August, 1906

Nature generally precedes the development of pus with the protective adhesive inflammation.

This description would apply to the course of a case going on to suppuration directly from the beginning of the trouble. But this is exceptional. It generally proceeds on the installment plan, but if not interfered with usually manages to square accounts in the end. Nature is always on the alert to overcome the invasion of infection, and generally succeeds in stopping its advance at one point or another anywhere up to the development of suppuration. But this stoppage is only a temporary one as the very nature of the trouble is such that once begun the parts are permanently crippled and

from extension of the septic process, practically making the infected region extraperitoneal. If not interfered with in this stage the process usually goes on to one of the following results: Ist, the abscess may break through the protective adhesions and set up a diffuse or general peritonitis with its dire results; 2d, the abscess may perforate into any of the hollow viscera, usually the gut, and discharge itself in this way, allowing the cavity to heal but leaving the patient with a crippled appendix liable to cause recurrence at any time and constituting the condition of recurrent attacks of suppurative appendicitis; 3d, the appendix becomes so distended with its inflammatory contents that

Fig. 6, Slit open.

Fig. 7, Slit open. Fig. 8, Slit open. await only the next oportunity, which will come with the first cause that interferes with the normal function of the parts, to renew the process and continue it where last left off. This corresponds with the repeated attacks of socalled catarrhal appendicitis.

The process having advanced to the stage of suppuration, Nature's remedy, not only in inflammations about the appendix, but anywhere in the peritoneal cavity, is an adhesive fibrinous exudate thrown out around the regon of inflammation which closes off the general cavity

it strangulates its own circulation, becomes. gangrenous, amputates itself and floats about in the pus of the surrounding abscess. Its cecal orifice, which had previously been plugged, either by a concretion or by a stricture or by swelling of its mucous membrane, becomes permanently sealed through the adjacent inflammation. As in the previous case the abscess develops and points in the direction of least resistance which ordinarily is the gut and generally the cecum into which it ruptures, discharging its contents including the separated

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events that in any given case it is very improbable that one of them will not give way during the strain of the course of the affection.

So far we have been considering only what we might designate as functional obstruction. of the lumen of the appendix as the cause of its inflammation. Other obstructions act in the same way though with more prompt and pronounced effects. One of the simplest of these is an acute bend in the continuity of the appendix, causing constriction of the lumen. This specimen shows such an appendix. The proximal portion was normal, to all appearances, while the mucus layers of the distal portion were gangrenous. This appendix, now slit open and straightened out, was found acutely bent on itself, its proximal and distal portions adherent as the result of previous attacks of inflammation, and the distal portion was distended with purulent contents. (Photograph does not show contrast and therefore omitted.)

Another cause of obstruction, and a very fre

and yet are followed by spontaneous cure. While I have no specimens of this class that must have passed per anum I have a few that were rescued before they reached this stage. Two of them (Figs. 1 and 2) are completely gangrenous appendices that were greatly distended, ready to separate, but yet in situ, and two others (Fig. 3) had already amputated themselves at the time of operation and floated out with the pus of the abscess cavity. It would be well if this last course would be the rule in all or even in many cases of appendicical suppuration. But unfortunately it is the exception. "There's many a slip 'twixt the cup and the lip," and there are comparatively many more slips 'twixt inflammation of the appendix and its cure by natural means, more than justify any dependence on the successful outcome of Nature's unaided efforts. It would take more time than I have at my disposal now to go into detail as to the reasons for failure in Nature's efforts, but suffice it to say that there are so many weak links in this chain of

August, 1906

(Figs. 4 to 8) and will call your attention especially to one (Fig. 4) with the concretion in situ because it is the largest concretion I have seen. It is kidney-shaped and measures one and a half inches long by three-quarters of an inch in diameter. It may readily be seen how a concretion will cork up an appendicical orifice, and, being larger than the orifice, act as a ballvalve against the outflow of any fluid accumulation distal to it, especially when under pressure. Furthermore, its continued contact with the mucous membrane causes ulceration, affording avenues for the entrance of infection, and this ulceration is progressive, frequently resulting in perforation. One of the specimens (Fig. 11) shows this nicely. The concretion is tied in its original situation at the proximal end of the appendix and the semicircular gangrenous patch below it shows where it ulcerated

and, on slitting it open, the swollen and engorged mucous membrane.

