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Fecal fistulas are fairly frequently encountered by those engaged in the practice of surgery. Usually they arise as an unexpected and distressing complication of abdominal operations. Sometimes they heal spontaneously and all that is required of the surgeon is "masterly inactivity." The eradication of others, however, may be an extremely difficult task—one that will tax the skill of the most resourceful operator. There are certain well founded principles which may be used as a guide in the treatment of fecal fistulas and which may expedite the task of the physician and the recovery of the patient. To ignore these rules is often to invite poor results or disaster and, as many of them have not been clearly elucidated before, we will set them forth in the following paragraphs. The few statistical deductions of this report are based on an analysis of data on 65 consecutive cases of persistent external fecal

"Conservative treatment of subphrenic infection should be given a trial unless the clinical manifestations and the radiological investigations indicate or strongly suggest abscess formation.... In many instances these measures will succeed and an abscess may thus be aborted, the fever subsiding in a few days, the pain and tenderness diminishing, and the convalescence from the original causative lesion or operation being resumed.... If the characteristic clinical picture of subphrenic infection continues unabated for three to six days, it is wiser to operate than to temporize indefinitely with medical measures. Operative treatment should be carried out immediately as soon as the subphrenic abscess is diagnosed or suspected." The foregoing statements are taken from the book "Abdominal Operations" by Rodney Maingot, 1 and they reflect the opinions of teachers of surgery today. Once the diagnosis of a subphrenic abscess has been established, the importance of immediate operation to evacuate the abscess is

• Tracheotomy is now recognized as a singularly effective means for removing retained secretions, for improving ventilation, and for obtaining physiological advantages in many different disease states, in addition to bypassing mechanical obstruction of the airway. The indications for tracheotomy can be separated into two broad categories, mechanical and secretional ventilatory. The benefits of tracheotomy in bypassing an obstruction are realized to a much greater degree if the operation is performed before severe obstruction develops. The physiological improvements following tracheotomy are improvement of ventilatory efficiency and removal of secretions, as well as assistance to the patient with a reduced vital capacity, such as in spinal cord injury, poliomyelitis, encephalitis, severe burns, and after extensive thoracic or abdominal operations.

The effectiveness of D-pantothenyl alcohol in the treatment of paralytic ileus was tested by comparing two groups of 50 patients after abdominal operations. Both groups received the customary postoperative care as seemed indicated by the attending surgeon, but in addition 50 patients received intramuscular injections of 250 mg. of D-pantothenyl alcohol every six hours until normal peristalsis was established, while the remaining 50 received a placebo in the same manner. In the group receiving the drug it was possible to discontinue the use of tubes and of venoclysis sooner than in the other group, but it was debatable whether the actual difference in the average case was of practical importance. The drug was used in 12 additional patients who had profound postoperative intestinal atony, and in each case it appeared to cause resumption of bowel sounds, passage of flatus, and relief from distention. No undesired side-effects were observed.

To the Editor:— InThe Journal, Dec. 11, 1943, Seelig, Verda and Kidd recommended potassium bitartrate as a substitute for talcum powder in surgery. Some time ago we commenced a series of experiments using a substitute for talc. The first compound used was starch, selected because of its smoothness and qualities as a dusting agent, as well as its being a carbohydrate which might be broken down into its simpler components in the peritoneal cavity and be utilized. We found, however, that starch could not be sterilized in the usual manner without becoming gelatinized and forming a glaze over the gloves causing them to be stiff and stick together. Despite this it was used for two abdominal operations on one dog, the first consisting in simply handling the bowel with unrinsed gloves, and the second rubbing a small quantity (several grams) on the bowel surface. In neither operation were adhesions

The method originated with me accidently in May, 1914. After operating for acute appendicitis on two malarial patients I instructed the nurse to give the patients 10 grains of quinin muriate by rectum every six hours until such time as the patient could take quinin by mouth. To my surprise these patients had no nausea, vomiting, gas pains, backache or postoperative thirst. The result was so marked that I have used it in all laparotomies since, with the following results in twenty cases including the various abdominal operations: No nausea or vomiting in 10 cases. Slight nausea and vomiting in 6 cases. Much nausea and vomiting in 4 cases. No gas pain in 19 cases. Slight gas pain in 1 case. No backache in 20 cases. No desire for water within the first twelve hours in 9 cases. Only moderate thirst in 11 cases. In all cases the postoperative thirst

