No. 4113.

JUNE 28, 1902.

The Cabendish LectureON

INFLAMMATION OF THE VERMIFORMAPPENDIX.

Delivered before the West London Medico-Chirurgical Societyat the Town Hall, Hammersmith, on June 20th, 1902,

BY SIR FREDERICK TREVES, K.C.V.O., C.B.,F.R.C.S. ENG.,

SURGEON TO H.M. THE KING; CONSULTING SURGEON TO THE LONDONHOSPITAL.

MR. CHAIRMAN AND GENTLEMEN,-The subject is the notperfectly novel one of appendicitis, the reason beingthat there are certain points in connexion with thistrouble which I think are still open to discussion. I

should imagine that there has scarcely been anythingmore remarkable in the way of medicine at the close ofthe nineteenth century than the sudden appearance of thedisease now known as appendicitis. If we remember thatthis is proportionally the very commonest acute maladymet with in the abdomen excepting possibly the com-plicatioris of hernia it is really astounding that 20 yearsago this affection was absolutely unknown. It was notuntil the year 1886 that the very name itself had anyexistence. It was, as a matter of fact, by Fritz in 1866 thatthe name was first used, and it is particularly curious thathe used it in a sense totally apart from the sense in which itis used at the present day. One knows that the academical-minded have a great objection to this uncouth term

"appendicitis" ; it lacks precision, but it has found its placein the clumsy nomenclature of medicine and has been

accepted by the public with an extraordinary amount ofgenerosity. Of course, I need not say that under no

circumstances is appendicitis to be regarded as a new disease.It is probable that even the cave man with his rudimentarymethods of eating suffered occasionally from appendicitis.The disease is not new but newly discovered ; it has beenhidden for centuries under a lot of vague clinical facts andmedical verbiage. In old records we hear about appendi-citis as gastric catarrh, gastric seizure, cramp of the bowels,iliac phlegmon, and many other terms. Moreover, a largenumber of examples of peritonitis were no doubt examples ofappendicitis. In 1887 a certain elaborate treatise on peri-tonitis included no less than 26 entirely different forms ofthat particular affection. There are a few earlier reports ofthe trouble and in those earlier reports the appendix wasblamed as being the cause of the disturbance. But all theseearlier reports were like the voice of men crying in thewilderness ; no sort of heed was paid to them although therewere two authors who accused appendicitis of being thecause of what was then known as iliac phlegmon.The point that should be first insisted upon in connexion

with this malady is this : it is a pure peritonitis. There isno consideration about it which is apart from peritonitis.Until the peritoneum is involved there is no malady. Anacute attack of appendicitis is an attack of peritonitis. It is

very desirable, therefore, that in speaking of this affection wespeak of a definite form of peritonitis, and the features andcomplications and possibilities of the malady and the treat-ment to a certain extent are simply those of peritonitis. Noprogress will be made, I think, until a proper estimate ofthis malady is realised and all terms about the twisting andturning of the appendix are thrown aside. Then it will beunderstood that the trouble is nothing but a form of

peritonitis. That leads me to say one word about thedisease originally in the appendix. Fritz used the term todescribe a malady that had no symptoms ; he described itto indicate those changes in the appendix which precededthe implication of the peritoneum and which clinically mayhave no kind of existence. In connexion with that point Ishould like to emphasise these three solitary facts. The first isthis : that quite extensive changes may take place in theappendix without the production of a single solitarysymptom. The appendix may be almost obliterated withoutthe production of a single symptom of appendicitis, itsmucous membrane can be entirely destroyed, and it can

