COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64055302 RD91 G32 1 890 The rules of aseptic RECAP Columbia ^ntbcrsittp tntbtCitpotKrtD^^ork QloUf gf nf Phgatriana ani ^argrona iAtUvmn iCtbrarg Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/rulesofasepticanOOgers THE RULES OF ASEPTIC AND ANTISEPTIC SUUaERY A PRACTICAL TREATISE FOR THE USE OF STUDENTS AND THE GENERAL PRACTITIONER BY AEPAD G. GERSTEK, M. D. PROFESSOR OF SrEGERY AT THE ^'EW YORK POLYCLINIC ; VISITING SURGEON TO MOUNT SINAI HOSPITAL AND THE GERMAN HOSPITAL, NEW YORK ILLUSTRATED WITH TWO HUNDRED AND FIFTY-TWO ENGRAVINGS AND THREE CHROMO-LITHOGRAPHIC PLATES 'niRD EDITION, NEW YORK D . A P P L E T O N AND COMPANY 1891 Copyright, 1888, 1890, By D. APPLETON AND COMPANY. RESPECTFULLY DEDICATED TO THE FATHER OF ANTIPARASITIC SURGERY^ Sir JOSEPH LISTER, Baet. PREFACE TO THE THIRD EDITION. The necessity for issuing within two years a third edition of this work may be safely assumed as a sign of the spread of antiseptic doc- trine and practice among the members of the medical profession in this country. The general outlines and scope of the book, being based upon the course of lectures yearly delivered by the author to a body consisting of practicing physicians, have retained their practical character. Principal accentuation was placed upon the points showing important divergence from older methods. Additional new matter was introduced in the chapters on Herniot- omy, Haemorrhoids, Appendicitis, and the Surgery of the Kidney. As in the former editions, statistical material was brought in only when the typical and uniform character of the operations pertaining to one sub- ject permitted its safe use as a gauge of the value of aseptic or anti- septic methods. The additional experience of two years' work was util- ized in widening the basis of the conclusions thus drawn from the com- putation of numbers. The casuistic material, all original and carefully recorded, forms, in the opinion of the author, the most valuable part of the work. Its quan- tity will be found materially increased in the chapters that have been re- written, or newly introduced. 56 East Twenty-Fifth Street, New York, September 8, 1890. PREFACE TO THE FIRST EDITION. The object of this volume is a systematic yet practical presentation of the Listerian principle that has revolutionized surgery within the last fifteen years. Its adoption has wrought so many incisive changes in practice, has shifted the surgeon's standpoint regarding all the important disciplines of the art in such a radical manner, that most English text- books of surgery, even those recently published, have become partly or entirely inadequate to the wants of the modern physician. To a large number of medical men the aseptic and antiseptic methods present an incongruous chaos of seemingly contradictory and often in- comprehensible detail, arbitrary and varying, according to the predilections or whims of this or that teacher. Yet the principle involved is based on the correct observation of a common biological process — namely, that of the decomposition of organic substances. The well-known methods employed since the earliest dawn of civilization for the preservation of organic, especially animal, sub- stances, are based upon the empirical yet correct appreciation of the causes of putrefaction, and the practical adaptation of these methods to the healing of operative or accidental wounds contains the whole essence of the new surgery. Evils that former generations of surgeons deplored, but could not effectually combat, such as septicaemia, pyaemia, hospital gangrene, and erysipelas, have been much abated, as a direct consequence of a clear understanding of their essential nature and causation. Prevention has become the watchword of modern practice, and it can be said that, by the successful employment of the preventive methods of the present day, surgery has become a conservative branch of the heal- ing art. viii PREFACE. Tlie elimination of the accidental disturbances of repair caused bj wound infection has depressed the percentage of mortality following amputation of the extremities from an average of thirty-iive per cent to about fifteen per cent. The dread of undertaking and submitting to a surgical operation has greatly diminished, and timely — that is, early — surgical interference has become more and more frequent, to the great advantage of both p)atient and physician. As a direct consequence of the implied obligation of rendering timely aid where possible, a laudable eagerness for an early diagnosis is developed, and, there being so much to be gained by diagnostic knowledge, thorough and practical study of the morbid processes requiring surgical aid lias been greatly stimulated. The fear of suppuration with its dreadful consequences does not stay now the hand of the surgeon as of old, when an operation was always considered a forlorn hope and a last resort. Strangulated herniae, for instance, are not allowed to gangrene as often as formerly, and herniotomy is readily resorted to, as it is well known that the dangers of an aseptic herniotomy done on a healthy gut are diminutive in comparison to the certain and enormous danger of strangulation itself. By the conviction that a fault of omission may he followed by irre- mediable mischief, the sense of responsibility is stirred up to vigilance, which again breeds self-reliance and firmness of purpose in advising and carr^ang out incisive measures, made clearly necessary by a well-recognized danger to life or limb. And an additional degree of responsibility is imposed by the very safety of aseptic operations. It can not now be successfully denied that the surgeon^s acts deter- mine the fate of a fresh wound, and that its infection and suppuration are due to his technical faults of omission or commission. The principle underlying antiseptic surgery has ceased to be the subject of serious controversy. The author does not undertake to prove each of his statements to the satisfaction of those who look but see not. His object is instruction rather than controversy. Every one will have to pass his period of apprenticeship with its l)lunders and lessons. But he who becomes a master, to whom the primary healing of a fresh wound remains not a curiosity but becomes a matter of course, will not doubt the great change that has come over surgery. PREFACE. IX The purely practical tendency of the work made a rather free ar- rangement of the several parts of the subject-matter a necessity, or at least a convenience; yet a sufSciency of systematic order Avas preserved to give the collection of papers the character of a well-rounded, organic whole. The author begs to state explicitly that completeness — that is, the inclusion of all the disciplines of surgery — was not aimed at, else a com- plete text-book of surgery would have resulted. The leading idea, trace- able tlirough all the matter contained in the book, is to illustrate the incisive practical changes that the adoption of aseptic and antiseptic meth- ods has wrought in surgical therapy. Hereby the changes in wound treatment are meant, as well as the notable extension of active surgery into iields formerly considered a noli me tangere. As a consequence of the stupendous growth of operative surgery within the last decade, a fruitful development of operative technique is to be noted also. In accordance with the desire of the author to present to the profession a vivid and true picture of contemporaneous methods, tlie terms used as the title of this work should be accepted in their widest signifi- cance. Confinement to the meager details of those manipulations which, strictly speaking, constitute aseptic and antiseptic measures, would have yielded an inadequate and tedious compilation. On the other hand, it is hoped that the pathological and technical diversions, introduced for the sake of laying a rational foundation to the principles composing the essence of antiparasitic sm'gery, may be admitted as germane to the subject. The methods of wound treatment herein explained are to a certain extent still undergoing changes, hence should not be accepted as final. Yet it is undeniable that, as the clearness of the comprehension of the mn^\Q principle of asepticism applied to wound treatment has advanced, so the frequent changes and bewildering vacillation characteristic of the ex]3erimental stage of the new discipline have naturally given way to steadier methods. At present, changes are not so frequent as formerly, yet progress, especially the conquest of new fields for the legitimate prac- tice of active surgery, is not at a standstill. The author is well aware that the practical directions recommended by him are not the only ones that lead to success. Yet, in the main, he X PREFACE. has refrained from quoting other authorities. As reasons for this may be adduced, Urst, the disindination to write a bidky text-book, and, further, the knowledge that the interest of the reader is proportionate to the directness and immediate character of the facts and thoughts contained in the work under perusah As far as possible, all important statements will be found borne out by illustrative examples taken from the authors j:)ersonal experience. The author is much indebted to the gentlemen composing the house staffs of the German and Mount Sinai Hospitals for tlie ready kindness and courtesy with which their help was proffered in tracing and extract- ing histories of cases, and in making the very numerous photographic plates that form the bulk of the illustrations. Great technical difficulties, inherent to the unfavorable season, the small space and inadequate Kghting of the operating-rooms of the men- tioned hospitals, had to be overcome in exposing the sensitive plates. The matter was rendered still more difficult by the circumstance that operating and photograpliing were done by one and the same set of per- sons, and that the welfare and interests of the patients themselves had constantly to be sedulously considered. In view of the defective character of many of the author's negatives, the greatest praise belongs to Mr. William Kurtz, to whose artistic taste, skill, and versatility is due their excellent reproduction by phototypo- graphic process. Proper credit is given for the lithographic plates copied from Rosen- bach, for the excellent microphotographs reproduced from Koch's classi- cal reports, and for a few other illustrations borrowed from Esmarch, Henke, and Bumm. In conclusion, the author may be permitted to express the hope that, by pubHshing his share of experience gathered from a modest public and private practice, he may succeed to somewhat propagate and popularize the principles and practice of antiparasitic surgery. New York, September 3, 1887. CONTENTS. Part I.— ASEPSIS. CHAPTER I. PAGE What are Sepsis and Asepsis ! 3 CHAPTER II. Aseptic Wounds — Aseptic Treatment ... ...... 5 1. General remarks ....... .....& II. Rules of surgical cleanliness . . . . . . . - . 7 1. Hands 7 2. The instruments ............ 7 3. Wound irrigation ........... 7 4. Sponges 8 5. Materials for ligatures and sutures ........ 8 6. Drainage-tubes and elastic ligatures ........ 9 7. Disinfecting lotions ........... 10 8. Dressings - H (1) Types of dressings .11 a. Simple exsiccation. Bismuth, iodoform . . . . . .11 b. Chemical sterilization combined with exsiccation. Dry dressings . 12 c. Schede's modification of the dry dressing, favoring the organization of the moist blood-clot 12 d. Simple chemical sterilization. Moist dressings ..... 13 (2) Preparation of dressings .14 a. Gauze ............ 14 (a) Corrosive-sublimate gauze ........ 15- (6) lodoformized gauze 1& b. Absorbent cotton, or common cotton batting . . . . .15 c. Sawdust 16- d. Moss 17 III. Practical application of rules . ........ 17 1. In operating ............ 17 2. Change of dressings 20- IV. Aseptic measures in emergencies ......... 23 Operating bag and kit .......... 25. CHAPTER m. Soiled Wounds. — Antiseptic Treatment. — Difference between Aseptic and Antiseptic Methods. — Illustration of Antiseptic Method 27 xn CONTENTS. CHAPTER IV. Special Rules regauding the Treatment of Accidental Wounds I. Temporary measures . II. Definitive relief . 1. Contaminated wounds 2. Aseptic wounds . 3. Gunshot wounds 29 31 31 34 35 CHAPTER V. Special Application op the Aseptic Method A. General principles .... I. Technique of sursical dissection . II. Sutures ..... III. Drainage ..... £. Application of aseptic method to diverse organs and I. Ligatures of arteries in their continuity II. Extirpation of tumors Preservation of asepsis Safe removal .... Complete removal JII. Amputation of limbs .... 1. Aseptics and antiseptics of amputation a. Clean cases .... b. Mildly septic cases . c. Septic cases of greater intensity 2. Hemorrhage .... a. Artificial ana'inia . b. Ligatures and final luemostasis 3. Securing of a good stump . IV". Operations about non-suppurating joints 1. Puncture and irrigation 2. Arthrotomy .... a. Hydrops genu .... b. Vegetations .... c. Floating bodies of the knee-joiat d. Suturing of the fractured patella 3. Arthrotomy for irreducible or habitua fracture .... V. Operations for deformities . 1. Knock-knee and bow-leg 2. Bony anchylosis in a vicious position 3. Deformed callus . 4. Club-foot and pes valgus VI. Plastic operations VII. Aseptics of the oral cavity . VIII. Laryngeal operations . 1. Tracheotomy rt. Superior tracheotomy b. Inferior tracheotomy 2. Laryngofissure . 3. Extirpation of the larynx . region dislocation, and for dcfor mity due to 36 36 36 44 47 48 48 52 52 01 61 64 66 67 69 69 72 74 76 76 78 78 79 »0 80 82 86 86 87 88 88 91 96 100 100 102 103 107 108 CONTENTS. Xlll IX. Goitre X. Amputation of tlie breast XI. Abdominal operations 1. General remarks 2 Herniotomy a. Herniotomy for strangulation h. Radical operation for hernia 3. Laparotomy a. Exploratory incision h. Abdominal tumors . («) General remarks (6) Special observations (a) Ovarian tumors (j8) Removal of uterine appendaj (7) Supra-vaginal hysterectomy (S) Nephrectomy . c. Gastrostomy . d. Colotomy («) Lumbar colotomy (6) Inguinal colotomy (c) Excision and suture of gut (enterorrhaphy) XII. Hydrocele, varicocele, and castration 1. Hydrops of the tunica vaginalis 2. Varicocele ... 3. Castration . . XIII. Aseptic operations on the rectum 1. General observations 2. Haemorrhoids 3. Rectal tumors XIV. Aseptics of the bladder 1. Catheterism 2. Litholapaxy 3. Cystotomy a. Perineal section h. Suprapubic section PAGE 111 113 119 119 121 123 133 139 139 140 140 147 14*7 150 151 153 154 155 156 156 158 163 163 164 165 167 16V 167 171 173 173 175 177 177 177 Part II.— ANTISEPSIS. CHAPTER VI. Natural History of Idiopathic Suppuration. — Treatment of Suppuration I. The cause of suppui-ation, or phlegmon II. Portals of infection .....,- 1. Infection through lesions of the skin . 2. Infection through lesions of the mucous membranes III. Entrance, progress, and localization of the infection . Mechanical irritation ...... Chemical and caloric irritation .... IV. Development of phlegmon ..... o 183 183 18.fi 185 186 187 189 190 191 XIV CONTENTS. V. Spread of suppuration ......„„ VI. Diagnosis and treatment of phlegmon . . . , , 1. General principles ........ a. Superficial suppuration, or septic ulcer .... b. Cutaneous and subcutaneous phlegmon .... c. Deep-seated or subfascial phlegmon. Lymph-gland abscess d Acute infectious osteomyelitis e. Chronic suppuration due to bone necrosis. Necrotomy . 2. Phlegmonous affections of some special regions . a. Face. Floor of the mouth. Neck. Temporal and mastoid regions («) Face (b) Neck (a) Fauces and pliarynx ..... (j8) Submaxillary and parotid cynanche (7) Acute glandular abscesses of the anterior and lateral cervical regions .... (S) Glandular abscesses of the temporal, mastoid, and occipita regions .... b. Mammary and retro-mammary abscess c. Empyema ..... d. Phlegmon of the palmar aspect of the hand, of the arm, and axilla e. Suppurative affections of the lower extremity , («) Ingrown toe-nail (b) Chronic ulcers of the leg . (c) Acute suppuration of the prepatellary (d) Acute suppuration of the knee-joint {c) Suppuration of the inguinal glands jf. Perityphlitic abscess a. Acute appendicitis (without tumor) (a) Simple appendicitis (no tumor) {b) Perforative appendicitis (no tumor) b. Acute appendicitis with tumor ; perityphlitic abscess . Types of acute perityphlitic abscess .... 1. Ilio-inguinal type (Willard Parker's abscess) 2. Anterior parietal type ..... 3. Posterior parietal type ..... 4. Rectal type ....... 5. Mesocaeliac type ...... c. Chronic or relapsing apj)endicitis and perityphlitic abscess g. Abscess of the liver ....... h. Lumbar abscesses ........ i. Pyonephrosis, renal abscess, and calculous kidney . (a) Nephrotomy ........ (b) Nephrectomy ...... ^ . k. Anal abscess. Fistula in ano . . . . o bursa PAOE 193 198 198 199 199 203 205 208 222 2^2 223 225 225 231 CHAPTER VII. Erysipelas and Pskudo-Erysipelas 289 CONTENTS. XV Part III.— TUBERCULOSIS : ITS ASEPTIC AND ANTISEPTIC TPvEATMENT. CHAPTER VIII. PAGE Natural History and Treatment of Tuberculosis 293 I. Etiology of tuberculosis. Tubercle bacillus ....... 293 II. Complication of tuberculosis with pyogenic or suppurative infection . . . 297 III. Treatment of tuberculosis 297 General principles ........... 297 Local treatment of tuberculosis . . . . . . . . . 298 1. Cutaneous tuberculosis. Lupus ......... 298 2. Tuberculosis of the mucous membranes ........ 299 3. Tuberculosis of the lymphatic glands, or scrofula ...... 299 4. Tuberculosis of tendinous sheaths ......... 301 5. Tuberculosis of bone. Caries. Cold abscess 303 6. Tuberculosis of joints. White swelling 305 General part 305 a. Technique of joint exsection ......... 305 (a) Septic injection from without ........ 305 (5) Complete removal of tuberculous tissues ...... 306 (c) Control of hsemorrhage ......... 306 ((/) Preservation of function 306 b. After-treatment ........... 307 Special part 308 a. Shoulder-joint 308 b. Elbow 310 c. Wrist and hand ........... 314 d. Hip-joint ............ 315 e. Knee-joint ..... ..o ... . 319 /. Ankle and foot . . . . . . . . . , .325 Part IV.- GONORRHCEA : ITS ANTISEPTIC TPvEATMENT. CHAPTER IX. Natural History and Treatment of Gonorrhcea . . . . , . . . 331 I. Etiology of gonorrhoea. Gonococcus ......... 331 II. Treatment of gonorrhoea 333 1. Acute gonorrhoea. Clap .......... 383 a. Anterior gonorhoeal urethritis ......... 334 b. Deep-seated gonorrhoeal urethritis ........ 336 2. Chronic gonorrhoea. Gleet . . . . . . . . .339 a. Inflammatory stenosis (incipient stricture) and permanent or- cicatricial stricture of the urethra ......... 339 (a) Anterior urethra .......... 339 (b) Deep urethral strictures 345 xvi CONTENTS. PAGE b. Vegetations of the urethra ......... 348 c. (Jranular urethritis ........... 348 d. Chronic catarrh of the posterior part of the urethra, and elnonic cystitis . 348 Pakt v.— syphilis : ASEPTIC AND ANTISEPTIC TREATMENT OF ITS EXTERNAL LESIONS. CHAPTER X. Aseptics and Antiseptics applied to External Syphilitic Lesions .... 353 L Aseptic treatment of primary induration 353 2. Antiseptic treatment of the primary syphilitic ulcer 356 a. Chemical sterilization and surface-drainage by medicated moist dressings 356 b. Chemical sterilization by strong caustics 357 c. Sterilization by the actual cautery 358 PAET I, ASEPSIS. CHAPTEE I. WHAT ARE SEPSIS AND ASEPSIS? It is not intended here to enter into an exhaustive exposition of the essence of suppuration and the whole complex of conditions known under the name of sepsis. It may suffice for the present to give a rough out- line of the views that prevail regarding the causation of the conditions in question. Albuminoid substances, such, for instance, as blood or blood-serum — in fact, all the tissues of the dead animal body — will become putrid under certain well-known conditions. These are, first, moisture ; secondly, a cer- tain temperature called warmth, for short ; and, thirdly, the presence of living organisms, or fungi, named schizomycetes, better known under the name of bacteria and micrococci. If all these factors are present, the ani- mal substance in question will ferment or joutrefy. Absence of any one of these factors will be sufficient to prevent decomposition. To illustrate this proposition, we shall mention common facts. Fresh meat or fish, well dried, can be indefinitely preserved ; freezing and, to a certain extent, roast- ing will also prevent its spoiling ; and, lastly, exclusion of micro-organisms by air-tight packing or sealing, after boiling, will insure preservation for an indefinite length of time. The active agents of decomposition are the micro-organisms, which will develop at once their disintegrating activity as the conditions favorable to their development (moisture and a certain temperature) are present. We then either thoroughly dry the substance to be preserved or jDroduce and preserve a very low or very high temperature in it, all of which will j)re- vent the development of fungi. Exclusion of the fungi is herein unneces- sary. The third mode of preservation is that employed in canning meats. They are first boiled thoroughly, then the vessel wherein this boiling was done is hermetically sealed while the substance is still very hot. Here we have a combination of first destroying the vitality of such fungi as are con- tained in the meat before boiling, and, secondly, exclusion of access of new micro-organisms to the sterilized substance. Note. — The most effective sterilizer is the actual cautery. It not only destroys all the nox- ious germs contained within the tissues, but at the same time provides these with an often dry and always hermetic seal against further infection. If the eschar and its vicinity be well dusted 3 4 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. with iodoform powder, it will often happen that complete cicatrization will take place beneath its protection, even before the detachment of the eschar. All accidental or surgical wound presents conditions that are eminently favorable for the development of the fungi in question. The oozing blood and lymph, the bruised and dead cells of the various exposed tissues, fur- nish, severed from their natural connections, the moist pabulum of a proper temperature. The myriads of particles of filth or dust, filling the air in all inhabited localities, contain, according to indubitable evidence, a very large proportion of spores or seeds that, on falling upon the wound and its secre- tions, promptly develop into fungi, and at once set up a fermentative process known as decomposition. The products of this fermentation are more or less highly poisonous sub- stances — Bergmanu's sepsin, or the ptomaines of the French authors. They promptlv set up local changes in the shape of inflammation, and cause sys- temic trouble — that is, septic fever. It is further necessary for us to know that in septic processes of a wound not only the ptomaines are absorbed by the lymphatics, but that often an actual invasion of the living tissues by the fungi will take place, and that the lymphatics and veins will also serve as channels for the imiDortation of dangerous quantities of fungi into the circulation. Secondary deposits, metastases, will then easily occur. Clinical observers properly distinguish between different, more or less intense fonns of septic infection, in which bacteriology, however, does not always demonstrate correspondingly different forms of fungi. On the other hand, it is known that impoverished nutrition, but esiiecially a certain mor- bid state, namely, diabetes mellitus, presents an extremely favorable con- dition for the development of bacterial sepsis. Regarding syphilis and tuberculosis, this can not be said, as it is not difficult in these states to prevent suppuration of accidental or surgical wounds. Case. — In 1879 the author removed from the lumbar region of a young brewer a good-sized lipoma. His skin was covered at the time with a recent syphilitic roseola following a chancre. Under ordinary antiseptic precautions prompt union by the first intention followed, although the treatment was altogether ambulatory, the patient having been operated on and treated throughout at the German Dispensary. Prompt primary healing of the wounds caused by the extirpation of syphilitic buboes is a rather common experience in the syphilitic ward of the German Hospital. The excellent results obtained after exsections of tuberculous joints are also proof positive of the assertion that tuberculosis in itself does not dispose to suppuration and sepsis, and that prevention of septic processes in the wounds of the victims of tubercu- losis is not difficult. Diabetes mellitus, however, does undoubtedly heighten the disposition to septic conditions. Ordinary antiseptic precautions often fail to prevent suppuration : hence, an injury, or the necessity of a bloody operation in a diabetic, should never be treated lightly. It is the immortal achievement of Lister to have first attributed to fer- ASEPTIC WOUNDS— ASEPTIC TREATMENT. 