginning with the
serosa and working inward. As far as
the surgeon is concerned, it is immaterial
whether this is exactly the same kind of
inflammation as that where the morbid
process starts with the mucosa. Suffice
it for him to know that the appendix is
diseased and may give rise to symptoms in
a certain proportion of cases.
CONCLUSIONS.
1. Only a little over fifty per cent,
of appendices removed during the course
of operations for pelvic lesions will be
found microscopically to be normal.
2. The remainder will show forms of
acute and chronic inflammation or the re-
sult of former inflammation.
3. The average length of the appendix
is between 8 and 9 centimeters. In 107
cases of the present series the average
length was 8.25 centimeters.
4. The maximum length of the ap-
pendix is found between the ages of 20
and 30. After this period the average
length of the appendix is less. While
this diminution probably is in part due
to normal atrophy, in a certain proportion
of cases it is influenced by inflammatory
changes.
5. Menstrual pain may be due to or
enhanced by the presence of an inflamed
appendix. The congestion incident to
menstruation increases the inflammation
and gives rise to attacks of appendiceal
colic.
6. It is exceedingly difficult to dif-
ferentiate between pain due to pelvic
lesions and pain duQ to chronic appendi-
citis. In the present series of cases a
much larger proportion of patients whose
appendices were abnormal gave histories
of having or having had this pain of
doubtful origin.
7. The appendix is adherent twice as
frequently in those cases where micro-
scopic examination shows past or present
disease. A certain proportion of adherent
appendices are, however, perfectly nor-
mal microscopically.
8. Mere shape of the appendix can-
not serve as an index of its normality or
disease. Appendices may be club-shaped,
constricted or bent upon themselves and
yet be perfectly normal microscopically.
9. The appendix is the seat of fecal
concretions in at least 8 per cent, of all
cases. Their existence does not denote
that the appendix is diseased.
10. Nearly 50 per cent, of patients
with chronic disease of the appendages
show accompanying disease of the ap-
pendix.
11. This inflammation may be the re-
sult of the direct contact of the appendix
with diseased adnexa or infection may
travel from the latter to the appendix
through the lymphatics connecting the
two.
12. In chronic disease of the append-
ages adhesions of the accompanying ap-
pendices are present in nearly 50 per cent,
of the cases, where microscopic examina-
tion shows the latter to be diseased. In
a certain proportion of cases, however,
although the appendix may be adherent
it is also perfectly normal.
13. In chronic disease of the append-
ages the appendix which is club-shaped,
constricted or contains fecal concretions
is not necessarily diseased.
Digitized by VjOOQIC
436
PEIvVIC DISEASES— PETERSON.
Jour. M. S. M. S.
14. In 60 per cent, of patients with
uterine fibromata there is accompanying
disease of the appendix.
15. In 70.9 per cent, of patients with
ovarian cystomata the accompanying ap-
pendices are diseased. The appendix is
not infrequently adherent to an ovarian
cyst and may even infect the latter.
16. The ordinary median abdominal
incision in the class of cases under con-
sideration amply suffices for the removal
of the appendix.
17. Such removal should neither in-
crease the mortality nor prolong the con-
valescence.
18. Since it is impossible for the sur-
geon to determine which appendix is dis-
eased by gross appearances alone, and
since nearly 50 per cent, of appendices
where the abdomen is opened for other
purposes are found diseased microscop-
ically — it is the surgeon's duty, in the ab-
sence of contraindications, to remove the
appendix in every such case, otherwise he
will leave behind diseased appendices
which may prove a subsequent source of
suffering to the patient.
19. Systematic -examination of series
of removed appendices show the occa-
sional presence of primary carcinoma in
such an early stage that it could not have
been detected by inspection at the time of
operation. Removal at this early stage
means probably a nonrecurrence and the
saving of a life. Even were carcinoma of
thfe appendix not commoner than once out
of 200 abdominal sections, it would still
be an argument for the removal of the
appendix in every case where the abdo-
men is opened for other purposes.
REFERENCES.
1. Baldy, J. M. — Appendicitis; Its Relation to
Pelvic Inflammations, American Medicine, 1904,
Vol. VII, p. 629.
2. Chognon — Des adhcrences de I'appendice
vermiculaire avec les organes avoisinants dans les
operations intra-abdominales, 1894, Lyon, No.
914.
3. Clado — Appendice Caecal. Comptes Rendus
Societe de Biologic, 1892, p. 133.
4. Clark, John G. — Unsettled Questions in Ab-
dominal Surgery, American Journal of Obstet-
rics, 1904, Vol. XLIX, p. 577.
5. Deaver, John B. — Pus in the Pelvis De-
pending upon and Complicating Appendiceal Dis-
ease in the Female. Methods of Treatment.
American Medicine, 1902, Vol. IV, p. 885.