The advantages of vaginal drainage for certain cases of pelvic abscess in women have long been recognized. The equal advantages of rectal drainage for the rarer condition of pelvic abscess in the male, have been less widely accepted. It has not been, however, an uncommon practice in the past to drain, in this way, residual pelvic abscesses occurring in men after abdominal operations for suppurative appendicitis. Nature was allowed formerly to effect an uncertain and occasional cure of appendiceal abscess by the same route, and occasionally the efforts on the part of Nature in this direction have been supplemented by the surgeon. With improvement in the diagnosis and operative treatment of acute appendicitis, there is less and less occasion for resort to this method of drainage, either by the surgeon, or on the part of Nature. Yet there unfortunately exists a very restricted class of cases in which this simple

To the Editor: —InThe Journal(May 4, p. 1339) Dr. Bell reports very satisfactory results in treating acute and subacute suppurative conditions with bismuth paste. I note that in two of his cases symptoms of bismuth absorption occurred, and while in his cases the progress of the poisoning was checked by proper treatment, others employing this treatment in similar cases might be less fortunate and thus encounter serious complications. I feel prompted, therefore, to issue a warning against the use of the bismuth paste as a substitute for the drainagetube shortly after abdominal operations. In such acute cases our old methods of drainage are entirely satisfactory, and bismuth paste should not be injected unless the suppuration continues for an unusually long period. Under such conditions its injection is permissible, as by that time the adhesions have become sufficiently firm to prevent their rupture through undue pressure caused by the

To the Editor:— The article "Leukemia with Thrombocytosis" by Dr. Carl B. Drake inThe Journal, March 21, interested me very much. It is unfortunate that the case is labeled "leukemia" and not "polycythemia," since the report brings up a number of points of interest in connection with the latter disease. First of these is the hemorrhagic tendency in polycythemia, which is often quite striking and has been commented on by many observers. In my own series of twenty cases it has been a common symptom. The bleeding may be spontaneous, as from the nose, the stomach or the bowel, or it may be present as a persistent oozing following such operative procedures as extraction of teeth or abdominal operations. The tendency to bleed appears to have nothing whatever to do with the platelets, the bleeding time or the clotting time but is probably the result of injury to the

It is now more than eleven years since I devised and began to use the transverse incision in operations for appendicitis. My first publication was in theMedical Recordof New York in November, 1905, in an article entitled "Transverse Incision in Abdominal Operations." Since that time I have published another paper on the method inNorthwest Medicine, February, 1910. Gwyllam Davis of Philadelphia, working independently, published a paper in theAnnals of Surgeryfor January, 1906, describing a transverse incision operation. In the article on "Appendicitis" by J. B. Murphy in Volume Six of Keen's Surgery my operation is described in a comprehensive paragraph. Notwithstanding these publications the method has attracted but little attention, and the vertical right rectus incision is the one in general use. I believe that the transverse incision is greatly superior to the vertical as a routine procedure. Eleven years' experience has confirmed me in

Every one who practices abdominal surgery observes gastric and intestinal distention occasionally, which symptom is responsible for much of the postoperative distress that frequently follows abdominal operations. This distention is usually relieved by such ordinary measures as enemas, gastric lavage or colonic irrigation, but it sometimes follows a relatively simple operation, such as that for the removal of the appendix during the interval following an acute attack, and it may even cause death in such cases despite all treatment. It is evident, therefore, that any measure which affords relief in those cases in which a fatal termination is to be feared, deserves careful consideration. There are many references in the literature to the use of physostigmin for the relief of abdominal distention, but the application is based on theoretical considerations rather than on clinical experience, and recent observers state that the drug is uncertain in its therapeutic effects and that

The dramatic manner in which sponges are counted after each operation, in some hospitals, is evidence of the fact that "accidents still happen." It is quite probable that more medicolegal cases come to trial because something has been left in the operative field than because too much has been taken out of it. Approximately 27,250 abdominal operations have been done at the Mayo Clinic within the last five years, and thirteen were for the removal of sponges. In most of these thirteen cases the patients came from rural districts, and had been operated on for acute conditions by general practitioners who probably had had very mediocre assistance and were further handicapped by the confusion attendant at such operations. The only wonder is that such accidents do not happen more often in this kind of surgery. After a more or less stormy convalescence, the patient recovers from the operation; but he

In view of the fact that many surgeons are using hot and cold packs for one reason or another, on and within the abdomen either before, during or after abdominal operations, it seemed advisable to determine the effect of these agents on the organism. As changes in blood pressure are conveniently recorded, and as at the same time these changes are an important index of the condition of the patient, we have determined the changes in blood pressure produced by the application of either heat or cold on or within the abdomen. We obtained the results herein reported when using cats as the subjects of the experimental study. The animals were anesthetized with ether. Records were made of thees in blood pressure by connecting the carotid artery through a cannula with a mercury manometer so arranged as to trace the pressure variations on a smoked paper attached to a slow