NOTE. A number of specimens were not amenable to illustration, as photography could not show the desired points. To bring out the detail in those that are printed herewith was no easy task, and I wish to express my thanks to Dr. I. S. Hirsch, Radiographist to Beth Israel Hospital, for his successful work.

THE VALUE OF EDUCATION AND TREATMENT AS SAFEGUARDS IN VENEREAL INFECTION THROUGH MARRIAGE.*

THE

By JOHN A. FORDYCE, M.D.,

NEW YORK.

Organic stricture is frequently met with. Often it is partial, more exceptionally, complete. The cause is likely ulceration and subsequent healing with contraction of the scar. Possibly the condition is congenital in some cases. Two of these specimens (Fig. 10 is one, the other not showing up well enough to reproduce) show complete fibrous stricture; they were both found distended with liquid contents but not yet gangrenous or perforated at the time of operation. Two others (of which Fig. 9 is one) show partial stricture, which was made complete during the inflammatory stage by swelling of the mucous membrane. One of them (Fig. 9) is only recently out of the belly and was found distended with creamy pus dis

tal to the stricture.

Various other local conditions that cause trouble are found in the appendix, among them foreign bodies, such as pins, seeds, intestinal worms, etc., also neoplasms and tuberculosis. But I have limited myself to the more common conditions in which I have been able to mount and preserve the specimens so as to show the pathological changes.

I am indebted to Dr. H. M. Silver for the opportunity of presenting to you a fresh specimen removed by him this afternoon from a suppurative case. The prepared specimens, though they preserve most of the important points, lose a number of features that are evident only in the fresh state. You will notice the angry inflammatory redness of the serous coat, the edematous mesentery, the patches of grayishwhite adhesive exudate on the surface, the local gangrenous patch with the perforation in its center, the purulent fecal contents exuding,

State has been fully considered in the numerous communications to this and other societies formed on similar lines. It is, perhaps, not saying too much when it is stated that the medical profession, as well as others interested in sociological questions, are becoming more alive to the possibilities of limiting their diffusion and preventing some of the malign results which follow in their wake. When it is more widely taught that these infections are not necessarily of venereal origin, but are often acquired in an accidental or innocent manner, the necessity for more general instruction regarding their nature. will be acknowledged by those who now consider that they are not proper subjects for discussion.

As safeguards in protecting the family and race from venereal disease, our chief reliance must be placed on education as a preventative measure, and on treatment if such infection takes place. Theoretically, education seems a simple and rational solution to the problem, but at present this method has its limitations, owing to conventionality, the odium which attaches to the very mention of these affections and false modesty. As physicians, we are aware of the need of such teaching, and recognizing that ignorance alone, even among the otherwise liberally enlightened, is responsible for so much disaster, are we not failing in duty or lacking in moral courage if we passively wait for the barriers to remove themselves? Until our means for propagating this knowledge becomes better systematized, most of the work will devolve on the medical profession, but, unfortunately, even here only a sporadic interest is encountered. The indifference on the part of the profession in general, and even in those in hospitals and dispensaries where these diseases are met with, is due perhaps largely to cynicism, for not uncommonly the attending physician expresses the opinion that the patient would neither understand

* Read before the Society for Sanitary and Moral Prophylaxis, April 12, 1906.

nor heed the cautions given. Certainly it is not fair or safe to trust to good fortune, but careful instruction as to their duration and contagiousness should be imparted that further dissemination may be restricted. If concerted action in this matter were taken by medical schools, medical societies, health boards, etc., then this dormant duty might be awakened into activity. We may not be able to materially affect the disease acquired through sexual commerce, but we can at least reduce the number of victims of gonorrhea and syphilis insontium if we live up to our convictions in every instance.

