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but is located beyond the reach of the
finger.

In nearly three hundred and fifty con-
secutive cases of rectal trouble occurring
in private practice, there were found
twenty cases of stricture of the rectum.
Of these, two were malignant and the
others were benign. Twelve were sit-
uated high up in the rectum near the
sigmoid flexure beyond the reach of the
finger, and six were located near the



anus. In other words, benign strictures
occur about one- fourth times oftener in
the rectum than Allingham would lead
us to suppose; and, further, that it
affects the upper portion of the rectum
twice as often as it does the lower
portion.

In the out-patients' department of
the surgical clinic of the Medical Col-
lege of Ohio most cases of stricture of
the rectum were found to be located
near the anus, and the only case where
the stenosis was located higher up was
the case (V) above reported.

The fact that fewer cases of stenosis
of the rectum high up were seen in the
out-patients' department of the surgical
clinic than in private practice shows
that these charity cases apply for relief
to the medical man, and are probably
treated by him for some bowel trouble
without the real cause of the disease
being recognized.

BIBLIOGRAPHY.

1. Van Bursn: '* Diseases of Rectum,*'
edition 1881, p. 261.

2. Allingham: *' Diseases of Rectum,"
fifth edition, p. 3.

3. AsHTON : •* Diseases of Rectum," fourth
edition, p. 213.

4. Kblsey : ** Diseases of Rectum," p. 345.

5. Esmarch: **Krankeiten des Mastdar-
mes und des Afters," edition 1887, p. 106.

6. Henry Smith: ** Surgery of Rectum,"
fourth edition, p. 25.

7. Ball : ** Diseases of Rectum ind Anus,"
p. 149.

8. Sir Benjamin Brodib: Medical Ga-
zette^ vol. 16, p. 30.

9. Van Buren: "Diseases of Rectum,"

P- 359.

10. Allingham: ''Diseases of Rectum,"
p. 365.

11. Esmarch* p. 106.

12. Mathews : *' Diseases of Anus, Rectum
and Sigmoid Flexure," p. 348.

13. Gant: *' Diseases of Rectum and
Anus," p. 147.

14. Curling: ** Diseases of Rectum,"
edition 1859, p. 86.

15. Salmon : Fourth edition, p. 23.

16. Bardslbben: "Surgery," vol. 3, p.

958.

17. Cripps: ** Diseases of Rectum," p. 223.

18. Cincinnati Lancet - Clinic, 1894,
November 17.



I Curling, p. 86, reports a similar case oc-
curring in the London Hospital in 1850.



Belladonna is indicated in dullness,
delirium, vertigo, headache, distention
of the veins, epilepsy and typhoid fever
delirium, etc. — Med, Summary.



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SH



THE CINCINNATI LANCET-CLINIC.



THE PRESENT STATUS OF ABDOfllNAL
SURGERY.*

BY RUFUS B. HALL, A.M., M.D.,
CINCINNATI.

Whilst duly appreciative of and grate-
ful for the honor of presiding over so
distinguished a body of medical gentle-
men, I nevertheless feel that the con-
ferring of this honor imposes also im-
portant obligations. If I hope to please
this energetic and ambitious body of
medical men I must not weary you with
any very extended remarks, and these
should be upon a subject that will in-
terest all practitioners of medicine. I
have decided to invite your attention
for a few minutes to the topic, **The
Present Status of Abdominal Surgery."

When Ephraim McDowell, in De-
cember, 1809, accomplished his great
feat, the successful removal of an ovarian
cyst, he became one of the greatest
benefactors of the human race. After
years of doubt and contention as to his
claim, this honor was at last conferred
upon him. The medical profession of
the whole world did him homage. In
later years when this operation was
conceded to be a legitimate surgical
procedure, through the combined efforts
of our distinguished Dunlap of Ohio,
Nathan Smith of Connecticut, Gallop
of Vermont and the Peaslees of Penn-
sylvania, it was believed by many who
are still living that the limit of surgical
procedure inside the abdomen had been
reached. In 1863 ovariotomy was re-
ported as having been performed in
America 117 times, with 68 recoveries
and 49 deaths. Time will not permit
the review of the early history of the
operation in this country and abroad,
and the mention of all those distin-
guished men who helped to place it
within the domain of legitimate sur-
gery. Suffice it to say that the mor-
tality attending the operation for re-
moval of ovarian cysts that are uncom-
plicated is not now more than 3 or 4
per cent.

