Extracts and Abstracts.

TRAUMATIC APPENDICITIS.

BY ALVAH H. TRAVER, M. D.

The literature on appendicitis has been so exhaustive that at first one would think it difficult to say anything on the subject not already known. The various symptoms and the significance of the same; the various operations and the advantages claimed for each, have been thoroughly described and are generally understood. However, the knowledge of the causes of appendicitis is as yet far from complete.

The common causes of appendicitis as given by most authors are catarrhal inflammation of the colon and adjacent appendix, and the presence of a foreign body in the appendix, most often of the nature of a fecal concretion. Some authors speak of traumatism also as a contributing cause.

Deaver says: "The connection between exposure and the development of appendicitis is most clear and direct, and must be accepted as clinically important. The same is also true of traumatic appendicitis in a limited number of cases. Appendicitis has been known to follow traumatism in the region of the appendix with such frequency that its etiologic significance cannot be ignored." Fowler says: "In one of my cases the patient gave a history of a blow over the region of the appendix first before the onset of the attack." McNutt, writing on this subject, says: "We learn by experience that a goodly number of cases of appendicitis are the direct result of blows, falls, wrestling, etc. Three such cases have come under my own observation recently. One boy was kicked by a school-fellow, another was pushed with a stick, the third, a man, fell, striking right side of abdomen." Curtis says: "A certain number of cases of appendicitis have followed direct injury, such as blows or kicks in the right iliac re gion. The writer recently operated upon a boy whose abscess formed immediately after a severe blow from a ball received in that region." Mynter says: "Direct injury occasionally precedes an attack of appendicitis. I found this the case four times in seventy-five cases, Hankins found it sixteen times in 190 cases, while Fitz found trauma given as the cause 190 times in 257 cases, and from a very large number of cases he had collected considers it the cause of the attack in ten per cent of cases." I would like to report a case of traumatic appendicitis that recently came under my care.

Mr. E. E., aged 24, train brakeman; has always been a strong, healthy man; never had any severe illness; never had any intestinal trouble of any kind; bowels have always moved regularly. On March 1, 1901, while applying a brake on a freight car the chain broke and he fell between the moving cars. He got up from the ground and walked a few feet, then fainted. He was then carried into a nearby building and later taken to the Albany Hospital. Examination: Patient semi-conscious; numerous bruises were present on head, chest, right hip and right side of abdomen. No fractures or dislocations were present. There was a marked bulging of the right iliac

region, which became more prominent when patient moved. On deep pressure a distinct tumor was felt in the appendicular region. The patient was put to bed and ice bags applied to head and abdomen. At the end of thirty-six hours he regained complete consciousness and complained of severe headache, pain in chest, right hip and right side of abdomen. On coughing the pain in right ilias region became intense. During his stay in the hospital he was troubled greatly with tympanites and constipation. On leaving the hospital, the latter part of April, the hip was still very unsature. The hernia was prominent and tenderness was still present in appendicular region. I was out of the city during May and June, so did not see the patient; but on my return found the patient in practically same condition as on leaving the hospital. During the summer I examined the patient frequently. The pain and tenderness in appendicular region were constant and became very severe when bowels moved. The tympanites and constipation were very troublesome. Present trouble: On October 19 the patient was taken with acute abdominal pain, most severe in right side. In the course of twenty-four hours his bowels became very distended and he had frequent attacks of vomiting. I saw the patient on the evening of the 23d. He had frequent attacks of vomiting of dark fluid possessing fecal odor. His general appearance was that of a very sick man. His temperature was 100.6, pulse 112. The abdomen was very much distended and general tenderness present, but tenderness was most marked in right iliac region.

The diagnosis of appendicitis was made and immediate operation advised. But both patient and his friends refused to consent to an operation. They finally consented to allow him to be removed to the hospital, providing I would not operate. On admission to hospital anodynes were stopped, heart stimulants were given and ice bags applied to abdomen. In the morning he had recovered from the effects of the anodynes, and more thoroughly appreciated his dangerous condition and readily consented to operation.