5 mentative influences the disturbances of repair, and to have led wound- treatment into a rational, hence successful, direction. Modern wound-treatment is based entirely on the old and well-known principles of the preservation of orga?iic substances. Of the several modes of preservation, freezing is the only one that is inapplicable in human sur- gery. Exsiccation, however, and burning with the actual cautery (roast- ing) ; then chemical sterilization by germicides, and the combination of chemical sterilization with exsiccation, contain the essence of aseptic sur- gery. They insure wounds against decomposition, and are a secure pre- ventive of suppuration. CHAPTER IL ASEPTIC WOUNDS— ASEPTIC TREATMENT. I. GENERAL REMARKS. Supposing that the skin in the region to be operated on be shaved, then energetically scrubbed in hot water with soap and a clean brush for five minutes, then the surgeon's hands be scrubbed, likewise his knife, and now an incision be made through the skin ; supposing that this happen in an atmosphere free from particles of dry filth called dust : such a wound could be safely termed a clean or aseptic one. All particles of filth adhering to skin, hands, and instrument were removed by this simple process of scrub- bing, and no new particles could settle down out of the atmosphere, which we assumed to be free from dust. Experience has taught that such a wound, however large, will heal without suppuration, first, if its edges be approximated by sutures made with a clean needle and clean wire, silk, or gut ; and, secondly, if the im- munity from an invasion of filth be maintained until the bloody serum marking the line of union become dry. But we can vary our experiment, and show that a wound can heal with- out suppuration even if contact of the walls of the same be imperfect or none. Case. — Mrs. J. B., aged forty-nine ; branchial cvst of the submaxillary region of the size of an orange. Had been punctured a number of times. Oct. 7, 1882. — Incision of six inches in length; difficult extirpation. The large vessels of the neck were freely- exposed, a considerable affluent of the deep jugular vein was deligated. Catgut used was rather brittle. Suture and drainage of the large wound. Antiseptic dressings. Imme- diately after the operation patient had a severe coughing spell. Oct. 12. — On changing the dressings it was found that the interior of the wound was distended by a massive blood-clot, giving an appearance as though the tumor had not been removed at all. 6 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Sanguinolent serum was discharging from the drainage-tuhe. Dressings renewed. Oct. 16. — Tumor much diminished in size. Drainage-tube removed. Oct. 20. — Wound firmly liealed; outline of neck iioniial. Throughout, normal temperatures. Here we see that undoubtedly secondary venous haemorrhage had taken place into the large cavity of the wound. The distention did not reach a sufficient degree to jH-oduce a rupture of the line of sutures. The enormous clot was rapidly absorbed, and the wound healed without suppuration, though not by primary adhesion. If the wound had not been aseptic, putrefaction of the clot and dangerous septic processes would have inevit- ably followed. Still more curious is the course of an aseptic wound that is not united at all, but is left gaping, provided that suitable means are emj^loyed to preserve its aseptic character. Case. — Mrs. C. T.. aged forty-three, came from Ohio to have a syphilitic defect of the nose repaired. Total rhinoplasty, Sept. 18, 1883, at Mount Sinai Hospital. A suitable flap containing the periosteum was raised from the forehead. The edges of the frontal wound could not be drawn together, therefore a properly shaped, well-disinfected piece of rubber tissue was laid on it, and this was covered with an iodoform dressing. Sept. 23. — Stitches removed from nasal sutures. Dressing on forehead dry, therefore it was left undisturbed. Oct. 1. — Dressing of frontal wound being removed, the rubber- tissue covering became visible ; after this was taken away the edges of the wound were found to be cicatrized to the width of half an inch on both sides. A moist, fresh-looking remnant of tlie blood-clot was still covering a strip of the middle of the wound. No suppuration whatever. Dressings renewed. Oct. 6. — Entire wound cicatrized with the exception of a spot as large as a penny at the upper end. Oct. 10. — Discharged cured. Here, then, is an example of the now commonly observed fact that a gaining defect will cicatrize over without suppuration if putrefactive changes be excluded from the clot filling up the gap. This observation involves a radical difference from the old tenet that whatever wound does not heal by primary adhesion must heal by suppuration. A third possibility has become demonstrable, for which older pathology had no explanation. It is necessary to state that in both of the latter examples the condition of a dustless atmosphere during the time of the operation was not present ; the operations were done in ordinary rooms, openly communicating with the dusty streets of Xew York, yet the behavior of the wounds was per- fectly correct. The extreme difficulty of preparing and maintaining a dustless atmos- phere in a room of an inhabited locality is well known to everybody, and, as a matter of fact, the general practitioner must and will have to do his surgery in more or less dusty rooms. Since the procurement of this con- dition is practically unattainable, frequent irrigation or rinsing of the wound becomes a necessity. But even a constant and powerful stream of fluids will not be able to dislodge all the particles of dust that may have settled down upon and insinuated themselves into the nooks and crevices ASEPTIC WOUNDS— ASEPTIC TREATMENT. 7 of a wound. Hence it is desirable to employ a liquid that, aside from its non-irritant quality, will have the property of extinguishiug the noxious effects of those particles of dust that can not be washed away by the irriga- tion, but remain imbedded in the tissues. This is cliemical sterilization. Different disinfecting solutions are used for this purpose to answer vari- ous requirements. Their composition and uses will be mentioned hereafter. Note. — Kiimmel, of Hamburg, has shoTvn that a dustless operating-room can be had in a well-appointed hospital, and Neuber, of Kiel, has excellent results from operations done in such a dustless room, with well-cleansed hands, apparatus, and instruments, without the employment of antiseptic fluids. Even the dressings used are not impregnated with any antiseptic chemical, but are merely " sterilized " by being exposed to dry heat. No sponges are used, all blood being removed with a sterilized solution of common salt (6 : 1,000), which is absolutely unirritat- ing, and certainly forms the most gentle manner of cleansing a wound. n. RULES OF SURGICAL CLEANLINESS. 1. Hands. — The hands and forearms, especiallij the finger-nails, of the surgeon and his assistants should be well scrubbed in hot water with soap and brush for five minutes ; likewise the region of the body of the j)atient to be operated on after carefully shaving off the hair. After this follows an immersion of the hands in alcohol, and then in corrosive sublimate lotion (1 : 1,000) for one minute. Note 1. — Kiimmel's recommendation of green soap (potash or soft soap) is excellent, on ac- count of its great solvent properties. Note 2. — Rings, especially those having stone settings, should never be worn by the surgeon or his aids in an operation. Bangles and bracelets of female nurses should not be tolerated. Every one's arms should be bared and scrubbed to the elbows. 2. Tie instruments should be subjected to a careful and minute cleans- ing with soap and brush, especial care being taken to remove dry jDarticles of blood, pus, etc., from the grooves and behind the clasps of the more com- jiosite instruments, which ought to be taken apart each time for cleansing. Hollow instruments (trocars), or those that can not be taken apart, should be boiled in water for thirty minutes. They should be immersed for ten minutes in a three-per-cent solution of carbolic acid before use. Note. — The surgeon should learn to get along with as few instruments as possible. In selecting instruments, preference should be given to the most simple. The best instruments are those having smooth and well-polished surfaces ; grooved or roughened handles are hard to clean, and unnecessary. 3. Wound Irrigation. — During the operation the wound should be fre- quently irrigated with the proper kind of a disinfecting fluid ; the hands of the surgeon and his assistants should be also washed at not too long intervals in a disinfecting fluid (corrosive sublimate, 1 : 1,000) ; the instru- ments should be kept immersed in a three-per-cent solution of carbolic acid (which is the least injurious to them). The most convenient form of irrigator is the well-known '^'fountain syringe" of vulcanized rubber. Note. — Whenever any one of those engaged at an operation touches a not disinfected object — hands a chair, opens the window or door, helps the angesthetizer during a vomiting spell of the 8 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. patient, scratches his face, or wipes his nose — it is absolutdy necessary that his hands be scrubbed and disinfected anew. Instruments that are accidentally dropped should be left untouched. Raw assistants, and especially nurses, male and female, trained or untrained, should be earnestly in- structed beforehand, and constantly watched afterward, regarding this all-important discipline. 4. Sponges should be beaten free from calcareous particles, then im- mersed for fifteen minutes in dilute muriatic acid to dissolve the remnant of lime, washed in cold water, then thoroughly kneaded by hand with green soap in hot water for five minutes, rinsed, and then immersed in a five-per- cent solution of carbolic acid, in which they remain until required for use. Sponges used once in an aseptic operation can be used again. Careful wash- ing out with green soap and hot water of all the remnants of fibrin and blood, then immersion in a five-per-cent solution of carbolic acid, are suffi- cient. It is not good to use too many sponges at an operation. When sat- urated with blood at an operation, they should be washed free from it in tepid ivoter, then thrown into a basin filled with carbolic solution, and hence handed to the surgeon. Carbolic acid is preferable for preservation of sponges until use, because it does not become decomposed and inert, as, for instance, corrosive sublimate. Note. — Selected Florida sponges are cheap and good. In New York a pound can be bought for about two dollars, each sponge costing on an average two cents. 5. Materials for Ligatures and Sutures. — Well-prepared catgut of differ- ent thicknesses will answer every purpose for ligatures and sutures. The finest suture work on the intestines can be neatly and reliably done with catgut No. 0. The most massive pedicle can be safely tied with catgut No. 4. For ordinary ligatures and sutures No. 1 will be most convenient, and should constitute the bulk of the surgeon's supply. The simplest way of preparing catgut is Kocher's : Wash in ether, then immerse catgut for twenty-four hours in good oil of Juniijcr (ol. juniperi baccarum, oil of the berry, not the oil gained from the wood) ; transfer into and preserve in absolute alcohol 1,000^ corrosive sublimate 1, until use. Alcohol keeps catgut hard and firm, yet flexible. Where it is desirable to prevent too early absorption, as, for instance, in intestinal sutures, a hard- ening process should be added to the disinfection. After disinfection the article should be washed in alcohol, then placed into a quart of a five-per- cent solution of carbolic acid containing thirty grains of bichi-omate of potash. Forty-eight hours' immersion will produce catgut that will resist the action of the living tissues for a week or longer. Large-sized catgut needs a longer immersion. Wind up on bobbins. Note 1. — Good catgut can be procured from L. H. Keller & Co., 64 Nassau Street, New York, for a moderate price. Dry preservation makes catgut more suitable for transportation : Immerse the prepared article for five minutes in ether, 100 ; iodoform, .5. Take out and place in a well-corked, wide-mouthed bottle. A film of iodoform will cover each thread. Note 2. — The author observed once unmistakable wound infection by improperly kept catgut. Case. — Jenny Marks, servant-girl, aged twenty, admitted November 10, 1883, to Mount Sinai Hospital with habitual subcoracoid dislocation of the right shoulder-joint. " Sprain " had been diagnosticated by a physician, seven weeks previous to her admission, who ordered a liniment. On admission, reduction was easily effected by manipulation, but the weight of the limb was suf- ASEPTIC WOUNDS— ASEPTIC TREATMENT. 9 fieient to reproduce the dislocation. A plaster-of-Paris jacket, inclosing the reduced arm, was applied and worn for four weeks without any effect. Dec. 11th. — The joint was freely opened by an anterior longitudinal incision, when it became evident that the tendency to dislocation was due to laxity or redundancy of the anterior part of the capsular ligament. By two semi-ellipti- cal incisions, a piece of the capsule one inch long and half an inch in width was removed. The capsular as well as the muscular and the skin wound were united by three tiers of interrupted catgut sutures, a drainage-tube having previously been carried just within the capsule. The next day moderate fever (101° Fahr.), but great dejection, headache, and vomiting were observed, the patient complaining of much pain in the joint. Dec. 13th. — The thermometer indicated 103° Fahr., with a corresponding increase of the general disturbance. The patient was aneesthetized, and the wound was exposed. No redness, only slight oedema was visible. The wound was re- opened. Firm agglutination was present everywhere except in four places, where swollen, dis- colored ligatures applied to the circumflex artery and some smaller vessels were seen surrounded by a halo of yellowish, semi-fluid, broken-down tissue, evidently representing small abscesses that were forming about the catgut ligatures. They were removed, the wound was irrigated with carbolic lotion, and packed with gauze. The fever fell off at once, and no further complication interrupted the course of healing. The habitual luxation was also cured. SilJc and common cotton or linen thread can be rendered unirritant either by boiling it for an hour in a five-per-cent solution of carbolic acid (Czerny) or by immersion during twenty-four hours in a solution of alcohol 100, corrosive sublimate 1, then preserving in alcobol. Silk-worm gut is excellent material for suturing. It is prepared like silk, and before use should be soaked awhile in carbolic lotion to make it supple. Its advantage : it is easy to thread. 6. Drainage-tubes and elastic ligatures are cut into proper lengths — that is, a little shorter than the height of the wide-mouthed bottle in which they are kept. This is filled with a five-per-cent solution of carbolic acid, that should be renewed from time to time. The tubes will always occupy an upright 230sition in the bottle, and can be taken out easily. Note. — Rubber tubing of black material is preferable to the coarser and unyielding white stuff, on account of its softness and pliability. Theoretically speaking, a iderfectly aseptic wound does not require any drainage. If the secretions following an operation or injury do not contain anything that is capable of inducing putrid changes, they will be absorbed, and will not cause any disturbance in the wound or the general health. The large blood-clot around a fractured bone is harmlessly absorbed ; a large blood-clot in an aseptic operation wound will be also absorbed without local or general disturbance, as Mrs. B.'s case (see page 5) has shown. The expe- rienced surgeon who has mastered the technique of asepticism will not hesi- tate to close up without drainage a small wound, as, for instance, after deligating the subclavian or iliac arteries. But, in operations where large surfaces were long exposed, and Avhere the wound is very irregular, the pos- sibility of a however slight and unavoidable contamination should always be kept in view. Vents should therefore be provided in the shape of prop- erly placed drainage-tubes for the easy egress of secretions, possibly contain- ing elements of future decomposition. If the healing be prompt, the tubes can be withdrawn on the third, fourth, or sixth day. In case of suppura- tion, bland or destructive, they will be in place and very opportune. 10 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 7. Disinfecting Lotions. — With a few exceptions (very large wounds re- quiring prolonged irrigation, and in operations involving the peritoneum), two lotions will be found sufficient. For the immersion of the instruments, a three- per-cent solution of carbolic acid, and for the irrigation and disinfection of hands and skin, a solution of corrosive sublimate of 1 : 1,000 — 1,500. Note. — The almost exclusive use by the author of carbolic acid and corrosive sublimate as germicides is intentional. It was determined by the fact that these substances are, first, thoroujrhly reliable and highly effective ; secondly, procurable almost everywhere, in the country store as well as in the city ; thirdly, because adherence to certain carefully selected substances results in a thorough knowledge of their proper use under varying conditions. Boiled water is preferable as a solvent. It alone would be sufficient if we were absolutely sure against the introduction of filth into the wound. Note. — A ready and handy way of mixing the lotions is the following one: Carbolic Acid. — One tablespoonful or four teaspoonfuls to a " quart bottle " of hot water will make a lotion of the strength of about three per cent, reckoning 650 grammes to the ordinary wine-bottle, erroneously called a " quart bottle." Corrosive Sublimate. — Keep on hand a few ounces of an alcoholic solution of the salt of 1 : 10 in a glass-stoppered bottle (in boxwood case for transportation). One teaspoonful of this added to a quart bottle of hot water will make about a 1 : 1,500 solution, which can be weakened by dilution. The addition of one teaspoonful of cooking salt will prevent disintegration of the mer- curic preparation. Boro- Salicylic Lotion.— In cases where carbolic or mercurial poisoning could be produced by the use of mercuric or carbolic irrigation, Thiersch's solution is commendable as a substitute. It consists of salicylic acid 2, boric acid 12, and hot water 1,000 parts. It is non-poisonous, very bland, and the peritoneum can be washed with it with impunity. External wounds of large size should be also irrigated with this lotion. A final thorough irri- gation with corrosive sublimate should sterilize the wound before closing it. Creoline Emulsion. — Somewhat more convenient than Thiersch's solu- tion is a mixture of creoline with water in the proportion of from one half to two per cent. It is also non-poisonous, and does not irritate the skin or corrode instruments. Note. — The selection of different lotions should be governed by the following experiences : Carbolic lotions are dangerous to small cJdldren, even in great dilution, and should never be used on them. Corrosive sublimate is also poisonous, causing saUvation and occasionally fatal diph- theritic inflammation of the ileum and the thick gut, if its use is immoderate. Wherever super- ficial ulcers or inflammations of the cutis require the antiphlogistic action of the very diffusible carbolic lotion, it should be employed in the strength of two or three per cent. The continued use of higher concentrations will corrode the tissues, and is otherwise dangerous. Where a direct application of the lotion to the wounded or diseased surface is desirable, as, for instance, in all bloody operations, mercuric bichloride deserves the preference over carbolic acid. Even weak solutions (as 1 : 5,000) have a decided germicidal power, and can be used on very extensive wounds for hours without serious danger of intoxication. The final irrigation of an operation wound should always be done with a stronger ^^1 : 1,000) solution. Abscess cavities will always require the stronger solutions. The greatest advantage of corrosive sublimate over carbolic acid is, however, to be sought in its different effect upon the fresh blood-clot and the tissues exposed to its action in a fresh wound. It will be seen that irrigating an amputation wound, for instance, with carbolic lotion, will each time provoke very profuse oozing. Vessels that had stopped bleeding by the formation of a clot ASEPTIC WOUNDS— ASEPTIC TREATMENT. H within their cut orifices begin to bleed anew after carbolic irrigation. This is caused by the peculiar macerating effect of carbolic acid upon the fresh blood-clot. Its color turns from dark red to a light brick-red, its toughness and cohesion are lost, and the slightest touch of a sponge will suffice to detach it from the orifice of cut vessels, thus renewing the hsemorrhage. Another disagreeable effect of carbolic lotions upon wounds is the profuse discharge of bloody serum continuing for one or two days after the operation, rendering one or more changes of dressings necessary within a day or two, and thus depriving the wound of needed rest at the most critical period of repair. Corrosive sublimate does not dissolve clots, hence oozing stops by natural means during its use. It does not irritate the vaso-motor nerves as carbolic acid seems to do, hence the oozing subseciuent upon an operation done with its aid is very scanty. Drainage is easier, can often be altogether spared ; no early change of dressings is required, and cure under one dressing is possi- ble, and, in fact, is the rule after its proper use. 8. Dressing's. — We have mentioned that there are two ways of preserving the aseptic character of a wound, viz., by exsiccation or by sterilization of the secretions. These two methods can also be advantageously combined. (1) Types of Dressings. a. Simple Exsiccatiox. — Small, or comparatively small wounds, ad- mitting of an exact coaptation of the deeper as well as their superficial parts by suture, are exquisitely fit for this method of treatment. Plastic operations about the face may serve as a fair type. Bisinutli and Iodoform. — Certain finely powdered substances, as iodo- form or subnitrate of bismuth, have the quality of rapidly inspissating blood and serum to a dry crust. Accordingly, after the hgemorrhage has been controlled and the wound closed by suture, a quantity of the substance chosen is dusted over the sutures. No further dressings are applied. The escaping bloody serum forms a paste with the powder, which by its steriliz- ing property prevents decomposition, while the paste remains moist. Free access of air will hasten exsiccation, and the dry, hard crust once formed will securely prevent further ingress of dust into the wound. In cases where the powder is washed away by profuse oozing, the dusting has to be repeated every half-hour after the operation, until the object — the forma- tion of a dry crust — is accomplished. XoTE. — Elderly subjects are prone to iodoform