To be of value the preventive must be administered timely. We must seek not only to avoid contamination of the prospective wife, but we must go back early enough and prevent that of the husband. To attain this end such education must form an essential part of the training of the young. It is impossible to impart this knowledge in every home, because of the ignorance or indifference of the parents, and outside influences must, in many cases, be depended upon. The schools are perhaps the next best place, and in addition to the compulsory study of physiology and hygiene in the lower and higher grades, the curricula should be supplemented by special lectures on this question to young people who have reached a proper age. I am especially in favor of warning young men just entering college, and consider lectures, modeled after those given by Lassar, of Berlin, or Pontoppidan, of Copenhagen, and others, of distinct value. Such lectures should, however, be given early in the year when the schedule for work is incomplete, and the unoccupied time and the sudden escape from parental control are apt to lead to an abuse of freedom. It is easy to appeal to students: their instruction should cover, besides the physiology of the generative system, the dangers and consequences of irregular sexual life, in language which could not be misunderstood. Medical students, too, should have the benefit of this knowledge at the very outset of their career, and I visits to the venereal wards of a hospital would not be without a salutary effect. An object lesson such as could be there afforded would do much to impress mere didactic instruction.

Individual judgment and future discussion must determine the extent and kind of information to be conveyed to young women on this subject. The nature of diseases which so influence the future health and happiness of wives should not altogether be concealed. Although the topic is a delicate one to broach to young women in any social class, they should nevertheless be in a position to protect themselves, if parents and guardians are negligent on this vital point.

Men rely too much on feminine ignorance regarding the real nature of venereal infections; and, while perhaps the conscientious would not. wilfully expose their wives to such dangers, still there are some who do and will take advantage of this lack of knowledge.

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If the etiological element of many of the diseases which arise after marriage resulting from venereal infection of the husband were known to the wife, what domestic calamities would follow! On the other hand, if young men were aware of the fact that young women had sufficient enlightenment in these matters, would they not guard themselves more carefully from infection, or, if it did take place, would not at more rigorous treatment precede the marriage state?

A system to be productive of results must be far-reaching: it must be given sufficient prominence to be impressive, and must penetrate all strata of society. The great majority outside of the pale of institutions of learning we must in time reach through the co-operation of churches, societies such as this one and heads of large employment centers.

It is, perhaps, placing the best construction on human motives when we state that ignorance is often the cause of venereal disease in the young. When properly informed, many right-minded individuals would sedulously avoid all such sources of infection; although, without undue pessimism, I might say that a large percentage would not be influenced in this way, and for this reason we must make the treatment of this class of diseases an important factor in preventing their transmission by marriage. Instruction should form as necessary a part of the treatment as the medication; and it is the duty of the physician to disabuse the patient's mind of the idea that gonorrhea, for instance, is merely a local catarrh and easily cured. He must be impressed with its seriousness and warned against marrying while in an infectious stage. He will surely transmit the disease to his wife with such consequences as acute and chronic pelvic inflammations, resulting in chronic invalidism, incurable sterility and even death. If he attaches but trivial significance to his own condition and thereby neglects treatment, the outcome may be a double epididymitis producing sterility, a prostatitis with partial or complete impotency, or the infection may extend to the kidneys. The infectiousness of this disease may be retained for years and doubtless, even physicians, in establishing the etiology of an arthritic outbreak, overlook the rôle of the gonococcus under the assumption that it has been destroyed by time. I recall a patient with a multiple joint and tendon sheath involvement thirteen years after infection, in whom gonococci were demonstrated in the pus from the involved structures. Fortunately, through the almost universal use of the Crède silver nitrate instillation in maternity hospitals and private practice as prophylaxis against ophthalmia neonatorum, the effects upon the eyesight of the offspring are minimized and the number of blind from this cause greatly reduced. Often and sufficient emphasis must be laid upon the fact that the patient cannot consider himself cured with the cessation of the discharge, that

August, 1906

the disease in its latent stage is dangerous, and that frequent bacteriological and microscopical examinations must be made before his marriage can be sactioned.

ace.

