Read Ebook: The Hospital Bulletin Vol. V No. 2 April 15 1909 by Various

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In selecting a case I have not taken one that is a surgical curiosity, or at all an unusual one, but I have taken this because it is just in these cases that a doubt sometimes exists as to the treatment when diagnosed, and often the condition of the appendix and surrounding peritoneum is in doubt, even if a diagnosis of trouble originating in the appendix is made.

Child was put to bed; an ice cap placed on the abdomen. Liquid diet. The next day, December 27th, leucocytes stood at 35,200. Temperature unchanged, but the pulse had risen to 110 beats. A hypodermic of morphine and atropine was given, and patient taken to the operating room, anesthetized, and abdomen cleaned for an aseptic operation.

Prof. Winslow made an incision in the abdominal wall, well out toward the crest of the ilium, using the gridiron incision. The caecum was found and pulled over toward the middle line, and in looking for the appendix, which was supposed to be behind the caecum, a great quantity of pus was found. This nasty smelling, grayish pus welled up into the wound and was sponged away. Several pieces of mucous membrane and presumably the tip of the appendix were found in the pus. Also several faecal secretions. The pus was sponged away and carefully a search was made for the appendix, or rather what remained of it. It was found tied down by adhesions and dissected loose. It broke away in pieces, and it was unnecessary to ligate any of the arteries of the meso appendix. The stump of the appendix close to the caecum was crushed, cauterized and ligated. No attempt was made to invert it, as the tissues would not stand it. The pus cavity was found to extend up behind the caecum and over toward the median line for some distance. The puncture, which I will refer to later, was then made in the right lumbar region, and two cigarette drains were introduced extending clear back into the bottom of the abscess cavity. Then a gauze drain was introduced into the anterior wound, and this sutured up. The wound was then dressed and the patient taken to the ward. Recovery from anesthetic without ill effects.

The child went on to an uneventful recovery, and went home on January 21st fully cured.

This was undoubtedly one of those cases of gangrenous appendicitis where, owing either to the intensity of the infection or to a thrombosis of the vessels supplying the appendix, the vitality of the tissues is lost and gangrene results. Now, "even in this, the gravest form of appendicitis, the general peritoneal cavity is often protected against infection by walling off the pus, and the appendix, detached in the form of a slough, is often found on opening the localized abscess." But "in other cases there is from the beginning the symptoms of peritoneal sepsis and peritonitis."

Now, it seems to me that a great deal depends on the kind of infection--or, rather, the kind of organism infecting--and often the difference between a localized abscess and a general peritonitis is really the difference between a colon and a streptococcus infection. Again, should a general peritonitis develop, I have noticed from a number of cases in the wards that the prognosis practically depends on the organism, although we all know that a general peritonitis is a mighty grave condition, no matter what it is due to.

Another point in favor of the child was the fact that the gangrenous process seemed to start in the tip of the appendix, and it seems that when it starts there, there is greater likelihood of localization, and when it starts in the base a greater likelihood of general peritonitis.

I said that there was often doubt as to the condition in the abdomen in these cases. Now, there can be no doubt that the two main points in the diagnosis of a localized abscess are tumor and an aggravation of the symptoms present. But this case exemplified the fact that there may be cases where there is no aggravation of symptoms, and in a great many cases it may be impossible to feel the tumor until it has become very large, owing to its situation, viz., post caecal. Even in this case, from which a great quantity of pus was evacuated, there was no absolute certainty of finding pus on opening the abdomen, although it was suspected strongly.

I have seen a patient walk into the hospital on Sunday with a temperature of 100 and a pulse of 99, and when the abdomen was opened on Monday morning a most virulent form of general streptococcus peritonitis was found, from which the patient died the next day. It is said that it is much better to depend on the pulse and its variations than on the temperature.

I would like to call attention to several points in the treatment of this case also.

First, the place of incision was, as I said, well up towards the iliac crest, and not in the time-honored McBurney point. The wisdom of this is self-evident.

Second, the care used in not breaking up the wall of the abscess formed by the peritoneum.

Also, the fact that the appendix was carefully dissected up and tied off and allowed to heal by itself, obviating, as much as possible, the danger of a faecal fistula. The older books advised evacuating the abscess and leaving the appendix to slough off, and, while I have seen seven cases where this method was used and not a single faecal fistula, yet it seems to me the more rational treatment to remove the offender, as I have also assisted in three operations where the appendix was removed at the second operation. That is, an operation supposedly an appendectomy was done, and later, at a subsequent period, the diseased appendix was found still causing the same old trouble.