poisoning if the agent is too freely used. In these cases a mixture of equal parts of iodoform and bismuth is safer. Small cuts, abrasions, and burns can also be similarly treated, care being taken to first render the injuries aseptic by ablution with corrosive subli- mate lotion. XoTE. — Acetic Acid. — An excellent way of treating small injuries is to wash them as soon as possible — after staunching the haemorrhage — with pure acetic acid ; or, if this can not be pro- cured, with ordinary vinegar. The intense smarting is soon controlled by the application of cold water. After this the part is dried with a towel. The dry but flexible eschar produced by the union of the acid with the exposed tissues gives excellent protection, under which the wound heals without reaction or suppuration. The great advantage of this form of treatment will be especially appreciated by physicians, as the eschar is insoluble, and the injured or chapped hands 4 12 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. treated in this manner can be washed repeatedly without compromising repair or risking new infection by contact with pus. More extensive burns or denudations are, within reasonable limits, also adapted to the exsiccative treatment. However, to prevent injury of the granulations at change of dressings, due to their matting into the meshes of the gauze, protecting the burned surface by a layer of rubber tissue will be found very useful and commendable. But the larger the absorbing sur- face, the more caution is needed in the use of iodoform. b. Chemical Sterilizatiox combined with Exsiccatiox. Dry Dressings. — In extensive injuries or large operation wounds the amount of oozing is generally so large that dusting alone will not suffice to control decomposition. Besides the patient's person, the bedding or splints will be uncomfortably soiled ; hence it is necessary to provide a receptacle for the absorption of the secretions. For this purpose absorbent dressings are used that have been rendered aseptic by saturation with a chemical germicide : iodoform, corrosive sublimate, or carbolic acid. A small surplus of the chemical used will suffice to prevent decomposition of the absorbed serum or blood. No impervious covering (^lackintosh) should be used on the outside of the dressing, as the free admission of dustless air is desirable. It will hasten the exsiccation of the absorbed secretions, and thus insure the protective action of the dressings, even if the chemical employed become evaporated or inert. As evaporation of the deepest parts of the dressing — those nearest the skin and farthest from the surface — is the most difficult, and is made still more difficult by their greater saturation with serum, a few layers of iodoformized gauze placed immediately over the line of union will be of very great service in hastening exsiccation. These are covered with an ample mass of dressings impregnated with corrosive sublimate, which are held down with a roller bandage. This is the method of dressing most commonly resorted to nowadays, and has been found the most simple and eifective by the majority of modern surgeons. c. Schede's Modification of the Dry Dressing, favoring the Organization of the Moist Blood-Clot. — There is a considerable num- ber of cases where extensive loss of substance consequent upon an injury or an operation precludes approximation of the walls of the wound, and renders healing by primary adhesion impossible. In these cases a blood- clot forms and fills up the defect soon after the injury or the operation. In an aseptic wound this blood-clot serves a highly useful purpose in pro- tecting the raw surfaces, preserving their vitality, provided that the integ- rity of this blood-clot be again protected from exsiccation on one and from putrefaction on the other hand. If this condition is fulfilled, granulations will gradually consume, as it were, the blood-clot ; and, by the time the clot disappears, cicatrization will be completed. When healing under the moist blood-clot is aimed at, the dressings will have to be arranged as follows : Immediately over the wound is laid a suitably trimmed piece of fine rubber tissue, previously well soaked in carbolic solution. It should just overlap ASEPTIC WOUNDS— ASEPTIC TREATMENT. 13 the edges of the wound. This is covered with a layer of iodoformed gauze, and the whole is well enveloped in an ample covering of dry corrosive sub- limate gauze. The outer dressings will absorb and render innocuous the surplus of blood and serum ; the film of rubber tissue will preserve the underlying clot in a moist condition. j^OTE. — Tissues of low vascularity, as bone, fasciae, and tendons, will certainly undergo superficial or deep-going necrosis if exposed to evaporation, even if asepsis be rigidly preserved. Case. — George Braun, German Hospital, aged sixty-six. Rodent ulcer of the nose. Feb. 19, 1886. — Extirpation of diseased parts followed at once by partial rhinoplasty. Sutured parts dusted with iodoform. Large defect on forehead (the flap including periosteum) inadvertently covered with iodoform gauze, without interposition of rubber-tissue protective. When the dressings were removed ten days later, no suppuration was found, but the surface of the frontal bone was seen to be exposed (no blood-clot), and very dry. After four weeks the first sparse granulations were observed sprouting out of the denuded bone, which eventually became cica- trized over in the fall of the same year. Had the protective not been omitted, rapid cicatriza- tion would have been secured. d. Simple Chemical Sterilizatiojst. Moist Dressiis^gs. — A moder- ately moist condition of the outer dressings is very favorable to rapid ab- sorption. This fact is parallel with the phenomenon seen if a thoroughly dry sponge is thrown on water. It will not absorb rapidly and sink, but, on the contrary, will Jioat on the surface for a considerable period of time. But moisten this sponge first thoroughly, then squeeze it out completely, and then throw it into water, and it will at once become filled and sink. Where rapid absorption is desirable, as in the presence of septic or fetid discharges, and where clogging of the drainage-holes by inspissated secre- tions is to be avoided, dry dressings will be advantageously replaced by a moist dressing. By applying a piece of impermeable material to the out- side of the well-moistened dressings, evaporation and exsiccation will be prevented. The dressings will remain in a moist condition for an indefi- nite period of time, and will act like a poultice. Ruhler tissue (not rubber sheeting) is an excellent and cheap substitute for Lister's ''Mackintosh" and his ''protective." It can be had in all rubber stores. A rather stout quality is the best article, as it is not apt to tear, and can be repeatedly used as the outer covering of moist dressings. It ahoays forms the outermost layer of what is called throughout this hook a "moist dressing."" Oiled silk, well soaked in carbolized lotion, is a toler- able substitute for rubber tissue. Another substitute is waxed paper, or " tracing paper." A piece of stout, brown paper, such as is used by shop- keepers for packing, well soaked in grease, preferably tallow, will answer on a pinch. If none of these articles can be had, frequent moistenings of the dressings will have to be employed in order to prevent evaporation. One or more teaspoonfuls of carbolic or mercurial lotion instilled into the dressings every half-hour or so will have the desired effect. This form of moist wound-treatment was very extensively employed by the author in his seven-years' service at the German Dispensary, and has been found so satis- factory both to patients and surgeons that it is still the standard form of moist dressing used at that institution. 14 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. (2) Preparation of DresxirKjs. a. Gauze. — (iauze, called in the trade cheese-cloth, or tobacco-cloth, forms undoubtedly the most convenient material for wound-dressings. It is cheap, can be bought everywhere, absorbs well, is soft and pliable, and can be easily prepared for use by every practitioner. For hospital pur- 14 in. ! UPPER AND U in. \ LOWER EXTREMITY. HIPJOINT. TRUNK. HERNIOTOMY. SCROTUM. SHOULDER ^1 JOINT. AXILLA. ANKLE l\ JOINT. 14 m. 24 in. NECK AND ARM n 14 in. AXILLA AND BREAST. 28 in. EXSECTION OF SHOULDER JOINT. Win. AMPUTATION DP THIGH. 28 in. 28 in. Fig. 1. — Patterns for various dressing.s, modified from Neuber. poses, moss or peat dressings in the shape of cushions or bags are more convenient. In the practice of the country physician, however, they are out of the question. ASEPTIC WOUNDS— ASEPTIC TREATMENT. 15 {a) Corrosive Sublimate Gauze. — The raw gauze is treated as follows : To free it of its oily contents, and thus to make it more absorbent, twenty-four yards of the fabric are boiled for an hour in a wash-kettle filled with sufficient water to cover the material, to which should be added two pounds of washing-soda or a pint of strong lye. After this the stuff is washed out in cold water, passed through a clothes- wringer, and immersed in a sufficient quantity of a 1 : 1,000 solution of corrosive sublimate for twenty-four hours, then passed again through a clothes-wringer, dried, and put away in a well-covered glass jar until required for use. The fabric is so folded by the manufacturer that each fold is just one yard long. It is best to divide the twenty-four yards into segments of six yards each, which can be again folded by the surgeon into large or small, square, oblong, or narrow compresses to suit each individual case. If a long time has elapsed since the preparation, reimpregnation with a 1 : 1,000 solution of corrosive sublimate is advisable before use. Note. — la a stnall proportion of cases, contact with corrosive-sublimate dressings will cause an angry-looking dermatitis, which at the first blush very closely resembles erysipelas. The absence of fever and sickness, the exact limitation of the rash by the extent of the dressings, will soon disperse possible doubts. Profuse application of vaseline or some other bland ointment will readily dispose of the irritation. The strength of the impregnation should be then also reduced by washing the gauze in water. If it should be found that mercury is not borne at all, it should be substituted by carbolic-acid solution or Thiersch's boro-salicylic lotion, or creoline emulsion. (5) Iodoform Gauze. — The moist, absorbent gauze is evenly sprinkled with iodoform powder from a pepper-box, or the author's iodoform, duster, well rubbed into the meshes by hand, and then put away in a wide-mouthed bottle. Boiler hajidages are made out of corrosive-sublimate gauze. Fig. 2 iodoform screw cap — The author's duster, with and removable bottom tor replenishing. Note. — Roller bandages made of a starched fabric known as " crinoline," or " crown-lining," are very useful in completing every dressing. They are moistened in water, and applied over the dry roller-bandage. They soon become stiff again, and make a very compact and neat dressing, that will not shift easily. The stuff is the same that is used extensively for plaster-of-Paris bandages. In emergencies various substances of absorbent qualities can be utilized as dressings ; such are, for instance, cotton, moss, and sawdust. i. Absorbent cotton", or common cotton batting, well soaked in corrosive-sublimate solution, then wrung out, will make a tolerable dress- ing. Its drawbacks are that it packs and gets hard and lumpy, but, prop- erly used, it will answer every practical purpose. Care should be taken not to tear the cotton into irregular masses. After unrolling it, suitably large, square pieces should be cut off with the scissors ; these pieces should be folded, then soaked in the lotion, squeezed out hard, and unfolded again. 16 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. thus preserving their shape and uniform thickness. Two or more of these pieces laid one over another will make a very passable dressing. Case. — Michael B., aged sixty-three, sustained, early in the morning of November 13, 1883, a compound fracture of the left elbow-joint. He was put to bed, and, under the advice of the family attendant, applications of cold water were made to the injured part. Twelve hours after the injury, the author found a Y-shaped fracture of the lower end of the humerus, the conical sharp point of the upper fragment protruding through a small wound above the olecranon. The joint was filled with a large clot, and some oozing from the perforation was noticed. The edges of the perforation wound were snugly fitting around the i)rotruding bone, and during the subsequent manipulations good care was taken not to allow the bone to slip back. Not having been informed of the nature of the injury, the author arrived unprepared at the patient's bedside. The case, however, did not brook delay, hence everything had to be extemporized. Sev- eral ounces of a ten-per-cent alcoholic solution of corrosive sublimate and a little iodo- form were ordered from the nearest druggist, and at the same time several bundles ot common cotton l)atting were procured. Soon plenty of a 1 : 1,000 corrosive-sublimate solution was ready, in which square pieces of cotton were soaked as described. The patient's poverty compelled an economical management of affairs. An old but clean bed-sheet was ripped up into roller-bandages, which were likewise impregnated. This done, soap and hot water were applied to the elbow, and the skin was shaved clean all around, but especially near the perforation. This was followed by a vigorous rubbing off of the skin and protruding bone witli the mercuric lotion, which at the same time was copiously poured over the region of the elbow from a pitcher. After this, reduction of the protruding bone and adjustment of the fragments by extension of the arm was effected. The size of the perforation-hole at once became much smaller. In order to provide some drainage, a small fillet of cotton, well dusted with iodoform, was inserted into the cutaneous part of the outer wound, which was also liberally dusted. Over this were placed four layers of cotton pad?, which were snugly bandaged to the limb. Two lateral splints, made of a pasteboard box, secured the extended position, in which the arm was suspended from a nail in the ceiling. The temperature never rose al ove 100° Fahr. Nov. 19. — The dressings were removed. The swelling, due to the etfusion of blood, had disappeared to a great extent. Oozing had ceased; no suppuration. The fillet of cotton was withdrawn, and the arm was put up in a plaster-of-Paris splint flexed at a right angle. Passive motion was commenced on removal of the splint, four weeks after the injury. Ultimate result was ascertained in October, 1884: Flexion was normal; extension could not be carried beyond 140°. c. Sawdust. — With a view to the occasional impossibility of procuring any of the common dressing materials in times of war or some other public calamity, the author has tested the efficacy of sawdust as a dressing during his service at Mount Sinai Hospital, extending from August 1, 1883, till February 1, 1884. Clean pine, spruce, or hemlock sawdust was impreg- nated with a 1 : 1,000 solution of corrosive sublimate for twenty-four hours ; then it was spread on sheets of muslin to dry, and finally was inclosed in different-sized bags made of cheese-cloth gauze. To prevent the shifting of the sawdust, a thin layer of wood-shavings, called by the trade " excelsior," was first inserted into the open bag ; then a proportionate quantity of saw- dust was evenly strewed into the meshes of the "excelsior," and then the bag was closed by stitches made with threads soaked in mercuric lotion. ASEPTIC WOUNDS— ASEPTIC TEEATMENT. 17 The thickness of the bags varied, according to their size, from one to two inches. After the wound was drained and sewed, some iodoform gauze was placed next to it ; then came one, two, or more smaller bags, and on top a large bag, the whole being snugly fastened with roller bandages. Aside from the trouble of preparing the bags, they were found very con- venient in applying and quite efScient in absorbing blood and serum, and preventing decomposition. d. Moss. — The different species of sphagnum, coating the surface of peat- bogs and the trunks of dead trees in our northern forests, are excellent material for making dressing-bags. On account of its cheapness, small weight, elasticity, and great absorbing power, moss has displaced other dressings at almost all of the surgical clinics of Germany. Its preparation is very simple. It has to be gathered with some care — that is, with no ad- mixture of the soil. After being dried, it is impregnated with corrosive sublimate, inclosed in gauze bags, and is ready for use. Moss-bags are in daily use at the German Hospital since 1884, and can not be praised enough both for their handiness and effectiveness. But, like other similar dress- ings, they are not adapted to the needs of the general practitioner, and will find their princijDal employment in hosjDital practice. in. PRACTICAL APPLICATION OF RULES. 1. In operating". — In order to gain a coherent idea of the practical work- ings of the aseptic apparatus, we shall now rehearse all the steps of a well- conducted operation. Assuming that a cancerous breast is to be removed in the rooms of the patient, it is first necessary to select a suitable person to act as nurse. Her duty is to administer a laxative the day before the operation, and to care- fully scrub with soap and brush the patient's breast, corresponding shoulder, and axillary space on the day preceding and on the day of the operation. A clean, well-lighted room is selected, out of which all unnecessary furniture, hangings, etc., should be removed. A bare, well-scrubbed floor is prefera- ble to a carpet. One or two narrow kitchen-tables, covered with a quilt and provided with a straw pillow, will make a capital operating-table. A piece of rubber cloth (3x4 feet) is placed over the quilt, and a clean sheet is laid on top. The nurse provides soap, nail-brush, plenty of hot and cold water, and towels. The operator and his assistants arrive at least a half- hour before the appointed time of the operation. Everybody's hands are washed in hot water with soap and brush. The necessaries are now un- packed and arranged, and the solutions of carbolic acid and corrosive sub- limate are mixed, for which purpose six or eight well-cleansed quart bottles should be held in readiness by the nurse. A fountain syringe is filled with sublimate solution, and suitably suspended from a nail or chandelier near the operating- table. A new pail or bucket is filled with hot water for rins- ing the blood out of the sponges ; alongside of it is placed a basin filled with 18 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. a three-per-cent solution of carbolic acid for the reception of the cleaned sponges, from which they ought to be handed to the assistants by the nurse. Two more japanned tin or earthenware basins are filled with a corrosive- sublimate solution, and placed on chairs to the right and left of the operating- table for the occasional rinsing of the hands of the operator and assistants. The instruments are arranged on an adjacent table in a certain order, which, to prevent confusion, should be rigidly adhered to during the entire operation. Note. — The author has found that it is very convenient to be independent of the patient's resources, as far as the necessary vessels for sponges and instruments are concerned. A nest of four good-sized, flat-bottomed block-tin wash-basins, six tin soup-basins (six inches diameter), and four tin bake-pans, will serve every purpose, and the small expense will be abundantly re- paid by the cleanliness and sense of comfort that will result. Two coats of some reliable oil-paint or japan will prevent corrosion of the metal vessels. The asphalt is dissolved in gasoline or ether, then applied evenly. As soon as the solvent evaporates, the pans will be ready for use. All vessels are wiped clean. The knives, sharp and blunt retractors, scissors, anatomical, mouse-tooth, and dressing forceps, probes, and grooved director should be put into one pan with carbolic lotion ; all the artery for- ceps by themselves into another one. Between the two pans is placed a third one, filled with hot water, in which all the instruments not in actual use should be rinsed free from blood before being returned to the carbolic lotion. This will keep them and the carbolic lotion clean and bright all the while, and no time will be lost in hunting for them in the bottom of a turbid pool of soiled carbolic solution. In a smaller tin basin, ligatures, in another one needles, are arranged, threaded with fine (No. 0) and coarser (No. 1 or 2) catgut. A third small basin will hold the drainage-tubes and a number of safety-pins. The dressings are now attended to. Eight or ten small (6x8 inches), and just as many large (19x28 inches), compresses of gauze are cut, care being taken not to make the dressings too scanty, as an ample first dressing may save the trouble of many subsequent dressings. The best rule is to let the outermost compresses overlap the wound on all sides by at least eight inches. To this should be added a sufficient number of strips of iodoformed gauze, three or four rather wide gauze roller-bandages, and the same number of starched or crinoline roller-bandages. All this should be wrapped in a clean towel and laid aside in a secure place until needed. These having been attended to, ansesthesia may commence in an adja- cent room. The anaesthetizer should be provided with ether and a cone, a tin basin for the reception of ejecta in case of vomiting, a towel, a hypo- dermic syringe, a wide-mouthed bottle with morphine solution for injections in case anaesthesia be imperfect, a similar bottle with whisky to be used in case of heart-failure ; finally, with a dressing-forceps and gag for withdraw- ing the tongue if it should sink back on the epiglottis. The anaesthetized patient is placed on the operating-table, and the parts, being exposed, are freely soaped and shaved. After this a piece of rubber cloth (3x4 feet) is so placed over the patient's body as to leave exposed only the field of operation. Now the parts are well rubbed off with a towel ASEPTIC WOUNDS— ASEPTIC TREATMENT. 