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Free Medical Services on Medical Men, their Families and Students. It has been asked what is the law on this subject. There is no law. No one has a legal or unassailable right to gratuitous medical services. Medical men as a fact do almost universally treat other medical men and their families without charge, and most men extend this privilege to medical students. It is certainly customary for students at a medical college to get free medical attention from the professors at that school. Few doctors would charge a medical student a few when he was known to him or when he was in pocr circumstances, but there would be nothing wrong in a wealthy medical student paying a poor professor a honorarium, if he wished to and under these unlikely conditions he ought to wish to do so. It is not customary to charge medical men or those of their family depending on them for medical services. That is, there should be no bill if it is to come out of the medical nan's pocket.

Selected Articles

THE TREATMENT OF DIFFUSE SUPPURATIVE PERITONITIS FOLLOWING APPENDICITIS.

BY FRANZ TOREK, A.M., M.D.,

New York; Attending Surgeon to the New York Skin and Cancer Hospital; Adjunct Attending Surgeon to the German Hospital; Adjunct Professor of Surgery in the New York Post-Graduate Medical School.

It is only within the last decade that recoveries from more or less generalized suppurative peritonitis have occurred in sufficiently large numbers to make this malady, which formerly had an appalling mortality, appear in a brighter light. Numerous articles have been written upon the subject, showing an increase in the number of recoveries; nevertheless, the fact that a mortality as high as 30 to 40 per cent. is still reported by surgeons as representing very favorable figures, goes to show how serious is the ailment with which we are dealing.

Up to the present time I have operated in eighteen cases of diffuse suppurative peritonitis by the method described below, and I feel prompted to publish these for the reasons, (1) that I have had the good fortune of being able to save all cases operated upon not later than seventy hours after the onset of the diffuse peritonitis, and even two on the fourth day; and (2) because my method of operating differs in many particulars from that described by other surgeons. When I had operated upon my first few cases without losing any of them, I thought the result might possibly be a matter of chance or good luck; but now, after looking back upon a respectable number of cases, especially inasmuch as all of them were of a very severe type, I cannot help believing that there is something in the method of treating them that has helped to bring about this gratifying result.

In this list of eighteen cases I have had three deaths-one operated on at the end of the third day (Case 17) and two operated upon on the fourth (Cases 14 and 18). One of these fatal cases (Case 14), a boy of ten years old, was actually moribund when he was brought to the operating table. He had reached that stage in which pain ceases to be felt; as I pressed on his much distended, board-like abdomen, he declared, on being questioned, that he had no pain. A case like this one would naturally not be touched by any one whose aim is to present favorable statistics, it would have been very easy to report 100 per cent. of cures; for, in every one of the three fatal cases operated upon at the German Hospital, I expressed my opinion to the physicians who saw them with me that I entertained no hope for their recovery, but simply operated in order to give them the only chance they could have. I may add that it is my intention to continue to operate, even in cases that are apparently hopeless, excepting perhaps those that are actually moribund, like Case 14. These eighteen cases show a recovery of 83 1-3 per cent., and a death rate of 16 2-3 per cent. (Since reading this paper I have added three cases to my list, all of which were successful, so that the mortality has been reduced to 14 per cent.)

To appreciate what can be attained by the method which I have adopted, it is necessary to understand exactly what was the severity of the cases included in my list. By "Diffuse Suppurative Peritonitis Following Appendicitis," I mean cases of appendicitis accompanied by the presence of free pus spread over the greater part of the peritoneal cavity. Unfortunately, there is a good deal of confusion in the terminology, the same cases being described as spreading peritonitis, diffuse peritonitis, general peritonitis, etc. The reason for this lack of exactness lies in the fact that these conditions are really nothing but different degrees of the same thing, viz.: of free purulent peritonitis. They might with perfect correctness all be called by the name free purulent peritonitis (peritonitis purulenta libera). But everybody knows that a case in which the pus has become widely diffused is of far more serious import than one in which it is only just beginning to spread. Clinically, therefore, we must make a distinc

tion. The class of cases that I am reporting used to be designated as general peritonitis. This term, however, has been more and more abandoned, as in cases that are seen at operation, it is exceedingly rare that every portion of the peritoneum is involved. Some part of it will regularly be found healthy. There remain the terms spreading peritonitis and diffuse peritonitis to designate the varying degrees to which the pus has spread over the peritoneal cavity, and of these the former should be used to designate the earlier stages, the latter those in which the pus has spread over a considerable area.

It seems almost unnecessary to state, yet, to avoid misconception on the part of some, it may be well to mention that no case of abscess, no matter how large, can be classed as diffuse peritonitis. Even if the abscess extends over to or beyond the median line and up close to the liver, it is nevertheless a case of localized, not diffuse, peritonitis, if it is walled off from the rest of the peritoneal cavity. These cases are usually seen in the second week, or even later, whereas diffuse peritonitis is seen in the first few days. To be classified as diffuse peritonitis, it is necessary that the pus, or at least the greater part of it, is free in the peritoneal cavity. I say "the greater part of it," because in advanced cases of diffuse suppurative peritonitis, as a rule, a part of the pus will be to some degree, though imperfectly, separated from the remainder of it by adhesions between adjoining coils of intestine or between intestine and parietal peritoneum.

Whereas, the distinction between diffuse suppurative peritonitis and large abscesses is almost self-evident, it must also be understood that by no means all cases of free purulent exudate can be grouped under the caption of diffuse peritonitis. As already intimated, some excellent writers have classed all cases of free purulent exudates together, even if their extent was but limited, and described them under the name free purulent peritonitis (peritonitis purulenta libera). Or, what amounts to the same thing, cases of spreading peritonitis and diffuse peritonitis have been recorded together, and statistics have been given for a combination of the cases with an exudate of limited extent, and those with a diffuse exudate. If I had elected to include my cases of free

purulent exudate limited to the right side of the abdomen and to the pelvis, or perhaps extending but slightly beyond the median line, the results would be represented by a much better figure even than the very satisfactory one given above. However, as my object is not to present statistics, but to describe an efficient method of operating in the more advanced cases, I am compelled to exclude the less extensive ones, because in these, which are correctly classed as spreading peritonitis, a different method of operating was employed. The term "diffuse suppurative peritonitis," as I employ it, refers to cases in which the free pus extended well over to the left side, a condition which was recognized, before operation, by the extent of the rigidity of the abdominal muscles and the corresponding tenderness, and was verified at the operation.

The method of operating was the following: The incision, in all but four cases, was in the median line. In two of these (Cases 12 and 13) it was about 1 to 11⁄2 inches to the right of the median line, going through the rectus muscle; in the others (Cases 7 and 10) it was about 24 to 21⁄2 inches to the right of the median line, going through the rectus fascia, but not through the muscle, this being drawn by the aid of retractors toward the median line (Kammerer's incision). The principle which guided me in the selection of the incision was to place it midway between the estimated right and left limits of the exudate, and, as in almost all the cases the exudate extended all the way over to the left, the incision naturally corresponded about to the median line.

As regards the length of the incision, it extends from the pubes to above the umbilicus, the upper limit being at least two inches above the umbilicus, usually higher. In some cases the incision extended all the way from the ensiform cartilage to the pubes. An incision from umbilicus to pubes, with which I occasionally began, proved to be insufficient for thorough work, and was lengthened upward with a detour about the navel. I have never excised the navel, as even this small unnecessary expenditure of time seemed unwarranted. The length of the incision is such that the abdominal walls may be retracted suffi

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