SURGEON'S CLUB, ROCHESTER, MINN., JULY 10. 1908.

the second day is added an ounce to one and a half ounces of beer, every couple of hours, alternating with this same quantity of buttermilk.

"On the third day toast, soft boiled eggs and tea are added to the diet. and on the fourth day the bowels, which have not moved up to this time, are emptied by means of one and one-half to two ounces of castor oil. The patient generally is allowed up on the fifth day and leaves the hospital on the eighth.

"(b) Cases of appendicitis requiring drainage. Acute cases with large abscesses are usually drained by means of a split rubber drain (see drain 2) through the incision and glass drain (see drain 4) through stab wound in more dependent portion of abdomen. In smaller collections of pus only the split rubber drain is used.

"The glass drain, when used, is generally removed at the end of twenty-four hours and a gauze wick inserted as the glass drain is being removed.

"The gauze from the rubber drain is removed on the fourth day and the rubber drain itself about the sixth; it is left a day or so longer if on the sixth day there is still much drainage. As a rule, these patients are up on the seventh or eighth day, leaving the hospital four or five days. later.

"Except that the bowels are not moved until the drain has been taken out, the treatment and diet of these cases is the same as for the simple

cases.

"The point so much discussed as to when to, and when not to, operate in appendicitis, can be only generally stated here, as elsewhere, there are numerous exceptions to any rule made to cover all cases. If a case is received within thirty-six hours of its inception it is usually operated upon; if received after this time, on the third, fourth or fifth day, they were usually carried through the acute stage to recovery or formation of localized abscess."

"Perforation usually occurs within forty-eight hours and within six hours after perforation; if there is still a rise in temperature immediate operation may be of benefit, but never after that time, when the temperature has subsided after rupture. At this time all the damage that can be done has already occurred and a reparative process is in progress, which is not benefited by operation.

"The treatment of these cases is to aid Nature in her process of repair; rest in Fowler's position; nothing by the mouth but hot water. In cases of vomiting, stomach lavage with warm saline. Hot saline by rectum if retained; if not, subcutaneously; hot-water bags to extremities and cold pack over appendix. Within a week by this method localized abscesses have formed, which may be opened and drained and the appendix removed five or six weeks after the resulting sinus has healed..

GALL-BLADDER CASES.

"In the case of cholecystostomy the drain (see drain 5a) is sutured with catgut to the incised gall bladder and is removed about the seventh or eighth day, by which time the sutures are absorbed. In order to prevent soiling of the dressings, the rubber drain into the gall-bladder is connected with a small rubber tube by means of a small glass tube, the latter rubber tube conducting the discharges into a bottle held in the dressings. In these cases abundant non-absorbent cotton dressings are used, held by plaster and covered outside by a broad gauze binder. The diet in these cases is practically the same as given for appendectomies, save that the return to full diet is more gradual and solid food is not given until after the drain has been taken out and the bowels moved. This is accompanied usually on the seventh or eighth day by giving seidlitz powder or rochelle salts instead of castor oil.

"The patients are up on the ninth day, leaving the hospital about the eleventh to fourteenth day. Dry aseptic dressings are used daily upon the resulting sinus until healed.

"Cholecystectomies-The treatment of these cases does not differ materially from the preceding; the split rubber drain (see drain 2) being removed about the seventh day. A point to be noted in these cases and usually occurring about the second day, is the possible stasis of bile indicated by a peculiar, pale, anxious expression, with nausea and vomiting and due to retention of bile and fermenting secretions in the stomach. These conditions are immediately relieved by gastric lavage with warm

water.

"Choledochotomy-In these cases the drains are removed about the seventh day. If there is a tendency to obstruction with vomiting, or drainage is not acting well, sometimes calomel in one-fourth grain doses is given. If there is much jaundice, saline solution per rectum is given during the first twenty-four hours following the Murphy method, to rid the system of the toxic products.

"In other details the treatment follows the general plan of abdominal

cases.

STOMACH AND INTESTINAL CASES.

"1. Gastroenterostomies-In these cases, as before stated, the stomach is washed out thoroughly, emptied, and one-sixth grain of morphine given before operation. Afterward they are placed in bed in an exaggerated Fowler's position and given absolutely nothing by mouth during the first twenty-four hours.

"Second day, one and one-half ounces of hot water every couple of

hours.

"Third day, hot water alternating with beer.