19 dipped in corrosive-sublimate solution and freely irrigated, and a number of clean towels wrung out of the same solution are suitably spread around the field of operation, protecting the operator and assistants against contact with the clothing or body of the patient, and providing for a clean place where instruments or sponges may be laid down for a moment if necessary. The end of a wet towel is tucked under the breast and armpit of the side to be operated on, and is hung over the edge of the table in such a manner as to conduct the blood and irrigating fluid into a bucket placed on the floor underneath. It serves as a drip-cloth. Every assistant should strictly attend to the duty allotted to him, and not meddle. All unnecessary talk should cease, and the work proceed in an orderly manner. The first assistant should keep his eyes open, and know and aid the operator's intentions. He should be alert, but not over-zealous. Fig. 3. — Patient made ready for amputation of mamma. The anaesthetizer must take good care that, in case of vomiting, no ejecta are thrown on the wound or its vicinity. Towels soiled by vomit should be at once replaced by clean ones. Now the parts are distributed. The trustiest man serves as first assist- ant over against the operator ; a younger physician at the left of the operator is second assistant, and irrigates or helps as need may require ; another physician takes charge of the instruments and ligatures, and the nurse attends to the sponges, and keeps in readiness " sublimated " and dry towels and a pitcherful of corrosive-sublimate solution. Aprons are donned, everybody's hands are finally scrubbed with soap and brush, rinsed in mercuric solution, and the operation begins, ft 20 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Note. — The employment of copious irrigation during operations requires measures for pro- tecting the person and clothinj: of the surgeon against the influence of the chemicals commonly used. An ample apron, made of light rubber sheeting, and reaching from the chin to the toes, is most convenient, and can be easily cleaned. The surgeon's shoes may be protected by a pair of light rubbers. However, they are apt to sweat the feet. The author overcame this draw- back by the use, at the hospital, of wooden pattens (French sabots) worn over the shoes. They are donned and doffed without the aid of the hands, and keep the feet warm and dry, and can be bought at 75 Essex Street, New York. In removing the breast and contents of the axilla, lia?morrhage should be carefully attended to by ligaturing every bleeding vessel with catgut. Having removed the diseased parts, the wound is carefully irrigated, each recess being attended to in succession ; drainage and sutures are applied. The projecting end of the drainage-tube cut off "flush " is transfixed with a safety-pin, the wound is once more irrigated through the tube so as to clear it of clots, and the clots and irrigating fluid are removed from the wound by gentle pressure exerted with a sponge or two. lodoformed gauze strips are next placed along the suture and around the drainage-tube, pass- ing under the safety-pin, and a few pads of gauze are held pressed against the wound while the patient is slightly raised to cleanse her back and face and the table from blood. The soiled towels are replaced by dry ones, and the dressing completed by applying as many gauze compresses as required. These are fastened rather tightly with gauze bandages, the other breast and arm-pits being first padded with absorbent cotton. A large, square piece of absorbent cotton, somewhat overlapping the dressings, is next applied, and snugly held down by crinoline roller-bandages ; the corresponding arm is included by the bandage or is placed in a sling ; the patient is brought to bed, and an opiate is administered. 2. Change of Dressings. — In most cases where the rules above given are conscientiously and intelligently observed, no fever will follow the operation. After the effects of the anesthesia are over, the patients will be found cheerful and contented, feeling no pain or sickness, their only com- plaint being the tightness of the bandage, which they will soon learn to bear. The temperature will range during the first three days at about 100° Fahr. ; after that it will sink to the normal standard. Sometimes, especially if the drainage is not properly placed, and some serum or a blood-clot is retained in the wound, the thermometer will indicate from 100° to 103° Fahr. As long, however, as the patient is cheerful, and does not feel sick with headache and general dejection, as there is no sharp, throbbing pain about the wound, or some other grave disturbance of the local or general comfort, no alarm need be felt. In these cases we have to deal with an ele- vation of temperature benign in character, and identical with the harmless fever observed after almost every simple fracture. It is due to the absorption of the extravasated blood or lymph, bland and harmless on account of the absence of putrefactive changes. This is Volkmann's "aseptic fever." The temperature soon becomes lowered, appetite reappears, and the dress- ings need not be disturbed. ASEPTIC WOUNDS— ASEPTIC TREATMENT. 21 Should, on the other hand, the patient complain of chilliness, headache, sickness, general dejection, and drawing pains in the limbs, or persistent and increasing pain about the wound, the thermometer indicating at the same time a high or only a moderate elevation, the dressings should at once be removed, and a search instituted for the cause of the disturbance. Previous to this a new dressing should be prepared similar to the one to be removed. This and a tin pan containing carbolic lotion, with a dress- ing-forceps, anatomical forceps, scissors, scalpel, grooved director, and a piece of drainage-tube, together with another vessel holding a few small pads of cotton wrung out of the same solution, should be placed on a small table near the bed. An irrigator filled with warm carbolic or mercuric lotion should be suspended from the bedpost or a nail, and a pail for the iua's after amputatiou reception of the soiled dressings should be at hand. A piece of rubber cloth covered with a draw-sheet and spread under the patient's back will protect the bed, and a pus-basin or square tin pan held alongside of the patient's thorax will receive the irrigating fluid. After this the turns of the roller-bandage are cut through without jar, and the outer layers of the dressing are gradually removed. As the deeper parts are being raised, irrigation should commence, in order to moisten the gauze and aid in its gentle removal. Care should be taken not to disturb the drainage-tubes. After the removal of the soiled dressings, the physi- cian's hands should he carefully cleansed lefore touching any part of the wound. While the irrigating stream is playing, the vicinity of the wound is gently wiped with a small pad of moistened cotton, in order to remove clots of blood or fibrin that can not be dislodged by irrigation. 22 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. If the edges and vicinity of the wound look normal, the skin pale, not swollen, and not painful to touch, it shoiild be forthwith redressed. A care- ful physical examination of the internal organs will then certainly reveal, as the cause of the fever, some internal complication, as, for instance, pneu- monia, or, at any rate, some newly developed or overlooked disorder inde- pendent of the wound. If the aseptic measures employed were insufficient, the edges of the wound will be found swollen, reddened, and painful ; the wound will have lost its aseptic character, and is the seat of a septic process ending in sup- puration. Prompt action is required to limit the inevitable destruction of tissue, and to check the further poisoning of the system. From this moment on, aseptics must give way to antiseptics ; prevention having failed, curative measures must step in to eliminate the mischief that might have been prevented by the exhibition of more care, attention, or skill. The therapy of septically infected or suppurating wounds will be treated in the following chapter. In case that the course of the healing of the wound is correct, as indicated by the absence of local or general disturbance, the first dressing may remain unchanged for from seven to forty days. Flesh-wounds should be dressed on the fourth to the seventh day, as it is desirable to remove the drainage- tubes and sometimes the stitches. The finer catgut sutures will generally be absorbed by this time, and their exposed part can be simply wiped away. Where stout retention sutures w^ere employed for the approach of the edges of a wide, gaping wound, they will be found cutting through the tissues by this time, and quite useless. They should be removed, and the stitch- holes dusted with iodoform. According to the completeness of the result, the dressings will have to be changed every third, fifth, or seventh day, their bulk decreasing with the diminution of the secretions. Finally, the few granulating spots need only a dressing consisting of a patch of some unirritant plaster, such as empl. cerussae or empl. hydrarg., and an occasional touching with nitrate of silver, to aid final cicatrization. Where the opera- tion has involved parts of the skeleton, as in amputations of extremities, exsections of joints, necrotomies, etc., the dressings have to be left undis- turbed much longer. After exsections of the knee-joint, for instance, where bony ankylosis is aimed at, the first dressing is not removed without a clear indication before the thirtieth or fortieth day. No patient should be dis- charged ''cured" before cicatrization is complete, as it has happened that such "cured" cases, left to their own care, contracted erysipelas the day after their discharge, and died of it. Note. — All the manipulations about a freshly agglutinated wound should be very deliber- ate and gentle. In removing stitches, a forceps should gently raise the thread ; then it should be cut as close to the stitch-hole as possible, and lightly withdrawn. Drainage-tubes are grasped at the projecting end, gently rotated to and fro till they are freely movable, then with- drawn. Sometimes it will be found that a painless fluctuating swelling occupies some deeper part of the wound. In these cases retention of serum is generally caused by clogging of the ASEPTIC WOUNDS— ASEPTIC TREATMENT. 23 drainage-tube by a clot. On withdrawing the tube, a quantity of clear or turbid yellowish serum will escape. In these cases it is good to replace the cleared tubing to prevent further retention, and thus to bring about contact of the separated walls of the wound, which will at once become adherent. At the subsequent change of dressings, the tube can be definitively removed. Case. — Mrs. Clara G., aged forty-six. Alveolar glandular cancer of an aberrant (detached) lohe of the right Ireast. Tumor of the size of a small fist, situated in the axillary space close to the edge of the pectoralis major muscle. It was connected by a stout pedicle with the adjacent part of the breast-gland proper. Jan. 16, 1885. — Amputation of mamma; total evacuation of axillary fat and glands. Drainage by counter opening made through the latissimus dorsi muscle. Suture of the entire wound except a part of axilla, where the skin had been extensively removed. Course of heal- ing feverless. Change of dressings on the tenth day. Primary union of all the sutured parts. Axillary wound granulating. Under the lower flap of the breast-wound a pain- less, soft, fluctuating swelling discernible. By gently inserting a probe between the corresponding edges of the united wound, entrance into this sac was effected, where- upon about two ounces of a yellow, slightly turbid, and very viscid scum escaped. A small drainage-tube was inserted, and the wound was redressed. Jan. 30th. — Walls of the cavity were found firmly adherent. Tube removed. No suppuration. The iDterior of freshly healed wounds of normal appearance should never be syringed ; the injection of a strong jet of fluid is unnecessary and often injurious;, as it tends to separate tender adhesions. rv. ASEPTIC MEASURES IN EMERGENCIES. Unremitting attention to, and a severe self-discipline in always carrying out the measures of strict cleanliness known to be necessary to uniform success in the management of wounds will gradually become, however irksome in the beginning, a mere matter of accustomed routine. As the mind and senses learn to exercise vigilance without special effort, the sur- geon's results will become more and more gratifying. His attention, freed from the severe strain unavoidable in acquiring command of the detail of a difficult business, will concentrate itself upon higher objects, and the smooth routine resulting from long and severe training will not divert attention from the finer detail of his special work. It is a great mistake, paid for by the loss of limbs and lives, to believe that the mastery of practical cleanliness or asepticism can be acquired with- out a clear comprehension of the principle, and without earnest and severe training in the handicraft of asepticism. The wholesome truth, that failure of achieving primary union in fresh wounds is mainly and almost always due to one's own lack of knowledge and skill, and that these attributes can be secured only by the exercise of great diligence and many, often unsuc- cessful trials, should be constantly present in our mind. Failures are bitter lessons, but their honest study will inevitably bring to light the causative deficiencies, and will teach us to avoid them. The school for learning to employ the principles of asepticism is open to every general practitioner in the treatment of the many affections and injuries pertaining to minor surgery. Mistakes made in the removal of a 24: RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Aven or the treatment of an incised wounrl of the hand are easily found out and easily corrected. They carry much and sometimes more instruction than a large operation. It is wicked to attempt to learn the first lessons of aseptic surgery in capital operations, when, possibly, the surgeon's experi- ence is bought with the life of his trusting patient. The attempt of remoT- ing an ovarian tumor, for instance, should be permitted only to those who have learned to invariably heal a fresh wound by primary adhesion, as this is the first and sole test of the possession of the ability justifying such a grave undertaking. Emergencies will necessarily involve varying modifications of the means, never a deviation from the principle of asepticism. A hasty tracheotomy for the removal of a foreign body, a herniotomy to be done in the dead of night amid the squalid surroundings of a tene- ment, or the first care of a compound fracture or a gunshot- wound, will present special and varying diflSculties, to be overcome only by good train- ing, circumspection, and versatility. They can be overcome, as many examples in the experience of every successful surgeon testify. In addition to the case of compound fracture of the elbow-joint quoted on page 16, another instructive case may be told from the author's experience. Case. — Herman John, laborer, aged sixty-one. Right, irreducible, strangulated femoral hernia. Rupture of long standing, strangulated since the evening of April 1, 1882. Symptoms of great acuity necessitated prompt action. Dr. H. "Wettengel, the family attendant, administered the anaesthetic in the middle of the afternoon of the following day, while author was making the necessary preparations for the presuma- bly inevitable operation. The place was a narrow, dark, rear room of a rear house of a squalid tenement, and a lamp had to be procured. The divested patient's pubic and inguinal region was shaved, while anaesthesia progressed. A flat bake-pan was covered with one of the few clean towels to be had ; on this were spread the instruments, and over them was poured a quantity of a five-per-cent carbolic lotion. No sponges were on hand, as the summons had been very hasty, and no time was aiforded for prepara- tions. Therefore, a part of a clean bed-sheet was torn into a number of small pads, which were well soaked in the same lotion to serve as sponges. A remnant of the lotion was saved in a pitcher for purposes of irrigation. After an unsuccessful attempt at reposition, the inguinal region and the surgeon's hands were once more well soaped and washed off with the carbolic lotion. The epigastric artery had to be tied, and ex- ternal herniotomy was performed. A small knuckle of gut slipped back easily into the abdominal cavity, but evidently did not represent all the contents of the sac, within which an additional soft body could be felt that resisted every gentle effort at reposi- tion. The sac being opened, a slender portion of omentum was found to be adherent to it. This, being dissected away, was replaced into the abdominal cavity. The outer wound was well irrigated, and united by a number of catgut sutures. A few strands of catgut were inserted into the lower angle of the wound for drainage. In the ab- sence of other dressings, a clean sheet was used for the manufacture of a number of compresses and roller-bandages. These, being well soaked in carbolic lotion, were applied to the wound in the shape of a spica bandage. Vomiting ceased. Oozing being very scanty, the dressings soon became dry, and, the patient's condition being excellent in every respect, they were not disturbed until a fortnight after the opera- tion, when the wound was found healed throughout by the first intention. ASEPTIC WOUNDS— ASEPTIC TREATMENT. 25 Yet it must be said that such conditions render operating very risky, and in every way uncomfortable. If unavoidable, the additional risk must be shouldered by the patient as well as the surgeon. Operating- Bag and Kit.— Timely preparation made in the shape of procuring a well- arranged hand-bag, contain- ing the most necessary arti- cles for operating in an emer- gency, will well repay the small expense and trouble. A leather hand-bag, about sixteen inches long, will be sufficiently large. Have a sufficiently long, rather stout strap sewed to one side of the interior of the bag, so as to provide loops for five or six bottles, which will be held safely in the upright position. The first loop will be occupied by a half-pound tin can of ether ; the second is allotted to a two-ounce bottle of corrosive- sublimate solution (ten per cent alcoholic) ; the third to a four-ounce bottle of pure carbolic acid ; the fourth to a wide-mouthed bottle containing cat- gut and silk of different sizes on spools : the fifth to a wide-mouthed bot- FiG. 5. — Author's operating bag, with tin pans and rubber cloths strapped to it. Fig. 6. — Interior of operating tie filled with drainage-tubes of different sizes in carbolic lotion ; the sixth to a wide-mouthed fruit-jar with tight cap, containing two or three dozen sponges in carbolic lotion. A stout pair of scissors for cutting the dress- 20 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. ings, a dressing-forceps for the anoestlietizer, and a razor can be conveniently stuck in behind the bottles. On the other side of the bag two more spaces are reserved for a dusting-box filled with iodoform-powder and a wide- mouthed vial for an assortment of surgeon's needles. The bottles contain- ing pure carbolic-acid and corrosive-sublimate solution should be inclosed Fia. 7. — Gi^nuau instrument-pouch. Fig. 8. — Interior of German instrument-pouch. in boxwood or tin cases for safety. A side-flap will hold nail-brush, safety- pins, and one complete dressing rolled up m a clean towel. The body of the bag is reserved for the instruments, which are rolled up in another clean towel, and for three or four small tin basins, together with a fountain syringe and ether cone, each kept in a separate rubber sponge-bag. To the bottom of the hand-bag is strapped on the outside a nest of four oblong tin pans of fitting size. Such a bag contains all the necessaries for an emergency, and has been used by the author many years with much satisfaction. Note. — Surr/ical pocket-cases, as generally sold by surgical cutlers, are mostly incomplete and unsatisfactory. Their main objection is the small size and frailty of the instruments con- tained in them. The instrument-pouch depicted in Figs. 7 and 8 is very complete, and is worn strapped to the waist underneath the coat. It contains, besides the instruments held by a com- plete pocket-case, a sharp spoon, a key-hole saw, a flat oblong iodoform dusting-box of hard rubber, and a set of diverse detachable knife-blades, that can be fitted to smooth hard-rubber handles, all very easy to clean. In an emergency, the hip-pouch will be found large enough for the reception of one complete dressing to a moderate-sized wound. SOILED WOUNDS— ANTISEPTIC TREATMENT. 27 CHAPTEK III. SOILED WOUNDS.— ANTISEPTIC TREATMENT— DIFFERENCE BETWEEN ASEPTIC AND ANTISEPTIC METHODS.— ILLUSTRATION OF ANTI- SEPTIC METHOD. Ix the preceding chapter the treatment of freshly made, clean, or un- contaminated wounds was discussed ; its subject was the aseptic form of treatment — that is, the manner in which a fresh or clean wound has to be managed in order to prevent its septic infection. The aseptic discipline is a purely preventive one. Antiseptic treatment, on the other hand, refers to such wonnds as have become the seat of infection, causing inflammation, suppuration, or the higher forms of sepsis — phlegmon and gangrene. The object of the anti- septic treatment is the limiting and elimination of estahlislied septic pro- cesses by drainage and disinfection. It is also preventive, but in a narrower sense than the aseptic method. There all mischief is prevented from the outset ; here further extension of present mischief is sought to be checked. The aseptic method will generally preserve all the parts involved ; the anti- septic method can not restore the integrity of parts destroyed by ulceration, suppuration, or gangrene. Illustration of Antiseptic Metliod.—^ov the sake of illustration, let us go back now to our former example of breast-amputation. Some gross fault having been committed, such as, for instance, the use of unclean instruments, or a sponge that, having fallen to the floor, was picked up by the nurse and was handed for use in the wound. The mild course of the case is compromised, and trouble will follow. In such cases the patient's general condition is deeply disturbed, more or less high fever is present, with headache, sickness, general dejection, and drawing pains in the limbs. The tongue is foul, much thirst and loss of appetite are complained of. The wound is painful and throbbing, and the patient dreads any movement lest the sore parts be hurt. Under these circumstances an immediate examination of the wound is imperative. The preparation mentioned in the preceding chapter being made, the wound is exposed. Its edges and the vicinity will be found angry- looking, swollen, hot, and tender. The stitches should be all removed. The point of the grooved director should be inserted between the edges of the wound, which are gradually separated till the index-finger can be insinuated. Exerting gentle pressure, the wound is thus opened throughout its entire extent. One or more small foci containing pus will be laid open and discharged. The wound should be carefully irrigated with warm mercuric lotion till the slight haemorrhage ceases, and lightly filled with sublimated gauze. After this the outer dress- ings, with the addition of an externally placed piece of rubber tissue to pre- 28 RULES OF ASEPTIC AND ANTISEPTIC SURGEEY. vent evaporation, should be renewed, and the timely interference will be soon rewarded by a decided improvement in the patient's condition. In these cases the dressings must be changed as often as they become soiled through. If the fever should continue, renewed search must be instituted for overlooked points of retention. In some cases examination of the wound will reveal only partial or quite circumscribed inflammation. In locating the exact point of retention, the sensations of an intelligent patient will greatly aid the surgeon. If the retention be near the edges of tiie wound, the grooved director will easily separate them and find its way into the focus. A dressing-forceps should be then insinuated along the director, and withdrawn with its branches partly opened. Pus escaping, a slender drainage-tube should be inserted into the track. If the point of retention be remote from the edges of the wound, and its locality well marked by redness and pain, an incision will best answer the purpose, and often may prevent suppuration of the rest of the wound. Let us assume that for one reason or another nothing efficient was done to relieve the patient on the second or third day after the operation. Finally, the increasing severity of the symptoms will compel some action, and, the wound being laid bare, the following state will be generally met with : The wound will be more or less gaping, ichor or pus escaping everywhere ; the skin will appear flushed, swollen, and painful ; the edges of the wound will be marked by a grayish-yellow, closely adherent coating, that extends through its whole interior. This coating represents molecular, often deep-going necrosis of the wound surface. Independent abscesses will often be found established along the connective-tissue planes contiguous with the wound, and should be forthwith incised and drained. The wound should be well irrigated and loosely filled with sublimated gauze. Over this should be applied a moist dressing of ample proportions, covered with an overlapping piece of rubber tissue to prevent evaporation and inspissation. The secre- tions will thus be readily and continuously drained away and disinfected, and the warm moisture of the dressings will at the same time exert a very soothing influence upon the inflamed parts. Frequent, at least daily, change of dressings is proper, accompanied by copious irrigation. Detached shreds of necrosed tissue should be removed with thumb-forceps and scissors. If new abscesses form, they must be found and opened jiromptly. The fever will soon abate, and the wound will gradually assume a clean granulating appearance. As the amount of secretion diminishes, the dressings should be changed less frequently. Essentially, the so-called '• idiopathic " plilecjmon, or spontaneous sup- puratio7i (abscess) is a form of local septic infection which can be traced back to an infection extending from a lesion of the skin or the mucous membranes. Even the suppurative or infectious form of osteomyelitis must be classed under this heading. THE TREATMENT OF ACCIDENTAL WOUNDS. 