Immediate operation was performed. On opening the abdomen we found the omentum firmly bound to the anterior abdominal wall. After carefully loosening this we came down to the intestines firmly knotted together. The field of operation was walled off with gauze and the coils of intestines separated. Pus was found present between the coils of intestines. I could easily locate an enlarged and very adherent appendix lying deep down in the pelvis. As it was absolutely impossible to bring it up into the incision, the adhesions were broken up as carefully as possible and the base of the appendix tied off. The appendix was found to be perforated in several places. The pus was thoroughly sponged out. The cavity from which the appendix was removed was packed with iodoform gauze and a glass drainage tube introduced into the pelvis. The wound was closed with through and through silk worm gut sutures and regular dressing applied. The patient stood the operation fairly well. For twenty-four hours following operation he continued vomiting dark fluid. Drainage rapidly diminished, so that the tube was removed the next day after operation. The highest temperature following operation was 100.4 degrees, highest

pulse 100. He made a rapid recovery with no complications, except hematuria which cleared up in about fortyeight hours.

The reasons which lead me to conclude this attack of appendicitis was caused by previous injury are:

Ist. The distinct evidence of injury to right iliac region.

2. The inflammatory tumor in appendicular region following injury.

3d. From the time of the injury to the onset of the attack of appendicitis he was troubled with tympanites, constipation and constant pain in right iliac region. He had been troubled with none of these previous to injury. 4th. At operation the old firm adhesions gave evidence of previous severe inflammation. It is to be noted that he had had no previous attack of appendicitis or other cause. for such inflammation except the injury.

That such inflammation could have been the cause of this attack of appendicitis is perfectly possible. McBurney, in speaking of trauma as a causative facto! in appendicitis, says: "Any traumatism, however produced will give rise to an infected atrium—a necessary preliminary to inflammation here as elsewhere. If inflammation has led in involvement of the peritoneal coat of the ap pendix, and to the peritoneal coat of any structure adjacent to it, new tissue will be formed, leading in such case to periappendicular adhesions with resulting links and twists of the appendix itself, which interferes with its already poor circulation, and inflammation results."

Morrow says: "The chief cause for the bacterial infection of the mucosa of the appendix is by force applied in way. I believe that injury to the mucosa occurs most often from twisting of the appendix on its long axis as the result of adhesions."

From a careful analysis of the conditions found present at operation, and the history of the case, I believe I am justified in concluding that the inflammatory adhesions and resulting twisting of the appendix, caused by the previous injury, were the causative factor in bringing on the attack of appendicitis in this patient.-Albany M. Annals.

ALCOHOL AND SUBLAMINE AS HAND DISINFECTANTS.

Drs. Danielsohn and Hess report some comparative tests from Prof. Fürringer's division of the Friedrichshain Hospital, Berlin, as follows:

"We are compelled to indorse the claims of superiority for sublamine over sublimate. The non-irritancy of the preparation was most agreeably noticeable; the hands were not attacked in the slightest degree by this new disinfectant, while we had to suffer more or less from skin irritations after the use of sublimate. A further merit of sublimine is its considerably greater solubility, which, in practice, when speed is necessary, will be thoroughly appreciated."

The authors conclude that in the Fürbringer method sublamine may be substituted with advantage for sublimate, but consider the omission of alcohol in the disinfection inadvisable, even though favorable results may be obtained without it.

Prof. Fürbringer, in his "Comments on the Above. Treatise," adds:

"The undeniable advantages of sublamine have induced me to introduce the same among others as a hand disinfectant in my division."-Deutsche Med. Woch.

COCAINE ANESTHESIA IN MINOR SURGERY.

BY J. W. ROBERTSON, M. D., LITCHFIELD, MINN.