The introduction of saline solution subcutaneously, intravenously or per rectum, to support the circulation in shock and collapse, is markedly efficacious, and if properly given is perhaps the most valuable treatment for these conditions. Intra-abdominal transfusion of salt solutions into the peritoneal cavity, as advocated by Lawson Tait, is of undoubted value to combat shock following abdominal operations, as is also the employment of proctoclysis in the treatment of peritonitis and general toxemic conditions, as suggested by Dr. J. B. Murphy of Chicago. Aside from the fact that the solution must be aseptic, the temperature of the solution as it enters the tissues is of the utmost importance. With the usual solution-containers—the fountain syringe, glass flask and glass pressure bottle—there is difficulty in maintaining an equable temperature, for they rapidly radiate heat, and usually there is considerable drop in the temperature of the fluid from the start to the

Tuberculous peritonitis generally occurs in the young, principally in women, although it may affect either sex. After considerable experience with abdominal operations, I have found that tuberculous peritonitis is usually cured by a celiotomy. The simple opening of the abdomen without anything else being done, nothing being removed and no irrigation being instituted, has sometimes resulted in a cure. At other times, complications have been found which had to be remedied. Often the operation was performed for pus tubes, which were very properly removed on account of mixed infection. It has become a custom with some surgeons when operating for tuberculous peritonitis to remove the tubes whether there was mixed infection or not, simply in order to close an avenue for the entrance of tubercle bacilli, which were supposed to be poured out from the end of the tube into the peritoneal cavity. I have protested against this practice for

In 1909 and again in 1913 I1published two papers on the subject of acute intestinal obstruction. Since that time I have been keenly interested in the clinical phase of this subject as it has arisen in patients coming under my own observation, and also in the voluminous published reports on this subject. In reviewing the literature, one is amazed at the conflicting reports pertaining to the fatal factor in acute intestinal obstruction. This is strikingly illustrated in the extensive review by Ellis.2 Nesbitt,3in 1899, in a study of the content above the occlusion, found that food rich in lecithin resulted in cholin and neurin, and he believed that neurin was the responsible fatal factor in acute intestinal obstruction. Buchbinder,4in 1900, showed that the intestinal wall is not permeable to bacteria until a severe degree of gangrene develops, or until injury is produced in

It has been said that as long as surgery remains an art sponges will be overlooked and unintentionally left in the abdominal cavity. Yet I believe the day is coming when we will not place a sponge, clamp or any other instrument wholly within the abdomen. The ablest surgeons the world has known have had the misfortune to have left a sponge, a drainage tube or an instrument in some cavity of the body. The possibility of leaving a sponge in the abdominal cavity has been a source of anxiety to every surgeon, and although we have devised numerous methods to avoid this accident, the human element is always present, and must be reckoned with, and alas, too often this unfortunate accident takes place. The man who has to bear the stress of the unexpected calamities that occur in surgery realizes how easy it is to leave a foreign body

When one contemplates the marvelous change in the past twenty years in our knowledge of the diseases of the digestive apparatus and honestly tries to analyze what has been the fundamental cause of this change— this metamorphosis from poverty of method and uncertainty of result to our present wealth of diagnostic data and successful therapy—I feel that we must admit that it is to the surgeon and to the physiologist that this great change is mainly due. The use of the stomach tube has been an aid, and the more refined and newer methods of studying gastric and intestinal secretions have proved of interest; but an attempt to evolve a gastro-intestinal pathology fundamentally on the basis of secretory variations is to lean on a frail reed—and in the stomach the secretory findings must be regarded as but general indexes of the tendency of the functional digestive act rather than as

Thrombosis of veins is common in the pelvic region and in the lower extremities. It may follow abdominal operations or develop during the puerperium. Thrombus formation in the veins of the upper extremities, secondary to such conditions, is not common, and thrombosis of the axillary vein caused by effort is comparatively rare. As a clinical entity the condition was first described by Von Schrotter in 1884. Cadenat1in 1920 reviewed twenty-four cases from the literature. Paggi2in 1933 collected reports of seventy-four cases from medical writings. Matas3in 1934 reported one case and reviewed the literature of approximately 100 cases. Since then about twenty additional cases have been described by various observers, but great numbers have not been observed by any one person. A review of the cases by the various authors showed that the patients were young, in good health and engaged in work. Although males

To the Editor:— InThe Journal, July 25, pages 267-269, in an article entitled "Hyperventilation in Abdominal Surgery," Dr. T. J. Ryan concludes that "carbon dioxide is of no value in the prevention of postoperative pneumonia." This conclusion is drawn from a group of 135 cases in which, at the close of abdominal operations, carbon dioxide was administered only once, for about three minutes, and a control group of 276 in which carbon dioxide was not administered. The morbidity is reported as 2.2 per cent for those who received the inhalation and 1.4 per cent for those who did not, and the mortality as 0.74 per cent for those treated and 0.36 per cent for those who were not. Obviously, if these figures are significant they indicate, not merely that carbon dioxide is without value in the prevention of postoperative pneumonia, but rather that this treatment tends to increase the