29 But, on account of the great practical importance of the subject, requir- ing special consideration of several anatomical regions involving important modifications of the antiseptic procedure, it is deemed expedient to treat of this theme in a special chapter (page 183). CHAPTEK IV. SPECIAL RULES REGARDING THE TREATMENT OF ACCIDENTAL WOUNDS. I. TEMPORARY MEASURES. Taking charge of a fresh case of accidental wounding, the surgeon should bear in mind that, on the one hand, by the avoidance of suppura- tion, a complete or almost complete restitution of normal conditions can be accomplished in a great majority of cases ; on the other hand, suppuration will enormously increase the gravity of a given injury. A compound fract- ure of the leg, or an incised wound of the wrist, with opening of joints and severing of arteries, veins, and tendons, may serve as examples. In approaching a fresh case of bloody injury, we should always consider the possibility that the wound may be surgically clean, or may still be asep- tic, and that our first ministrations should not carry septic contamination into the wound, and thus harm the patient instead of aiding him. As a matter of fact, a large proportion of incised and lacerated wounds, of com- pound fractures by blunt force or gunshot, are aseptic. They need no dis- infection. The surgeon's first object should be in these cases not to spoil matters by liastij action and ill-considered zeal. With the comparatively rare exception of injuries to large vessels accompanied by dangerous haem- orrhage, where immediate action is unavoidable, conditions should be created by the surgeon, under which safe — that is, aseptic— approach to the wound is made possible. Temporary protection of the wound in the shape of a simple dressing is meant thereby. lodoform-powder dusted profusely over the wound and its vicinity, a compress made of a clean towel dipped in hot water or carbolic lotion, also well dusted with iodoform and tied on to the wound, will be sufficient. The addition of a temporary splint in cases of compound or gunshot fracture will make transportation to the patient's home or to a hospital possible, and will thus afford time for the absolutely necessary preparations. Extensive or even superficial examination of an accidental wound by probing or digital exploration in the street, on a train, or in a railroad-station or drug-shop, is strongly to be condemned, as it almost necessarily exposes the wound to unavoidable infection. Meddle- some and untimely surgery of this kind smacks of ostentation, is unneces- sary, and in many cases positively more dangerous than the injury itself. 30 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Bergmann's experience during tlic Russo-Turkish war has shown that most gunshot wounds are aseptic, and. tliat, witli the exception of those cases where shreds of soiled clotliing or gun-wads were carried along by the pro- jectile into the bottom of the wound, healing without suppuration can be confidently exj^ected if the wound is not infected by meddlesome and un- cleanly surgery. These experiences refer principally to gunshot fractures of the knee-joint. As a matter of fact, it may be safely assumed that an examination by l^robing or digital exploration, i>erformed on the filthy floor of a public l)lace or on the street pavement, even by the most experienced surgeon, can not be, and is not cleanly or aseptic. It is extremely dangerous, unnecessary, hence culpable. Even in most cases of profuse arterial hsemorrliage, mesial constriction with an extemporized tourniquet, as, for instance, the " Span- ish windlass," or digital compression of the afferent arterial trunk, can be successfully employed, while the patient is transferred into a suitable locality, where permanent relief can be safely af- forded by deligation. The collected and businesslike manner of the surgeon will at once allay confu- sion, prevent hasty and injurious interfer- ence, will infuse the patient and those present with hope and confidence, and will facilitate well- FiG. 9. — Extemporized tourniquet — " Spauisli winclluss." considered and ra- tional action. As a rule, the fate of a fresh wound is deter- mined by the views and training of the physician who first attends to it. If the patient be so fortunate as to fall in with a man fully imbued with the spirit, and familiar with the practice of aseptic surgery, he is truly to be congratulated, because his chances of avoiding suppuration are excellent. If his first attendant be one of those to whom wound infection by dust or filth adherent to hands or a probe be a myth, he is to be pitied. Without previous cleansing, im- mediate probing of the gunshot wound of a vertebra, for instance, accom- panied by digital exploration, will be performed on the patient extended on a mattress laid on the dirty floor of a railroad station. Of course, the bullet will not be found, and nothing beyond the infec- tion of the wound will be accomplished. A dressing will be applied any- way, and the patient will be taken home. Suppuration, that otherwise might have been avoided, will surely set in, and the patient is doomed. No THE TREATMENT OF ACCIDENTAL WOUNDS. 31 amount of consulting can devise a way, for no surgical skill can establish efficient drainage of the inaccessible parts of the wound. The chances for recovery were thrown away here from the outset. On taking charge of a fresh wound, the fearful and often irremediable consequences of a first false step should be always present to the mind of the surgeon, and his attention should be directed chiefly to the avoidance of septic infection. A temj)orary aseptic dressing having been applied, the general condition and comfort of the patient should be looked to by the administration of stimulants or sedatives. After transfer home or to a hospital, the necessary measures for permanent relief should be carried out as soon as the patient's general condition will permit. II. DEFINITIVE RELIEF. Preparations, comprehensive and thorough, as required for an aseptic operation, should now be made in the manner described in Chapter II. The patient is well stimulated if necessary, is anaesthetized if the case require it, and, his clothing being removed by cutting or in some other proper manner, he is placed on the ojDerating table. After this should come a careful cleansing and sterilization of the sur- geon's and his assistant's hands by scrubbing with soap and brush and immersion in a germicide lotion, followed by a likewise thorough cleansing of the integument in the vicinity of the wound. Plenty of soap-lather, with the use of a razor, scrubbing with soap and brush, rubbing and wash- ing off with a solution of corrosive sublimate, will soon accomplish this. 1. Contaminated Wounds. — The character of further procedures will have to be decided by the answer to the question : Is the wound clean or is it con- taminated? Gross evidence of contamination, such as, for instance, street- dirt imbedded in the wound or the clots, or the knowledge that the wound- ing was done with a filthy instrument, as, for instance, a foul and fetid butcher's cleaver, will answer the question in the affirmative. In these cases the leading object should be thorough cleansing and disinfection of the wound, followed by very comprehensive measures at drainage. If the external wound be small, it has to be well enlarged, so as to afford a good insight. Every nook and recess of the wound should be systematically gone through, cleansed of clots and dirt, thoroughly irrigated, and well drained. G-reat care must be taken not to overlook recesses, as one particle of filth left behind unawares, may cause very grave trouble. Drainage of the more remote recesses should be made as direct as possi- ble ; that is, a rubber tube carried to the surface from a distant corner of the wound through a properly placed counter-incision, will be more direct, therefore better, than a long tube bent or twisted and brought out through a distant opening. Haemorrhage must also be, of course, well stanched by ligature or otherwise. Divided tendons, nerves, muscles, or fractured bones are next united by 32 RULES OF ASEPTIC AND ANTISEPTIC SURGEEY. suture, and, if the edges of the wound be viable, they are also approximated by sutures. Where extensive loss of substance precludes uniting of the edges, or where uncontrollable oozing prevails, the wound should be packed. This is best done by first lining the entire wound with one layer of iodo- formized gauze, within which are packed a suitable number of loose balls of sublimated gauze. After a final irrigation and clearing of the drainage- tubes, the wound and its vicinity are enveloped in a moist dressing that should be protected from evaporation by a large piece of rubber tissue or Mackintosh. In case of fracture, the limb is supported by a splint. On account of their frequency, and their gravity in case of suppuration, inju- ries to the cranium and their treatment may receive special mention. Scalp-wounds have been held undeservedly in bad repute on account of their alleged tendency to suppurate. They heal as kindly as, and in fact, on account of their great vascular supply, heal better than, many other wounds, provided that they be first carefully cleansed, well drained before suturing, and sufficiently protected by a suitable dressing from subsequent contamination. In case of a greater denudation of the cranium, the loose scalp should be raised (after shaving and thorough cleansing of the skin), blood-clots should be turned out, and the wound well irrigated and rubbed out with corrosive-sublimate lotion. A bistoury is inserted into the deepest part of the recess formed by the flap, and thrust out through it. Into this opening a short piece of slender tubing is placed, after which the edges of the wound are brought together by an exact line of sutures. A dry dressing will be proper in these cases. If a compound fracture of the cranium be present, the first care of the surgeon should be to ascertain that no septic material remain imbedded in the recesses of the wound. The external wound must be adequately en- larged to permit of thorough inspection, cleansing, and disinfection. After this the nature of the fracture should receive due attention. Often foreign matter, such as street dirt or the hair, will be found impacted between the depressed fragments. In this case the edges of the fractured area are to be sufficiently removed by the aid of the chisel and mallet to permit of an easy elevation or extraction of the fragments and foreign matter. This is followed by a thorough cleansing of the exposed dura mater, especially of the recesses formed by the stripping off of this membrane from the inter- nal surface of the skull. If the foreign body or fragments of bone have injured the dura mater, the rent must be widened, in order to permit of careful extraction and cleansing. A slender drainage-tube having been in- serted in the dural rent, its edges are approximated by a few catgut stitches. The chips or button of bone, removed eitlier by the chisel and mallet or by the trephine, should be saved and preserved in a boro-salicylic solution till the operation be completed, when they are replaced in the cranial de- fect, over which the skin is united by an external suture, leaving sufficient space for the emergence of the drainage-tube. A moist dressing is appro- priate in these cases. THE TKEATMENT OF ACCIDENTAL WOUNDS. 33 Case. — Eegino Libertello, aged thirty, an Italian cobbler, was admitted to Mount Sinai Hospital, on November 30, 1889, with a fresh scalp-wound, two inches long, over the left half of the occipital bone, and parallel to the sagittal suture. On exposure of the bottom of the wound a deeply depressed fracture was noticed, and within one of the fissures a small bundle of the patient's hair was found to be imprisoned, where it had been evidently driven by the brickbat that had caused the fracture. The general con- dition was good, no cerebral symptoms of any gravity being present, with the excep- tion of a marked dilatation of the right pupil. The presence of hair within the cleft of the fracture was considered an ample indication for thorough disiufection ; hence the man being anesthetized, the scalp shaved and disinfected, the wound was well en- larged, and the periosteum raised from the skull. The edges of the oblong depression were carefully removed by the chisel and mallet, the loose fragments of the outer and inner table extracted, when the uninjured dura mater carue in view. A portion of the fractured inner table was left in situ, and, after thorough wiping and irrigation, a fillet of iodoform gauze was applied to the dura, and carried out of the wound by its lower angle. A number of external catgut stitches and a moist dressing com- pleted the procedure. The depressed area was ovoid, measuring one by three quar- ters of an inch. Immediately after the operation the pupils were equal in size. The drainage was removed on December 4th. The patient was discharged cured on December 14th. If the steps described above are adequately taken, as a rule no septic fever and no destructive suppuration will follow an accidental injury ; though aseptic fever, due to absorption of non-decomposed secretions, may often enough be observed. Tissues or bone whose vitality was compromised by the crushing force causing the injury will be gradually detached. This will be accompa- nied by a rather scanty secretion of thinnish sero-pus, and very little fever, if any. Case. — P. S., agent, aged forty-six, was, January 26, 1886, while in a state of deep alcoholic intoxicatii:)n, run over by a heavily laden truck, and was at once brought to the German Hospital, where he was anaesthetized about two hours after the acci- dent. There was hardly any shock noticeable. The soiled and torn garments were cut away from the extremity, which was then carefully cleansed from adherent street-dirt and blood-clot by the application of soap, hot water, the scrubbing- brush, and a razor. There was very little external hemorrhage present, but the ap- pearance of the member gave unmistakable evidence of extensive and serious in- jury. A laceration of the integument in front of and corresponding to the middle of the left leg, four inches long, was found. Also compound comminuted fracture of the tibia and fibula. The tibia was broken into four, the fibula into at least three frag- ments. Severe haemorrhage from the torn tibialis antica artery had caused an enor- mous infiltration of the leg, which had attained double the size of its fellow, and was quite cold. The integument was much discolored in the vicinity of the exter- nal wound, and very tense. Elsewhere the skin appeared abnormally' pale and glossy. Esmarch's bandage was applied, the external wound was enlarged to about eight inches, the massive clots, some containing particles of street dirt, were turned out of the muscular interstices, and from between the fragments one perfectly detached piece of the tibia was extracted. From the middle of the main cavity into which the frag- ments protruded, a counter-incision was made backward through the calf of the leg, into which a large-sized drainage-tube was placed. Three more counter-incisions, cor- 34 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. responding to as many recesses, were made. Tlie torn artery could not be found. A large moist dressing was applied, and the limb fixed between two well-padded lateral board si)lints, held together by a pure gum bandage. Moderato oozing soiled the dressings somewhat during the following night, wherefore the elastic bandage was removed in the morning, and the soiled parts of the underlying dressing were well dusted with iodoform. Another envelope of gauze was laid on top of the old dressings and the splints were replaced and fastened with muslin bandages. Jan. 31st. — The patient's temperature had not risen above 100° Fahr., he complained of very little pain, no hemorrhage had followed, the circulation of the limb was good, hence the dressings were not disturbed until this date. The wound was found to be in good condition ; some blood-clots were still adherent to the drainage-tubes. Wound was re-dressed and limb put up in a solid plaster-of-Paris splint. In the beginning the dressings were changed about weekly; from February 1.5th, every fortnight. March Sd. — After the exuberant granulations surrounding it had been scraped away, the entire belly of the tibialis anticus muscle was found to be of a grayish-yellow color and necrosed. It was not putrid, although a good deal of secretion was present. The wound was enlarged and the necrosed muscle was removed. Thereafter the secretion diminished materially, although five sequestra were consecutively rcTuoved. Consolidation was rather slow, but finally complete, so that the patient was able to walk without support in Octo- ber of the same year. Shortening about one inch. If left to themselves, deep-seated and extensive contaminated w'ounds, presenting a small external orifice, are, for obvi- ous reasons, most dangerous. Free exposure, thorough-going cleansing and disinfection, together with good drainage, are then imperative. 2. Aseptic Wounds. — The nature of many wounds and their causation are such as to jHCclude the probability of contamination. Most gunshot wounds and many compound fractures belong to this class. In these cases interference should be very discreet. It should consist of thorough cleansing of the integument, ordinarily an aseptic dry dressing, or, in case of doubt, of superficial drainage and a moist dressing, together with reduction and support and retention by splint where a fracture requires it. Case. — John D., aged thirty-two, December 4, 1885, sustained a compound com- minuted fracture of the upper half of the tibia by a horse-kick. Dr. W. T. Kudlich, of Hoboken, saw him immediately after the accident, cut off the clothing, disinfected the vicinity of the small wound, and dressed it amply with iodoform gauze. A temporary splint was also applied, and probing or examination toas thoughtfuLlij refrained from. The patient was brought to his home, where, the next day, he was anesthetized. The temporary splint and dressings were removed, the vicinity of the wound was carefully cleansed and disinfected, and, vvith the observance of all necessary cautelcB, a thorough examination of the injury was instituted. A compound comminuted fracture was easily made out, and three loose fragments of bone were removed. The laceration of the soft parts and ecchymosis were found very moderate, and confined to the tissues an- terior to the tibia. A couple of short drainage-tubes were inserted into two recesses, and, the wound being well irrigated, was enveloped in a moist dressing. The limb was put up in a solid plaster-of-Paris splint, with the knee bent at an obtuse angle, and was suspended from a frame. The temperature remained normal or almost noi-mal throughout. Dec. 18th. — Appearance of wound normal. Moderate secretion due to limited necrosis of a loose fragment of bone. Dec. 28th. — Second change of dressings. Ex- uberant granulations have filled up the defect. Jan. 18th. — A fenestrated silicate-of- THE TEEATMENT OF ACCIDENTAL WOUNDS. 35 soda splint was applied. The secretion continued to be scanty. In May consolidation was perfect, but a small sinus remained until October, when, after the extraction of several small spicula of bone, definitive healing of the wound ensued. 'So appreciable shortening resulted. Note. — In the more extensive injuries of the extremities caused by crushing force, the gravity of the case hinges more upon the extent of the injury to the soft parts than to the bones. A compound fracture by direct force — for instance, the blow of a hammer upon the tibia, where the crushing and laceration of the soft parts are comparatively limited — is by far not as dangerous as, for instance, the stripping off of the entire integument of the lower extremity, or the crush- ing and pulpification of the large muscles, vessels, and nerves situated on the anterior and internal aspect of the thigh, though these latter injuries be uncomphcated with fracture. The shock and the presence of extensive thrombosis, in addition to the fact that, with the large quan- tity of mortified tissues, preservation of the aseptic state is extremely uncertain and difficult, class these injuries among the most grave and dangerous. 3. Gunshot Wounds. — The fact that most fresh gunshot woiinds are asep- tic has been pointed out by Esmarch, and is now -well established. Reyher and Bergmann's experiences in the Eusso-Turkisli war put the fact beyond controversy. Wise precaution against infecting a fresh gunshot wound will be richly rewarded by excellent results. In most cases cleansing and disinfection of the skin in the vicinity of the points of entrance and exit, together with a dry dressing, will be sufficient. If the case is complicated by fracture, a suitable splint, preferably plaster of Paris (Bergmann), shotild be added. If the course is free from septic fever and suppuration, this will be mani- fest within the first three or four days ; in that case, the first dressing and the splint can be left undisturbed for the length of time required for the accomplishment of bony union. Flesh-wounds will be healed within a fortnight or three weeks. Gun- shot fractures will require a longer time for healing and consolidation, but are in no way diiferent from ordinary compound fractures. The projectile will cause very little or no irritation in aseptic — that is, non-suppurating — gunshot wounds. Generally it will become encysted. Search for the projectile in the bottom of the wound is rarely indicated. It can occur, however, that pressure of a projectile or its fragment, or a sharj) s^Dicultim of bone on a nerve-trunk, may necessitate search and extrac- tion. This must be done under careful asepsis. It is even not necessary to remove a projectile lodged under the skin. It will do no harm if left there itntil the channel which it cut by its passage through the tissues is obliterated, when its removal by incision can not lead to an infection of the bullet-track. In cases of injury to large vessels or the intestines, immediate interfer- ence can not be delayed, but should be carried out under most rigid anti- septic precautions. Note. — Recent successes (W. T. Bull) achieved by immediate laparotomy and suture of the wounded iatestines justify the procedure. Where the nature of the charge or the short distance from which the shot was delivered makes the entrance of a gun-wad probable, or where the 36 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. examination of the superjacent clothing shows a large defect, rendering the probability great that shreds of soiled cloth have been carried to the bottom of the wound, dilatation, search, and extraction may be indicated. But it is better to w^ait in cases of doubt, as even these foreign substances may become encysted and harmless. Should suppuration follow, the patient will not be worse off than if a fruitless search had been made at the outset, and the use of the suppurating track as a guide will materially facilitate the finding of the irritating body. XoTE. — Reyher's observations (Yolkmann's " Sammlung," Nos. 142, 143, 1878) may serve as a fair sample of the radical change that has taken place in the results of the treatment of gun- shot fractures. Gunshot fracture of the knee-joint was formerly considered an indication for immediate amputation. Reyher treated eighteen fresh cases aseptically — that is, by simply cleansing and disinfecting the skin about the wound, and occluding the same by an antiseptic dressing. Where the wound was gaping, or where there was ground to suspect the entrance of dirt or shreds of clothing into the bullet-track, dilatation, irrigation, and extraction of the foreign body, with sub- sequent drainage, was practiced before the wound was sealed up. Of these eighteen cases, fif- teen recovered, with movable knee-joints — 83"3 per cent of recoveries. One patient died of fatty embolism in twenty-four hours after the injury ; another of haemorrhage from the divided popUteal artery and vein on the fifth day ; and the third one of pysemia. Of nineteen that came under his care several days after the reception of the injury, with well-established suppuration, eighteen died, and one recovered with a stiff joint. In spite of an energetic antiseptic treatment by incisions, drainage, and irrigation, a mortality of 85 per cent was noted. Of twenty-three that were not subjected to any form of antiseptic treatment, twenty-two died, one survived, a mortality of 95"6 per cent — clearly justifying the practice of the older sur- geons, who at once performed amputation in cases of gunshot fracture of the knee-joint. Infected accidental wounds or gunshot injuries that become the seat of suppuration can be classed under the heading of phlegmonous processes, and their treatment will be dealt with in a subsequent chapter. CHAPTER V. SPECIAL APPLICATION OF THE ASEPTIC METHOD. A. General Principles. L TECHNIQUE OF SURGICAL DISSECTION. Modern surgery demands that the invasion of the uninflamed tissues of the human body by the surgeon's knife should be surrounded by all the safeguards that are known to be effective in preventing suppuration. The mortality following operations sanctioned by pre-antiseptic surgery has been remarkably depressed by a conscientious and intelligent adherence to the principles of surgical cleanliness. A large number of recently devised use- ful operations have become legitimate under the assumption that suppura- SPECIAL APPLICATION OF THE ASEPTIC METHOD. 