No. wn

become stenosed or shrunken without the production ofa single symptom. I am reminded of a case in which Iwas doing the ordinary operation of ovariotomy and Icame across an appendix showing the grossest changes. Inthis case neither the patient nor the medical attendant hadany suspicion of trouble in the appendix, for this womannever had any symptoms of appendicitis. The second fact isthis. An attack of appendicitis, as we know it, may bepreceded by a number of minor disturbances or minor seizuresfor which we have no name but which may be includedunder the title appendicular colic. But this term is actuallywrong. Colic, I imagine, means pain in the intestinal tubedue to disorderly muscular action and there is no muscle inthe appendix capable of producing the phenomenon of colic.A patient gets an attack of pain in the abdomen with afeeling of nausea and this lasts for perhaps two or threehours and then the whole thing is gone, but these troublesdo not come under the head of appendicitis and probablydo not concern the actual peritoneum. Thirdly, we musttake a little more heed of a condition that shouldbe called chronic appendicitis as seen in patients whohave an abiding trouble in the right iliac fossa but neveran attack of appendicitis. These attacks of chronic appen-dicitis are common enough. Some men and women are neverfree from some sense of discomfort in the abdomengnawing pain, a burning pain, a griping pain, a feeling thatthere is something coming away there, a desire to supportthe back. People often walk across the room with the bodybent and the hand pressed on the abdomen. These symptomscome under the proper heading of chronic appendicitis andshould be more fully recognised than they are now. To thesethree remarks I should like to add another as to the ridi-culous classification of appendicitis. Every monograph onthe subject begins with a ridiculous list of forms of appen-dicitis-the gastric form and so on-and if you discuss a casewith a medical man he often says : " Do you think this iscatarrhal or suppurative, or what -is it? " This sameelaborate classification has a place in the history ofall maladies. There was a time, for instance, whenthere were about 15 or 20 different forms of pleurisyand these all came down to one thing. How many formsof synovitis were there 20 years ago ? How many formsare there now ? Inflammation of the apppendix, catarrhof the appendix-what does it lead to? Ulceration,stricture, perforation, gangrene. There is nothing to be

gained by this ridiculous classification. Appendicitis is aninflammatory trouble due to certain micro-organisms and itbegins as a catarrh, excepting cases of actual torsion. I donot propose to say anything in detail as to the causes, orreputed causes, of this malady. We know it is mostcommon in young people, 80 per cent. of the cases comingunder the age of 30 years and, curiously enough, 73 percent. occurring in males.

I should like to draw attention to certain factors in thecause of appendicitis which I think have a good deal to dowith the treatment of the disease. The first factor is theextraordinary effect of a tropical or sub-tropical climate. Ihave often said that, although my practice is in London, alarge proportion-I will not say the majority-of my patientscome from tropical countries, not necessarily hot countries butcountries in which intestinal trouble is inevitable, such asIndia, the Straits Settlements, China, South Africa, andother places akin to them. It is obvious how these cases areso frequent ; persons with a disturbed appendix go to acountry in which intestinal troubles are common and beingmore liable to the disease they contract it. I think there-fore that no person should be allowed to go to a tropicalcountry if he is a suspected subject of trouble in the

appendix. It is very noteworthy how persons who havehad a little suspicion of this malady in themselves willcome to an acute termination of it after having gone toreside in a tropical or sub-tropical climate. Another curious

point is the frequent coincidence in the female subject of anattack of appendicitis with the menstrual period. Itcannot be an accident, because in one particular case thatI had the attack occurred on the fourth or fifth dayand never varied from that. One might say that outof nine or 10 attacks in females perhaps as many asfour or five will be associated with the menstrual period.Of course, that is explained by the circumstance thatthe two organs concerned are closely allied and that theycertainly can mutually disturb one another. I haveactually seen a cystic ovary in a child, aged 10 years, andattached to that cystic ovary a diseased appendix ; I was

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unable to arrive at the conclusion that the appendix was thecause of the cystic condition of the ovary. Anyhow, thesetwo organs are close together, and I need not remind you ofthe fact, which has been well demonstrated, that they hwethe same lymphatic arrangement. The association of thesetwo maladies is very common and I think it should be amatter of routine in every case in which the appendix is

I

removed in the female subject that the right ovary should beinspected, because the cases in which this organ, has been sodiseased as to need removal are very striking. One mustremember that fact in the causation of appendicitis becausewe cannot get away from the fact that an abiding ovariandisturbance may induce trouble in the neighbouring organ orvice ve1’sâ.The last point in this connexion is one that I am sure will

be at once agreed to by everybody in this room and it isthis. If there is one solitary factor in the production ofappendicitis which is overwhelming it is a loaded caecum. I

really think it is a little exaggeration, but not a gross one tosay, that if loading or overloading of the csecum couldbe avoided there would be exceedingly little appendicitis.That is so almost uniform a feature of this trouble that one Ineed hardly go into the history of some of the cases. Youknow what these histories are-a child with teeth over-