Again, the use of the lumbar puncture, so as to drain the abscess cavity from its very bottom. I wonder this is not done oftener, as it appeals to me as being a most sensible thing.

Then the abscess cavity was sponged out with gauze, and not washed out with the antiseptic fluid that books advise, thus spreading bacteria all over the peritoneal cavity, and really doing no good. Nature was allowed to throw off such things as she deemed necessary, an avenue of escape having been provided.

And, lastly, the omentum was found and brought down, covering in the cavity as much as possible, and thus aiding in the walling off process.

DIRECT LARYNGOSCOPY.

BY RICHARD H. JOHNSTON, M. D.

ITEMS.

The Board of Trustees of the Permanent Endowment Fund of the University held its annual meeting on January 11. Judge Stockbridge was re-elected president and Mr. J. Harry Tregoe secretary-treasurer, and, with Dr. Samuel C. Chew and Judge Sams, constitute the executive committee for the year 1909. The funds and securities in hand total the gross sum of ,635.74.

A special meeting of the Washington Branch of the General Alumni Association was held at the office of the president, Dr. Monte Griffith, March 11, 1909, to consider the advisability of petitioning the Board of Regents to establish a Board of Alumni Counsellors, a paid president and a Board of Trustees, independent of the teaching faculties. Resolutions in favor of these measures were adopted.

Dr. Louis W. Knight, class of 1866, of Baltimore, has presented to Loyola College a valuable collection of papal medals.

Drs. H. O. and J. N. Reik have removed their offices to 506 Cathedral street.

Drs. W. D. Scott and W. E. Wiegand attended the banquet of the Virginia Military Institute Alumni Association of Baltimore, held at the New Howard House, March 2, 1909. Dr. W. D. Scott responded to the toast "The Younger Generation and the Splendid Work of the Virginia Military Institute Today."

Dr. Hugh A. Maughlin, class of 1864, of 121 North Broadway, an official in the United States Custom Service, who was assistant surgeon in the Sixth Maryland Regiment during the Civil War, is dangerously ill of pleurisy at his home. Dr. Maughlin is a member of Wilson Post, G. A. R.

Dr. James A. Nydegger, class of 1892, past assistant surgeon, United States Public Health and Marine Hospital Service, has been promoted to the rank of surgeon.

Dr. Eugene H. Mullan, class of 1903, assistant surgeon, United States Public Health and Marine Hospital Service, has been commissioned a past assistant surgeon, to rank as such from February 2, 1909.

Dr. Samuel T. Earle, Jr., of Baltimore, Md., records the case of Mrs. F. H. D., who, the latter part of August, 1907, while eating ham, swallowed a plate with two false teeth. Ten days later she had a violent attack of pain in the abdomen, followed by a chill and fever. There was no recurrence of this for one and a half months. Since then they have recurred from time to time, but not as severe, nor have they been attended with chill and fever. A diagram taken of the lower abdominal and pelvic regions showed the plate in the sigmoid flexure of the colon, on a level with the promontory of the sacrum. Examination through the sigmoidoscope brought it into view at the point shown by the X-ray. There was considerable tenesmus, and the passage of a good deal of mucous, also a tendency to constipation. Under the influence of two hypodermics of morphine, gr. 1-4, hyoscine hydrobromate, gr. gr. L-100, and cactina, which produced satisfactory anesthesia, Dr. Earle was able to grasp the plate through the sigmoidoscope with a pair of long alligator forceps, and withdraw it immediately behind the sigmoidoscope.

Mrs. Carroll has been granted a pension of 5 a month on which to support herself, seven young children and the aged mother of her husband. The house, which Major Carroll had partly paid for, is mortgaged for ,000. Since the conference adjourned the medical officers of the Army have raised enough to pay the taxes on the house, one monthly note of and the overdue interest on the first mortgage, amounting to 5. Believing that the members of the medical profession will wish to contribute toward a fund for the purpose of paying the balance due on the house, the committee requests contributions of any amount. They may be sent to Major M. W. Ireland, United States Army, Washington, D. C. The editors of THE BULLETIN sincerely hope our alumni will honor the memory of our most distinguished alumnus by contributing liberally to this most worthy cause.

