CHAPTER V Every ambitious man has been impressed by certain lessons (Part 5)

respirations are to be knocked down to twelve or less per minute with opium. This is the first step. When the respira- tions have been reduced to this rate, it is an index of the degree to which peristalsis has been inhibited. With inhibition of peristalsis, the spreading of escaped contents ceases. The shocking peripheral irritation which is being shot into patient's centres of consciousness is also inhibited by the opium. Local anesthesia of the skin and tissues at the site of incision is then secured, and in the typical typhoid cases a tube wick drain is quickly inserted to the cecal region (within a few inches of which some ninety per cent, of all typhoid perfora- tions occur). This operation requires less than one minute for its performance; sometimes less than thirty seconds. In cases of dangerous typhoid hemorrhage, the same procedure is fol- lowed. The reason for the beneficial influence of drainage in cases of hemorrhage without perforation is the evacuation of parenteral bacteria whidi are free in the peritoneal cavity in many of these cases, and which often seem to introduce the most serious toxic feature. Lymphatic hjTiertrophy in the bowel wall proceeds in a compensatory way satisfactorily in the presence of the typhoid bacillus in most cases, but when parenteral bacteria appear in the peritoneal cavity hypergenesis of lymphoid tissue is not sufficient to give birth to a controlling proportion of those leucocytes and macrophage cells which have been previously managing the typhoid toxin. In many cases of typhoid paresis of the bowel, parenteral poisons which are over-stimulating or paralyzing abdominal ganglia, may be drawn away by an operation which hardly needs to be dignified by the name of operation. Patients with any form of acute TO-MORROW'S TOPICS 277 peritonitis seem to bear opium remarkably well. Dr. Alonzo Clark many years ago laid down the dictum, "Do not measure the opium which is given to an acute peritonitis patient. Measure nothing but his respirations." The reason why opium is preferable to morphine in these cases is because it causes less nausea, inhibits peristalsis more surely, remains active for a longer period, has greater diaphoretic properties, is excreted more slowly, and has fewer secondary complications than mor- phine. The advocacy of the employment of opium in these cases is met instinctively by opposition on the part of doctors and nurses generally, because the dangers of that drug and its alkaloids have led us to forget their actual value under certain conditions. Furthermore, there is a special objection to opium in surgery, as demonstratd by Cantacuzene in his experiments upon guinea pigs. He showed that simultaneously with lessen- ing of sensation, there is a tendency for phagocoytosis and reparative processes to come to a state of rest. This would naturally give bacteria opportunity to multiply. Infected ani- mals subjected to the influence of morphine died sooner than ones not under its influence, other things being equal. In this particular situation — emergencies of typhoid fever and gastric ulcer—other things are not equal. Opium in itself is a dan- gerous resource, but in this situation we are choosing between the lesser of two great dangers, and when opium is employed in conjunction with a rapidly performed operation for securing drainage, with means for lessening wound pain through the aid of local anesthesia, the principles of the fourth era of surgery are applied in a field in which the principles of the third era of surgery, with its detailed work, were extremely destructive to typhoid patients. In cases of perforating ulcer of the stomach or duodenum, the principles of the fourth era as we apply them in cases of typhoid fever, will save many patients who would succumb under the ideal technic of the 278 TO-MORROW'S TOPICS third era of surgery. The idea of merely turning the tide of battle quickly by means of an operation which suffices to turn the patient over to himself, giving him home rule, and reserv- ing ideal technic for some later day, was all based upon the observations which I mad^ originally in connection with desperate cases of appendicitis. This was at a time when an easily borne procedure which did not repair defects or aim at removal of products of infection was absolutely and diamet- rically opposed to the teachings of the day. At the time of the height of the second or anatomic era in •surgery, a great authority predicted that surgery could go no further. He stated that all of the main facts were known and all avenues for new discovery had been investigated, with the result that nothing was left for surgery excepting the perfec- tion of manual technic, and the training of students in methods for best exercise of judgment. The only hope for the future of surgery he believed lay in these two fields of endeavor. Since that time the third or pathologic era of surgery has placed the whole anatomic era in the light of a detail, so small that real danger exists of students neglecting to learn its valu- able principles. The vast impetus given to surgery by the principles of the pathologic era will seem equally unimportant when the principles of the coming fourth or physiologic era have undergone full development. At the present time I can see nothing clearly beyond the fourth era of surgery, and in that respect am probably quite as small minded as the surgeon who saw nothing beyond the second era. It is my belief that the home rule idea (dependence upon the internal resources of the patient) is to become a large feature of the Medicine of to-morrow. Neurasthenic patients are benefited by almost any sort of a charlatan in whom they have confidence. Christian Science has made more cures than we of the regular profession like to admit. A doctor of TO-MORROW'S TOPICS 279 mediocre attainments and positive nature, with a convincing manner, gets patients out of bed sooner than they are gotten out by an erudite scholar who