lapping, a man with no masticating teeth to eat meat, thecommercial traveller who has his meals all over the countryand eats and drinks and smokes too much, and a man whohabitually bolts his food. Nothing plays, I think, so impor-tant a part in the prophylactic treatment of appendicitis asthe recognition of the fact that if the caecum can be keptfree from indigestible food and undigested food the risk ofattack is very much minimised.With regard to clinical matters it would be a gross waste

of time of this society if I were to deal in any way withthe clinical phenomena of this common trouble. But inthis connexion I want to deal with one solitary point-with the so-called McBurney’s point. Tenderness at this

magic spot has become a sort of talisman ; it is an

inspired sign, it is a sort of religious stigma, itis the touchstone of the disease. The hand of theexperienced man is put on the spot and there is tender-ness and the patient has got appendicitis. I need notremind you where this spot is, but let me say what is said ofit. It is said to be always present in every case of

appendicitis, it is said to be not present in other troublesmet with in the abdomen. It is said to indicate the seat ofthe disease, it is said by some to indicate the position of thediseased appendix. It is said by others who are morecautious-by McBurney to wit-that it actually indicates theprecise space of the appendix. Well, now, that is the mostmodest account that could be given of the possibilities ofMcBurney’s point. Beyond that there is a great deal more,but that is keeping soberly within the limit of fact. Theconstruction that I would venture to put upon it is this.There is a certain tenderness in the right iliac fossa in

appendicitis and McBurney’s spot corresponds roughlyto the centre of the right iliac fossa and therefore itis reasonably the place where tenderness is exhibited.Next it is a symptom quite common in other maladies, mostnotably in colitis. In the next place I should say thatit is a feature exceedingly common in perfectly healthyindividuals in a quite normal state. Last of all, it doesnot indicate the situation of the disease and it does notindicate, which McBurney insists that it does, the situationof the base of the appendix. Any man operating and

cutting through the situation at this point will know perfectlywell that there may be tenderness there and the base of the

appendix does not correspond to that spot. Feeling that itwas a matter that needed investigation I asked Dr. A. Keithif he would carry on investigations on certain lines that Iindicated and I am deeply indebted to him for the admirablemanner in which these investigations were carried out. Whatstruck me was this. So many persons are tender at certainpoints in the right iliac fossa and very often acutelytender. But there is no such point on the left side andthere must be something, therefore, anatomically differentthere. What is it ? The ureter or what ? ’t This is howthe facts come out. Sections were made along thespino-umbilical line ; that line measures in the normalmale adult six inches and it crosses the rectus muscleat the anatomical point known as Munro’s point and it

roughly corresponds there to McBurney’s point. Well, now,the ureter has nothing to do with Munro’s point because itdoes not cross the line there. Exactly the same condition

exists on the left side, so that nothing is to be learnt fromthat. The next thing is’ this. The structure that exactlycomes beneath that point is the ileo-cxcal valve. The tenderthing that can be discovered in the body of a healthy personat that exact spot is the ileo-caecal valve. As you know, allorifices are peculiarly well supplied with nerve fibres and arepeculiarly sensitive, such as the sphincter of the anus, theorifice of the pylorus, and other sphincter-like openings. Thatthat is the cause of the tenderness in that particular spotadmits of no dispute. The base of the appendix, you willbe surprised to hear, is one inch below McBurney’spoint, as discovered in 50 bodies prepared by formalin.Dr. Keith was good enough to examine the bodies of27 living medical students with this result :-in 11the point of tenderness was exactly on the point; innine it was a little above the point ; and in four it was.a little below the point. Those data pretty nearly corre-spond pro rata with the condition found in 50 hardenedbodies by formalin. Moreover, in only three out of 27students was there any particularly tender spot in the rightiliac fossa ; in none was there any tenderness discovered on.the left side of the body. That, I think, should renderdefinite the circumstances about McBurney’s point and thepart it plays in this trouble. Any medical man present whohas examined in detail cases of colitis will well know theextraordinary tenderness there is often discovered and main-tained at McBurney’s point.