In the use of cocaine as an anesthetic it is absolutely necessary that we should know the physiological action of the drug. Corning says: "Cocaine given in moderate doses (from 14 to 1⁄2 gr.) acts as a stimulant to the heart's action, while at the same time its characteristic effect, mental exhilaration, is also apt to appear, especially if the hypodermic method of exhibition has been employed. When, however, it has been given in excessive doses (from 5 to 10 grs.) the phenomena induced are of a distinctly threatening character. Among the more striking manifestations are abnormal exaltation of the feelings, loquacity accompanied by mental incoherence, severe sweating, fall of temperature, shallow, irregular respiration, nausea, feeble pulse and ultimate collapse. While the production of these graver occurrences demands, as I have said, in a majority of cases, relatively larger doses, the rule is by no means invariable, for again and again it has happened that small amounts of the alkaloid have given rise to most threatening symptoms. Especially when the drug is used about the head should care be exercised in its administration, for here it is apt to reach the nerve centers in a state of relative concentration, and give rise to symptoms altogether out of all proportion to the quantity administered.

In a recent issue of the Northwestern Lancet occurs the statement:

"The three disagreeable after-effects following the employment of cocaine intraspinally are headache, vomiting and rise of temperature. According to Dr. Cordero, all these after-effects may be obviated by the administration of amyl nitrite."

Another operator insists that cocaine cannot be sterilized and that there is always danger of infection. I could. quote many cautions in this same line by numerous physicians, and it makes an operator feel that he is continually treading on dangerous ground. Now, for many years, I have been using solutions of cocaine in all operations about the eye and nose, and have never seen a single bad symptom which I could attribute to the effects of cocaine.

About five years ago I began using hypodermic injections of cocaine in many minor operations, but I was very careful not to use the injections where the circulation could not be interrupted. I got a case one day—it was a large wen on the top of the head-where the patient had chronic heart disease and asthma, and I preferred to take the chances with cocaine injection rather than give an anesthetic. I used a 2 per cent solution, and made the operation without any trouble, and the patient had no pain or bad effects from the cocaine, in fact she said "that the only thing she noticed was the numbness of the scalp."

My next operation was the amputation of the second toe in a very nervous girl. My next was the removal of

a great-toe nail. I then ventured to enucleate a cancerous gland from the neck of an old man. Being success ful in this, I tried it in the enucleation of an eye-globe, which is getting quite near the nerve centers. I had to use large quantities of a 4 per cent solution to relieve the pain in this case. I also tried it in a large fatty tumor of the neck, with good results.

I kept using stronger solutions without any of the terrible physiological symptoms mentioned by many operators. I finally was requested by a very prominent member of this society to remove a small sebaceous cyst from beneath his ear. He had been using cocaine hypodermically in minor operations for some time with very good results, and had no objection to it being used upon himself. A few drops of an 8 per cent solution was injected into the skin at the site of operation, and the tumor dissected out. This was the first time that I ever got any of the prominent symptoms attributable to this drugexaltations of feelings and loquacity. These symptoms were quite marked, but instead of being disagreeable they were just the opposite. The doctor suggested, however, that I would get just as good results by using weaker solutions of the drug. I followed his suggestion and tried a 1 per cent solution in a small necrosis of the foot, with equally good results. Since then I have used nothing stronger, although I used it in making an incision in the back for a perinephritic abscess near the right kidney in a very nervous person.

Formerly I used the chloride of ethyl as a freezing mixture for a local anesthetic in many minor operations, but now I use it only where I have an abscess or something of that kind to open.

I reported at our last meeting an operation under cocaine in a case of an immense strangulated hernia. Since then I have made an operation for removal of a cancerous gland which lay deep in the tissues of the neck, and an epithelioma of the lip, in which considerable tissue was removed. My last operation under cocaine anesthesia was the repairing of an extensively lacerated cervix, with success which even exceeded my own expectations. I have also used it in several cases where needles were removed from the hands and feet after location by means of the X-ray.

In all I have made more than 100 operations, not counting the eye operations, under cocaine anesthesia, and I am now doing seven-tenths of all my surgery with this local anesthesia, and have not seen any of the terrible symptoms mentioned by very many authors.

a long time. It is indeed a unique way of prolonging the anesthesia.

The third method is known as the block system. The solution is injected into the nerves supplying the part to be operated upon, which immediately stops all pain below. the injection.