6. Doran, Albert— Quoted by Sutton (171.)
7. Einhorn, H. — Ueber Perforationen des Pro-
cessus vermiformis und des Coecums. Munchncr
Medicinische Wochenschrift, 1891, bd. XXXVIII,
S. 121, 140.
8. Guinard, A. — Douleurs D'origine Appcn-
diculaire. Bulletins et Memoires de la Socidte
de chirurgie de Paris, 1904, Jan.
9. Kelly, A. O. J. — Tumors of the Vermiform
Appendix. University Medical Magazine, 1900,
May.
10. Kelly, H. A. — Under what Circumstances
is it Advisable to Remove the Vermiform Ap-
pendix When the Abdomen is Opened for Other
Reasons? Journal of the American Medical As-
sociation, 1902, Vol. XXXIX, p. 1019.
11. Kruger — Appendicitis und ihre Bezie-
hungen zu den weiblichcn Genitalorganen.
Deutsche Zeitschrift fur Chirurgie, 1897, Vol.
XLV., S. 401.
12. MacLaren, Archibald— The Relationship
between Dysmenorrhoea and Appendicitis. Amer-
ican Gynaecological and Obstetrical Journal, 1900,
Vol. XVII, p. 14.
13. Ochsner, A. J. — Appendicitis as a Cause
of Inflammatory Disease of the Right Ovary and
Tube. Journal American Medical Association,
1889, Vol. XXXIII, p. 192.
14. Peterson, Reuben — Appendicitis and Pel-
vic Disease. American Gynecology, 1902, Vol.
I, No. 2.
15. Poncet et Dormoy— Quoted by H. P.
Newman in Appendicitis from the Standpoint of
the Gynecologist. Journal of the American Med-
ical Association, 1903, Vol. XLI, p. 894.
16. Ribbert — Beitrage zur normalen and path-
ologischen Anatomic des Wurmfortsatzes. Archiv
fur Pathologische Anatomic, 1893, Bd. CXXXII,
S. 66.
17. Sutton — Surgical Diseases of the Ovaries
and Fallopian Tubes; 1891, p. 127.^
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OCTOBBR, 1904.
SUCCINIC PEROXID— YARBROUGH.
SUCCINIC PEROXID— (ALPHOZONE).*
CHARLES C. YARBROUGH,
Detroit.
437
Within recent years developments in
pathology have shown* that infection by
micro-organisms must be considered as
the chief etiologic factor of disease con-
ditions. The importance of these devel-
opments cannot be overestimated, for
through their instrumentality not only
has the treatment of a great many dis-
ease processes been placed upon a rational
basis but physicians have thereby been
enabled to institute measures which are
effective in their prevention.
It is now an established fact that nearly
all pathologic conditions of common
occurrence are due either directly or in-
directly to the action of pathogenic
germs. The basic principle of rational
treatment is: remove the cause and the
effect will cease. This means, substanti-
ally, destroy the germs and a cure is ef-
fected. So long as the offending germs
are present and active in the affected or-
g^n or tissues, just so long will the dis-
eased condition persist. Hence, it fol-
lows, that we must look to measures that
will destroy or inhibit the growth and
multiplication of these micro-organisms
as our best means of combating patho-
logic conditions in general.
This is my reason for bringing to your
attention today succinic peroxid, a re-
cently discovered chemical compound
which is a powerful destroyer of disease
germs and which bids fair to eclipse all
other germicidal substances yet produced.
It has so many desirable properties, I
♦Read before the Section on General Medicine
at the annual meeting of the Michigan State
Medical Society at Grand Rapids, May 27, 1904,
and approved for publication by the Committee
on Publication of the Council.
firmly believe it will prove to be one of
the most valuable of modern additions
to the physician's armamentarium. This
compound may have a number of tech-
nical names, such as succinic peroxid,
disuccinyl peroxid, etc., but its simplest
title, and the one by which the profession
will know it best, is Alphozone. This
latter, for the sake of simplicity, I will
employ in this paper.
Alphozone was discovered by Prof,
A. M. Clover, of the University of Mich-
igan. Prof. Clover no doubt has devoted
more research study to the chemistry of
peroxids than any other chemist, and
Alphozone is the outcome of his extensive
investigations. Alphozone is an Amer-
ican product, through and through, and
one to which we can point with pride.
Germany is noted for her synthetic chem-
icals, so much so that a great many phy-
sicians have begun to believe that every-
thing of the kind must of necessity be
"made in Germany." It is true Germany
has produced a large number of valuable
compounds, many of which are extens-
ively employed in this country, but this
does not mean that American chemists
cannot, in the field of chemistry, make
discoveries of equal importance.
As the name "succinic peroxid" sug-
gests, Alphozone is an organic peroxid
and is derived from succinic acid. It
has for its empiric formula, CgHjoOg,
which may be writen structurally, as fol-
lows :
CH.COOH
CH.COO
CH.COO
CH.COOH/
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438
SUCCINIC PEROXID— YARBROUGH.