carries doubt in his mien. When- ever a new drug is introduced, it makes remarkable cures while enthusiasm lasts, but when skeptics get after it, its therapeutic value rapidly wanes. When Count Mattei was in court, and being subjected to trial for fraud, he presented five cured cancer patients, and yet his medicine was distilled water only. We laugh. Wait a minute 1 How about those five cancer patients ? Are we perhaps overlooking something as large as a whole principle? (i) Cancer relates to senescence of cells, and this senescence is manifested in reversion to embryonal types. The new embryonal cells which have lost chromo- somes out of their nuclei multiply with abnormal rapidity, and crowd out other and better cells. (2) The mind which is known to exercise control over various bodily functions may perhaps extend its influence even to the point of inciting the production of hormones which restore the lost fighting power of normal cells. This may be a crude form of statement, but I feel that we are overlooking something which the doctors of to-morrow will state in mechanistic terms. We see patients get well when they are given the wrong medicine by doctors in whom they have confidence. Account for the phenomenon in any way you please, but account for it you pragmaphobe ! In the days of the heroic era surgeons did not dare to excise a certain crippled joint. The anatomic era gave operators an opportunity to do joint excisions with a high degree of skill and to take pride in the advance of their art. The glory of the pathologic era lay in allowing surgeons to excise the crippled joint not only skillfully in a technical way, but to obtain primary union of the wound beside. That seemed to be the end desideratum — derniir cri — of surgery. TO-MORROW'S TOPICS symbols requiring metaphrastic version, yet which had been overlooked by translators. Passing mention had been fre- quently made by authors, of adhesions which belonged to inflammatory disease of the stomach or to cholecystitis, but the large proportion of cases in which adhesions and other peritoneal defects are found in the upper part of the abdomen give no symptomatic history of any acute inflammatory process according to our present methods in reading symp- tomatic history. We had previously assumed that patients with peritonitis had either a good deal of peritonitis or none at all, yet here was evidence that under conditions of modem civilization many a man has some kind of insidious peritonitis in the upper part of the abdomen, at some time in his life. There is some degree of peritonitis which commonly passes without classification as such. Other obser'ers had attempted to explain the nature of adhesions which occurred in the vicinity of the cecum and of the sigmoid colon, but had mentally con- nected such adhesions either with acute inflammatory processes in these two regions, or with some mechanical cause. Byron Robinson believed these adhesions in the region of the cecum and the sigmoid to be caused by traumatism inflicted by the psoas muscles, when they were not due to acute inflammatory processes. On giving closer attention to the question of the origin of insidious toxic adhesions in the upper part of the abdomen, it was found that certain peritoneal defects, due to embryonic remnants, were sometimes mistaken for adhesion tissue, and these had to be recognized and classified separately. While I was talking, writing and making class room demon- stration upon this subject. Lane called attention to his ileal kink and Jackson brought into prominent notice the veil-like membrane which commonly invests the ascending colon, and sometimes other parts of the colon. Lane and I began in the same year to write upon the subject of toxic intestinal proc- I 282 TO-MORROW'S TOPICS esses and the structural insignia of such processes. His paper ^ypeared in January of 1903 (The Lancet) and mine in December of 1903 (Medical Record). We were both recog- nizing the same general phenomena, but his observations began in relation to the lower part of the abdominal cavity while mine began in the abdominal attic. One reason why the insignia described by Lane and by Jackson attracted attention in ad-ance of my attic cobwebs was because the latter required a special incision, while the former were right at hand for incidental obsen-ation in the every-day appendicitis operations. It was a question in my mind if the Lane kink and the Jackson membrane were related in any way to the insidiously forming adhesions of the upper part of the abdomen. The hobeque at first seemed to take me along the road of tracing both the adhesions and the abnormal connective tissue structures de- scribed by Lane and by Jackson to some insidious toxic influ- ence. It had been my impression that peritoneal adhesions proper of the upper abdomen could be accounted for by the passage of toxins through the walls of the bile ducts and gall- Madder, and that remnants of normal structures became hyper- trophic because of toxic influences. It seemed probable that tv^xins which were being excreted by the liver in excess of the nwtaK>lizing power of an individual caused desquamation of endothelium. This process was followed by plastic exudate which became organized into adhesion tissue. The web-like character of some of these adhesions suggested spider webs, and in a paper upon the subject these cases were characterized as gaH spider cases, for convenience of nomenclature. A Ixter \Sew included the idea that toxins not only made their way :hTv>ugh the thin walls of the bile ducts and gall-bladder insidi- vxsih\ but when poured upon the mucous surface of the duode- ^v.n^t they might excite a secretion of hormones which would xkrxnge the function of stomach and bowel. 