I want at this stage to say one word about phantomappendix-an appendix described as vertical, of the size-of your little finger, and sometimes lying obliquely. That

appendix is a phantom and it is a curious phantom.The vertical appendix is due to constriction of theuppermost fibres of the rectus muscle that can be often,excited by stimulating the nerve as it enters the muscle.I need not remind you that the appendix, the cascum,the peritoneum surrounding them, and the muscles of theabdomen which cover them and the skin which covers thesemuscles are all supplied by one nerve, in the main theeleventh dorsal’. Even when the patient is under anaesthesiaa little hard pressure in that spot where the nerve enters therectus muscle will bring out this vertical appendix.

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In order not to take up too much of your time I think Imight finish what I have to say by dealing with what, afterall, is the most interesting part of my subject-the operativetreatment of this trouble. It is most remarkable that thissubject, which one would think is simple enough, is perfectlybewildering by divergent opinions coming from men whose-authority one cannot repudiate and must recognise, andadded to this is the difficulty that we are still entirelylacking in reliable statistics. What is the general death-rate from appendicitis ? 2 Of course, hospital cases are casesof certain gravity and in those cases the death-rate isestimated at something like 15 per cent. But take 10’medical men who have practised in a large town for, say, 20years and therefore must have had to deal with a great manycases of appendicitis. What number have they lost in thatperiod’? ’? They would be shocked at the suggestion thatthey had lost 15 per cent. It is impossible, therefore, to getquite at the figure. But records have been obtained casuallyfrom practitioners and also from the German army in time ofpeace. It is curious that in both these instances the figurecomes out at 5 per cent. I know that this figure is open todispute, but still I do not think that out of 100 cases of

appendicitis I have lost more than five in the course of myprivate practice. I think, therefore, that 5 per cent. may beaccepted as the general rate of mortality in appendicitis.When one goes further into the question of operative treat-ment of appendicitis the whole crux is, What is tobe done during an acute attack ? 7 There are certainmen whose opinions must be listened to who assert thatyou must operate in every case of appendicitis as soon asthe diagnosis is made. I know that that is not perhapsquite the common position taken up by surgeons in thiscountry, but, as you know, it is almost universal-atleast, in America. An operation, they say, should be carriedout as soon as the diagnosis is made-not on the second,third, fourth, or fifth day. There are others who operate onlyon compulsion ; they say, " No, the majority of the patientsget well," and they only operate in exceedingly acute casesin which pus is evident or in cases that are really spun oatand going to such a length that they feel there must besome condition within the iliac fossa which can only bereached by operation Those are the two sides of it.

Speaking from mo other than the very uncertain basis of

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-one’s own experience I would take the opportunity of sub-mitting these isolated points to your copsideration, believingthat they form the basis upon which something like a sound- opinion can be arrived at. First of all there are advocates ofwhat may be called indiscriminate operation. They use termsof this sort-"You must operate ; the appendix is ruptured ;there is perforation ; there is acute peritonitis ; there is

gangrene." " And mark-and this is the point that I want to

draw attention to-these expressions are used exactly inthe same sense as you use such expressions as ’’ There is

perforation of the bowel ; there is a perforating ulcer in thestomach ; there is gangrene or hernia of the intestine." Andso they say an operation must be carried out even before areasonable diagnosis has been made, as soon as an attack issuspected. What I very seriously object to is this : that the

<two things are put in the same category. It is an absolutelyfalse analogy and distinctly misleading. Is it for onemoment reasonable to put perforation of the appendix inthe same category with perforation of the stomach ? It ismonstrous. Not only can a perforation of a fair size occurin the appendix but a fair degree of gangrene may be metwith without causing serious symptoms. I have found aconcretion lying outside the appendix one month after an-attack, when all the symptoms have subsided and without asingle drop of pus. That must have been due to rupture ofthe appendix or perforation of the appendix or, if youlike, gangrene of the appendix. Is it very reasonable,therefore, to use those terms in the same sense as you usethe term rupture of the bowel, gangrene of the ileum, orperforation of the stomach? The analogy is absolutelyunjustifiable. The second fact that I do not think can bepressed too strongly is this. The very great majority of all- cases of appendicitis get well spontaneously. I am speak-ing of a whole series of cases which come under the care of amedical man in general practice, and I think that it may besaid that we are not very far from the truth when we say thatthe death-rate from appendicitis is. 5 per cent. The third fact,which I think should be emphasised as strongly as the last- one, is this : operation during an acute attack of appendicitisis attended with great risk to life. What that risk is weagain have great difficulty in expressing in figures becausethey are not easy to get hold of. But we must take