The fourth, or spinal anesthesia, is to inject the solution into the spinal canal between the tenth and eleventh dorsal vertebræ, producing anesthesia below the injection. This method is in reality a block system.

In the fifth we have a method of producing local anesthesia with cocaine, which is frequently used by dentists, and that is cataphoresis, the diffusion of cocaine into the deep-seated tissues by means of electricity. I think this will some day be developed so that we can produce local anesthesia in any part of the body and to any extent desired.

The reasons I call the attention of the society to this method of anesthesia are:

I. It is far preferable to the freezing with ethyl chloride, because it is much easier to operate upon normal tissue than when it is frozen, and also because the anesthesia lasts much longer.

2. Our patients do not have the nausea and vomiting so commonly exhibited after taking ether or chloroform. 3. We can make all minor operations at our offices, and the patient can get up and drive home into the country. as soon as the dressings are in place.

4. There is not the fear of an operation where it is. known that the subjects do not have to take an anesthetic. 5. I do not believe there is any danger in the employment of cocaine if proper care is used.

6. I do not believe there is any danger of getting infection from the injections of cocaine or eucaine if the solutions are properly made.

7. This anesthetic can be used where chloroform and ether would be dangerous, as in very young and very old people, or in persons suffering with organic disease of the heart.-Northwestern Lancet.

VOIDABLE RELEASES IN PERSONAL INJURY CASES.

The general rule regarding releases in personal injury cases is to sustain them where it could be shown that the person giving the release had a full understanding of the nature of the transaction. The Court of Civil Appeals of Texas has set aside a release which was said to have been obtained upon representations of the defendant's

The first and most common is the Schleich infiltration method, which is to introduce the point of the syringeneedle just into the skin, and then introduce the needlepoint into that portion of the skin thus anesthetized, and inject it still further on, etc. With this method you are all familiar.

The second is Corning's method, which is practically the same as the Schleich, except he uses a specially devised syringe, and after the cocaine solution is injected he injects an oil and infiltrates the surrounding tissue with it. As the oil hardens it holds the cocaine in the tissue for

The physician stated that the bones of the arm were united and the arm was well; that as soon as the swelling passed away the arm would be as good as ever; and that it would be safe to make a settlement. The facts in evidence warranted the conclusion on the part of the court that the physician made such representations to the party for the purpose of inducing him to execute the release, and that the injured person believed the statements were true and relied upon them. The bones of the arm at the time of the trial were not united, and the arm was practically useless.

The defendant company set up that the statement of

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the physician was a mere opinion, and hence had no nullifying effect upon the subsequent contract. This the court holds is unsound doctrine, saying that the physician's opinion amounted to a statement of fact, stating in effect that he was a sound man, that the bones had united and that he would be all right. The fact that the statement made by the physician was not intentionally false did not affect the right of the party to have the release set aside if he was misled by the statement. Innocent misrepreInnocent misrepresentations may as well be the basis of release as where such statements are intentionally false.-Medicine.

SYNCHRONOUS BILATERAL TRAUMATIC PUL

MONARY HEMORRHAGE.

BY R. HARVEY REED, M. D. (UNIV. OF PA.), ROCK SPRINGS, WYOMING, Professor Emeritus of Principles and Practice of Surgery and Clinical Surgery, Ohio Medical University; Division Surgeon, U P. R. R. Co.; Surgeon, U. P. Coal Co.; Surgeon-General of Wyoming.

Pulmonary hemorrhage, the result of disease, is no uncommon occurrence, particularly in localities where tuberculosis prevails. I have seen a few cases of unilateral pulmonary hemorrhage, the result of a severe traumatism, but I do not recall a single instance in which synchronous bilateral interstitial pulmonary hemorrhage has occurred as the result of a traumatism, prior to the case I am about to report.

