terprises originate in this manner. A medical laboratory could be started on this plan in any community, and if wisely administered would soon win the confidence and support of the public. FINANCIAL ASPECTS. In discussing the financial aspects of medical laboratories we must consider the following phases of the subject: (a) initial cost of physical plant and equipment; (b) annual upkeep; (c) fees. Physical Plant and Equipment.-The modern medical laboratory should include the departments of clinical pathology and of radiology. Clinical pathology will include clinical microscopy, clinical chemistry, clinical bacteriology. Radiology will include the diagnosis of cases requiring the X-ray. The department of scopology, including the use of all manner of scopes for the examination of organs reached through the natural orifices, such as the bladder, sigmoid, esophagus or stomach, might or might not be included, depending entirely upon the adequacy of the local hospital facilities for this class of work. The physical plant may be owned or rented. If owned it would seem that $25,000 would be a proper estimate for the initial cost of the physical plant including ground and buildings erected especially for the work. The professional equipment is estimated at a cost of $10,000. Necessity might require the abandonment of the department of radiology, but such course would cripple greatly the usefulness of the institution. will attract the efficient man as director. These points are all emphasied by Dr. William S. McGill, Director of Laboratories for New York State Department of Health, and are almost literal quotations from his article on the importance of medical laboratories in medical practice. They have. been developed in the field of actual experience and are therefore tried out principles, not theoretical statements. The salary of the director is the largest single item in the annual upkeep budget, and should be $5,000 a year. The other items which may only be mentioned here, such as insurance, supplies, animal house, breakage, coal, subordinate employees, office expense, educational fund, etc., are estimated at an additional expense of $10,000. This makes the annual upkeep budget for a medical laboratory of the kind now under discussion $15,000 at least. - It Fees. What will the laboratory do to maintain itself? The only source of income is from fees and here it is well enough to discuss this phase of the question. It may be stated as a fact that no medical laboratory doing social medical service can be created and maintained by the income from fees from pay patients. Those who do not pay will far outnumber those who do. would be financial folly to borrow money to cover the initial cost of a medical laboratory depending upon the fees to support it after the physical plant has been created, and in addition provide a sinking fund with which to pay off the original loan. In the first few years of the medical laboratory's existence the income from fees would be an uncertain quantity. The public and the medical profession alike would have to be educated to avail themselves of the facilities offered. Financial Summary.-1. The two essential items of the financial problem are the annual upkeep budget of $15,000. It is the professional equipment of $10,000 and estimated that neither of these items can be reduced. Annual Upkeep Budget.-The value of the laboratory and its ultimate success when once properly established and equipped depend wholly upon the professional ability and the personality of the director. The director must possess such technical training, medical education and personality as to readily secure and premanently main tain the confidence of the medical profession in the tributary territory. It is needless to say that time is required to establish such 2. $25.000 would start a medical laborarelations and therefore the director should tory in any community, $10,000 being rebe paid an adequate salary and assured quired for quired for professional equipment and of permanent employment. On no other $15,000 for the first year's annual upkeep conditions may a capable director be secur- budget. The laboratory would be housed ed. The realization of the opportunities in rented quarters and at the end of the for service of the medical laboratory depend first year would face the problem of finding almost wholly upon the special energy, wise $15,000 for the second year's annual upkeep judgment and untiring industry of the di- and so on each year thereafter. No doubt rector. The man makes the laboratory and its demonstrated usefulness would finally the larger the institution the more ex- result in the acquirement of a physical tended will be its usefulness, because it plant and an endowment. It would seem unwise to attempt the establishment of a medical laboratory with a sum less than $25,000. 3. $25,000 would buy a lot and erect a laboratory building, but nothing would be left for equipment and annual upkeep. 4. $35,000 would buy ground, erect a building and equip it, but nothing would be left for annual upkeep. 5. Private endowment could not only inaugurate but permanently establish a medical laboratory with a bequest of $335,000; $25,000 would create the physical plant, $10,000 would supply the professional equipment and the remaining endowment of $300,000 at 5 per cent would supply the annual upkeep budget of $15,000. Inability to supply this large sum of money need not deter philanthropy from inaugurating this enterprise, however, as $25,000 or any greater sum would do this. The trustees would then work out the problem of permanent establishment. 6. The field of medical research is unlim ited and therefore its financing may be a matter of thousands or millions. The estimates given in this report are intended to care for clinical work primarily and for research work secondarily. They do not afford extensive opportunity for the later. 7. The financing of medical laboratories is much easier of accomplishment than of hospitals. The initial cost is not nearly so great. The maintenance expense can be made to accommodate itself to the desired the administration is simpler and less comwork without large overhead charges, and plicated. A small per cent only of the total investment need be tied up in buildings and equipment. By far the larger part can become endowment and thus be constantly making the benefits of the laboratory available for the sick. NOTE.