The Haemostatic Forceps ik Exsbcting the Appendix. BY ALEXANDER J. C. SKENE, M. D. REPRINTED PROM THE Weto Forfe JHetitcal Journal for March 5, 1898. Reprinted from the New YorTc Medical Journal for March 5, 1898. THE HAEMOSTATIC FORCEPS IN EXSECTING THE APPENDIX ALEXANDER J. C. SKENE, M. D, Finding that the treatment of the pedicle of ovarian tumors with compression and heat applied with the elec- tric current gives infinitely the best results, I have em- ployed the same method in appendicectomy with equally fortunate and gratifying results. The advantages of this method over the ligature for controlling bleeding, in abdominal surgery especially, have been discussed in relation to ovariotomy and hys- terectomy in the New York Medical Journal, March 27, 1897, but there remains much to be said in regard to the practice of the method in salpingectomy and appen- dicectomy. Professor Emil Eies, of Chicago, has given (see American Gynaecological and Obstetric Journal, January, 1898) his unfavorable experience with the ligature in removal of the tubes and ovaries, and as my experience fully agrees with his I quote from his valu- able essay. After noticing that Schauta and Chrobak report but little more than fifty per cent, of their lapa- rotomy patients as really cured. Dr. Pies suggested that Copyright, 18C8, bt D. Appleton and Company. 2 THE HAEMOSTATIC FORCEPS one of the most important causes of these unsatisfactory results was to be found in the formation of stump exu- dates, and offers a new explanation of this cause in the following observation of several cases in which micro- scopical examination was made of the uterus removed some time after salpingectomy. “ Stump exudates were found by Schauta in twenty- eight cases out of his one hundred and seventy-two sal- pingo-oophorectomies. They have been found even more frequently by other observers, and in my own ex- perience I have repeatedly found them to he at the bot- tom of troublesome symptoms months after the opera- tion. They produce pain, sometimes so severe that the patient is unable to attend to her work; in some cases the pain is even worse than it was before the operation. The exudates are found around the stumps of the re- moved tubes, and vary in size from a barely palpable thickening of the uterine horn to the size of a hen’s egg or larger. “ As an explanation of the formation of these tumors, Schauta offered the following two possibilities: “ 1. The inflammatory process creeps on through the uterine wall into the surrounding parametric and peri- metric tissue; and “ 2. Germs were present in the broad ligament at the time of the operation (though no actual observations could be offered as evidence of this), the connective tissue of the broad ligament was laid bare by the opera- tion, and in this way the germs could invade the peri- tonaeum. “ Though these observations did not meet with any opposition, it can not be overlooked that we have no observations bearing out the correctness of these hypoth- IN EXSECTING THE APPENDIX. 3 eses. Besides, I can not help feeling that they are very artificial. “ The cases are the following; “ Case I.—Mrs. J., twenty-four years old. Seven months previously a- left pus tube and ovary had been removed. A sinus remained which would not close. Besides, the patient has an ovarian abscess the size of a fist, and hydrosalpinx on the right side. Uterus adher- ent all over, forming part of the wall of the sinus. I operated September 28, 1896. Laparotomy, Removal of ovarian abscess, hydrosalpinx, uterus, excision of sinus, which leads toward the right crista ilii and ter- minates in an abscess, which contains five silk ligatures. Recovery.- “ The stump of the tube which had been removed seven months previously is excised and examined in a series of sections embracing the entire stump up to the interstitial portion of the tube. The cavity is open throughout. The epithelium is the usual low columnar epithelium of this portion of the tube and stops at the surface of the stump without investing the cut surface of the stump. No threads to be found in the stump. “ Case II.—Miss W., twenty-five years old. Several 3rears ago removal of both tubes and right ovary. Now chronic pelviperitonitis and adherent retroflexion. Operation by Dr. W. H. Rumpf on December 8, 1896. Vaginal hysterectomy. “ Both tubal stumps are examined in series. They are perfectly permeable, though the cavity is very nar- row. Epithelium well preserved up to the abdominal opening of the stump. Besides, the left tube contains some epithelial ducts outside the circular muscular layer of the tube, one of which enters the circular muscular layer itself, but does not show any communication with the tubal cavity (remnant of the Wolffian body). No threads to be found in the stump.” These same unfavorable results are reported by A. Lapthorn Smith in his “ experience of two hundred and 4 THE HAEMOSTATIC FORCEPS forty-nine abdominal sections” (American Journal of Obstetrics, No. 241, page 64). He has seen several cases from one to two years after the appendix had been re- moved, who were suffering from faecal fistula or peri- csecal abscess. This is the testimony of Armstrong also, who reported in the British Medical Journal, October 9, 1897, that faecal fistula followed fifteen times in five hundred and forty-one cases. Smith very clearly proves that “ because of the mncons glands which are imbedded in the mucous membrane of the appendix it is quite as nnsurgical to put a ligature around the base of the ap- pendix a quarter of an inch from the caecum and then cut the appendix off as to propose to close an opening in the bowel by picking up the edges of the opening and tying a ligature around