'istas continued TO-MORROW'S TOPICS 283 to increase, and I began to believe that toxins or bacteria passed directly through the walls of bowel in cases in which intestinal stasis was present. Later investigators proved the correctness of this theory. Examination of adhesion tissue which was sent to the laboratory resuhed in finding the colon bacillus enmeshed in such tissue occasionally. In other cases anerobic bacteria developed upon the culture media. In the majority of cases no bacteria were present. This did not eliminate, however, the idea of bacterial toxic origin of adhe- sions, because various bacteria might cause insidious desqua- mation of endothelium, followed by plastic exudate and adhesion formation, without themselves remaining for any length of time in such tissues. Later, evidence was obtained showing that anerobic bacteria and their toxins seemed to be particularly prone to make their way through the walls of various abdominal viscera and to cause tissue changes in both endothelial and connective tissue structures. It was observed that the original Lane kink, sigmoid adhesions, and "cob-webs of the attic of the abdomen" were most abundant near rela- tively immobile parts of the alimentary tract. The bowel at various normal flexures suffers also from certain effects of hyperplasia of the connective tissue of its normal supports. It is somewhat difficult to draw the line between normal connec- tive tissue of the supports of these flexures and the adventi- tious connective tissue that is of evolutionary origin plus or minus toxic influence. Adhesions occurring near such fixed points would be in line with the general direction which my hobequs was now following, relating to the toxic origin of such hyperplastic tissues. When toxins cause injury to cell protoplasm with the breaking down of cells, fibrinous tissue appears, but this new fibrinous tissue is readily broken down. Those parts of the bowel with the longest mesentery which are most actively engaged in peristaltic contractions would \ TO-MORROW'S TOPICS have a well recognized tendency to break down young fibrinous 1 tissue so that it would be absorbed again. Near the fixed points fibrinous tissue would have a tendency to become organized into adhesion tissue, or to constitute hyperplasia of such "normal" structures as are found in Lane's kink and Jack- son's membrane. On subjecting the denser tissue from Lane's kink and Jackson's membrane to microscopical examination it was found to be strongly suggestive of the connective tissue hyperplasia which is found in Dupuytren's contration. The character of the latter, by the way, has never been explained. It is presumably a selective affinity manifestation of toxic origin, related to the so-called "rheumatic" group of tissue inflammations. My present belief is that Lane's evolutional theory is cor- rect, but that a theory of toxic influence is also correct, in some aspects of the adventitious tissue question, and that the special influences at work in any given case are to be studied in reference to the particular case. In Dupuytren's contraction of the palmar fascia the new tissue is dense, because of the dense structure of its local parent connective tissue; while, in relation to bowel tissues, it is more loosely organized, corresponding again to local tissue character. We now know that bacteria can pass through the bowel wall and congregate in suitable niches. Adams, when making sponge tests, inserted bits of sterile sponge into the peritoneal cavity, under most careful aseptic precautions. He found sometimes that bits of sponge were buried in new adhesions of simple irritative origin, while adhesions about the sponges in other cases were filled with bacteria. While trying to direct attention of the profession toward adhesions in the upper part of the abdomen, I noted one day when speak- ing of "cobwebs in the attic of the abdomen" that it immedi- ately brought an especially intelligent look into a number of TO-MORROW'S TOPICS 285 faces in the class. Taking my cue from this I began to use the expression in the presence of my class at the college and at society meetings, and found that the phrase sufficed to introduce the subject rapidly. This phrase and its context matter were soon quoted in various parts of America and abroad. The direction toward effectively engaging the interest of the profession in this subject has at last turned at the guide post of a phrase, and progress of the idea was continuous from that time on, although Lane soon captured the attention of the profession in a larger way. At first only one clinician of note, Dr. Musser of Philadelphia, engaged in conversation and correspondence with me upon the subject. Lane coming into the field later attracted more attention, and has had to do most of the battling which I was about to enjoy. Like many other inventors with imagination he has for the time being lost the sense of relative values of the toxin question, and this subjects him to ridicule and threatens to obscure his real values. His basic ideas correspond to those which I presented in connection with the subject of attic adhesions. Suggestions of great value began to come from men whose thoughts had been turned toward the subject, and who were equipped with special kinds of knowledge relating to the question. The subject in my own hands next included a study of the class of patients who were most susceptible to abdominal toxic influences, and the fact was brought out that the neurasthenic group of patients with defective ductless glands furnished the majority of cases with "attic cobwebs" or Lane's kink, or extensive development of Jackson's membrane. The hobequs has now taken me into the whole field of metalwlism of toxins and protein poisons, as well as into the field of bacteriology of the gastro-intestinal tract. It is probable tliat we have in the attic adhesions and other adventitious abdominal tissues the key to a vast new literature of to-morrow, Unmetabolized poisons or bacteria. I 286 TO-MORROW'S TOPICS or both, apparently pass through the walls of the bile ducts and gall-bladder, of the pylorus, and of the entire enteron. In patients who are not well enough protected by their natural physiologic resources, these toxins cause injury to the proto- plasm of endothelial cells and of connective tissue