37 tion can be excluded. The cranium, large joints, the tendinous sheaths, and the peritoneal cavity are now safely accessible for curatiye or even diag- nostic purposes. The statement that a real observance of asepticism offers a sure guaran- tee against suppuration, be the performance of a bloody operation however clumsy, rough, and unskillful, is true, but can not be pleaded as an excuse for the absence of that equipment of pathological and anatomical knowledge and technical skill which go toward forming a good surgeon. Although the general standard of safety and success in surgery has been considerably raised, excellence will be attained by those only who unite the qualities of a good diagnostician, pathologist, and anatomist with the tact, energy, and technical skill of the accomplished surgeon. The technique of surgical dissection is based upon principles, the ob- servance of which enables us to safely explore and manipulate any accessible part of the human body. Aside from the ever-present desideratum of preventing infection, the avoidance of accidental injury of important organs and the control of hsem- orrhage first deserve attention. The 'principle of doing every step of cm operation under the guidance of the eye, is the most important discipline of dissection to he acquired. It should never be sacrificed without the most stringent necessity. Its non- observance is the source of most that is embarrassing, appalling, and dis- astrous in operative work. Upo7i this principle is iased the rule to always mahe an ample and ade- quate incision, which should be gradually deepened layer by layer, until the part sought after is freely exposed. Fig. 10. — a, Bellied scalpel for cutaneous incision, b, Sharp-pointed scalpel for deeper dissection. For the cutaneous incision a bellied scalpel, held like a fiddle-bow, is the most useful. A careful and clean incision will insure a lineal cicatrix. As soon as the skin is divided, the subcutaneous vessels will become visible. If they are crossing the line of incision, they should be grasjDed between two artery forceps, divided between, and safely tied off with catgut. In cut- ting through the fascia, the grooved director used to play an important part in for- mer times. Its use has been 11. — Manner of holdino' the knife for the cutaneous t , -, -i _e t incision. "(Esmarch.; Supplanted by a sater mode Tig, 38 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. of preparation, known as cutting between two thumb-forceps. The author once observed that, in thrusting a grooved director underneath the fascial coverings of a hernia, the hernial sac was opened, and the adherent gut nearly torn through. As it was, only its serous covering was lacerated. In another instance, puncture of the deep jugular vein by the point of the grooved director happened, and led to very annoying haemorrhage from the deepest parts of the wound, which made exposure and ligature of the injured vein very difficult. It may be said that, unless very thin layers are taken up by the grooved director, the surgeon never can tell beforehand what he is going to cut through while using it. Veins especially are easily injured, as, being put on the stretch, they become empty. Stretched, they lose their identity to the eye, and look exactly like ordinary connective tissue. Fig. 12. Fio. 13. Securing and tying vessels traversing the line of incision. Cutting between two forceps has the peculiarity that, a thin layer of tissue being raised before each cutting, air enters into and rarefies its meshes, rendering clearly visible the vessels, which can be easily isolated and secured before they are cut. From this result two very great advantages : First, the patient does not lose one drop of blood from a vessel secured previous to its division ; and last, but not least, the wound remains dry and clean. No time is lost in hunting for a retracted vessel in a pool of blood, there is no occasion for hast}^ and rough sponging, and everybody preserves an even tenor of mind very essential to success. The advice, so often met with in text-books, that the knife should be laid aside where the tissues are loose, and that tearing or scraping with for- SPECIAL APPLICATION OF THE ASEPTIC METHOD. 39 ceps or the finger-nail is safer, is, to say the least, very questionable. This advice is born of the fear of unexpected hsemorrhage, which, however, can be always avoided by cutting between two forceps. The beginner, especially, is prone to carry this mode of blunt preparation to great lengths, and lacer- ation of large veins, the peritoneum, or cysts is the result. Fig Cutting between two thumb-forceps. (Esmarch.) A consideration of no small importance is the fact that a clean-cut wound will sometimes heal in spite of some local reaction and fever. This means, that the blood- and lymph- vessels of the parts concerned being not much bruised, sufficient nutriment is carried to the walls of the wound to over- come a moderate degree of micrococcal infection. Where the nutrition of the parts is seriously interfered with by tearing and bruising pertinent to blunt dissection, a much higher degree of asepticism is required to secure absence of suppuration. Note. — The old surgical tenet, that torn and bruised operative wounds ai^e not prone to heal kindly, is based upon the fact that devitalized tissues form an especially favorable pabulum to microbial development. The observation that very well nourished tissues, as, for instance, those of the face, will heal readily under almost all circumstances, and without the observance of anti- septic precautions, is explained by the fact that they are very well vascularized, and a rich supply of oxygenated blood is one of the strongest gennicides. We often saw the parts become red, swollen, and painful, and were expecting suppuration, but in vain, as all the local symptoms and the fever receded, and good union followed. As the wound is gradually deepened, sharp or blunt retractors should be employed to well expose to view its bottom, in which is centered the sur- geon's interest. The skin, muscles, fasciae, tendons, or the periosteum can be held back by sharp retractors ; vessels and nerves, the |)eritoneum, and friable glands or cysts should never be hooked up by them, blunt retractors deserving the preference. Most of the retractors commonly sold by the instrument-dealers are 40 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. worthless. A useful retractor must have a good, ample curve, a propor- tionate and safe grasp, a smooth, solid handle, and a strong shank, so as to be able to sustain a good deal of press- ure without bendins; or breaking. Fig. 15.— Small blunt retractors. Fig. 16. — Medium-sized blunt retractor, a, Actual size. Fig. 17. -Large-sized blunt retractor, h. Actual size. Fig. 10. — Large four-pronged sharp retractor (Volkmann). SPECIAL APPLICATION OF THE ASEPTIC METHOD. 41 Fig. 20. — Manner of holding the knife for deep dissection. (Esmarch.) The shapes and sizes most useful for general surgical work are depicted by Figs. 15, 16, 17, 18, and 19. The deeper the knife penetrates, the nearer it approaches important organs, the shallower its strokes should become. A somewhat pointed scalpel should be used, and its strokes, especial- ly where they sever dense tissues, should be made with the very point of the instrument, which should be held like a pen, but rather steeply. Use of the grooved director, or the scissors, or the sichleshaped bistoury in the bottom of a deep wound is always unsafe, as it may lead to unex- pected haemorrhage or something worse. Especially dangerous is the last- named instrument, as its very nature renders impossible the observance of the principle of not cutting what we do not see. It cuts from within out- ward, takes up unseen tissues, and may become the cause of unnecessary trouble and embarrassment. Should it become evident, as the wound deepens, that the first incision is inadequate, and that, in order to afford access, its edges must be subjected to severe tension, and that work is thereby cramped, an extension of the first incision is in order. This should be done methodically from without inward until the wound is sufficiently enlarged. Note. — The author once saw an ovariotomist make abdominal section with exaggerated minuteness, layer by layer, until the belly was opened, tying each small vessel as it was exposed. When a digital exploration had made evident the insufficiency of the incision, he enlarged it by cutting through the entire thickness of the abdominal wall loith a stout pair of scissors at one stroke. Of course the incision was uneven, some layers being further cut than others, haemorrhage was considerable, and finding and securing of the retracted vessels not easy. The shape of every operation wound should be such, if possible, as to afford the best conditions of access, and, later on, for natural drainage. The funnel shape (Fig. 21, a) is meant by this — that is, that the first incision should be the longest, the next one a little shorter, the last one the shortest. Even if no drainage- tube is inserted in such a wound, as long as the closing stitches are not too tight and too many, the interstices of the suture will afford ample drainage. Bottle-shaped wounds (Fig. 31, b) are disadvantageous in every way. They result from a too small cutaneous incision, are uncomfortable and FiQ. 21. — A, Funnel-shaped wound, shaped wound. B, Bottle- 42 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. unsafe during the operation, and after closure offer poor conditions for natural drainage. They alwaA^s require a drainage-tube, and, even with a tube, if not absolutely aseptic, become a very hot-bed of suj)puration, as the discharges of infected recesses may not find ready egress. Where the incision must be carried through condensed or i7ijlamed tis- sues, preparation between two forceps will be generally impossible. All the more stress should be laid upon the amplitude of the first cut, and upon the adequate dilatation of the wound by serviceable and solid retractors. As the wound deepens, the hooks should be alternately released and inserted deeper, so as to follow up closely the work of the knife. On account of their hypersemic state and density, haemorrhage will be found a great deal more profuse in inflamed than in normal tissues. The presence of vessels will become manifest only by the haemorrhage caused in cutting them. The smaller arteries can be easily controlled by increasing the tension exerted by the retractors on the edges of the wound. Larger vessels must be tied off. But the density and often the brittleness of the tissues prevent grasping of the bleeding points with artery-forceps, hence an- other expedient must be used. An ordinary curved, or, better, a perfectly round haemostatic needle, armed with catgut, is carried with a needle-holder through the tissues adjacent to the bleed- ing point in two or three stitches, so as to surround it like a purse-string. Being tied, it closes the bleeding orifice. Fig. 22. Haemostatic needle. Fig. 23. Manner of applying haemostatic needle (Esmarcli). When a plexus of considerable vessels, especially veins, is encountered in the bottom of a wound, or where, for some reasons, it is desirable to hasten operative work, the employment of mass ligatures will be found an expedient and safe way to rapid progress. ThierscJi's spindle and forceps is an invaluable apparatus for applying mass ligatures to dense tissues in difficult and deep situations. A blunt, probe-pointed, curved needle and a straight ivory spindle, armed with stout silk or catgut, and an appropriate forceps, make up the apparatus. The SPECIAL APPLICATION OF THE ASEPTIC METHOD. 43 probe-pointed needle is grasped by the beak of the forceps, and is cau- tiously insinuated under the plexus or mass to be tied off. Veins and arteries are not apt to be injured by the blunt point, as they are inclined to slide off from it. As soon as the ligature thread is drawn through under the mass, a knot is made, and, the spindles serving as solid handles, it can be tightened with a great deal of firmness and security. The mass can be safely divided between two of these ligatures. The treatment of veins in operative wounds is similar to that applied to arteries. There are some points, however, that constitute an impor- tant difference, and deserve special attention. The tension exercised by retractors is very apt to ob- literate the normal characteristics of veins. The dark blood they contain is driven out of them, and they can not be distinguished from ordinary connective tissue. Especially in blunt prepara- tion, lacerations of veins are apt to occur and cause serious difficulty. To find a bleeding vein is not as easy as to locate an injured artery, readily marked by its Jet of blood. And, even if the bleeding point is recognized, it is not always easy to stop a torn vein, as the laceration may be, and in fact frequently is, an irregular and extensive slit. On the other hand, venous hasmorrhage can often be effectively checked by simple pressure or plugging. If the finding of a torn and retracted vein should be difficult and involve too much time, it will be found a good expedient to plug up the place from which the haemorrhage issues with a strip of iodoformed gauze, held in place by light finger-pressure until coagulation occurs. Formerly the author used a bit of sponge for this purpose, but the following experience has shown that sponge is not a safe material : Case. — Theresa Kops, housewife, aged forty-eight. February 10, 1883. — Ampu- tation of left breast, with evacuation of the contents of the axilla for scirrhus of the mammary gland. Wound sutured throughout ; drainage by counter-incision through latissimus dorsi. Aseptic dressing. After feverless course, first change of dressings on February 21st, when the wound was found united. Drainage-tube was withdrawn. Feb. 22d. — Severe chill, phlegmonous infiltration of axillary region. Feb. 23d. — Incis- ion through cicatrix, and evacuation of a large quantity of pus, followed by a small fragment of sponge; drainage. Uninterrupted healing of the axillary abscess by granulation. In removing the axillary glands a small vein was put on the stretch, and, being ruptured, retracted so far that it could not be found. A good- sized sponge was stuffed temporarily into the recess from which the hsemor- FiG. 25. — Thiersch's spindle apparatus. 44 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. rhage issued, and the operation was finished. When the sponge was ex- tracted, it came away, as usual, with some resistance, due to the matting of the blood-clot into its meshes. The sponge was a very soft and brittle one, and its own cohesion was apparently less than the cohesion of its surface to the tissues matted to it. A small portion of the sponge tore off and was left behind in the wound. It caused no trouble for eleven days, and only after the disturbance of its relations by the removal of the drain- age-tube did its decomposition set in. Since that time a strip of iodoformed gauze was used for the mentioned purpose by the author, which would not tear, and could not be overlooked, as its end is carried out of the wound for a mark. Close attention to the details enumerated above will secure a dry and easily accessible wound, '^o sudden and uncontrollable haemorrhage will occur to create flurry or alarm ; no embarrassment will cause undue haste or an ill-considered move ; the patient will fare well, as, even with the seem- ing deliberation, the operation will be speedily accomplished, and, what is the main thing, no unnecessary loss of blood will be sustained. n. SUTURES. Primary union with a linear cicatrix is the ideal of the healing of an aseptic wound. As it depends to a great measure upon an exact coaptation of its edges in such a manner, that circulation of the integument should not be interfered with, and as exact coaptation under varying circumstances requires a variation of the procedure, a discussion of the important differ- ences in the technique of suturing may receive some consideration. Exact coaptation of the corresponding points of the edges of the wound by finger-pressure or otherwise, before and tohile j^^ssing the stitch, is the first condition of a true suture. Where there is no considerable loss of integument, and where the edges of the wound are ecpially thick and have sufficient body, this can be done easily by compressing the edges between the index and thumb until they touch on the same level, A good-sized curved needle is then jDassed through both edges of the wound, which will be retained in their correct relation by simply tying the catgut thread. Where one of the edges is thick and the other rather thin, coaptation is more difficult, as the thinner edge is apt to slip back, leaving a portion of raw surface exposed. Or where both edges of the wound are thin, as, for instance, on the neck, the scrotum, and the dorsum of the hand or foot, they have the tendency to curl under, raw being in contact with epi- dermidal surface. Both of these relations will produce an uneven line of suture, and will frustrate exact primary union. Partial healing by granula- tion is then unavoidable. Under these circumstances the best result will be achieved by the fol- lowing plan : The edges of the wound are brought togetlier and pinched up by index and thumb in such a way as to form a continuous ridge, on SPECIAL APPLICATION OF THE ASEPTIC METHOD. 45 the top of which should appear the line of incision. A straiglit needle is thrust transversely through the base of this ridge, and the suture is tied while the fingers still retain their position. The appearance of the com- pleted- suture is rather grotesque ; but, when the stitches are absorbed or re- moved, the peculiar-looking ridge will flatten out spontaneously, and the re- sult will be a beautiful fine cicatrix. See Figs. 26 and 27. In tying a surgical knot, a certain little knack will be found extremely useful, especially where good assist- ance can not be had. It consists in Jamming down the first or double cast into the angle of the suture nearest to the operator by a slight Jerk, made upon the distal end of the thread, while the mesial one is held steadily on the stretch. This Jamming of the catgut will be Just sufficient to hold the edges of the wound together, until with the second cast the knot is Fig. 26. tied. It will even hold to- gether edges approximated with some degree of force. Where there is much loss of integument, as in many cases of breast amputation, or where the sutures may have to stand a good deal of strain, as, for instance, the abdominal stitches after ova- riotomy, aside from the su- tures of coaptation above mentioned, supporting or re- tentive sutures are necessary. They have to embrace a good deal more integument than the finer stitches, and should be inserted from one half to two inches away from the edges of the wound. Lat- eral concentric pressure by the hands of an assistant will very much facili- tate the proper placing of these sutures. They can be made in several ways. The simplest one is to pass three or four or more interrupted catgut sutures of wider scope, and then to tie them while the edges of the wound are firmly supported by an assistant (Fig. 28). The required number of finer stitches is passed afterward. An- other good way is the application of a mattress suture, illustrated in Fig. ,. '^x Fig. 27. 