At the last regular meeting of the University of Maryland Medical Association, held in the amphitheatre of the University Hospital, Tuesday, March 16, 1909, the program was as follows: 1, "The General Practitioner: His Relation to His Patients, to His Fellow Practitioners and to the Community in Which He Lives," Dr. Guy Steele, Cambridge, Md.; 2, "Medical Ethics," Dr. Samuel C. Chew. Dr. A. M. Shipley, the president, was in the chair, and called the meeting to order promptly at 8.30 P. M. The attendance was large and appreciative, and listened to two remarkably able addresses. Those who had the privilege and pleasure of listening to the words of wisdom and advice both of Dr. Chew and Dr. Steele went away with a clearer conception of their duties to their professional brethren and the public.

Immediately after the adjournment of the Medical Association the Adjunct Faculty, with its president, Dr. Joseph W. Holland, in the chair, held a very important meeting, the gist of which is as follows: Resolved by the Adjunct Faculty of the Medical Department of the University of Maryland that the Board of Regents be implored to effect such changes in the charter as to make possible the election of a president with a fixed salary, and with the duties usually associated with that office in standard universities, and a Board of Administrators independent of teaching faculties. The Adjunct Faculty also endorsed tentative plans looking towards the formation of an advisory board of alumni counsellors.

At the meeting of the Section on Ophthalmology and Otology, Thursday, March 11, 1909, at the Faculty Hall, the following of our alumni read papers: "Rodent Ulcer of the Cornea , with Exhibition of the Case," Dr. R. L. Randolph; "Purulent Otitis Media of Infancy and Childhood," Dr. H. O. Reik.

At the meeting of the Section on Neurology and Psychiatry, Friday, March 12, 1909, the following participated:

"History and Forms of Chorea," Dr. N. M. Owensby;

"Etiology of Chorea, Dr. H. D. McCarty;

"Treatment of Chorea," Dr. W. S. Carswell.

Dr. Fitz Randolph Winslow, class of 1906, a former resident physician in the University Hospital, and a resident of Baltimore, has located at Hinton, Virginia.

The Phi Sigma Kappa Fraternity had an at-home Saturday, March 27, 1909.

About sixty members of the Theta Nu Epsilon Fraternity, University of Maryland, attended a banquet at the Belvedere recently. It was served in the main hall, and the tables, which formed a semicircle, were beautifully decorated with trailing asparagus and cut flowers. During the meal a string orchestra rendered popular selections. Dr. Arthur M. Shipley, toastmaster, introduced Mr. Frederick W. Rankin, who made the address of welcome. Mr. Rankin was followed by Dr. C. H. Richards, who responded to the toast "Past and Present;" Dr. W. D. Scott had as his subject "The Fraternity Man;" Dr. R. Dorsey Coale, "The Undergraduate;" Dr. Randolph Winslow, "The Near Doctor;" Dr. John C. Hemmeter, "Our University," and Mr. C. B. Mathews, "The Ladies." The reception committee in charge of the arrangements was as follows: Frederick W. Rankin, chairman; Ross S. McElwee; John W. Robertson, John S. Mandigo, Arthur L. Fehsenfeld, J. F. Anderson.

DEATHS.

Dr. Joseph R. Owens, class of 1859, mayor of Hyattsville, Md., and treasurer of the Maryland Agricultural College, died at his home, in Hyattsville, March 15, 1909, after a lingering illness of six months. Death came peacefully, and at the bedside were his wife, who was Miss Gertrude E. Councilman, of Worthington Valley, Baltimore county, Md.; his daughter, Mrs. Geo. B. Luckey, and his son, Charles C. Owens, of New York. Besides these he is survived by his mother, Mrs. Percilla Owens, 90 years of age; a son, Mr. L. Owens, of New York, and a daughter, Mrs. A. A. Turbeyne, of England.

Dr. Owens was born in Baltimore, February 20, 1839, and was 70 years old. His parents removed to West River when he was seven years of age. When he was ten years old he entered Newton Academy, Baltimore, and in 1859 was graduated from the Medical Department of the University of Maryland. Immediately after leaving the University he was appointed resident physician at the Baltimore City Almshouse, and served in this capacity to 1861, when he returned to Anne Arundel county and began farming on West River. In 1885 he removed to Hyattsville and accepted the position of clerk of the Claims Division of the Treasury Department, Washington. He held this office until 1890, when he was named as treasurer of the Maryland Agricultural College, which position he filled until death. For several years Dr. Owens was collector of taxes in Anne Arundel county. When the municipal government of Hyattsville was changed from a board of commissioners to a mayor and common council, Dr. Owens was elected councilman from the Third ward, and served with marked ability until May, 1906, when he was elected mayor.