-Anyone desiring to communicate with the Medical Laboratory Committee concerning the contents of this report ahould address, Chairman Medical Laboratory Committee, care Dr. Chas. Wood Fassett, Secretary Medical Society of the Missouri Valley, St. Joseph, Mo. JUNE, 1913 Organized at Council Bluffs, Iowa, September 27, 1888. Objects: "The objects of this society shall be to foster, advance and disseminate medical knowledge; to uphold and maintain the dignity of the profession; and to encourage social and harmonious relations within its ranks."-Constitution SOCIETYE Official Proceedings THE MEDICAL SOCIETY OF 26th Annual Meeting, Omaha, Neb., September, 1913 No. 6 PERITONEAL ADHESIONS OF THE INSIDIOUS TOXIC GROUP.* Robert T. Morris, A. M., M. D., New York Professor of Surgery, New York Post-Graduate Medical School and Hospital. The study of peritoneal adhesions is to be taken up from a new perspective, as a feature of progress of the present century. We were slow to comprehend the importance of adhesions following acute inflammatory processes, and it was only toward the latter part of the nineteenth century that this subject received elaborate attention. It is probable that adhesions resulting from acute inflammatory processes in the peritoneal cavity form a small proportion of those which are to engage our attention presently. A number of peritoneal defects representing embryonic remnants *This and the following papers comprise the Symposium on the Colon presented to the Medical Society of the Missouri Valley at Kansas City, March 21, 1913. are sometimes mistaken for peritoneal adhesions of unknown origin, but these are the result of imperfect absorption of apposed peritoneal structures, when the various abdominal viscera of the embryo ascend to permanent positions. Peritoneal defects which remain as the result of arrested development commonly do very little harm, because the viscera adapt themselves to abnormal peritoneal supports pretty well in the course of development. In post-mortem examination in cases which had given no history of acute abdominal inflammation, we will find not only these peritoneal defects simulating adhesions, but also many areas of new adhesion, particularly about the cecum, the sigmoid, and in the upper part of the abdodmen in the vicinity of the bile tract and pylorus. These adhesions have developed insidiously and have not attracted attention, in many cases, aside from the moderate degree of abdominal tenderness or pain, which has usually been ascribed to indigestion or constipation by the physician. In approaching the subject of insidious adhesion formation we are to remember that more than sixty species of bacteria have been isolated from the colon. Some of these are apparently symbiotic and of value in assisting in the process of digestion. Others are at all times harmful. Many of the benign bacteria, when occurring in excess, become harmful when their toxins are taken into the circulation in excess of the ability of the individual to manage them by metabolism or to excrete them freely through his emunctories. The results of general toxemia are manifested in many ways, but that part of the subject is mentioned here only in passing, as the point to which I wish to call attention is the local influence of toxins in the vicinity of the colon. A number of the anerobes apparently pass through the bowel wall without much difficulty when there is intestinal stasis, and this movement may not be confined to anerobes, as we sometimes find bacilli of the colon bacillus group in adhesion tissue. Under the conditions of modern civilization intestinal stasis is increasing, because of the larger proportion of neurasthenic individuals with relaxed peritoneal supports. The radiograph is now showing us a sur prisingly large number of prolapsed colons, but aside from this acquired defect many other causes tend to produce intestinal stasis. Colonic bacteria, which do little harm even when in excess, if kept moving, may begin to exert a malign influence when they are unduly retained in the colon. Two localities in which they seem to make marked impression locally are in the region of the cecum and the sigmoid. In the region of the bile tract and pylorus adhesions are still more frequent, perhaps, because of the influence of toxins which are being thrown off in great quantities by the liver. Toxins which make their influence felt through the bowel wall, or through the walls of the bile duct or gall-bladder, seem to cause a desquamation of endothelium, and when this endothelium is shed, plastic lymph, which is exuded subsequently, be comes replaced by connective tissue, leaving more or less permanent adhesions, which form gradually and during long periods of time in susceptible patients. We are finding now a great many cases of Jackson's membrane and of Lane's kink. It is my present belief that Jackson's membrane and Lane's kink represent hyperplasia of subperitoneal connective tissue, due to the influence of bacteria or from toxins which make their way through the bowel wall. With Jackson's membrane particularly, there seems to be a tendency to progressive formation of the structure. Methods in medical treatment which lessen intestinal putrefaction and fermentation undoubtedly lessen the tendency to formation of insidious peritoneal adhesions and of Jackson's membrane, and perhaps of Lane's kink; but when adhesions or Jackson's membrane or Lane's kink have formed there is interference with the motility of the bowel, and the tendency to intestinal stasis is increased. In cases in which medical means are not sufficient to prevent intestinal putrefaction and fermentation, and to overcome stasis, surgical resources are in order. The methods first proposed included the idea of disposing of more or less of the colon through actual removal, in order to relieve general toxic conditions proceeding from the colon. the colon. We have gradually simplified the surgical procedures, and at the present time I