abortion she began to have colics similar to those she had before the operation, and has continued to suffer more or less pain ever since. The pains now are frequent and severe, and she is again taking frequent hypodermics of morphine. I believe the stones have re-formed, and to relieve her another operation ought to be done, a cholecystectomy if possible.

Another patient had several characteristic colics some months after a cholecystotomy, with removal of seven faceted stones; the last colic, being followed by jaundice, was relieved by the passage of a small nonfaceted stone; patient has remained well since, now about two years.

Recurrences are exceptional, however, and we expect the patients to recover promptly and permanently, and are justified in giving every assurance that relief will follow operation. In only a very small per cent of the cases operated upon do we have the stones to re-form.

Occasionally, after cholecystotomy, the fistula will not close, leaving the patient a sufferer from the discharge of mucus or bile. This is always annoying, and occasionally causes great suffering by irritating and inflaming the skin. When the passages are freed of stones and there is no obstruction to the flow of bile to the duodenum, and the gall-bladder is properly sutured to the abdominal wall, there is little danger of a permanent fistula. In about ten per cent of cholecystotomies the fistula exists. Mayo Robson had fourteen fistulas out of one hundred and eighty-nine cholecystotomies, nine of them being cured by subsequent operations.

A permanent fistula usually means obstruction to the cystic or common duct; in the absence of malignant disease, a stone probably that has been overlooked at the operation. It is impossible, in some cases, to be certain that the ducts are free and that there is no hindrance to the flow of bile into the duodenum. A mistake sometimes responsible for fistula is the stitching of the gall-bladder to the skin, as was advised by Tait, and not to the aponeurosis, the proper way.

The mortality in uncomplicated cholecystotomies for cholelithiasis is almost nil, probably not more than one or two per cent. Of Robson's one hundred and ninety-six cholecystotomies eleven died, "five the subjects of cancer and four of infective cholangitis and jaundice," the two simple cases being in old men, one with a heart lesion and the other developing cerebral symptoms some days after operation. When the stones are in the common duct the mortality, of course, is greater. Courvoisier states that in four per cent of all cases of chole

Robson believes the

lithiasis stones are found in the common duct. per cent greater, it being over 13 per cent in his own cases. The mortality after choledochotomy is about 20 per cent; in Kehr's cases, 6.6 per cent; in Fenger's, 14.3 per cent; in Robson's, 23.8 per cent; and in Murphy's, 40 per cent.

A comparison of results in cases treated medically and surgically is almost impossible. The medical ones nearly always recover, for they are turned over to the surgeon when death is about to ensue just in time to give the surgeon credit, unjustly, for the fatal termination. If all patients with cholelithiasis were treated medically, and none of them subjected to operation, the mortality would certainly be far greater than at present. On the other hand, if all the patients were operated upon in a well-equipped hospital by a competent surgeon as soon as the diagnosis could be made the results would be brilliant, and rarely indeed would a death be recorded. However, we must treat these cases, and it is exceptional when this can be done in an ideal way. When the surgeon is consulted, as a rule medical treatment has been tried and has failed; there are usually complications present, and the time has gone by when an operation could have been done without danger. But remember, to obtain the best results we must operate early, at a time when we can tell those interested that recovery will almost surely follow.

The success of operation for the relief of gall stones will depend upon the location of the stones, the condition of the biliary passages, and the complications found. With the usual incision manipulation is rather more difficult than through the median incision below the umbilicus, or through the incision for appendicitis, as the abdominal wall is rigid and less yielding on account of the proximity of the incision to the costal arch. The vertical incision I almost invariably make two and a half to three inches long and to the outer edge of the right rectus muscle, but the oblique or Kocher is advocated by some, and will often give better access to the duct when necessary to do choledochotomy. Either incision may be extended at any angle, and must often be quite free, that the stones may be gotten at and removed. By placing a sandbag under the patient (liver level) the duct will be brought nearer the surface and we will be aided greatly in the manipulation. The operative technique in this region is the same as in other regions of the abdominal cavity, being varied slightly by the

anatomical structures there found and the extent and character of the inflammation caused by the stones.

In all abdominal operations with an infected area I advocate careful and extensive gauze packing; surround the infected structures, push aside the healthy ones with gauze towels, and extensive manipulation may be done with safety, and if infected material escapes the gauze will prevent its doing harm. The same precautions should be taken in all gall-stone operations as in cases of acute appendicitis. When the gauze is properly placed I am master of the situation, and do not hesitate to break up extensive adhesions and do all manipulation necessary to get at the stones or diseased structures and remove them.