them, because this would sim- ply bring mucous surfaces into contact, and, when the ligature has cut through or otherwise fallen off, the secreting glandular surface would separate and the contents of the bowel escape. Those who follow this method may say that they cauterize the mucous mem- brane after cutting off the appendix, and not only disin- fect it but also destroy its secreting surface. But this, I maintain, is impossible for them to do, because they manifestly can not reach the mucous membrane brought together by the ligature, nor still less the part of it which lies below the ligature. If there were only one case of faecal fistula instead of fifteen in five hundred it would bo worth while preventing it. “ The ideal method, in my opinion, and which I have followed in these cases, is for an assistant to hold up the intestine an inch on each side of the appendix, and, after tying and cutting the meso-appendix, to snip the appendix oft even with the caecum. The hole in the IN EXSECTING THE APPENDIX. 5 intestine is then sewed up with fine silk, care being taken to include only the muscular coat. A director is then pressed upon the line of the suture until it sinks below the surrounding surface, when another row of sutures brings the peritoneal surfaces together. Such a closure will almost surely unite by primary union, doing away with all danger of faecal fistula or circumcaecrd inflamma- tion, by which the opening in the appendix is sometimes closed, and in which cases, although there is no faecal fistula, the patient is subjected to a good deal of discom- fort while Nature is throwing out a layer of plastic lymph to seal the defective closure. Some authors recommend the peeling off of the peritoneal coat of the appendix so as to form a cuff a quarter of an inch long, and then, after tying and cutting off the appendix in the man- ner which is condemned above, make up for the defect by sewing the peritonaeum over the end of the stump. This is much better than leaving a sloughing stump free in the abdomen, but is by no means as good as the meth- od advocated above, in which no stump at all is left, and nothing but a fine, thin line of Lembert suture, which we know gives absolutely no trouble.” This same method was fully described by Haggard, of Nashville, in a paper reported in the Transactions of the Southern Surgical and Gyncecological Association at the tenth annual meeting in St. Louis last November. He summed up the merits of this method as follows: “ Total excision of the appendix, with closure of the hole in the head of the colon, was said to do away with the following dangers: (1) Subsequent perforation of the stump under the ligature from infection in its own cavity, (3) abscess of the wall of the caecum from in- vagination of the infected stump, (3) continuance of in- 6 THE HAEMOSTATIC FORCEPS fected process from stricture in the stump between distal ligature and the proximal opening of appendix into the caecum, (4) imperfect invagination, with incomplete drainage of the stump, on account of the csecal wall being thickened and stiffened with inflammatory exu- date.” I have not had an opportunity of examining, post mortem, the stump treated with the haemostatic forceps, but have observed clinically that during the reparative process there was no immediate exudation that could be detected; neither have there been any remote exudates found on examination that caused pain. The recovery has been complete and permanent. This is as might be expected, from the fact that the lumen of the tubes and blood-vessels is completely obliterated by compression and heat, and does not, in fact can not, reopen. That complete disorganization of the mucous membrane of tubes or vessels and permanent closure of their lumen are effected has been demonstrated in many experiments. This experience in ovariotomy and kindred opera- tions led me to expect equally satisfactory results in appendicectomy, and my expectations have been fully realized in practice. In fact, this method of treating the stump of the appendix has special advantages in be- ing the only satisfactory way of controlling hemorrhage in softened septic tissues. In salpingotomy, ovariotomy, and appendicectomy the surgeon often finds that the pedicle or point of sepa- ration is diseased, and the ligature is likely to cut the tis- sues if made tight enough to close the vessels; and if that is not the ease the stump is infiltrated with septic material, which causes trouble no matter how sterile or aseptic the ligature may he. With the haemostatic for- IN EXSECTING THE APPENDIX. 7 ceps the vessels and lumen of the tube or appendix, as the ease may be, are completely closed and the stump thor- oughly disinfected at the same time. I have had abun- dant opportunities to prove the advantages of this meth- od of controlling bleeding vessels in pelvic surgery. I am now using it in other branches of surgery with equally satisfactory results. The following case history is given as reported by my clinical assistant, Dr. Erdmann; W. S. P., aged thirty-two years; a New York mer- chant, of medium build, active disposition, neurosanguine temperament, regular habits, primary assimilation and ultimate nutrition good. Physical examination re- veals apparently perfect health. Complaint is made for the past month of a dull ache in the right iliac region, usually merely annoying, but at times severely lancinat- ing and markedly distressing. There are no other symptoms, either gastric or intestinal, except that the bowel is inclined to constipation. A physical examination was easily made because of the laxity of the abdominal wall, and revealed a small movable tumor in the region of the appendix. The patient’s condition