DISCUSSION.

DR. GARBER, Muskegon: I have been very much interested in both of these papers, as I have had some little experience in the line of appendicitis myself in the past few months, and I have come to the conclusion that there is no class of patients who more largely deserve the commiseration of the doctor and of all those who know anything of them than those who have had appendicitis and have recovered from it without an operation. They are almost sure of again. having an attack of the trouble, and very frequently it comes on at a time when an operation cannot be had; or escape from former attacks has made them believe that the trouble is not as grave as it is and so leads them to decline surgical aid. I recall quite a number of cases in my practice during the past few years who have had attacks and who have recovered without an operation, only again to have other attacks which have rendered their lives almost miserable. I recall particularly the case of a child who is a physical wreck as the result of a recurring appendicitis and in which an operation has been advised again and again but refused on the part of the parents because of recovery in former instances. So I am rapidly coming to the conclusion that the man who operates when his diagnosis is made, at least within the first forty-eight hours after the diagnosis is well established will save more patients than the man who procrastinates; yet the general practitioner so frequently sees apparent recovery without operation that he is loth to advise such procedure, especially in a community where public sentiment is not educated up to that idea. I fully agree with the statements made by Dr. Carstens that no one symptom or no set of symptoms particularly are diagnostic of appendicitis. It is the case taken as a whole that must determine whether you have appendicitis or not, or whether you ought to operate.

You cannot depend on fever because you may have a normal temperature with a condition that is absolutely grave. You cannot depend on the pulse although that is a pretty fair guide. You can have a man almost in extremis with the pulse 100. As I said before, I think the general condition as manifested by the exhaustion of the patient, facial expression and evidences of sepsis, all these taken together must determine. If you wait for the appearance of these things you will very often lose your case. So I believe that the surgeon who operates within a reasonably short time after his diagnosis is made will have the satisfaction of saving more patients than the man who procrastinates in the hope that nature will restore as she has so often done before. I would like to ask Dr. Carstens if it is his practice in those cases where an abcess is formed to remove the whole mass or simply to open that mass and provide free drainage.

DR. LONGYEAR, Detroit: I suppose this question will be up for discussion and there will be two sides in a thousand years from now, for the simple reason that the surgeon cannot give specific symptoms that positively indicate the time for operation. It is impossible to do it. The general practitioner is asking this of the specialist all the time--he says, "Give me some rule to go by that I may know that my patient is one for operation"; but that the specialist cannot do, for the simple reason that these cases develop so differently. We have cases all the way from what we call simple intestinal indigestion up to the sharp fulminating cases of appendicitis. Cases of simple intestinal indigestion, which are due to catarrhal appendicitis I think are very common, that is, much more so than any of us realize, and they require operation for their cure, and yet as a rule they are not very dangerous cases. Cases where the appendix is funnel shaped and enlarged at the intestinal opening are not very dangerous to life, and yet they will go on and on, reducing the patient constantly and producing the symptoms of intestinal indigestion. I operated on a young lady about eight months ago who had been suffering for eight or nine months, the physicians all doctoring her for intestinal indigestion. I could find no tumor and her

pain was not located always in the region of the appendix, it was all over the abdomen, and it was a question what was the trouble. I didn't know but it might be perhaps tubercular peritonitis, and after watching her for several weeks I found there was a slight evening temperature, the general morning temperature being sub-normal. When she came to my office in the forenoon it appeared to be about normal, and yet by having her mother take a thermometer home with her and try her temperature several times a day I found there was an even temperature of a hundred every night and sometimes she had slight chills during the night. In operating upon that case I found no inflammation of the appendix, but I found it very long, six or eight inches in length, and doubled upon itself and held in a position of acute flexion by the contraction of its mesenteric attachments. The removal of that appendix gave complete relief to the patient and she never had any more trouble with the so-called intestinal indigestion.

The point that Dr. Carstens speaks of, of the pulse being a good indicator as a rule-it may be as a rule, and yet we have cases where the character of the pulse is no indication whatever. This was illustrated in another case that I operated on in Harper hospital on Christmas day. I was called to see a man by his physician in the forenoon. He said that he had then had appendicitis for a week and he was becoming a little worried about him. There was the dullness on percussion and tenderness over the McBurney point, there was no temperature the temperature was normal and the pulse was 70. There was no indication for operation according to the rules the doctor has laid down. I think he used to lay them down more strongly in regard to the pulse, but lately he is beginning to weaken a little, and this case is an illustration that he was correct about weakening on that point a little. That man had had appendicitis for a week and his temperature was normal and his pulse was normal, but there were the physical signs of trouble. I told the doctor who was attending him that he must watch him, see him three or four times a day, and upon acceleration of temperature or pain (he must not give him any opiates at all) he must notify me immediately.

Well, that same afternoon at six o'clock he notified me that there was severe pain and the temperature was one hundred. We sent for the ambulance and took him to Harper hospital where I operated immediately. We operated Christmas evening; found the appendix with very small opening in it, a small amount of fetid pus surrounding it. It was removed, a drainage tube used and the man made a good recovery, with the exception of unilateral parotitis which developed on the second day, but it gave him very little trouble and he made a good recovery.

Q. What was his pulse?

DR. LONGYEAR: His pulse was about a hundred at the time of operation and he had had appendicitis a week, so that we cannot go by that. There is no question but what that man's chances would have been better if he could have been operated on two or three days before, and yet there was no rule to go by in his case; that is the point I am trying to make, that there is no rule to go by in many cases, and I think the doctor takes rather an extreme view when he says that every case should be operated on as soon as the diagnosis is made. The general practitioner knows very well, and I think the doctor knows very well if he looks back over his past experience in general practice, that a great many cases do get well, they often have one attack and they never have another one; but the point is that those cases must be watched by someone who is experienced in abdominal surgery, that is all, so that they may know the danger point and operate immediately. I think that is about all the points there is in regard to that.

SUTURING.

WILLIAM F. METCALF, M. D.,

Detroit.

Many of the principles referred to in dealing with this subject being established beyond discussion, it remains only for me after enumerating them to endeavor to hold your attention to some details of methods of suturing in gynecic surgery. Some of these principles being axiomatic you will kindly pardon my mention of them.

1. Aseptic wounds approximated by aseptic sutures and kept aseptic will heal by first intention, the rapidity depending upon the condition of nutrition.

2. Irritation of muscle fibres cause their contraction, therefore, where possible, the sheath or fascia only should be pierced with the stitch.

3. The edges of tissues of the same anatomical structure and physiological function should be coapted.

4. The epidermis should not be pierced by the needle, first, because of the difficulty of making this layer of cells aseptic; second, because of the pain produced by tension upon the stitches, and third, because irritation of the skin. causes contraction of the underlying muscles, the sensory fibres being accompanied by motor nerves.

5. En-masse sutures used in closing abdominal wounds by compression tend to interfere with local nutrition and also increase the danger of shock.

6. As few knots as possible should be left in wounds, as where the nutrition is low they tend to favor suppuration.

7.

Absorbable suture should not be used where there is any possible chance of septic fluids coming in contact with it. In such places silk-worm gut is a satisfactory suture.