things as they are, and I have been at infinite pains to gothrough records by hundreds and the death-rate in casesof operation-I do not say what operation-during an

acute attack comes out at about 20 per cent. Someof the hospital records come out higher than that. Thefourth point is a little by the way. Relapses may occurafter an operation carried out during an acute attack andthat is a thing which must not be quite pooh-poohed. Thelast thing which I should like to impress upon your memoriesin very large letters, so to speak, is that the removal of theappendix during the quiescent period is attended with

infinitely small risk.If these acts are admitted-perhaps you may say they are

not accurate or they are distorted, but I do not think they- can be very much out of what is actually the fact,-if thesefacts are accepted, then I think the line of treatment is not’dinicnit to establish and may be pretty clearly defined.Acting upon what one believes to be the best informationthat the records at present provide in the various directionsthat I have indicated I think one comes to some such con-clusion as this : all that we know of the pathology of inflam-mation of the appendix is positively opposite to the teachingthat operation should be carried out the moment the diagnosisis made. I think that that cannot be put too strongly. Weknow a good deal about the pathology of this trouble andI think that what we do know will not support the dictumthat as soon as the diagnosis is made operation should becarried out. The second point is this. An immediate opera-tion should be carried out in all the ultra-acute cases. Itis often said that you cannot diagnose them. I wouldventure to controvert that statement. I believe all thesecases are easily recognised, although there are two per- I

fectly distinct types of these ultra-acute cases. There are ! isome in which the local manifestations are not very 1

striking and where the overwhelming symptom is that thepatient has introduced into his system a gigantic dose ofpoison, with a temperature of 104&deg; or 105&deg; F., with the pain <

not very striking. Those are cases of septicaemia of the mostintense character and the patient dies, perhaps, within 36 or 48 1hours. In such cases the operation will probably do no good, 1but it can do no possible harm and it should be as a matter 3of positive routine carried out. The second class of acute 1

cases also cannot be mistaken. It is exactly parallelto perforation of the stomach and I do not think anyone canhave any difficulty in recognising the acute peritonism. Theultra-acute cases cannot be operated upon too soon. The

third proposition, which I hope also will meet with yourapproval, is this : an immediate operation should be carriedout as soon as there is any suspicion of pus. I suppose thatwill be universally accepted. I do not want a demonstra-tion of pus but a reasonable suspicion of it.

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If those three propositions are accepted that takes us along way. What, then, with regard to the residue of thesecases which represents the great mass of cases of appendi-citis ? I have excluded all the ultra-acute cases and I haveexcluded those cases in which there is pus, and I think thatin the cases that remain it is seldom imperative that an opera-tion should be discussed until about the fifth day. I thinkthat you will agree with me that in a case of appendicitis, ifthe temperature comes down and is getting towards normalabout the fifth day your anxiety is becoming compara-tively slight. And because the temperature keeps up afterthat day the case is not necessarily doomed, though veryprobably it will have to be dealt with. Having excluded thecases that I have mentioned I think that the phenomenaassociated with this malady will bear out that somewhatmoderate suggestion in the matter of practice that the sur-geon should hold his hand until some such time as the fifthday has been reached when the requirements of the case willhave been made quite manifest. Another matter that Iwill trouble you with is with regard to operative treat-ment carried out during the quiescent period. It so happenedthat in a paper which I read before the Royal Medical andChirurgical Society in 1887 I ventured to suggest that appen-dicitis when relapsing should be treated by removal of theappendix during the quiescent period. Looking back on thediscussion which followed that paper it is curious to notehow very feebly it was received and how the method advo-cated therein was scarcely accepted at all as a reasonablemethod of treatment. In that particular discussion one

physician of considerable experience said that in the wholeof his life he had never seen a case of typhlitis that couldpossibly have called for surgical interference of any sort. Sothat the reception of that paper was one which, I mustconfess, condemned me very much. Still, I do not think onehas any reason to complain of the infrequency with whichthe operation is carried out at the present day. I have sincethat particular date removed the appendix during the

quiescent period over 1000 times and out of that number Ihave lost two patients. I could without being very Jesuiticalexclude one of those cases because it was not primarily a caseof appendicitis but where there was a mass in the right iliacfossa and where as a result the appendix was concerned. ButI will acknowledge the two deaths.The next point that I want to ask you to consider is this,