The mortality in pelvic operations is definitely lower than it is in other types of abdominal operations when the usual surgical principles and standardized technics are employed; thus, the surgeon may not feel the same degree of hesitancy in undertaking pelvic operations as he does, for instance, in undertaking operations on the upper portion of the abdomen. For these reasons pelvic operations are often performed when there is only the slightest indication for them and at times when there is no real indication at all. It should be remembered that the mortality attending any operation reaches its maximum in the hands of inexpert or insufficiently trained men. Although benign lesions of the uterus rarely are difficult to eradicate, there are conflicting ideas regarding the best procedure to follow. I refer principally to the treatment of myomas, which occupy unusual positions with respect to the uterus. Myomas are most frequently encountered

To the Editor:— In the article by Wakefield, Mayo and Bargen entitled "Ileus Associated With Transient Renal Insufficiency: A True Enterorenal Syndrome" (The Journal, June 22, p. 2235) there appears to be no mention of stethoscopic examination and sounds heard over the abdomen in any one of the ten cases reported. It is very likely that such an examination was performed in each case for audible peristaltic sounds and was very likely absent in all, so that it was omitted in the report. The importance of listening for peristaltic sounds in the differential diagnosis of paralytic and mechanical ileus was deeply impressed on me by Dr. Roger T. Vaughan at the Cook County Hospital whenever the problem presented itself. Especially is this of value when the patient has had one or more previous abdominal operations. Dr. Vaughan insisted, and probably still does, that one listen with the stethoscope over each

Of an extensive literature devoted to the role which constitutional factors play in the development of disease, only a small part deals with the digestive tract. In the discussion of gastro-intestinal diseases the local anatomic aspect dominates the conception of the morbid state. This conception is principally based on the demonstration of anatomic lesions at abdominal operations, which undoubtedly in many instances cleared up the true nature of a formerly obscure process. This applies, however, in particular to acute diseases; we cannot say as unreservedly that the demonstration of anatomic lesions has satisfactorily cleared up the pathogenesis of chronic diseases of the alimentary tract. In most of these chronic diseases anatomic lesions usually are the end-results of a pathologic process, but they do not necessarily indicate its working. For the understanding of its development, pathologic physiology promises better information than anatomic facts. It becomes more and more clear that disturbances

Our purpose is to present observations supporting our belief that intestinal volvulus may be precipitated by plumbism, a sequence of events unmentioned in the literature as far as we can determine. It is well known that in some world areas, such as the Baltic region, volvulus may be a major cause of intestinal obstruction, reaching incidences as high as 50% of all obstructions. 1 Among the natives of the highlands of Peru as seen at this hospital, 2 volvuli also cause about 50% of all obstructions seen. The majority of these are of the sigmoid colon. We have observed repeatedly at autopsies and at abdominal operations that the natives of this area generally possess a long, redundant, mobile megasigmoid, usually with a narrow pedicle-like mesosigmoid predisposed to twist. Of the factors mentioned in the literature as being of import in the development of such anatomically long sigmoids, the two factors

During the last few years the opinion that embolism is a more important factor in the production of postoperative pulmonary complications than has heretofore been suspected has gradually been gaining ground. Since 1920, representatives of several of the largest surgical clinics in America and Europe have accepted this conclusion (Boland,1Farrar,2Cutler and Hunt3). In January, 1922, DeQuervain4of Switzerland stated that following operations upon the stomach, "three fourths of the true postoperative deaths are due to lung complications—emboli, pneumonia and lung gangrene," and that in a good share of the cases of so-called pneumonia, the processes are really embolic in nature. We5arrived at this conclusion in 1919, after having studied all the postoperative pulmonary complications and cases of femoral thrombophlebitis that had occurred in the gynecologic service of the Johns Hopkins Hospital during the preceding thirty years. At that time we expressed the

The history of abdominal operations forms one of the most interesting chapters of surgery. It is not the purpose of this paper to write it in its entirety, since, treated in detail, it would fill a large volume. It is rather the desire to give a few pen-pictures, chiefly of a personal type, of the experiences of men whom I have known and to show, if I may, the earnest cooperation of a considerable group of America's most distinguished surgeons. As it is still the custom in some parts of the south, speaking of events transpiring a generation ago, to group them chronologically as happening before or since the war, so we may wisely group the early data into the former period. America is justly credited with the initial step in this new departure of surgery and Ephraim McDowell of Kentucky is properly called the father of ovariotomy. Although this