Jour. M. S. M, S.
All peroxids are related in as much as
they contain an unusually high percent-
age of oxygen. The simplest peroxid is
hydrogen peroxid (HjOg) and with this
you all are, doubtless, more or less fami-
liar.
To show its chemical relation to hy-
drogen peroxid, Alphozone may be con-
sidered as being derived from hydrogen
peroxid by the replacement of each atom
of hydrogen in the molecule by a suc-
cinyl radicle (C4H5O8). Thus:
H-0 C^H.O,— o
H— O C,HjO,— O
There are numerous organic peroxids,
but Alphozone is the only one that pos-
sesses, per se, any decided germicidal
power. However, organic peroxids
which in themselves are not germicidal
develop this property after a time when
dissolved in or mixed with water. They
combine with a small portion of water
and form new compounds. This change
is known as hydrolysis and the products
as hydrolytic products. The products
formed are the corresponding acid and
peracid. In the case of Alphozone the
products of hydrolysis are succinic acid
and succinic peracid. These peracids are
all germicidal but vary in their potency.
A great disadvantage in employing or-
ganic peroxids other than Alphozone is
that hydrolysis takes place very slowly
so that the germicidal property is not
available until several hours have passed,
and this necessitates the preparing of so-
lutions some time before they are to be
used.
The peracids on standing in solution
for several days finally hydrolyze into
the corresponding acid and hydrogen
peroxid.
Alphozone closely approaches the ideal
germicide, for, besides its high germi-
cidal value, it is soluble, colorless, stain-
less, odorless, is non-poisonous, non-vola-
tile and practically non-irritating. It is
non-explosive under the most rigid tests.
It does not coagulate albumin. It is also
non-corrosive to animal tissues and non-
hygroscopic.
Alphozone is a fluflfy, finely crystalline
powder. It is, therefore, convenient to
transport or carry and is always ready
for instant use by simply dissolving it in
water. Such solutions are clear and
colorless.
The ready solubility of a germicidal
substance is a very important quality and
one which every physician fully appre-
ciates. Solutions of Alphozone a hun-
dred times too strong can be made in a
short time, and those of a strength usu-
ally required can be made almost in-
stantly. Solutions of Alphozone, it
should be remembered, do not retain
their strength indefinitely, owing to the
hydrolysis which slowly takes place.
Reduction in germicidal power is hardly
noticeable up to nearly a week, the length
of time depending upon the strength of
solution. It is advisable to make solu-
tions of Alphozone at the time they are
required, for then they will be reliable in
every instance.
A germicide in liquid form meets the
most requirements of the physician and
surgeon. A germicidal powder has a
number of uses, but a germicide in the
form of gas is of limited application.
Alphozone may be -used in two of these
forms — liquid and powder. As a pow^der
it may be used pure if required, or, for
ordinary purposes, diluted with 10 to 100
parts of some suitable powder, such as
boric acid, talcum, etc.
The nontoxic property of Alphozone is
one of its important characteristics. .This
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October, 1904.
SUCCINIC PEROXID— YARBROUGH,
439
nontoxicity is readily apparent when it
is remembered that the ultimate products
of the hydrolytic decomposition of Alpho-
zone are succinic acid and hydrogen per-
oxid. Being such an innocuous chemical
there need be no fear of untoward results
from its general use, and for this reason
it can be freely used internally as well as
externally. Alphozone may be employed
in place of almost all of the many ger-
micides and antiseptics now in use. As
it is odorless and stainless, it will most
agreeably displace those having offensive
odor, as well as those possessing staining
properties.
The germicidal energy exerted by Al-
phozone is most surprising, and it is re-
markable that a nontoxic germicide can
be so energetic. In the minds of most
physicians high germicidal value is asso-
ciated with toxicity, but in Alphozone we
have a substance that is not excelled in
germicidal value, not even by mercury
bichlorid. Being equally germicidal with
mercury bichlorid, as comparative tests
thus far indicate it to be, Alphozone can
be used in every instance where this sub-
stance is indicated and also in every in-
stance where.the bichlorid would be desir-
able if it were not for its toxicity and easy
absorption. Alphozone may be substituted
for mercury bichlorid in every instance
as a germicide and in the same strength
solutions, as it has none of the prohibitive
properties of the latter. Authoritative
investigators state that the germicidal
point for a l-to-5000 mercuric chlorid
solution is 15 minutes. It is found that
the germicidal point for a l-to-5000 Al-
phozone solution is 7.5 to 15 minutes.
