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.
Read Before the Baltimore City Medical Society,
Section on Medicine and Surgery,
February, 1909.
Direct laryngoscopy, as the name implies, is the inspection of the larynx through a hollow tube without the use of a mirror. The examination is made with the patient in the sitting position, under local anesthesia, or in the prone position, under general anesthesia. To examine the larynx in the sitting position it is practically always necessary to give a hypodermic injection of morphia and atropia a half hour beforehand, to relax the muscles and to prevent excessive secretion. The patient is seated upon a low stool with the head extended and supported by an assistant. With curved forceps 20% cocaine or 25% alypin solution is quickly passed into the throat, anesthetizing pharynx, tongue and epiglottis. Jackson's slide speculum is then introduced and the base of the tongue, with the epiglottis, gently pulled forward. At this point it is usually necessary to use more cocaine directly in the larynx, which is introduced by means of special cotton carriers. In a few minutes anesthetization is complete, and the examination can be made at leisure. It will be found easier to inspect the different parts of the larynx if the head is held about halfway between the erect position and complete extension. In some patients with short, thick necks and large middle incisor teeth the slide will have to be removed from the speculum to enable one to see well. The examination in the prone position under general anesthesia is made with the patient's head over the end of the table supported by an assistant. The speculum is introduced and the base of the tongue and the epiglottis pulled upward forcibly. In this position direct laryngoscopy, even in children, is unsatisfactory, and operative procedures are well-nigh impossible on account of the muscular rigidity. The force required to lift the tissues is so great and the position of the arm is so cramped that it is difficult to get a clear view of the field. The difficulty has impressed all who have worked in this particular line. It remained for Dr. H. P. Mosher, of Boston, to discover a method of direct laryngoscopy which makes it as simple under ether anesthesia as in the sitting position. In April, 1908, he described in the Boston Medical and Surgical Journal the "left lateral position" for examining the larynx and the upper end of the esophagus. He designed certain instruments which I believe are too cumbersome to meet with popular favor. In Mosher's position the patient lies on the table with the head turned toward the left until the cheek almost rests on the table; the chin is flexed on the chest. In our work at the Presbyterian Hospital we have found a modified Mosher's position and Jackson's child speculum the ideal combination for the examination in the prone patient. In children the procedure is carried out with or without anesthesia. Without anesthesia the head, hands and feet are held, the chin is flexed on the chest in a normal position by placing a pillow under the head, the speculum is introduced and the larynx inspected. In adults under anesthesia the same procedure is used, and will be found much simpler than the extended position. In adults, after the speculum is in position, if the anterior part of the larynx is not seen, gentle pressure on the thyroid cartilage will bring the anterior commissure into view. Operations can be done through the tube satisfactorily. With the different methods of direct laryngoscopy it is possible to remove any growth from the larynx.