Tony Nardoch, an Italian, age 48, a laborer on the Union Pacific Railroad, was lifting a "jack" on July 26, 1901, when, as he stated, something "gave away," giving him a severe "jerk," resulting in what appeared at the time as a slight sprain of the chest and shoulders. This, however, was followed very shortly by severe shock. As there was no external evidence of injury and no hemoptysis, it was thought by his boss and fellow laborers that he would soon recover. It was discovered, however, that the shock continued, and he was sent to the Wyoming General Hospital, where he was admitted July 29, 1901, three days after the injury.

A careful examination revealed the absence of deformity and all evidence of external injury. There was no increase of his temperature and no noticeable change in the pulse, although the respirations were rapid and labored, resembling that of pneumonia. Percussion revealed dulness over the central portion of each ling, which gradually diminished as we approached the periphery. Auscultation revealed the absence of the respiratory murmur at the central portion of each lung, which was gradually restored as we neared the margins, where it became normal; this, with the absence of hemoptysis, led me to believe that it was a case of synchronous bilateral interstitial hemorrhage, which diagnosis was made, and an unfavorable prognosis given. He gradually sank and died on August 2, five days after his admission to the hospital, and eight days after his injury. A post-mortem was held some ten hours after death, which revealed bilateral interstitial pulmonary hemorrhage. There was no evidence of tuberculosis, or of acute inflammation; but there was evidence of his having had an old pleuro-pneumonia, resulting in adhesions which had involved almost the entire pulmonary and costal pleura.

The pathological conditions present indicated that the right lung had suffered more than its fellow from the pneumonia. The apoplectic condition of each lung was confined almost entirely to the central portion, and did not extend to the periphery or the lumen of the bronchi. It appeared as though there had been a locus minoris hemorrhagica, the focal point of which was situated at a point where an imaginary line, extending directly through the center of the lung antero-posteriorly, and another imaginary line extending directly through the center of the lung from its superior to its inferior margin, would intersect. From the focus the hemorrhage seemed to gradually extend in all directions, closing up the air vesicles and smaller bronchi by pressure, the hemorrhage being less marked as we proceeded from these focal points in every direction toward the periphery.

When the central portion of each lung was thrown into water it sank like a piece of liver. The same experiment demonstrated diminished hepatization as we proceeded from the center toward the periphery, where we found the lung tissue normal, with the exception of the pathological changes, the result of the previously existing pleurapneumonia. The blood vessels were slightly atheromatous, but the heart, brain and abdominal viscera were to all macroscopic appearances sound. It seemed that the sprain produced a synchronous rupture of some of the defective pulmonary arteries of each lung, which, owing to their atheromatous condition, continued to bleed slowly, but surely, into the substance of each lung, until by pressure the air cells and smaller bronchi became collapsed, correspondingly diminishing the function of each lung, until the patient was finally drowned in his own blood.

The unique features of this case are the facts that an apparently strong, healthy laborer, who sustained a slight sprain, should have one or more small pulmonary arteries of each lung ruptured at practically the same relative points and at the same time, and continue to bleed for eight days without hemoptysis, inflammation or febrile manifestations, until he finally succumbed from asphyxia.

It is quite evident that if this man had been in a railroad wreck, no matter how slight, with these conditions. followed by fatal results, that it would have been exceedingly difficult to convince a jury that the wreck was not the cause of his death, and that the company was not

responsible for damages for the same.-West. M. Review.

TREATMENT OF FRACTURES BY PRIMARY

SUTURING.

In this article, read by Naelke before the German Surgical Society, and discussed by its members, the author gave the results of his study and clinical observations as to how far we are justified in suturing every kind of a fracture, by the method now nearly universally used in the treatment of patellar and olecranon fractures. This method was used in four simple fractures of the tibia and two simple fractures of the humerus. His conclusions are that the primary suture does not bring about the results predicted for it and that in none of his cases did union take place any faster than by the old method of immobilization. He says that the only notable advantage is the security of good coaptation; however, one of the cases

of oblique fracture slipped notwithstanding the suture and the result was some deformity and shortening, which often occurs by treatment with splints, plaster and other appliances. In very oblique and rotated fractures, in all complicated and compound fractures, the author says that the suture should always be used, as well as in double fractures of the arm and forearm, leg and thigh. In the discussion Herr Arbuthnot Lane of London said that perfect apposition of fractured bones was impossible, even under anesthesia, because of the formation of hematoma primarily, in the masculature and secondary inflammatory products, and later shortening, and that in order to coapt and retain the fragments nothing short of good suturing could possibly bring about an ideal union.

