sults-in other words, it is the synonym for all that is bad in surgery; while on the other hand, early operation simplifies and lessens the dangers of the operation. Everthing else being equal, the mortality will vary with the number of hours. allowed to elapse before operation. No satisfactory reason can be suggested for delay. My opinion is so pronounced on this point that I do not advise waiting even until daylight (provided I see the case for the first time during the night) but, on the contrary, urge immediate operation. And I might add that my experience and observation justify the opinion. I have operated at night and found the appendix in such condition as would warrant the belief that rupture would have occurred before morning had the operation unfortunately been postponed until that time. If I were asked to give an opinion as to the most common cause of delay in operation I should say, because of uncertainty of diagnosis. I believe the great majority of practitioners favor early operation when no doubt exists as to diagnosis. In violent and explosive attacks the diagnosis is easy, but in the milder forms, where symptoms are not very pronounced, the diagnosis is sometimes anything but easy. We should get together and arrive at some conclusions as to what group of symptoms warrants a diagnosis of appendicitis, and consequently justifies operation. This gives the patient the benefit of early operation, which will obviate complications that might arise should we wait for positive symptoms to assert themselves. This is the safe and conservative thing to do. Several years ago no one deliberately operated without there being present a tumor that could be seen and felt through the abdominal wall. Certainly no one would think of placing himself on record as recommending such a course today. The ordinary symptoms of appendicitis which, in my opinion, should govern us in advising operation are as follow: Pain, nausea, vomiting, elevation of temperature, increased rapidity of pulse, and rigidity of the right rectus muscle. Pain beginning more or less generally over the entire abdominal region and gradually localizing itself to McBurney's point, is a very suspicious symptom, and should not be treated by the administration of an opiate, which too often lulls both patient and doctor into a false sense of security, allowing valuable time to be lost in which the patient's life could easily be saved by an operation. To the above symptom add nausea and vomiting, increased rapidity of the pulse, with or without fever, and the case becomes still more suspicious. Then examine and find the right rectus rigid, and you have a perfect picture of appendicitis. Now ask the patient to place one finger on the point of greatest tenderness, and nine times out of ten McBurney's point will be located with wonderful anatomical precision. As time is a very important element in the success of abdominal operations, any method that will tend to expedite the operation and yet be effectual in its results, is always welcomed by the profession. In the suture which I shall here describe we have a suture applicable in the closure of a hole in the gut from whatsoever cause. It is also the best method of closing gunshot wounds. of the stomach. Having secured the artery of the meso-appendix with a ligature of fine silk in the usual way, and freed the appendix to its base, a small round needle threaded with fine silk is introduced well outside the circumference of the base of the appendix, and passed in and out, including serous and muscular coats of the bowel, until it emerges at a point well outside the circumference of the base of the appendix opposite the point of beginning. Now bring the needle back free to a point on a level with but on the opposite side of the base of the appendix from the beginning point, and pass the needle in the same manner as described for the opposite side. The suture when introduced represents a capital letter N. The appendix is now crushed with a clamp near its base and amputated flush with the cecum. To tie the suture, a single loop is made, and the ends of the suture are held at right angles to the direction in which the suture was introduced, and, taking care to see that the knot is kept over the center of the aperture to be closed, gradual traction inverts the edges of the opening, bringing serous surfaces in apposition. Holding both ends of the suture taut, a second knot is tied. The suture is now cut short, and the operation is done. PROSTHETIC SURGERY OF THE FACE. Report of a Case.* BY J. E. JOHNSON, M.D. MEMPHIS. THE case which I present for your consideration today is that of a young man to whom nature has been somewhat unkind. Mr. A. B., aged 26, family history negative, had a very common type of facial deformity, viz.: short upper lip, protruding upper alveolar process and teeth and receding chin. In the persistent effort to close the mouth by elevating the lower lip, the chin was badly wrinkled, as seen in photographs one and two. Golladay Lake, D.D.S., extracted the four front teeth, after which, with a pair of forceps I broke down the bone between the sockets of the extracted teeth and pressed down the outer hard layer of the alveolar process, thus shortening the process one-sixth inch, which was sufficient to receive four false teeth which Dr. Lake made on a bridge extending from the canine teeth. Then with a tenaculum through the lip in the median line, drawing the lip well down, I made an incision around the alæ nasi, extending so as to divide the nose from the lip. After partially dividing the levator muscles and crowding the orbicularis oris down with the scissors, the sutures were inserted with a full-curved Hagedorn needle, entering at the margin of the skin and going well back of the tissues and returning near the mucous membrane to enter the opposite side to emerge at the skin margin. Two such sutures were used, keeping the lip well drawn down while tying. My object was twofold, first, to lengthen the lip one-half inch, second, to throw the attachment of the lip to the septum one-fourth inch posteriorly. The denuded area on the septum was covered by drawing the skin from each side together. A little of the skin had to be removed to smooth the surface of the lip, but did not destroy the dimple of the lip. The cicatrix was in the fold around the alæ, close up under the nose, and for half an inch in the median line. It is scarcely perceptible. Now when the teeth are in apposition, the lips close without effort as seen in photographs 3 and 4. When he laughs, the tops of the teeth are not exposed. *Read before Tri-State Med. Assn. of Miss. Ark. & Tenn., Memphis, Nov. 12, 1902 Vol. 23-11 |