Surgery within the abdomen prior to
1872 was limited to the removal of

♦Address of the Retiring President, de-
livered before the Ohio State Medical Society,
May 10, 1900.



large ovarian cysts, except in a few in-
stances where a mistaken diagnosis had
been made by the opyator. In 1873
Battey (of Georgia), Hegar (of Heidel-
berg) and Tait (of Birmingham) each
planned and deliberately executed the
operation for removal of the ovaries
for definite pathological conditions
when they were not the site of tumor
formation. It is true each sought a
different object, but their work and in-
fluence greatly enlarged the field of sur-
gical procedure in the abdomen. They
extended surgery into the pelvis, and
to their influence, combined with that
of Lister, is largely due the present
broad scope of surgical procedure in
this department of surgery.

The removal of pus formations in
the tubes and ovaries, with the varied
allied diseases, with which Tait's name
is so closely associated, was a step
greatly in advance at the time of its
inauguration. It is an operation that
has saved many valuable lives and re-
lieved untold suffering. The technique
of the operation has been so improved
of late years that the mortality in pus
cases has been greatly reduced, making
this one of the great life-saving opera-
tions of the day.

The operation for removal of rup-
tured tubal pregnancy, if the operation
is made before the patient becomes ex-
sanguinated or septic, is one of the
most favorable in abdominal surgery.
It snatches the patient from the very
jaws of death.

The operation for myoma of the
uterus marks one of the great advances
in surgical achievement. This opera-
tion should be as successful as that for
removal of ovarian tumors, providing
the case is operated before complica-
tions arise involving the tumor, ab-
dominal and pelvic viscera. The new
operation of myomectomy, or rather
the revival of the old one with a new
technique, bids fair to become popular,
as it should, yet there will always be
cases where this procedure cannot be
employed. There is no question as to
its legitimacy in properly selected cases.
Total extirpation of the uterus for can-
cer is an operation that is practiced by
many surgeons to-day with good pri-



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515



mary results. Extirpation of the uterus
for cancer of the cervix, cither by the
vaginal or abdominal route, is an oper*
ation that is made with a surprisingly
low mortality, ranging all the way
from 2 to 10 per cent. Yet it is an
unfortunate fact that within a year or
two a large per cent, of -these patients
have a recurrence. This fact should
not deter the surgeon from rendering
his aid for the relief of these unfortu-
nate patients.

The operations of Caesarean section
and Porro's operation are, fortunately,
rarely required. When they are neces-
sary it is gratifying to know that there
are men scattered all over this State
and country who are prepared and will-
ing to operate in this emergency. It
has only been a few months since one
of the younger members of our profes-
sion, living in a country district, made
the Caesarean operation, saving both
mother and child.

Operation for rupture of the uterus
during labor, unfortunately, has a high
mortality attending it, owing to the
fact that these cases are usually infected
from the contents of the uterus empty-
ing into the abdomen before the opera-
tion is made. This infection, plus the
large amount of blood lost before the
operation, gives to it a very high mor-
tality. Yet operation promises some
chance of saving life.

The removal of the uterus in puer-
peral sepsis is an operation that is not
yet firmly established as a surgical pro-
cedure. To make a correct diagnosis
and be able to say that the patient in
question will not recover unless the
uterus is removed, and that she will
probably recover if it is removed, is a
very difficult problem for the physician.
This uncertainty and the high mortality
makes the legitimacy of the operation
questionable, it remains for the future
to decide this very important question.

Operations upon the gall-bladder are
often performed for gall-stones obstruct-
ing the common or cystic ducts, dropsy,
an empyema, wounds and perforations.
The field of operation pertaining to the
gall-blacider and gall-ducts has been
greatly enlarged in the past few years.
Medical opinion has greatly changed



regarding this class of diseases. For-
merly they were considered exclusively
medical; now they are considered
almost, if not quite, surgical. The
mortality attending the operation where
the common duct is not obstructed is as
low, if not lower, than any of the ab-
dominal operations ; while the mortality
attending the operation where the com-
mon duct is obstructed is very high,
probably 40 to 50 per cent. This ought
to be a great incentive to induce the
physician to advise an operation early
in the disease before the common duct
becomes obstructed.