Koenig argued that perfect coaption was not necessary to perfect function when the fracture was at some distance from a joint, but that when it passed through a joint, correct apposition and the formation of as little callus as possible were indispensable factors to good function, and that in such cases suturing was the proper thing. He reported two cases, one of fracture of the head of the humerus and the other an elbow fracture in which the suture gave perfect results.

Trendelenburg said that he also used the suture only in fractures either very near or through the joint and in fractures of the head of the femur he utilized a large screw which was screwed through trochanter and the head.

Pfeil recommended suturing of fractured bones ten years ago, but condemns the use of the screw on the ground that it does not heal and is apt to become an irritant. In twenty-nine cases of primary suture and four cases of screw appositions, he found a delayed union from insufficient callus formation and in one case the callus was so small that another fracture occurred directly in the line of union. Herr Korte of Berlin said that the suture

The most frequent seats of fractures in children are of the humerus, forearm, clavicle, thigh and leg, while fractures of the maxillæ, scapula, sternum and pelvis are so rare that time need not be consumed in considering them, nor is fracture of the rib frequently met with in children except in cases of violent crush.

True epiphyseal separation, and by this is meant a distinct separation of the epiphyseal cartilage from the osseous end of the diaphysis, occurs only in infants and is extremely rare, while osteo-epiphyseal separation is, according to Beck and Scudder, frequently observed between the ages of 14 and 17. Here the fracture is not limited to the cartilage, but passes into the diaphysis, and when of traumatic origin is most frequently found at the upper and lower ends of the humerus, the lower end of the radius, the upper and lower ends of the femur and the upper end of the tibia.

This form of fracture, or rather separation with fracture, cannot occur after the period of ossification, which, according to Quain, occurs in the humerus from the second to the fourteenth year; in the radius during the same period, while in the femur from the ninth month to the

fractured bones.

Hente of Breslau said that his clinical work in this line shows that union after primary suture is often delayed, and that such method will never have more than a narrow field of usefulness.

Lausenstein of Hamburg uses the primary suture in very oblique fractures, where the sharp portions of the fragments are strongly forced into the muscular structure. He recommends highly the Hausman screw, which he had used in sixty cases, but says that both by the suture and screw the union is ordinarily prolonged.

Schede utilizes only the ivory pegs where opposition by ordinary means proves inadequate.

Schlange warns against too frequent application of the suture, except in fracture of the tibia between the middle and lower third, where ordinary appliances are insufficient to hold the fragments. He advises the use of aluminum bronze wire.

place varies somewhat and depends also upon constitutional conditions; for example, in dwarfs and rachitic subjects the cartilaginous condition may continue up until the fortieth year. The tendency of epiphyseal separations is to produce premature ossification of the limb which may stunt growth.

In rickets the great brittleness of the osseous tissue makes fractures possible as the result of the smallest degree of violence, so does fragility in scurvy, infantile palsy of long standing; and Beck considers tuberculosis, especially of the knee, predisposing to fragility of the femur.

Causes. The causes of fractures in children may be due, as in adults, to direct and indirect violence, as well as to muscular contraction, the latter cause, however, is seldom a factor. Incomplete fractures are observed in children as a result of bending and partial separation, causing a so-called green-stick fracture which is due to

Bardenheuer of Kohln never uses the primary suture and has had the best of results by extension and early passive motion.

Kocher said that in diaphyses fractures the fixation treatment by splints or plaster was the proper method;

while the concave stratum, which is more flexible, is but bent. This infraction, as it is called, is frequently found in rachitic children in the tibia, fibula and femur.

As to the regions most frequently the seat of fracture: Forearm about 18 per cent. Of this number, 20 per cent occur at the lower end of the radius. Humerus about 20