If

With the subject of syphilis the same course must be pursued and all the possibilities communicated to him. He should be informed that his disease can be transmitted for the first four or five years after infection, even when all traces of it have apparently disappeared, that he jeopardizes the health of the general public through eating utensils or carelessness in the use of any article that may have come in contact with syphilitic secretions, especially salivary, and that demonstration of affection, as kissing, is a menHis wife can be infected directly or through the fetus, causing the active disease in her and leading to repeated miscarriages or leaving her in a state of anemia and cachexia, with the danger of later manifestations of the disease. she give birth to living children they may survive only a few years or bear unmistakable stigmata with late recurrences. As for himself, time may visit him with an optic neuritis resulting in blindness, visceral complications, spinal cord lesions, early paralysis or paresis, epilepsy, etc., etc. Such instances are met with in clinical experience, and prove the havoc this disease works when left to itself; but many of these conditions are preventable or remediable if conscientiousness and patience are combined with intelligence. The gloomy picture depicted need not be realized if the patient will avail himself of the specific remedies which, by long continued employment under proper medical supervision, will eradicate or render innocuous the virus. A man, properly and thoroughly treated before marriage, will not infect his wife, and will have healthy offspring, and the same is true of a woman. Likewise, a syphilitic woman who is actively treated during her pregnancy may produce a healthy child.

The late pernicious manifestations of the disease through the channels of the nervous system or the viscera in those who have been treated is, in a large majority of cases, due to laxity, unintentional, perhaps, or to the preparation or method employed not having been efficient.

Our work with the spirochæta has not progressed sufficiently for us to have recourse to bacteriological or microscopical tests as an indication of the existence or non-existence of the infectious agent in any stage of this disease, and until that time has arrived we must be satisfied with the consensus of clinical experience which shows that our only assurance of a cure is in the prolonged use of specific remedies over a period of three or four years and complete freedom from all signs of the disease for perhaps one

year.

Have we other measures besides education and treatment to limit the spread of these diseases? In this age of preventive medicine when there is so much interest and activity displayed by our

public authorities in checking infections, it would seem that the venereal one in matrimony and in every day life might be limited to some degree by restrictive legislation. However, a practical application of such measures has not proved of much utility. It has been a prolific source of secret prostitution and has led to such concealment and deception of the infected individual that physicians in charge of lock hospitals in countries where such restriction is in operation have little confidence in its efficacy. Moreover, medical inspection is often so superficial and cursory that it affords little protection while inspiring the community with a false hope of security.

The best plan it seems is a liberal policy on the part of the health authorities in regarding the infected individual as an invalid and not as a criminal, thus encouraging him to submit to early treatment, which should be readily accessible.

Therefore, it appears that the best safeguards which we now have to prevent the introduction of these diseases into marriage, aside from early and comprehensive teaching as to their nature and effects, are the sterilization of all sources of contagion by prompt and energetic treatment and emphatic warnings regarding transmission directly or through infected media, and the certainty of their conveyance to the innocent wife and children if matrimony is entered into without the consent of the attending physician.

SHOULD NOT SAFEGUARDS FROM VENEREAL DISEASE BE THROWN AROUND MARRIAGE?*

T

By JOHN A. WYETH, M.D.,
NEW YORK.

O the question to which I have been invited to speak, namely, "In view of the grave injury to the family and race from venereal infection, should not safeguards be thrown around marriage?" there can be but one answer and that in the affirmative.

The chief difficulty lies in determining the better method of securing this protection, especially to the woman and her offspring.

In my opinion, in discussing this important feature of the subject we can eliminate that large proportion of the gentler sex who appreciate the possibilities of maternity and are looking forward under both the natural and the social law to the enjoyment of this privilege.

From the dangers of direct infection before marriage this higher type of woman is protected not only by her innate purity but by the safeguards of her home and family and the rulings of modern civilization.

I would suggest that the solution of this problem can be best accomplished by dealing directly Read before the Society for Sanitary and Moral Prophylaxis, April 12, 1906.