Cholecystotomy is the most frequent operation done for gall stones, and is one of the easiest and safest done in the peritoneal cavity. After incising the parieties the gall-bladder and ducts are carefully examined by introducing one or two fingers, and if stones are detected after placing the gauze so as to catch any escaping fluid the bladder is incised (some advise aspirating before making the incision) and the stones removed. The gauze being removed and the region carefully cleansed, the incision in the gall-bladder is stitched to the aponeurosis, leaving a rubber drainage-tube in the gall-bladder. I prefer closing the incision in the abdominal wall with tier sutures when there is no reason to hurry, leaving just room for the drainage-tube. If necessary to complete the operation quickly, en mass sutures of silkworm gut answer the purpose well. I usually use No. 1 chromicized catgut to fasten the gall-bladder to the aponeurosis. The drainage-tube is removed usually in ten or twelve days, depending upon the condition of the gall-bladder, when the fistula will gradually close. When the mucous membrane of the bladder is much inflamed it is well to irrigate daily with sterilized water; if in a fairly healthy condition no irrigation is necessary.

In cases of cholelithiasis of long standing we often find the gallbladder much contracted-so small that it is impossible to fasten it to the abdominal incision. In these cases it may be well to do cholecystectomy, but when this is not advisable we can fasten a rubber tube in the bladder with a stitch, and by placing gauze properly feel pretty safe that there will be proper drainage, that the peritoneal cavity will be protected, and that the patient will progress satisfactorily. Again, in some cases we will be able to fix the bladder to the peritoneum by

separating the peritoneum for an inch or more around the abdominal incision, making a funnel-shaped cavity, after the incision in the gallbladder and peritoneum are united.

The so-called ideal operation suggested by Langenbach, suturing the incision in the gall-bladder and returning it to the cavity without drainage, should rarely be done. There is greater danger than in the usual cholecystotomy, and it is exceptional to find a condition justifying this procedure. Block suggests doing the operation in two stages -cutting through the abdominal wall until the peritoneum is reached and then packing with gauze, waiting for adhesions to form before opening the gall-bladder. This will be indicated only as suggested by Robson, in cases where there is cholemia, the hemorrhage being more easily controlled than in the usual cholecystotomy. There are many apparent objections to this operation, and only in some of the cholemic cases should it be resorted to.

When the stone is in the cystic or common duct we sometimes succeed in crushing (cholelithotrity) or pushing it back into the gallbladder. When this can not be done the duct must be incised (choledochotomy). This may be quite difficult, and often requires much patient and persistent work. After the stones are removed it matters but little whether the duct be sutured; if it can be readily done it is best to suture, but where there is much trouble, as is usually the case, we can leave the incision unclosed, feeling safe if a drainage-tube and gauze are properly placed. If the patient's condition is extreme we may be unable to relieve the obstruction, and under such circumstances an anastomosis may be made between the gall-bladder and the intestine (cholecystenterostomy), or between the dilated duct and the intestine (choledochenterostomy).

McBurney advises incising the duodenum and dilating the duct when the stone is impacted in its duodenal end (duodeno-choledochotomy). In his six cases he lost one, and this one died of prolonged vomiting from an irritable stomach.

Cholecystectomy is often indicated, and is being more frequently done by some operators. After separating the bladder from the liver the peritoneum of the cystic duct is incised circularly and the duct pulled out and ligated with catgut. When the gall-bladder is much diseased and the ducts are free of obstruction this seems to be the best operation.

LEXINGTON, Ky.

THE MEDICAL MANAGEMENT OF APPENDICITIS.*

BY J. W. IRWIN, M. D.

The management of appendicitis requires on the part of the medical attendant an accurate knowledge of the anatomy of the appendix vermiformis ceci and the cecum itself. Special attention should be paid to the small opening from the cecum into the appendix which is sometimes partly closed by a fold of the mucous membrane known as Gerlach's valve. There is no anatomical difference in the structure of the appendix and the cecum except perhaps a greater number of glands in the former.

The appendix is made up of four coats, usually a single artery, a vein, nerves, and lymphatics, and it is three or four inches in length and about the size of a pipe-stem. Its uses in man are not clear, and it is sometimes absent. Darwin, in his work on "The Descent of Man," refers to it as the useless rudiment of the cecum. Its absence in the orang-outang and wombat has left a hiatus between monkey and man in the story of evolution.

Haeckel refers to the appendix in his work on "The Evolution of Man" as a "rudimentary organ" which, in our plant-eating ancestors, was larger and of physiological value.

The cecum in man is about two and one half inches in length, but in some of the lower animals it is several feet in length. An instance of its great size will be found in the marsupial kaola. This little animal is about two feet in length, and its cecum is upward of six feet long.

Before Reginald Fitz, of Boston, in 1886, called attention to appendicular disease and advised for its cure the early removal of the appendix, disorders in and about the caput coli were generally diagnosticated and treated as typhlitis and perityphlitis, but since his observations were published and those of McBurney, which appeared five years later, abdominal surgeons have sprung into existence everywhere and with great rapidity to meet and contend with the ravages of a disorder which is not new and not very fatal. Typhlitis and perityphlitis are lost sight of.

It may be said that many people are alarmed by reason of the numerous hospital and private reports of appendicular diseases which

Read before the Kentucky State Medical Society, Paducah, Ky., May 7-9, 1902.