Progress in Surgery

1907 Boston Medical and Surgical Journal  
of the rectum to deal with I made a long incision parallel to and above Poupart's ligament. When I got into the belly I found the pelvic cavity filled with small bowels and so adherent to every thing that I abandoned the first incision for the time being, and opened the abdomen in the middle line, in order that I might have a better field for operation. The. small bowels filled the pelvis and hid the sigmoid and rectum from view. In sponging the adhesions apart, I broke into a pocket of
more » ... a pocket of foul-smelling pus on the left side of the sigmoid and rectum. 1 estimated there must have been half a pint of this pus. While the pus had a foul focal odor, I did not find any fecal concretions, nor did I find any communication with the bowel. I then placed the patient in the reversed Trendelenburg position, placed gauze around the bowels, so as not to infect the general peritoneal cavity, introduced cigarette drains from both wounds down to the pocket of pus and closed the wounds down to the drains. The subsequent steps of the treatment followed was to keep the patient in Fowler's position and to give daily enemas of normal salt solution by Murphy's plan. The patient made a slow but sure recovery, without developing any permanent fecal fistula, though for about a week after the operation the discharges had a decided fecal odor. The pathology of this case was unique to me, and I was at a loss to account for it, because I had never seen a similar condition in the operating room, nor could I find anything in the literature in regard to it. Hence I called it acute periproctitis, and acute perisigmoiditis. The etiology of this case was interesting, and in seeking for a cause I accidentally learned from the patient that a few years ago a traveling quack came through the town delivering lectures on " health and how to preserve it." Among other things he taught that people, in order to aid digestion and cure constipation, should eat every day a teaspoonful of sand. So this good man was induced by some friends to eat sand for constipation. This, I thought, may have been the secret of the trouble. The sand might have lodged in some of the folds or pockets of mucous membrane of the sigmoid or rectum and caused ulcération, secondarily setting up suppuration around the gut. Since writing the above report of my case I have read very interesting reports in Surgery, on " Divert iculitis of the large bowel," that throw a good deal of light on the pathology of my case. The Cholera Situation in Russia. -According to press dispatches from St. Petersburg, Oct. 31, the latest official cholera statistics for the week ending Oct. 22 show that the epidemic is now being checked with the approach of winter. There were 1,000 new cases reported and 416 deaths were recorded. More than half the number of cases, 569, were in Kiev and Volhynia provinces, where the winter is belated. There were only 103 cases in the four southern provinces and 75 in the five provinces of the Middle Volga region.-Halsted, more than other writers, distinguishes degrees of axillary involvement, giving four groups of cases depending upon the extent of involvement: (a) base of axilla only; (b) base and mid-axilla; (c) base, mid-axilla and apex; (d) veins intimately adherent. He shows how groups b, c, and d are much the most difficult and serious and lead with considerable certainty to an involvement of the supraclavicular region, and he finds this region above the clavicle the seat of disease in a surprisingly Large number of cases. Of his 232 cases the neck operation was done in 119; while of the remaining 113 cases, in which the neck operation was not done, 44 were operated upon subsequently. Halsted finds microscopic involvements of the neck glands in great numbers of cases which show no palpable evidence of disease in that region. For this reason, he insists upon the neck dissection in till cases in which the axilla is involved beyond the base. He lays down the following rules: the surgeon should perform the neck operation, " barring, of course, special contra-itidieations: (1) in all cases with palpable, operable neck involvement; (2) when the apex of the surgical axilla is involved. When mid-axillary involvement is demonstrable at the operation, special implication is almost certain, and hence, (3) in these cases also the neck should be typically cleaned of its lymphatics, as high, at the very least, as the bifurcation of the carotid. " We find ourselves for the past two years again performing the neck operation in most cases. We omit it in hopeless cases." As evidence that involvements of the neck do not imply necessarily a hopeless condition, Halsted cites 40 traced cases, in which cancer was found and removed from both neck and axilla. Four of these.cases survive the three-year limit, showing us positively good end-results in 10%. On the other hand, Greenough, and most of the other speakers, conclude from their studies thai cancerous glands above the clavicle practically oontra-indicate an operation for radical cure. Of 38 cases reported by Greenough, with involvement and removal of the neck glands, none survive. Willy Meyer does not favor the neck operation and finds none of his neck cases alive after a five-year limit. Ochsner dissected the neck seven times in 78 cases. His seven neck cases are dead. The studies and conclusions of these three speakers, however, are by no means as exhaustive and satisfactory as Halsted's, nor is their experience with neck involvements as extensive. L. S. Pilcher supports Halsted's views in an entirely interesting and convincing paper. The former surgeon has made a painstaking endeavor
doi:10.1056/nejm190711141572006 fatcat:snk3t4ew45frzcmuwodfavbtfq