does not prevent his contin- uance in the regular duties of his business; yet, in view of a history of six other similar attacks, he seeks relief from the pain and mental disquiet hv operative pro- cedure. The patient enjoyed good health until two years ago last fall. The first attack was provoked, apparently, by a bath taken immediately after dinner. The local symp- toms were typical of an inflammatory condition of the appendix vermiformis. The pain at first was general over the abdomen, beginning in the epigastrium, but soon became localized in the right iliac fossa. After four or five days of rest and medication relief was ob- tained, and the regular business duties were resumed. In February, 1896, while suffering from a severe cold, a second attack prostrated the patient. At this time the THE HAEMOSTATIC FORCEPS pain was at once localized in the region of the appendix, and recover}7 under treatment was retarded for nearly two weeks. Again, in May, 1896, after partaking heartily of lobster, the patient was seized in a similar manner for the third time. On this occasion his con- dition was deemed so critical that he was advised to sub- mit to an immediate operation. After nine or ten days, however, he was relieved by medical treatment, and in a short while was able to attend to his business duties. Six months later, Thanksgiving day, 1896, an extended rail- road trip was suddenly interrupted by a fourth attack similar to the preceding ones. This was followed by a fifth in February, 1897, and a sixth in May of the same year. The attacks were all similar in their onset, nature, and course. The pain came suddenly, without any pre- monitory symptoms, and after the first time it was at once localized in the region of the appendix'; there was no gastric disturbance except a slight nausea, nor intes- tinal, except tympanites; relief followed the exhibition of opium and local hot compresses. At the present time of comparative quiescence, and while he is yet in first- class condition to bear an operation, the patient has at last consented to the repeatedly advised surgical inter- ference. The operation was done January 11, 1898, by Dr. Skene. For the first time in the history of appendicec- tomy the method of operating with the electric haemo- static forceps was used. This departure from the cur- rent methods of ligature, suture, cauterization, invagina- tion, and others is the logical outcome of the success of Dr. Skene’s practice when operating upon the pelvic vis- cera. All the other steps of the operation were such as are advised by surgeons generally. The incision was the ordinary one over Mcßurney’s point, two inches in length. On inspection, both the appendix and the meso- appendix were found to be much enlarged and thick- ened, and superficially traversed by numerous dilated blood-vessels. There were no adhesions. The first grasp of the forceps was upon the meso-appendix close to IN EXSECTING THE APPENDIX. 9 its mesenteric attachment. A current which heated the forceps to 180° F. was then induced for half a minute. Upon removal of the forceps the tissues were found to be not charred but dried, having the appearance of white horny matter. Scissors were used to bisect this desiccated area. A second seizure was made upon the appendix itself close to the caput coli, and the same cur- rent continued for ninety seconds. The forceps was then removed and the tissue divided in the line of the desic- cated area away from the caput. The same result was manifested. Ho charred tissue, no bleeding, and, more important than all, no escape of the contents of the appendix. The tissues had simply been dried out. Just at this point a rather violent attack of retching came upon the patient, which continued for nearly a minute, yet without inducing any change whatever in the stump. All the severe pressure and strain had not forced even a speck of blood or serum into the compressed area. The abdominal cavity was left perfectly free from any foreign matter whatever. Sutures and dressings as usual. Time of operation, fifteen minutes. Anesthetic, Schleich solution Ho. 3 nine drachms. Time for induction of narcosis, seven minutes. The specimen measures seventy-five millimetres in length and forty-five millimetres in circumference and is of an irregular S shape. The contents were about a drachm of pus, mucus, and broken-down cellular tissue. The meso-appendix is also much thickened, even to ten millimetres, and its greatest width is twenty millimetres. A microscopic section made shortly after the opera- tion, according to the Johns Hopkins “ fifteen-minute ” method, confirmed the diagnosis by exhibiting the typical structure of an old recurrent hypertrophied inflamma- tory change. The convalescence has been unmarked by any compli- cations due to the operation. When the sutures were re- moved after a week the parietal wound was perfectly dry and clean. At the close of another week the patient was sitting up, enjoying his newspaper and cigar, and was discharged from our care on the seventeenth day. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. EDITED BY FRANK P. FOSTER, M. D. THE PHYSICIAN who would keep abreast with the ad- vances in medical science must read a live weekly medical Journal, in which scientific facts are presented in a clear manner ; one for which the articles are written by men of learning, and by those who are good and accurate observers; a journal that is stripped of every feature irrelevant to medical science, and gives evidence of being carefully and conscientiously edited ; one that bears upon every page the stamp of desire to elevate the standard of the profession of medicine. 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