One of our best known and most used
germicides is carbolic acid. By the ratio
of their germicidal value as evidenced by
comparative tests, Alphozone is 75 times
stronger than carbolic acid. Besides this
marked difference Alphozone has none of
the undesirable properties of carbolic
acid. It is not toxic or escharotic and, un-
like the carbolic acid, is free from dis-
agfreeable and persistent odor. Alphozone
is an advantageous substitute for carbolic
acid in many of the general uses of the
latter.
The popularity of hydrogen peroxid as
a germicide is due to its ease of applica-
tion, its nontoxicity, its being odorless,
colorless, stainless, its slight irritating
properties and to its quite marked ger-
micidal value.
It was perhaps the most all-around
satisfactory germicide up to the time of
the discovery of Alphozone. Alphozone
has all of the favorable properties of
hydrogen peroxid and others that are
characteristically individual. By a ger-
micidal comparison, Alphozone is over
100 times stronger than absolute hydro-
gen peroxid. Repeated experiments, un-
der the same conditions, prove that a
solution of Alphozone 1 part in 7500
(1/75 of 1 per cent.) will kill typhoid
bacilli in the same time that is required by
1 part in 66 (1^ per cent.) of absolute
hydrogen peroxid. The action of Al-
phozone solutions upon pus and blood is
much the same as that of hydrogen per-
oxid solutions, except the effervescence.
There is a general belief among physi-
cians that hydrogen peroxid destroys pus.
This belief seems to be not well founded
for test-tube experiments do not verify it.
If 1 cubic centimeter of pure pus be
placed in each of two test-tubes and to
one be. added 10 cubic centimeters of
physiologic salt solution and to the other
10 cubic centimeters of a 3 per cent,
hydrogen peroxid solution in small por-
tions till effervescence ceases, shaking
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4fo
SUCCINIC PEJ10XII>— YARBROUGH.
Jour. M. S. M. S.
both vigorously for a few minutes, then
allowing them to settle, it will be found
that there is about as much pus (as sedi-
ment) in the tube upon which the hydro-
gen peroxid acted as in the tube contain-
ing the .salt solution in which there was
no action, which quite conclusively shows
that pus is not dissolved by hydrogen
peroxid. In this experiment, using salt
solution and hydrogen peroxid 100 times
in excess, does not modify the results.
This belief, that pus is destroyed by hy-
drogen peroxid, is probably based on the
fact that the pus is displaced by the me-
chanical action of the escaping oxygen.
This mechanical displacement is a cause
for harm in confined spaces, as the pres-
sure produced forces more or less of the
pus and micro-organisms it contains into
the surrounding tissue, thus increasing
the infected area.
Blood is quickly decolorized by Alpho-
zone solution. A drop of blood added to
10 cubic centimeters of a 1-to-lOOO solu-
tion soon results in a nearly colorless
mixture. If 1 cubic centimeter of defibri-
nated blood be added to 10 cubic centi-
meters of a 1 per cent, solution of Alpho-
zone, it is changed to a clear, pale yel-
low solution. Alphozone solutions have
more or less the bleaching properties of
hydrogen peroxid.
Formaldehyd is at present considered
one of our most valuable disinfectants.
Its greatest value lies in the fact that it
can be used in the gaseous form.
It is the belief of almost every physi-
cian that formaldehyd is intensely ger-
micidal, but such belief is not well
founded for, in truth, the 40 per cent,
solution has about the same germicidal
value as carbolic acid. Repeated tests
prove that it requires 30 minutes for a 1
per cent, solution to kill Staphylococci
pyogenes aureus. A 1 per cent, solution
of carbolic acid will kill the same germ
in the same time. A 2 per cent, solution
of formaldehyd and a 1/50 per cent. Al-
phozone, each, kill staphylococci in 10
minutes, or, in other words, a l-to-10,000
Alphozone solution kills staphylococci in
the same time as required by a 1-to-lOO
solution of formaldehyd. Therefore, Al-
phozone is germicidally 100 times
stronger than formaldehyd (40 per cent,
solution), .
(Vanderlinder and De Buck state that
corresponding solutions of formaldehyd
are not more germicidal than carbolic
acid.)
Comparing Alphozone with other well-
known germicides, it can be said that it
is six times stronger than silver nitrate,
25 times stronger than tricresol, 50 times
stronger than lysol, 60 to 75 times
stronger than creolin, 100 times stronger
than potassium permanganate, 200 to
250 times stronger than salicylic
acid, 350 times stronger than a solution
of Seiler's tablets, (two tablets to the
ounce), 400 times stronger than eucalyp-
tol, 2500 times stronger than the listerine-
like compounds.
From the foregoing it will be obvious
that Alphozone has a wide field of useful-
ness, both in surgery and medicine.
Alphozone will be found a convenient
agent for the sterilization of the hands,
local surface areas, certain surgical in-
struments and appliances, dressings,
sponges, rubber sheeting, etc.
For the sterilization of the hands, the
method and suggestions by Welsh or
Lockwood may be followed, substituting