Splenectomy, fortunately, is an oper-
ation that is rarely called for, but when
that organ becomes the seat of disease,
necessitating its removal, it is not
exempt from the surgeon's knife. Two
of our members have recently success-
fully removed greatly enlarged spleens
and cured their patients.

The pancreas must always present a
limited field for the exercise of opera-
tive surgery. It is not surprising, there-
fore, that the experience of the past has
added little to our knowledge upon this
subject. Until Senn presented his essay
to the profession, in 1885, there was
not much literature by which to be
guided. He may be said not only to
have founded, but to have built up, the
surgery of this organ. The removal of
the organ is exceedingly difficult, tedious
and dangerous. Tapping or aspirating
cysts of this organ promises little, if
any, permanent relief ; but if the abdo-
men is opened and the cyst stitched to
the abdominal wall and drained, there
is a fair prospect of recovery.

Cysts of the omentum are not infre-
quently encountered and removed. The
operation is a difficult, tedious and
bloody one, but it promises good re-
sults. Tumors of the mesentery are
not infrequently encountered and have
been successfully removed. If the
tumor is a solid one the modem prac-
tice is to enucleate and remove it ; if it
is a cyst stitch it to the abdominal wall
in the line of incision and drain it.

In peritoneal tuberculosis surgery has
been of great service. Especially is
this true where there is encysted dropsy.
If the infection has entered through the



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THE CINCINNATI LANCET-CLINIC.



Fallopian tubes, with formation of an
abscess in one or both sides of the pelvis,
and the operator is able to remove the
pus cavities and establish drainage, a
surprisingly large number make com-
plete recoveries. But surgery has been
of little or no avail in peritoneal tuber-
culosis where there is no fluid in the
peritoneal cavity.

In gunshot or stab-wounds of the
abdomen involving the intestine and
stomach surgery has been of great ser-
vice. Especially is this true if the
operation for relief is made within two
to four hours of the receipt of the
injury. In operations made twelve or
more hours after the receipt of the
injury the mortality is very much
greater. The same could be said re-
garding perforations of the stomach
and duodenum due to ulcer. The im-
proved technique that our distinguished
Senn gave us in his bone-plates for in-
testinal anastomosis was afterwards
greatly simplified by the Murphy
button. Later this was greatly im-
proved by Dr. LaPlace's invention
of his clamp forceps, by means of
which end-to-end anastomosis can be
quickly and safely made, and when
completed no foreign body is left in
the intestinal tract. There has been
one great law established beyond dis-
pute in dealing with intestinal perfora-
tions, viz., the sooner the operation is
made after the receipt of the injury the
more certain will the patient recover.
From the very nature of the injury and
the extent of the operations the mor-
tality must always be high in this class
of operations. But when we remember
that the best statistics to date give a
mortality of 88 per cent, for all pene-
trating gunshot- wounds of the abdomen
treated without operation, we can well
afford to make an effort to reduce this
mortality. This, I am glad to say,
surgery is able to accomplish.

The various operations of gastrotomy
and gastroenterostomy have been fre-
quently made with very gratifying pri-
mary results, and recently the medical
and surgical world was startled by the
report of a case of total extirpation of
the stomach, with the recovery of the
patient. This operation has been fol-



lowed by several other similar ones,
with a few recoveries as well as a few
deaths. But it is an operation that will
probably not become popular.

Operations for rupture of the intes-
tine from trauma have been success-
fully performed on a number of occa-
sions. The prognosis of intestinal rup-
ture being utterly hopeless without
surgical interference, operation gives
the patient the only chance of life. The
advisability of operating for perfora-
tions of the intestine during typhoid
fever is a broad and difficult question
that is not thoroughly settled as yet. A
few successful operations for this con-
dition have been made. The first suc-
cessful case in Ohio, to my knowledge,
is the operation recently made by one
of our former presidents.

Operation for rupture of the urinary
bladder from trauma has been made
quite a number of times. The mor-
tality attending the operation must ne-
cessarily vary according to the amount
of injury to the pelvic bones and ad-
jacent structures. But considering the
almost necessarily fatal termination
without operation, a very high mor-
tality would not be a contraindication
to the operation.