He was elected for three consecutive terms without opposition, and was foremost in every move tending to the advancement of the town. As treasurer of the Maryland Agricultural College he became acquainted with many of the leading men of the State, by whom he was held in the highest esteem. He was secretary of the Vansville Farmers' Club for many years, a director of the First National Bank of Hyattsville. Interment was in the cemetery adjoining Old St. James' Protestant Episcopal Church, near West River, Anne Arundel county. The coffin was borne from his late residence, Hill Top Lodge, by seven cadets of the Agricultural College--Cadet-Major Mayor, Captains Burrough and Jassell, Lieutenant Jarrell and Sergeants Freere, Saunders and Cole. A squad of 25 cadets, five from each class of the College, under command of Captain Gorsuch, escorted the body to Pinkey Memorial Church, where the Episcopal burial service was read by Rev. Henry Thomas, rector of St. Matthew's Parish, of which Dr. Owens had been registrar and a member of the vestry for several years. The body, preceded by the college cadets, was taken to the Chesapeake Beach Railway Station and shipped to Lyons Creek, and thence to St. James' Church. Rev. Henry Thomas officiated at the grave. The pall-bearers were: Messrs. Wirt Harrison, Harry W. Dorsey, E. B. Owens, O. H. Carr, T. Sellman Hall and E. A. Fuller. A special meeting of the Mayor and Common Council was held in Heptasophs' Hall March 22, 1909, to take action upon the death of Dr. Joseph R. Owens, late Mayor of Hyattsville. Acting Mayor John Fainter Jr., was chairman and Town Clerk G. H. Carr was secretary. Former Mayor Dr. C. A. Wells eulogized the late Mayor, both as a public official and a private citizen. Dr. Joseph A. Mudd, W. P. Magruder, R. E. White, J. W. Aman and Edward Devlin, all members of the Council who served with Dr. Owens, and R. W. Wells, M. J. Smith and S. J. Kelly, the last named as members of the present Council, also made appropriate addresses. It was resolved that in the passing away of Dr. Joseph R. Owens, Mayor of Hyattsville, we have lost a conscientious official, a valued associate and a personal friend, and the citizens of Hyattsville at large, as well as his official associates, have experienced a bereavement, the effects of which they will ever feel.

Dr. Asa S. Linthicum, class of 1852, a former member of the Board of County Commissioners of Anne Arundel county, died at his home, in Jessup, Md., Sunday, March 28, 1909, from apoplexy, aged 78. About 25 years ago Dr. Linthicum retired from the active practice of medicine to engage in iron ore mining.

Dr. Linthicum's wife, who died about five years ago, was Miss Nettie Crane, of Clifton Springs, N. J. Interment was in Loudon Park Cemetery, Baltimore.

Dr. John Bailey Mullins, class of 1887, of Washington, D. C., a member of the American Medical Association and the American Society of Laryngology and Otology, formerly of Norfolk, Va., died at his home, in Washington, D. C., from cerebral hemorrhage, February 11, 1909, aged 42.

Resolutions on the death of Dr. John Bailey Mullins:

WHEREAS, It has been God's purpose to suddenly call hence one of our most useful and beloved members; be it

Dr. Samuel Groome Fisher, class of 1854, of Port Deposit, Md., died at the home of his son, in Port Deposit, February 22, 1909, aged 77. For more than 50 years Dr. Fisher was a practitioner of Chestertown, Md.

Dr. Charles Brewer, class of 1855, of Vineland, N. J., died at his home, in Vineland, March 3, 1909, aged 76. From 1858 to the outbreak of the Civil War he was a member of the Medical Corps of the Army, and during the war a surgeon in the Confederate States service. Under President Cleveland he was postmaster at Vineland, N. J., and resident physician at the State Prison, Trenton, from 1891 to 1896.

Dr. William F. Chenault, class of 1888, of Cleveland, N. C., a member of the Medical Society of the State of North Carolina, died at his home, in Cleveland, N. C., February 24, 1909, from cerebral hemorrhage, aged 46.

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