and it is a difficult matter in practice : When should thisoperation be carried out ? 2 A patient comes to you and says," I have had one attack," and you might almost tell him thatthe operation is so trifling that he should have the suspectedorgan removed. But the whole question is summed up inthis : What is the probability of relapse ? It is a curiousthing that the percentage of relapses has greatly gone up.At one time there were said to be very few relapses-from20 to 30 per cent. I am quite certain that it is safe eto say nowadays that the great majority will relapse.Therefore I think it could be put down, as a line to

guide one in directing this matter, that it is desirable toremove the appendix after the first definite attack. The lineof argument is this. In the majority of cases there will be arelapse and the patient must feel that the weight of figures isagainst him. Secondly, the risk of the operation is reallyalmost infinitesimal and will in time become quite trivial.There is just this little sort of comment to be made on abold assertion of that kind. If there has been an abscess inthe first attack then I think an operation may be put out ofcourt altogether because that abscess will in certainly95 per cent. of the cases obliterate the organ and render itharmless.

Well, then, I have been frequently asked this question :What has been your experience of cases that do not relapse ‘?Going back as I can now over some years, and having seensome thousands of cases of appendicitis, I have seen a

great many patients who have had only one attack andhaving known their career for a number of years-I donot want to quote them as exceptions to any rule butto put them forth as cases in which perhaps that rule

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may be subjected to consideration and perhaps relaxed-my experience has been this. I have seen children inwhom an attack of appendicitis has distinctly followedthe lodgment of some mass in the csecum. In one suchcase the child ate a lot of nuts and had appendicitiswith cramp and hardness over the organ..In that case wherethere has been only one solitary attack following the lodg-ment of some mass in the caecum the child may neverhave another attack unless it repeats the same alimentaryperformance. The other class of case is this: theadult who has a great many errors in the matterof feeding to correct. For instance, the commercial.traveller who perhaps has no masticating teeth eats any-thing he comes across at all times of the day : lunchesat one, two, or three o’clock, rushes into the bar withhis hat on the back of his head, eats anything that happensto present itself, bolts it, and goes about his business in anatmosphere of tobacco and alcohol. That man has grossdietary errors to correct and if they be corrected that manmay never have another attack. I think that in the considera-tion of cases of appendicitis the circumstances in those twoclasses of the disease that I have mentioned must beBtakeninto account. I might, perhaps, just quote one such case. Amedical man was working in a colliery district under the veryworst possible conditions. The man was up day and nightand got his meals anyhow, and he practically had no masti-cating teeth. He was a man temperate in every respect.Eventually he inherited a fortune, a very large sum of

money, and of course the very first thing he did was whatany of us would have done-he abandoned the professionand sought opportunity for rest. Previously he had hadone attack of appendicitis and he now came to me sayingthat he wanted to have some enjoyment out of life andhe thought that the first element of success in thatdirection was to have his appendix removed. I thoughtthat perhaps he might make a little cult of his appendix, soit was agreed that it should not be removed. That manobserved the general rules of health and I see himoccasionally and he has never had a single attack since.With regard to chronic appendicitis I think that in everysuch case the appendix should be removed when there is noother treatment for it.

Last of all I must say this : the removal of the appendixis not a panacea for every ill in the lower part of theabdomen, because there is apparently an impression abroadin the present day that any kind of disturbance below theumbilicus must of necessity involve the removal of this verymuch discussed organ.

The Hunterian LectureON

SOME POINTS IN PRACTICAL SURGERYSUGGESTED BY THE STUDY OF THE

LIFE AND WORK OF JOHNHUNTER.

Delivered before the Hunterian Society of London onFeb. 26th, 1902,

BY REGINALD HARRISON, F.R.C.S. ENG.,SURGEON TO ST. PETER’S HOSPITAL, LONDON; CONSULTING

SURGEON TO KINGSTON DISPENSARY AND BRAINTREECOTTAGE HOSPITAL.

MR. PRESIDENT,-When your predecessor asked me to

deliver the Hunterian Lecture this year I felt less diffidencein accepting the honour than I should otherwise have donebe ;ause I knew that your society had never ceased to showit, reverence for the illustrious man whose name it bears inthe most practical and useful forms.