"Fourth day, buttermilk, beer and tea.

"Fifth day, to the above light gruels are added.

"Seventh day, crackers, soft eggs, potato.

"The same procedure is instituted in cases of gastric resection, except that they follow about one day behind the gastroenterostomies in regard to diet.

"The bowels are not moved as a rule in these cases until the tenth day and then by means of cascara sagrada.

"In cases showing obstructive signs a high rectal enema of soap and water is given, which, if not effective, is followed by one of magnesia sulphate and glycerine.

"These patients are usually out of bed on the twelfth day and leave the hospital within two weeks.

"Frequently saline enemas are given these patients during the first thirty-six hours; the salt solution being allowed to flow into the rectum under very low pressure. It is especially indicated in those cases where shock may be noticed. In cases of vomiting following operation, careful gastric lavage with warm saline is found productive of good results; it may have to be resorted to several times to be effective.

"Prostatectomies-These cases are given one-sixth grain of morphia on being put to bed after the operation and given one quart saline solution per rectum every six hours. Whenever there is much pain or tenesmus or the drains do not appear to be working well, the patient obtains much relief from hot irrigation of the bladder through the smaller rubber tube of the drain. (See drain 5d.)

"The drain is removed on the fourth day and the patient encouraged to get up. They are dressed in overalls with abundant padding into which the wound may drain. After the patient is up sitz baths are frequently given; four being taken on the first day he is up and two on each succeeding day.

"The patient receives much relief from these baths.

"Spartein sulphate in one to two-grain doses every four hours, is given in cases of suppression of urine.

"Mucous fistula resulting from operation is removed by burning with electro-cautery without anesthetic.

"In the suprapubic operation, the dressed tube (see drainage 5a, special cases) is removed about the seventh or eighth day. In these cases irrigation through the penis may be necessary. The general plan of diet for abdominal cases is carried out with these save that no restriction is made to the taking of fluids.

"Glands of the Neck.-These cases are usually drained by means of the spiral drains (see drain 1) which are removed on the fourth day, the

rubber portion being taken out on the sixth day. They usually leave the hospital about the eighth day. In removal of the submaxillary glands there is frequently some pain and difficulty with the saliva during the first three days, which passes away, but which, when excessive, necessitates the use of atropine.

"Breast Cases-Are drained by means of the spiral drain (see drain I), the gauze of which is removed on the fourth day and the rubber portion about the sixth day. Usually two or more drains are necessary, one in the axilla and a second at a dependent portion of breast. In dressing, a slight pad is used between the side of the chest and the arm, and then the latter is bound to the chest leaving the forearm free. Use of the forearm is early encouraged, the patient being made to feed herself the day following the operation. Passive motion of the arm is practiced early and by the tenth day the patient is able to comb her hair.

"Goiter-In reference to goiter operations, as previously stated, before the operation they are given one-sixth grain morphia and one one-hundred-and-twentieth grain of atropine. Frequently before operation, certain cases are treated for several weeks by X-ray, which tends to lessen the symptoms, probably by formation of connective tissue thickening, and hence lessened absorption; the capsular thickening produced by it at any rate renders operative treatment easier. Patients are encouraged to sit up on the second day after the operation. Exophthalmic cases do not sit up until the third day. Salines are given by the bowels during the first twenty-four hours; restlessness and palpitation relieved by ice bag and salines; other treatment is entirely symptomatic. The area of operation is drained by a split rubber tube, which is removed on the fourth day.

"The dressings in the hospital are put up in packets wrapped about by sterile towels; they include two towels, two pieces of newspaper, two strips of gauze, raw and absorbent cotton. The forceps, scissors, etc., are brought to the bedside in an antiseptic solution. The dressings are removed and replaced by means of forceps, the soiled ones being placed and carried away in the pieces of newspaper. In the dressings the hands do not come in contact with the wound.

"In general, in vaginal and perineal cases the silkworm gut sutures are removed on the twelfth or fourteenth day, and vaginal douches of bichloride or creoline used. The diet being hot water during the first twenty-four hours, gradually increased during three days to semi-liquid and within a week to full diet.

"In all cases in which there is protracted vomiting, rectal feeding is resorted to, this consisting of milk or gluten two ounces, hot water one ounce, repeated every six hours; two quarts of saline are also given every twenty-four hours. In abdominal cases in which there is much pain from gas, small rectal enemas of warm water are given.”