Surgical intervention in peritonitis
is the natural result of our increased
knowledge of the causes of peritonitis.
The conditions demanding surgical in-
tervention for their cure are manifold,
and will not be referred to in detail ;
but it may be asserted with positiveness
that all accumulations of pus in the
peritoneal cavity, from whatever cause,
should be dealt with surgically and
without delay. Perhaps the one organ
calling most frequently for surgical in-
terference to prevent acute peritonitis,
except possibly the Fallopian tubes, is
the vermiform appendix.

Only a few years ago appendicitis in
all of its various forms was regarded as
purely a medical disease. But to-day
there is hardly a physician in our land
who is not willing to concede that there
are a large number of these cases that
should be treated surgically. The ma-
jority of physicians are inclined to the
opinion that the disease should be re-
garded as a surgical one front the first.



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Appendectomy is truly a life-saving
operation— one that has saved many
valuable lives and is destined to save
more in the future. It is one of the
triumphs of the surgery of our age.
Appendicitis is a disease that spares no
one; neither the old nor young, rich
nor poor are exempt. If the operation
is made in the interval of the attacks
the mortality is not more than 2 per
cent. Where an appendiceal abscess
is opened before rupture into the peri-
toneal cavity the mortality is very low.
Operation after rupture of the abscess
into the peritoneal cavity, the reverse
is true.

This brief risumS indicates what
may be expected of the abdominal sur-
geon of to-day. He has taken advant-
age of all advances in pathology and
general surgery and applied their prin-
ciples to his own special field. Every
new fact in therapeutics or in internal
medicine has been weighed to deter-
mine its possible use in symptomatic or
preventive treatment.

Standing fully abreast of his profes-
sional confrires^ the abdominal surgeon,
looks to the future with confidence.
Increasing knowledge, better morals
and cleaner lives will lessen in some
fields the call for his services. But he
will be better equipped for the work
that will always remain for him to do.



Bureau of Infonnation In Philadelphia.

The directors of the Philadelphia
County Medical Society will establish
a bureau of information for the benefit
of physicians on the way to Atlantic
City, at the College of Physicians of
Philadelphia, northeast corner of Thir-
teenth and Locust streets. This bureau
will be open from 10 a.m. until 5 p.m.
daily except Sunday, from Mondav,
June 4th, to Monday, June nth.
Physicians are invited to make free use
of the bureau, where they may obtain
full information relative to the situation
of the various hospitals, medical col-
leges, and other scieiftific institutions
of Philadelphia, and the time of opera-
tions and clinics at the dififerent hos-
pitals throughout the city.— iV. T, Med.
Record*



ALCOHOL: ITS PLACE.*

BY R. T. TRIMBLE, M.D.,
NEW VIENNA, O.

Well knowing the value of time
in the meetings of this association, it
is with hesitancy that I ask a hearing
upon a subject so often and fully dis-
cussed as alcohol. It is only the im4
portance of the theme that offers a
reasonable excuse for its presentation^
especially when one has no original
investigations or novel ideas to offer.
One merit, however, is promised as a
bM for your kind attention — ^the merit
of brevity.

First, is alcohol to be placed among
the foods, or does it belong to the list
of drugs whose names are properly
recorded in our materia medica ? The
magnitude of this inquiry can hardly
be exaggerated. Indeed, it seems to the
writer that the welfare of the race
largely depends upon the answer. More
potent for good than all the fervid
oratory of the temperance agitator, than
all the manv pages of literature upon
this theme that come pouring from the
press, than all sermons from the pulpit,
yes, far more potent would be the clear
unmistakable voice of the medical pro-
fession, speaking in the name of science,
stating as a plain unquestionable; fact :
'* Alcohol is not a food, is not an inno-
cent beverage for the human race, is
not conducive to the health and well
being of normal man ; but, on the con«
trary, it belongs among the drugs and
the active poisonous drugs at that, only
safe in the hands of the careful, con-
scientious physician, and the^ sale of
which should be under at least the same
restrictions as other poisons." Who
can estimate the good that would come
to the individual man and to society at
large from such a statement, bearing
the stamp of scientific truth, and from
a profession whose right to speak with
authority all must recognize ?

It is not my intention to give a tem-
perance lecture, nor to deal in tjie emo-
tional, but it does seem to me that of
all men physicians should most clearly



* Read before the Ohio State Medical So-
ciety, May zo, 1900. /



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THE CINCINNATI LANCET-CLINIC.



realize the evils that follow the in-
discriminate sale and use of alcoholic
drinks. The injurious effects of the
drink habit are constantly brought to
their notice. Not only do they see the
poverty of the drunkard's abode, not
entitled to be called a home, but also
are called upon to relieve the troubles
directly due to alcohol.