like to do an operation which throws a large part of the colon out of commission and at the same time calls for comparatively little surgery. Lane divided the ileum and led it into the sigmoid in order to throw most of the colon out of commission, but a still simpler process consists in merely placing a part of the lower extremity of the ileum against the sigmoid flexure of the colon, making a slit 21⁄2 inches long in both structures and then suturing the margins of the slits. This can frequently be done through an abdominal incision not over two or three inches in length, and with very little disturbance to the patient. The larger part of the colon with or without adhesions and Jackson's membrane then becomes inert and empty, and undergoes more or less benign degenerative change. The chief annoyance following the operation is frequency of bowel movement on account of the comparatively small storage reservoir, consisting of part of the sigmoid, and the rectum. Sometimes there are four or five movements a day for a while, which gradually lessen in frequency, but the patients are apt to have at least two movements subsequently. This, however, is said by them to be a relief, if they have been sufferers from intestinal stasis for years. 616 Madison Avenue. THE SURGICAL COLON. A. L. BLESH, M. D., Oklahoma City, Okla. EMBRYOLOGY AND PHYSIOLOGY OF THE COLON. In order to have even a working knowledge of the therapy of the colon whether surgical or medical, a clear conception of the evolution and function of the organ is absolutely essential. On the one hand the laboratory studies of Metchnikoff elaborating the somatic results of the various toxemies which so long were considered as purely theoretical niceties are being brought on the other within the range of the practical by the work of Arbuthnot Lane no matter whether or not we view Lane's work as ultra-radical looking upon it as not complying with the surgical rule, that the extent of the operation shall not exceed the pathological condition to be corrected, the fact remains that he has easily proven out upon the living patient the propositions which Metchnikoff has evolved by his laboratory studies. the umbilicus. mations. The alimentary system first appears in the embryo as a straight open gutter, later closing, the straight primitive intestinal tube from which is later evolved also the bladder. As it now is both ends are closed, and the one opening existing is through At both ends of this primitive tube all three primordial germinal layers come in contact and are later used in the developmental processes of the face and terminal intestinal and genito-urinary forThis primitive intestinal tract is divided into three parts: First. The cephalic; second, the abdominal or middle portion, and third, the pelvic and in this form is one of the earliest differentiated Structures. From the cephalic end is differentiated the pharynx, and esophagus, the trachea and lungs; the second forms the stomach, small intestine and the large as far as the upper part of the rectum, and from the third the middle part of the rectum. In the embryological fact that the anus and lower part of the rectum are produced from a separate blastodermic layer, and communicates with the common cavity only at a later period, lies the origin of the anomaly of imperforate anus in the varying degrees of its existence just as from similar biologic embryological deviations is found the explanation of the various facial and oral malformations. But since these two extremities of the primitive tract lie with out the province of this paper we will dismiss them from further consideration. In the development of the middle division, part of which enters into the forma tion of the colon, and which now lies along the spinal column, terminating at about the level of the future umbilicus we find convolutions beginning to appear at about the eighth week, together with the beginning of a rudimentary mensentery. The rapid elongation of this convoluted tube now causes an arching toward the left. This convoluting process invovles most the upper and middle portion of this lower third of the primitive tract and begins to assume the appearance of the small intes. tine, which it later becomes and takes position in front of the lower third. Now for this lower third, which because of its bearing upon future colonic deviations is to be remembered as lying behind and to the right of the primitive ileum, a dilatation or bud appears-the future cecum and colon. Here begins that process upon the completion or incompletion of which depends a future perfectly or imperfectly functionating colon. For clearness of comprehension the process may be divided into three successive steps: 1. Migration; 2, ro tation; 3, fusion. Migration.-The development of this enlarged process or bud from the primitive tube takes place in an upward direction toward the splenic region, thence across the upper abdomen to the right side, and thence descends along the right flank to the normal location of the cecum in the right flank carrying with it that portion of the small intestine which enters into the formation of the ileocecal valve. This excursion may be arrested anywhere along its course, and in this way give rise to a left-sided appendix, even in the absence of visceral transposition though this anomaly is rare. most frequent variation arising from arrested migration occurs in the descent from the hepatic flexure. Most of the variations consists in an agglutination of the fetal conical appendix to the posterior wall, and this premature fusion may be extra or intraperioneal. When it is extra-peritoneal it more often results in the angulations due to mesenteric bands known as Lane's kink, which in truth consists in quite a variety of malformations dependent upon more or less complete rotation or its absence. will be later considered more fully. This In the extra-peritoneal agglutination the appendix sometimes without the participation of a part or all of the descending colon prematurely fuses itself to the posterior parieties and in the further development of the colon and cecum a process of saculation occurs in which the growing bowel suspended by the adherent part, |