I am taking for my subject some points in practicalsurgery suggested by a study of the life and work of JohnHunter. It would be difficult to find a more agreeable orimproving occupation than that of recognising and tracinghow much we are indebted to him for the rapid strides ourart has made in almost every direction. Though Hunter didnot give us anaesthetics or antiseptics, he prepared surgery,by placing it on a scientific basis, for the reception of thesetwo grand discoveries of this age.

[Mr. Harrison proceeded to show that Hunter’s teaching asto the cure of hydrocele was true even of the present day.He proceeded :]

Hunter’s observations on perineal urinary fistula are

interesting. He says: "In whatever part of the urethrathe disease is the external opening seldom heals as long asthe seat of the disease has no disposition to heal. Letus compare this disease (urinary fistula) with the state ofparts after lithotomy. If the incision is made in sound

parts, and the whole injury be a stone which is extracted,the parts readily heal in spite of the urine passing throughthat channel. This, then, shows that there is anothercause of their not healing." Further he states: "To curethis disease it is necessary first to make the natural passagesas free as possible, that no obstruction may arise from thatquarter-and sometimes this alone is sufficient-for theurine finding a free passage forwards is not forced into theorifice and the fistula heals up. But the dilatation of thestricture is not always sufficient ; it is often necessary toperform an operation on the fistulas when they alone becomethe obstacle to the cure." Here we have in a few lines the

pathology and treatment of urinary fistula with a reserva-tion for exceptional or complicated cases. There can be nodoubt that in the larger proportion of cases where a strictureof the urethra co-exists with a urinary fistula, or is the causeof it, the removal of the stricture by some form of dilatation,with or without the retention of a catheter, as Hunter sug-gests, is sufficient in itself to effect a cure of the fistula, andso long as the patient is careful in keeping the stricturedilated such a consequence is not likely to recur. But thisconsideration by no means covers the whole ground. Wateror urine will invariably escape through the easiest channel.Cases are frequently met with where it has thus been foundimpossible to heal up these sinuses even though the stricturehas been fully dilated. This would seem to imply that eitherowing to a state of urethral spasm to which persons are moreliable who have had obstructions of this kind, or, as Huntersuggests, to the precise manner in which the false routescommunicate with the urethra, it is impossible to preventsome urine from entering them during the voluntary act ofmicturition. Either of these reasons is sufficient to explainthis difficulty in closing a fistula.Then arises the question, What more can be done to bring

about a closure of these fistulas ? for nothing can be moreintolerable to a patient than having to go about with aleaking and discharging sinus that fails to heal. Hunter’sreference to the making of wounds which "readily heal inspite of urine passing through them," to use his own words,has an important bearing upon this point, for it will be

recognised that their substitution for those which show notendency to repair, but, on the contrary, to remain patent assuppurating and offensive sores, may often be advantageouslyutilised. This point has frequently been demonstrated inpractice, and proved the quickest and safest way of dealingwith certain forms of urethral stricture complicated with oneor more urinary fistulae. Thus the secondary proceedingsto which Hunter refers--namely, operations on the fistul2themselves-may be obviated as unnecessary when thestricture is entirely freed and the urine so efficientlydrained as to be prevented from entering unnatural channels.And it is upon the two governing principles as laid down byHunter in the passage quoted as being generally applicableto this class of cases that I would desire to lay stress. Theseare (1) the necessity of securing a free outlet forwards for theurine, and (2) the provision of a wound when required for

this purpose which will, as Hunter states, readily heal in

spite of urine passing through it."I have already observed that in dealing with the expulsion

of urine from the bladder it must be remembered that itscourse is entirely determined by the degree of resistance thatis opposed to it. If this is less in the case of a false or anunnatural route it is certain to select this in preference to thenatural channel, whatever may be the condition of the latter.Hence to divert the urine from these fistulous openings andcause them to dry up and heal from want of use it is a firstprinciple to secure its escape by the natural channel, or, ifthe latter is permanently damaged, by a substitute. In thematter of urine drainage much depends on the nature andposition of the wound that is made for this purpose. Wenee this, for instance, in the case of wounds made for medianlithotomy as compared with those made for lateral litho-tomy. The former will not drain thoroughly and incon-tinently without a suitable drain-pipe or other appaiatus.The latter is entirely independent of all kinds of apparatus