46 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 29, combined with a continuous coaptation suture, all done with one piece of catgut. Where silver wire or silkworm -gut are available, the quill suture or Lister's button suture will give much satisfaction. Both of these forms of Fig. 28. — a. Interrupted retentive suture. Fig. 29. — Combined mattress suture and Glover': stitch. retentive suture will be very proper after abdominal operations. For the quilled suture, small cylindrical pieces of well-disinfected wood will answer. Buttons for Lister's retentive suture (Fig. 30) are cut out of stout sheet lead with a pair of scissors. It is sold by dental-supply traders under the name of "suction lead." The wire or gut is ai'med with a perforated shot. a « ^i^^'^""""" — t" a[ ^ Fig. 30. — a. Plate and sliot suture. b. Interrupted suture. Fig. 31. — a. Catgut suture from suppurating stitch- hole, b. Catgut from sweet stitch-hole, nearly absorbed. which is clamped to its end ; over this is slipped a button. The suture is passed, and the needle is unthreaded. Over the second end a button and shot are slipped, the stitch is tightened, and the shot is clamped. In uniting more extensive wounds, it is better to commence at the mid- dle and not at the angle, as the latter way may result in uneven distribu- tion and puckering. After abundant trial and comparison, the conclusion was arrived at by the author that, as a rule, the interrupted suture is in every way preferable to the continuous one. The exceptions are mentioned at the pro23er place. The chief advantage claimed for the continuous suture — namely, the saving of time — is Illusory. As regards safety in holding and exactitude of adaptation, the interrupted suture has no peer. Secondary Suture. — Kocher and Bergmann laave taught us to combine the advan- tages of the open treatment with those of the suture of wounds. Where it is deemed unsafe, for various reasons, to close a wound at once by suture, the wound is packed from the bottom with iodoform gauze. A suitable number of silk-worm gut or silver wire stitches are then passed through the edges of the wound. They are not closed. SPECIAL APPLICATIOX OF THE ASEPTIC METHOD, 47 but their ends are fastened together and arranged alongside of the wound, which is dressed as usual. Thus the escape of the serous discharges is absolutely unimpeded, and no retention can take place. On the fourth day the packing is removed, and, by the aid of the stitches left in situ, the wound is closed, provided that its condition is sweet. TTounds treated thus behave like fresh ones, and usually heal by agglu- tination. Secondary sutures are used with great advantage, also, for hastening the closure of ■widely gaping wounds. Fig. 32. — Perforated rubber drainacre-tube. in. DRAINAGE. Small aseptic "wouncls of a favorable, that is funnel shape, do not re- quire drainage by rubber tubing. As few stitches should be taken, how- ever, as possible, to permit the escape of the oozing between them. Small wounds of bottle shape ■will do very well with a narrow strip of iodoform ganze placed in one angle for capillary drainage, which should be renewed on the third day. Larger wounds, especially those with a sinuous cavity, require di'ainage by rubber tubing. Before using the tube, a number of oval holes should be clipped out of its side. "Through drainage," with a view to subsequent irrigation, is best efEected by placing the mesial end of the tube Just within the cavity to be drained. Drawing a long i^iece of tubing transversely through the cavity does not afford the best conditions for thorough irrigation, as the bulk of the irrigating stream will pass directly through the tube with- out entering the cavity at all. Where two or more short pieces of tubing are placed just within the cavity, the entire mass of the iiTigating stream is thrown into the cavity, to escape through the opposite opening only after having washed the entire extent of its interior. Aseptic rubber tubes never cause "irritation." Increased discharge or irritation of any kind is due to infection introduced into the wound by means of the tube at change of dressings. If the withdrawn tube is touched by unclean hands and is then reintroduced, it is ajjt to cause irrita- tion. But it is not the tube but the dirt adhering to it that is the cause of the trouble. The persistence of sinuses after certain operations, notably exsections, was also attributed to the use of drainage-tubes. This mistake is now ex- plained by the knowledge, that the sinuses in question do not heal on account of reinfection by tubercle bacilli, extending along the tubes with the discharges from an incompletely evacuated tubercular focus. In aseptic wounds, the oflfice of the drainage-tube is performed by about the end of twenty-four hours after the ojDeration. But other considerations, notably the unwilling-ness of disturbing the rest of the wound and of the 48 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. patient, make it inexpedieut to reopen the dressings so soon for the pur- pose of withdrawing the tube. It is generally left in situ until the first change of dressings. If there is no purulent discharge visible in the dressings removed from the third to the fifth day, the tubes can be safely withdrawn. If the healing was not entirely faultless, as seen from the presence of more or less pus in the dressings, it will be safer to re- introduce a short piece of tubing for the purpose of keeping patent the external end of the tube-track until the discharges shall have become scanty and serous. When a wound is in good condition and no pyogenic or tubercular infection be present, the surgeon will find it a very diflicult matter to keep a tube in place for a long time, should he desire to do so. The cicatrization of the deeper parts of the drainage-hole will irresistibly expel the tube, ot granulations will invade the lumen of the tube through its lateral fenestrse, and will simply fill it up completely. The tube should be always extracted for inspection at the first change of dressings. If it is found to be filled up with a more or less solid clot of sweet blood or fibrin, the interior of the wound can be assumed to be in good condition. Should the clots be foul and semi-fluid, the tube must be shortened and replaced after thorough cleansing. The decalcified bone drainage-tubes, devised by Neuber, have been abandoned by the author on account of their many inconveniences not overbalanced by the advantage of their absorbability. Glass drainage-tubes, provided with a number of lateral holes, are used extensively in abdominal surgery. By placing within their hollow a wick of iodoform gauze, tubular and capillary drainage can be combined to great advantage. It may be said, on the whole, that rubber tubing has so far not been supplanted by anything better for jaurposes of ordinary wound drainage. B. Applicatiox of Aseptic Method to Diverse Orgaxs axd PiEGIOXS. L LIGATURES OF ARTERIES IN THEIR CONTINUITY. With due observance of the rules of surgical dissection and of the laud- marks pointed out by anatomy, the exposure and deligation of the larger arteries will present no serious difficulty. The treatment of the vascular sheath deserves some S2)ecial remark. Free incision of the sheath will be found to facilitate very much the isolation of the vessel. No fear need be entertained of causing thereby necrosis or sujipuration in an aseptic wound. The sheath should be grasped and raised with a pair of mouse-tooth forceps, and the cone thus formed should be incised with the knife held horizontally. The incision can be extended to half an inch in length. (See Fig. 33.) SPECIAL APPLICATION OF THE ASEPTIC METHOD. 49 Isolation of the vessel is best accomplished by gently insinnatino- into the slit the point of a bent silver probe, while the edge of the cut is held up Fig. 33. — Incising the vascular sheath. (Esmarch.) by the mouse-tooth forceps. As soon as the j^oint of the probe emerges on the opposite side of the artery, it is followed up by an aneurism-needle armed with a catgut thread, which is tied in a square knot. Encircling a vessel with an aneurism-needle having a sharp or even a too slender point may lead to j^iercing of the artery wall by the instrument. Case I. — Carl Tompert, carpenter, aged forty, noticed in October, 1881, a pulsating swelling on the left side of his neck. By February, 1882, it had attained the size of a goose's egg. March 2d. — Ligature of left common carotid between the heads of the sterno-raastoid muscle at the German Hospital. In passing aneurism-needle under the artery without the exertion of unusual force, suddenly a jet of arterial blood was seen to spurt up from the wound. Traction on the aneurism-needle controlled the hsemorrhage, A catgut ligature was passed around the artei'y above and another below the aneurism- needle, and both were tied. The artery was divided between the ligatures, and then it was ascertained that the aneurism-needle had made a longitudinal slit into the artery wall. No drainage-tube was used, and the wound was closed by a few catgut sutures. Pulsation of tlie tumor had ceased, and subsequently it shrunk away to a stout cord-like structure. The wound healed by the first intention and no fever occurred, but the first two days following the operation very profuse general per- spiration was observed. Patient was discharged cured, March 20. In this and the subsequent cases, as well as in all other operations done hy the author since 1877, catgut was used exclusively as ligaturing material with the greatest satisfaction. Only one case of suppuration occurred in which the infection could be traced to the use of impure catgut (page 8). Secondary haemorrhage by slipping of the ligature was observed twice (page 72). Even in suppurating wounds, catgut has been found to be a safe ligaturing material. It is in every way preferable to silk, and in no case was its use ever regretted. Those who have been accustomed to tie vessels with silk, usually employ too much force in tightening catgut liga- tures. They overtax the strength of the animal thread, and to their great annoyance constantly break it. A small amount of traction is sufficient to safely tighten the knot, as it is not necessary nor desirable to sever the inner 50 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. coat of the artery. The many cuts, so common on the ulnar side of surgeons' fingers at the time, when silk was generally employed for tying vessels, are very rarely seen nowadays. To j^reserve its strength, catgut should never be immersed in any kind of a watery solution, as it is apt to become swollen and soft when brought in contact with water. The dish holding the ligatures at an operation should be dry, or should contain absolute alcohol. In all the cases here reported, no drainage-tube was used, reliance being placed on natural drainage. The catgut sutures employed were few and loose, and permitted a free escape of the oozing during the first twenty-four hours. Primary union of the wounds occurred in every case. Case IT. — Herrmann Stinze, fishmonger, aged forty-six, admitted to German Hos- pital January 3, 1880, with aneurism of the femoral artery, situated just underneath Poupart's ligament, displacing it forward and upward. Syphilis admitted. Causation, severe effort at rowing fifteen months before admission to hospital. Direct compression of swelling was unsuccessfully employed for eighty hours. Jan. 17th. — Deligation of external iliac artery. No drainage-tube. Catgut suture. Prompt establishment of collateral circulation. Primary union. Discharged cured February 28th. Patient examined March 28th, when at the site of the aneurism a cord of the size of the middle finger could be felt. Case III. — Henry Greenwald, clerk, aged fifteen. End of June, 1882, sustained stab-wound of left palm, followed by copious hsemorrhage, which ceased spontaneously. Development of pulsating swelling of palm, which, by the direction of the family physician, was kept tightly compressed with a leaden bullet. Aug. 17th. — In the Catskills severe arterial haemorrhage from pressure-sore over swelhng, when bullet was removed and another compressory bandage was applied. Aug. ^O^A.— Renewed hjemor- rhage. Esmarch's band being applied, the clot w^as turned out of the open sore, the sac of the size of a hazel-nut was split and excised, and both afferent vessels were tied. Suture. Primary union followed. Case IV. — August M., agent, aged forty-one, suffering from progressed ataxia, cut his ulnar artery August 20, 1881, in a suicidal attempt. Hfemorrhage was arrested by pressure made by a physician who attended to the patient immediately after the attempt. Aug. 23d. — Secondary liseTnorrhage. Esmarcli's band being applied, the wound was dihited, and, the partially cut artery being exposed, was doubly tied and cut through between. Suture. Primary union. Case V. — Alexander Goerlitz, engraver, aged tliirty-four. Had chancre eleven years ago, and had been in the habit of folding his legs while at work. June, 1883. — Noticed pulsating swelling in right popliteal space. 8ej)t. 15th. — Circumference of left knee, thirteen, of right knee, sixteen and a quarter inches. Knee semi-flexed. Skin over aneurism dusky and hot. Esmarch's constrictor applied above and below swelling for an hour under ether without success, circumference increasing to seven- teen and a quarter inches. Sept. 19th. — Ligature of right superficial femoral artery in middle of thigh. Sept. 21st. — Swelling hard, non-pulsating. Paralysis of dorsal flexors of foot and of extensors of toes. No necroses. Primary union. May 17, I884. — Knee can be fully extended, paralysis disappeared, muscles of leg have regained their normal bulk, tumor shrunken to a small, hard mass. Case VI. — August Bente, cigar-maker, aged fifty-one. No syphilis. In the sum- mer of 1883 felt neuralgic pains in right arm, followed by wasting of the brachial muscles, cyanosis, formication, and hyperidrosis of the extremity. In December severe dyspnoea supervened, and a pulsatile swelling under the right sterno-clavicular SPECIAL APPLICATION OF THE ASEPTIC METHOD. 51 junction and in the lower cervical triangle was made out by Dr. John Schmidt, who directed tlie patient to the author, then on duty at the German Hospital. Aneurism of the innominate and subclavian arteries at their junction was diagnosticated, and simultaneous ligature of the right common carotid and the axillary arteries was per- formed January 16, 1884. The latter vessel was tied in Mohrenheim's triangle, just below the outer third of the clavicle. No drainage-tubes ; suture. Immediately after the operation the pulsation of the swelling became more pronounced, and for the next four weeks the shooting pains in the arm were much complained of. Both wounds healed by primary intention. Toward the end of February decrease of the swelling and moderation of the subjective symptoms became manifest. In March and April thirty hypodermic injections of Bonjean's ergotine were made in the abdominal region, •and seemed to hasten the shrinking of the tumor. By May, the cyanosis, sweating, ■glossy skin, and formication, as well as the neuralgic symptoms, had very much abated, and the* patient had gained ten pounds of flesh. Under massage, the application of faradism, and active exercise, the atrophy of the muscles had also materially improved, and in June the patient could resume his occupation. Nov. 11, 1884. — Patient was presented to the Surgical Society. Pulsation had almost entirely disappeared, and what there was of it seemed to be transmitted. Bruit was not noticeable. A well-perceptible fullness and resistance could still be made out in the right supra- clavicular fossa. Occasionally short and mild attacks of shooting pains were felt in the arm and nape of the neck. A claw-like deformity of the nails of the right hand remained unaltered. In August, pulsation and other signs of relapse were noted, with increasing pain, radiating toward the occiput. Renewed injections of ergot were without avail. In October, during the author's absence from town, Dr. Adler incised an abscess pointing in the supraclavicular space, and a few days later performed tra- •cheotomy for threatening asphyxia. A sharp pneumonia followed, from which the patient recovered only to succumb in November to sudden suffocation. No autopsy was permitted. Case YII. — John H. Nittinger, grocer, aged forty-five. No syphilis; had had articular rheumatism seven years before. Pulsating swelling of left popliteal space of the size of a man's fist. Leg had been cedematous for three months; marked emacia- tion. Jan. 20, 1885. — Ligature of left femoral artery in Scarpa's triangle. Primary union of wound. Recovery retarded by circumscribed necrosis of integument over tuberosity of calcaneum (due to pressure?). Discharged cured, March 30, 1885. Case VIII. — Emmanuel Luecke (see history on page 186). Case IX.— Robert Klaile, school-boy, aged fourteen. Congenital arterio-phlebec- tasiaof anterior part of left foot; pulsating, dusky swelling, of doughy feel, of dorsum and planta pedis. Along the course of saphenous nerve were seen a series of flat, hard, ■dark-blue, rough nodes, some of them as large as a silver quarter, their size tapering off toward ankle. Two of them were ulcerated and covered by a dry scab. Left foot on the whole larger than its mate. Pulsation of femoral arteries abnormally strong. Heart hypertrophied. Ablation of diseased parts was declined. July 7, 1885. — Liga- ture of superficial femoral artery. Short stoppage, and return of pulsation. Imme- diate ligature of external iliac of same side. Wounds sutured ; no drainage. Primary union. Necrosis of terminal phalanges of first and second toes, of the integument of the •external side of leg, and of peroneus longus muscle. Scanty aseptic suppuration, and very slow detachment under antiseptic dressing. Tardy cure. The cicatrices on the toes became ulcerated in the winter, and the pulsation of the tumor, which had not diminished in size, had returned. Jan. 29, 1886. — PirogofE's amputation. Unusual number of ligatures required on account of many abnormally large arteries. Cap of •calcaneum was fixed to tibia by steel nail driven through from below. Catgut suture. 52 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Drainage through oonnter-iuoision alongside of tendo Achillis. No fever followed. First change of dressings was done February 10th. Primary union was observed throughout, except where a narrow strip of the integument had necrosed along the anterior part of the incision. Dry dressing. February 24th. — All firmly healed. Patient walks well without support. Case X. — Louis Wiersch, aged forty-two. diffuse cirsoid aneurism of right tem- poral region. July 2JI,, 1888. — Deligation of external carotid and of four large col- lateral vessels. Primary union. Marked diminution of pulsation. Discharged im- proved, August 4th. Case XI. — Carlo Somma, laborer, aged fifty-three, fusiform aneurism of right axillary artery. March 2, 1888. — Ligature of subclavian artery, third division. Immediate cessation of pulsation, and subsequent rapid shrinkage of tumor. Dis- charged cured, March 16th. n. EXTIRPATION OF TUMORS. In removing tumors, three requirements have to be commonly held m view : Firstly, the avoidance of septic infection from witliout or from within. Secondly, the complete removal of the neoplasm. Tliirdly, its safe removal. How to avoid infection from without was seen in previous chapters of this book. By infection from within, two kinds of infection are meant. One is the contamination by septic contents of the tumor that may escape into the wound through an accidental cut or a laceration of the tumor, caused by rough handling or the careless use of sharp re- tractors, as, for instance, in ex- tirpating suppurating glands. Case. — Sarah Barn, servant, aged sixteen; old Pott's disease of the cervical vertebrae : large glandular swelling of right sub- maxillary region, with several si- nuses leading down toward the spine. It was pretty certain that no serious degree of the affection of the vertebrae could be present, as the function of the cervical spine was nearly normal. Xovem- ier 4i 1886. — Flap incision and exsection of the large mass of tubercular glands at Mount Sinai Hospital. Though the utmost care was exercised in not grasping the glands with sharp-pointed instruments, one of them broke down, and poured out its contents into the large wound. As subsequent events demonstrated, seemingly thorough irrigation with a strong solution of corrosive sublimate did not disinfect all Fig. 34. — Gluteal tumor betore extirpation. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 53 Fio. 35. — Gluteal dresslnor. the parts of the wound. The dissection mainly extended into the intermuscular space namely, the slit between the scaleni and the posterior border of the sterno-mastoid. After the removal of the mass, the finger was easily inserted into a track leading toward the second vertebra, the anterior surface of which was found rough and bare of periosteum. It was thoroughly scraped and irrigated (the instru- ment could be felt in situ from the oral cavity) ; the outer wound was drained, sutured, and dressed. Nov. 5th. — High fever, with much de- jection. Skin below ear red, pain- ful, and swollen. The flap was re- opened, and a small abscess was detected just under the base of the flap, where probably irrigation had been insufiicient. Open treatment. Temperature fell oflE to normal at once. The patient was discharged cured December 1st. The other kind of infection is the dissemination through the lymphatics of cancerous or sarcomatous cell-elements into the body caused by pressure due to rough manipulation of the tumor. Note. — It is a well-known fact that, in some cases of malignant tumor of slow growth, after operation, a large number of secondary nodes will spring up and develop with great rapidity in the neighborhood of the cicatrix. Two causes, either singly or combined, may be at the bottom of this phenomenon. Either the operation was incomplete — that is, the surgeon's dissection hugged the tumor too closely, leaving behind a number of outstanding microscopical foci, — or the forcible manipu- lations of the tumor during the operation have disseminated along the lymphatics and veins embryonal cell-elements of malignant character into the vicinity of the wound or throughout the body. This is commonly called "change of the character of a malignant neoplasm, due to mechanical irritation." Undoubtedly there are many cases where an incomplete operation leads to wide dissemina- tion of the elements of the neoplasm. In these cases relapse in the unhealed wound or in the fresh cicatrix is observed, together with the simultaneous appearance of regional and more dis- tant nodes of new formation. Thus an incomplete or rough operation may, by generalization of the disease, hasten instead of retarding the patient's death. Seasonable hope of the complete removal of a malignant new-growth is the main justification for operative interference. There is, to be sure, a considerable class of cases where complete removal is from the outset out of the question. Great discomfort from putrescence of a sloughing tumor or frequent hsemorrhages do sometimes indicate partial removal. But, wherever possible, complete removal is to be aimed at by all permissible means, as the non-return of the disease depends solely upon the fulfillment of this condition. Our third object must be to remove the tumor with the least possible amount of immediate danger to the patient's life. Careful and deliberate dissection, guided by anatomical knowledge, limiting of the haemorrhage 54 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. to a minimum, and avoidance of accidental injury to important organs, is meant hereby. The most important condition to be fulfilled in eschewing these dangers is an adequate incision. A too large incision never can do any harm, its worst consequence being the necessity for a few more suture-points. An insufficient incision, on the other hand, may be the source of great danger to the patient, and of much embarrassment to the surgeon. When the incision is ample, the new-growth and its connections can be readily exposed without the use of much traction from sharp or blunt hooks, and forcible grasping and dragging to and fro of the tumor itself will be unnecessary. Most of the vessels that are to be divided will be noticed, and can be cut between two artery forceps without loss of blood. Accidentally injured vessels can be easily secured and tied off. The wretched expedient of digging a malignant tumor out of its capsule, and leaving behind the latter, should never be resorted to, as a speedy relapse is certain to follow. Dissection should be done altogether with the knife, and exclusively in healthy tissues. Blunt methods of preparation are not to be used at all, since they are unnecessary, and involve a certain amount of rough force. In removing infiltrating or ill-defined malignant new-growths, the sur- geon's knife should give the tu- mor a wide berth, and all cosmetic or functional considerations not involving present danger should be disregarded, the first object being the complete eradication of the disease. Note. — In extirpating malignant new- growths, which are known to cause an in- fection of the contiguous lymphatic glands at an early stage of their development, the rule of removing these involved lymphatic glands together with the fat wherein they are imbedded, should never be disregarded without a very cogent reason of expe- diency. The absence of a gross lymphatic tumor is no evidence of the freedom from infection of the pertinent lymphatic glands. The additional traumatism caused by this complementary step is richly repaid by the vast improve- ment of the patient's chances against a speedy relapse. In an ample wound the tumor can be handled with the necessary gentleness, and the main attack can be directed upon its adhesions to the surrounding tissues. With rare exceptions, sharp retractors are never to be plunged into the tumor. They should be used on the edges of the wound for dilatation, the tumor itself being held by hand throughout. The softer the mass of the tnmor, the greater care must be exer- Fia. 3(5. — Axillary tumur before extirpation. SPECIAL APPLICATION OF THE ASEPTIC METHOD. f)0 Fig. -37. — Axillary wound, imited, after extirpation of tumor. cised not to injure it. Cysts especially require very tender treatment. Lipomata and fibromata will stand a good deal of rough handling with- out harm. XoTE. — In former days lipomata used to have a bad