They understand as no others how
materially are the life chances lessened
in any conflict against disease, or the
results of injury, in the chronic alco-
holic, and they also see the destructive
work of drink upon the moral and
intellectual faculties, and appreciate in
their fullness the awful facts of heredity.
And we may add that physicians of all
men are the innocent sufferers in a
financial sense by reason of the sins in
this direction of many of those that ask
their services.

I will not take the time to quote sta-
tistics showing the evil effects of alco-
holic beverages ; the number of insane
attributed to this cause, the number of
criminals, etc. Dr. T. D. Crothers says,
and I believe truly, that alcohol directly
tends to cause moral degeneration, and
especially in this direction are its effects
hereditary. It is a well-understood fact
that the opium-eater is always a liar,
and may not the same be said of the
alcoholic victim ? Another fact is con-
stantly brought to the attention of phy-
sicians — the close relation, as cause and
effect, of the use of alcohol and venereal
diseases. Bacchus and Venus are surely
in a combine. No wonder that so many
distinguished members of the medical
profession have lifted up their voices and
uttered warnings against the dangers
of alcohol — Davis, Emmet, Thomas,
Crothers, Richardson, and a host of
others, known to you all.

Now, coming again to our question,
is it not a fact that alcoholic is a drug
and not a food? Recently there has
been much comment in regard to the
investigations of Professor Atwater,
which are claimed to prove that alcohol,
when ingested to a limited amount, is
consumed in the body as fuel, serving
as a force-producer, and so far entitled
to be called a food. A review of the
work of Atwater by Drs. Woodbury



and Egbert, in the yournal of Ameri-
can Medical Association of March 31,
clearly shows that the investigations
fall short of scientific accuracy, and are
not at all convincing. But even admit-
ting the facts claimed, they by no means
prove that alcohol is justly entitled to
be ranked as a food. Indeed, the in-
vestigations give nothing new ; they are
but old straw thrashed over. Though
a limited quantity of alcohol can be
burned as fuel in the body, and so,
under certain conditions, prove useful
in sustaining the physical forces, this
fact does not warrant the assumption
that it is a safe and proper substance
to be habitually supplied to the system
in a normal state.

If there are constantly evil effects
accompanying its use, this fact w^ill
overshadow any food value it may pos-
sess. Many substances might be capa-
ble of consumption by the organism,
and yet, by reason of dangerous conse-
quences accompanying their use, be
wholly unsafe and unsuitable as articles
of diet. Because gunpowder is capa-
ble of combustion does not justify its
being considered as fuel for a steam
engine. Alcohol, of course, supplies
nothing to repair tissue waste, and no
one claims it a food in this sense.

The statement of Lawson Tait, "that
the moderate use of alcohol is a neces-
sity in our modern life," is certainly,
I believe, contrary to the teachings of
both science and experience. The fact
that alcohol lessens oxidation and tissue
waste, thus lowering the temperature,
is surely no argument in favor of con-
sidering it a food. In a state of health
such properties are not necessarily to
be desired in a food substance, and may
cause very injurious consequences. The
fact that the habitual use of alcohol has
a direct tendency to increase the con-
nective tissue of almost all the vital
organs, giving rise to subsequent con-
traction, atrophy and fatty degeneration
of the parenchymatous structures — in
other words, inducing cirrhosis — makes
it one of the m6st insidiously danger-
ous agents in the list of drug^. In this
it is far more potent for evil than opium.
There is nothing to be said in excuse
of the opium habit, but really there is



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519



a question but what the orientals have
made a wiser choice in smoking opium
than the western races in their dram
drinking. Certainly opium does not
produce the physical degeneration nor
so directly tend to shorten life as alco-
hol. My conclusion on this phase of
my subject is that the place of alcohol
is not among the foods, but that it
belongs with the drugs, useful as a
medicine, but injurious as a beverage
in health, and that the medical profes-
sion owes it to itself and to humanity
to speak plainly and emphatically, pro-
claiming this truth. It is the glory of
the profession of medicine that it is
not alone concerned with the cure of
disease, but also its prevention; and



Online LibraryAlice Morse EarleThe Cincinnati lancet-clinic → online text (page 89 of 107)