reputation. It was said that their extirpation was often followed by erysipelas and phlegmon. One of the first operations ever witnessed by the author was done upon a healthy young man in 1868 in Prof. D.'s clinic, at Vienna, for a lipoma of the shoulder. It caused the patient's death from septictemia. This peculiarity, noted by surgeons in times gone by, was undoubtedly due to the readiness with which a phlegmonous process will spread in loose and ill-nour- ished adipose tissue. Of course, the infection always came from the hands and apparatus of the surgeons themselves. Where should dis- section first he direct- ed to, is a question, that puzzles every be- ginner, and it is not in- different from which side we approach a tumor. Surgery owes to Langenbeck a clear exposition of the principle which should guide us in this matter. In excising tumors holding close relations to large vessels, as, for instance, those in the neck, axilla, and in Scarpa's triangle, the greatest safety lies in first exposing these vessels alove and below the tumor, so as to have full con- trol of them during the subsequent steps of the operation. This precaution offers great security against injury of those vessels, and at the same time reduces to a minimum the otherwise formida- ble dangers of such ac- cidental injury, should it occur. If it become evident that the tu- mor has involved the walls of the adjacent large vessels, a ligature above, another below the growth, will per- mit of a safe and com- plete exsection in one mass of the tumor and the diseased parts of the vessel. Fig. 38. — Flap incision for removal of tumor of neck, di'ained and sutured. Wound 56 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. Note. — It is the common tendency of young surgeons to carry too far the dissection of a vessel adhering to a tumor. This is actuated by the desire of preserving the integrity of the vessel in question, and by the natural disinclination of complicating the operation by double ligature, which again involves extra dissection. The con- sequence of this tendency may be twofold : cither portions of the tumor adhering to the vessel wall are left behind to cause speedy re- lapse, or the vein is cut or torn. Fig. 39. — Uressint; for neck wounds. Fig. 40. — Dressing of neck wound completed by rubber-tissue bib and arm-sling. Whenever the surgeon has succeeded in formmg a pedicle to a tumor situ- ated in the vicinity of large vessels, cuttinfj of such a pedicle without first tying it off is a very risky step. Traction upon the tumor will obliterate any vessels included in the pedicle, and, when cut, the innocent-looking mass, closely resembling ordinary connective tissue, may open up into unex- pected and overwhelming springs of welling blood. The stump will at once retract, and finding and securing the retracted vessel in an inexhaustible pool of blood is a terribly difficult, sometimes impossible, thing. Should it be an artery, the tips of two or three fingers must be thrust at once into the place from which the hsemorrhage is issuing. The blood must be mopped up by rapid sponging, to enable the surgeon to find the vessel, in order to secure it with an artery forceps, or to surround it by a suture passed through the adjacent tissues. His mettle will be put to the severest test, and it will be a lucky day if his patient do not succumb on the table. In trying to secure the stump of a large vein accidentally cut across, the wide extent of its circumference will offer much difficulty, as an ordinary artery forceps is too small to take in the entire lumen of the vessel. One or more great leaks will remain, even if the vessel be fortunately grasped by one forceps. Two, three, or more additional instruments have to be brought SPECIAL APPLICATION OF THE ASEPTIC METHOD. 0/ into requisition till the end is accomplished. The haste, natural and almost unavoidable on such occasions, will easily lead to further tearing of the soft walls of the vessel, and, finally, salvation will have to be sought in plugging with iodoform gauze. Here prevention is much easier than cure. Lateral tearing or slitti7ig of a large vein is another accident to which disregard of Langen beck's rule may lead. There are two ways out of this contingency. One is to expose and deligate the vein above and below the laceration, while the fingers of au assistant compress the injured part of the vessel. The other one is the application of a lateral ligature or a con- tinuous suture of fine catgut occluding the rent. Both of these latter methods, however, are difficult and not very reliable, though they have succeeded in the hands of several surgeons, including the author's.* They were bred of the fear of tying large veins, for- merly so prevalent on account of the dangers of phlebitis and, in the extremities, of gangrene. In cases where a large portion of the vein wall is lost by sloughing or cut- ting, and the resulting aperture is very large, lateral liga- ture and suture are impossible. "Whenever feasible, a double ligature should be applied, whether it concerns the deep jugular or axillary and femoral veins. Langenbeck's advice to tie the accompanying large artery has been much impugned lately, as it was found that gangrene of the extremity followed its adoption. On the other hand, a growing num- ber of cases are on record, where deligation of the femoral or axillary vein led only to temporary disturbance of no great import. Case. — Henry Rickriegel, carpenter, aged twenty-three, admitted to German Hos- pital, March 2. 1887. Two days later the house-surgeon extirpated a mass of sup- purating glands from Scarpa's triangle of the right side. The saphenous vein, which passed into the tumor from belo\\', was tied and cut across. Likewise were treated a number of larger veins entering the tumor from above. The femoral vessels were not exposed, but the pulsation of the artery could be distinctly felt, and it was care- fully held aside. Finally, the Fig. 41. — Lateral lig- ature and continu- ous suture of in- jured vein. JTiG. 42. — Periosteal myxosarcoma of thigh before removal. * In a case of exsection of lymphomata of the neck, done in 1880 in the German Hospital, where the deep jugular was injured. The patient recovered. 58 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. mass was freed all around, until a stout pedicle was formed, which was seen entering the oval foramen of the fascia lata. This pedicle was tied with catgut and was cut through. In the mean time the patient had be- come semi-conscious and began to struggle, where- upon, suddenly, an enormous jet of venous blood was seen to well uj) from the bottom of the wound. The operator plunged his fist into the pool of blood, and thus succeeded in checking the hsemor- je until Dr. Fig. 43. — United wouud alter ruiiiuval ol iiiyxo.'^arcoiua of thigh. Bachmann, the chief of the house- staff, appeared, who luckily suc- ceeded, with the aid of Thiersch's spindles, in pass- ing two ligatures, one below, the other above the bleeding point, ef- fectually stopping tlie formidable loss of blood. Im- mediately, deep cyanosis and oedema of the lower extremity developed, and the author, who saw the patient directly after the operation, ordered elevation of the limb, which was brought about by its vertical suspension in a wire cradle. March 5th. — Cyanosis disappeared, oedema much diminished. Temperature, 101-5°. Circulation of limb good. The wound did well, but, March 18tb, temperature rose to 103° Fahr., and signs of phlebitis of the femoral vein in the middle of the thigh appeared in the shape of a cylindrical, painful, and hard infiltration. This and a number of similar attacks were subdued by the application of an ice-bag. The persistent oedema was combated by elastic com- ])ression with Martin's bandage, supplemented later on by massage. May 15th. — The patient was discharged cured, very little of the oedema being still noticeable. In this case, apparently, a portion of the trunk of the femoral vein was drawn into the cone of the pedicle containing the root of the saj)henous vein, and was excised along with the tumor. The ligature slipped off, and a wide gap was opened in the side of the femoral vein corresponding to the place of entrance of the saphena. The peculiarity of the walls of large veins to yield to lateral traction is well known to surgeons, and is a just source of anxiety, as the extended vein becoming empty can not be recognized. Double ligature of the vein will be insufficient to check the hfemorrhage when a large branch inosculates between the two ligatures. Such branch must be separately exposed and tied. Case I. — March ^7, 1880. — The surgeon in charge of the ward for syphilis and skin diseases at the German Hospital excised a large glandular tumor from Scarpa's tri- angle on John Te Gempt, aged twenty-four. The operation was finished without accident, and, according to the then prevailing custom, the woimd was mopped with SPECIAL APPLICATION OF THE ASEPTIC METHOD. 59 44. — Dressiuff after removal of myxosarcoma of thigh. an eight-per-cent solution of chloride of zinc. Ajyril llfh. — A large slough of the vein wall was detached, and fearful haemorrhage ensued, which Dr. Loewenthal, the house-surgeon, could not check completely by local pressure. When the author saw the patient, he was nearly exsanguinated, though conscious. ISTo pulse could he felt. Without anesthesia the femoral vein was exposed below the opening in its wall, while press- ure by three finger-tips completely controlled the htemorrhage. of the iist or of a sponge into the wound will not check hemorrhage effectually in these cases. The tips of the fingers pressed exactly upon the bleeding orifice, and without much force, will always succeed in controlling the vessel. As the vein bled from above, too, Poupart's ligament was cut across, and the external iliac vein was tied. After this the loss of blood became very much diminished, but a considerable vein inosculating just opposite the defect in the wall of the femoral vessel required separate exposure and deligation, whereupon the haemorrhage ceased completely. Unfortunately, the total loss of blood had been so considerable that the patient survived the operation only a short time, and died in collapse from acute anaemia. In a similar case the difficulty caused by tlie presence of an inosculating branch, situated between the two ligatures, was overcome by plugging. Case II. ^Ferd. Brenner, aged forty-nine. Noteviber 22, 1889. — The removal of a very large relapsed sarcoma, located deeply in Scarpa's triangle, was attempted at Mount Sinai Hospital. The femoral vein was found imbedded in the tumor mass. In essaying to ascertain whether the attachment was loose or more intimate, a piece of the vein wall measuring three fourths of an inch, and involving the entire width of the vessel, came away with the tumor when it was raised. The very profuse hfemorrhage was promptly checked by exact finger-pressure upon the aperture m the vein. Two liga- tures, one above the other below the tumor, were thrown about the vein, but hseraor- rhage continuing, it was concluded that a large branch, inosculating between the two ligatures, probably the profuda vein, remained unoccluded. As the excision of the tumor was out of question on account of its diffuse character, search and deligation of the inosculatory branch was deemed inexpedient. Hence the entire lumen of the vein included by the ligatures was tightly packed with strips of iodoform gauze, the ends of which were brought out through the defect in the vein wall. The wound was also packed and a compressory bandage applied. Slight cyanosis persisted for a few hours, but had disappeared by the next day. Packings removed November 26th. No hfemor- rhage. December 25tJi. — Patient discharged, with granulating surface. Deligation and imrtial exsection of the axillary vein for ingrowing cancer of the axillary glands has been often performed by various surgeons with en- tire success, and can he undertahen without hesitation whenever unavoidable. Case. — Betty Lowy, aged forty-two. Ajjril 26, 1889. — Amputation of right breast for extensive carcinoma. The axillary glands are found to be very much involved and enlarged, the axillary vein passing through the middle of the tumor mass. Excision . 10 60 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. of two inclies of the axillary vein between two catgut ligatures. Drainage, suture. No cyanosis or oedeina of arm followed. Primary union. Discharged cured May 30th. In deligating the deep jugtdar vein, avoidance of the pnetimogastric nerve ivill require close attention. When there is enough space to expose and liberate tlie vein freely, this Avill not be found very difficult. Low down at the root of the neck however, the decision of the question whether the ligature encompasses the nerve or not may occasionally be impossible. Case. — Mrs. Catharine Plunkett, aged sixty-four. Extirpation of recurrent lympho- sarcoma of neck, December 22, 1886, at Mt. Sinai Hospital. A tumor of the size of a hen's egg was located low down in the supra-clavicular fossa. Though it was freely movable, its close relation to tlie large cervical vessels was anticipated. A flap incis- ion and careful dissection laid bare the Jugular vein above and below the tumor, when it became evident that it would be imj'ossible to remove it without excising a correspond- ing portion of the vein. The lower ligature had to be applied somewhat behind the sterno-clavicular rim, and on account of the lack of space this was very difficult. Isola- tion of the vein had to be done with the greatest caution to avoid its injury. Finally a silver probe wormed its way around the vein, and the question arose. Was or was not the pneumogastric nerve included in the ligature? To test this the thread was firmly tied in a single knot. No change whatever of the respiration or pulse being noted, it was assumed that the nerve was not caught, whereupon a double ligature was passed through by means of the first thread, and, being tied, the vein was cut across. But on inspection of the mass it became clear that the nerve was included in the liga- ture and had been cut through. The tumor was easily dissected up after this until a pedicle was formed containing the jugular vein from above. This being tied, the tumor was removed. Drainage, suture, and dressings were applied in the usual manner. The patient recovered without one untoward symjitom. Dec. 31st. — The first dressing was removed, together with the drainage-tubes. Jan. «.^l" Fig. 129. — Microscopical as- pect of staphylococcus au- reus aad albus. (Under the microscope their ap- pearance is identical.) (From Eosenbach.) Fig, 130. — Streptococcus pyogenes. (From Eosenhach.) Fig. 131. — Chain - coccus of erysipelas (Fehleisen). (From Eosenbach.) Fig. 132.— Bacillus of pu- trescence. (From Eosen- bach.) jA Fig. 133. — Bacilli taken from a pu- trid bone-abscess in general sepsis (962 diameters). (From Eosen- bach.) Fig. 134. — Bacilli from emphysematous gangrene. (From Eosenbach.) golden yellow color of the mold it forms on a peptonized meat-agar culture- soil, ^' StajjTiylococcus pyogenes aureus,''^ or the golden grape-cocmis. It is called gTape-coccus [staphyle, grape) on account of the agminated or bunched arrangement of the single cocci that comj)ose a colony. (Fig- 129.) 184 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. This coccus is found in almost all forms of acute suppuration — in phlegmon, glandular abscesses, and in acute, infectious osteomyelitis. By certain methods of manipulation, a pure or unmixed culture of this fungns can be raised upon glass plates covered with a film consisting of a mixture of peptonized meat-jelly and agar agar, a vegeta- ble form of gelatin. This mold resembles in struct- ure the common form of mold dreaded by house- keepers, only it has a deep orange color. It has the peculiarity of thriving upon the living human tissues, causing their inflammation and ultimate death. (Plate I,. Fig. 1.) Another form of grape- coccus, not so common as the preceding one, and appearing either alone or associated with the gold- en grape-coccus, is Eosen- bach's " Staphylococcus pyogenes albus." It can not be distinguished from the yellow coccus under the microscope, but the mold produced by pure culture is easily recognized by its pearly white color. (Plate I, Fig. 2.) Both forms of grape-coccus have the clinical peculiarity of causing well- localized foci of phlegmon. All tissues within a certain area become uni- formly permeated by the grape-coccus. They coagulate, then emulsify, and the result is a distinct abscess. Another form of micro-organism — Rosenbach's '' Streptococcus pyogenes,'^ or pus-generating chain-coccus — is so called on account of the arrangement of the single globular cocci in more or less elongated chains. (Fig. 130.) Its laeculiarity is to rapidly extend along the lymph-spaces and lymphatic ves- sels. Its emulsifying property is not as pronounced as that of the grape- coccus, but it may become very destructive to the tissues by rapid infiltra- tion along the lymphatics, causing progressive gangrene. The peculiarity of extending along the course of the lymph-vessels, as well as its micro- scopical appearance, testify to its close morphological relation with the streptococcus, or chain-coccus of erysipelas, discovered by Fehleisen. (Plate I, Fig. 3, and Plate II, Fig. 4; then Fig. 131.) Pure cultures of the pus-generating streptococcus and the coccus of ery- sipelas diifer ver}' distinctly in several important points (see Plate II,. Figs. 4 and 5), but microscopically they can not be distinguished. Fig. 135. -Bacilli of putrefaction and diverse forms of cocci in putrid blood. (Koch.) Plate I. Fig. 1.— Pure culture of gold-colored grape-coccus of suppuration from a furuncle of the lip, on meat-peptone-agar, seen by reflected light. Fig. 2. — White grape-coccus by reflected light. Fig. 3.— Chain-coccus of pyemia by reflected light. (From Rosenbach.) NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 185 None of tlie pus-generating cocci cause what is commonly called putres- cence. Decomposition of tissues, accompanied hy the production of foul odors, is always due to the fermentative action of di- ■verse forms of elongated bod- ies, called bacilli or bacteria. Plate III, Fig. 8, shows a pure culture of the "Bacil- lus saprogenes," or bacterium •of putrescence. Fig. 9 is a pure culture gained from an osteal focus in putrid com- pound fracture with fatal septicemia. (Figs. 132 and 133.) The accomiDanying chro- molithographs were careful- ly copied from Eosenbach's monograph, and give a very life-like image of the several molds or cultures. On account of their ex- cellence and truthfulness, a Fig. 136. — Bacteria of blue pus (700 diameters). (Koch.) number of Koch's renowned microphotographs, illustrating various forms •of microbial growth, have been here reproduced. n. PORTALS OF INFECTION. It is safe to assume that, without exception, all forms of suppuration owe their origin to infection from without. The portals through which the pyogenic organisms known as cocci and bac- teria enter the system are, on one side, the le- sions of the outer integu- ment ; on the other, le- sions of the mucous lin- ing of the digestory, re- spiratory, and urogenital apparatus. The infection of larger accidental or surgical wounds has been treated of in the preceding chapters. Infection through minimal lesions of the skin or mucous membranes and its sequelae will now receive attention. 1. Infection through Lesions of the Skin. — The popular tenet that a wound that bleeds well heals well, is based on correct observation. Sharp Fig. 137. — Human kiclney in pyelo-nephritis. In the center, urinary canal filled with cocci (700 diameters). (Koch.) 186 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. hemorrhage is very apt to dislodge and carry off particles of filth deposited in the wound from without at the time of the injury ; and, further, it sig- nifies an abundant blood supply, good nutrition, hence prompt union. An- other point of importance is, that wounds that bleed profusely generally come under the care of a physician, and will receive at once proper atten- tion and protection from further injury. Small abrasions, lacerations, or punctured wounds that bleed very little, or not at all, have deservedly a bad reputation. If the injuring instrument or object does not inoculate the wound with filth, and subsequent infection is prevented by proper measures, healing will proceed without interruption. But as a rule, these wounds are neglected from the outset, because there is scanty or no haemorrhage. The sharp-edged tool of the mechanic, or the pointed object handled in the daily vocation of the laboring man is very rarely clean. In certain occupations, as that of the butcher anato- mist, or cook, the hands are frequently injured while m contact with ioul orcranic substances, and the injuring force will at the same time inoculate filth. No hemorrhage following, and the pain being insignificant, the matter is lightly passed over, and work proceeds without interruption. Ihe cleansin- effected by hemorrhage is absent, the small orifice of the skin is soon filled by lymph and obliterated, and we have to deal with a hermetic- ally sealed focus containing filth, leavened by a certain number of micro- organisms, that at once must and do begin to develop and multiply, causing a destructive purulent inflammation. , . . mi. Not all of these small injuries are infected from the beginning. They may and, as their frequent spontaneous healing proves, are often enough ^'^ A^a matter of fact, they do well at first, and as long as the patient takes care of them. But if, as often happens, the protecting scab is remjured, and infection by contact with foul matter follows, the consequence is sup- puration. NoTE-Inflamruatory lesions of the skin are fruitful sources of infection, among them eczema the foremost. The intense itching leads irresistibly to scratching, and the small excoria- tions thus produced are often the portals of infection. 2 Infection through Lesions of the Mucous Membranes. -Less numerous than the lesions of the skin, yet productive of frequent mischief, are the traumatic and inflammatory lesions of the mucous membranes, bhght injuries to the lips, tongue, buccal and faucial mucous membrane are very common. In most cases a profuse flow of saliva is instantly produced by a painful injurv, and, if hemorrhage be also present, infection rarely takes place Healthy oral cavities and their adnexa are especially exempt from infectious processes following injuries. Even gunshot wounds of these parts can heal without suppuration under favorable circumstances : Case -E L a^ed eighteen, admitted to Mount Sinai Hospital, December 7, 1884 with suicidal fresh pistol-shot wound of the tongue, extending from the tip backward to the left side of the base, dividing the organ in two unequal parts. Gunshot pertora- Fig. 4. — Culture of ehaiu-coecus from a case of acute progressive gangrene. Transmitted light. Fig. 5. — Chain-eoccus of erysipelas (Fehleisen). Transmitted light. Fig. 6. — Chain-coccus of erysipelas by reflected light. (From Rosenbach.) NATUEAL HISTORY OF IDIOPATHIC SUPPUEATION. 187 tion of the pillars of the fauces of the left side ; gunshot wound of the posterior pharyn- geal wall, the point of entrance situated just back of the faucial pillars of the left side, about an inch and a quarter from the median line, all of these injuries being produced by a bullet of 22 mm. caliber. A second non-penetrating gunshot wound on the fore- head without a point of exit. Free haemorrhage from the tongue, and also a stream of arterial blood from the pharyngeal wound. The latter being in close vicinity to the left internal carotid artery, tbe left common carotid was tied at once as a preventive measure, mainly with a view to the possibility of subsequent suppuration and second- ary hfemorrhage. The perfect condition of the teeth and oral mucous membrane was noted. The lingual wound was lightly rubbed over with a small sponge dipped in iodoform-powder ; the pharyngeal wound icas not probed, and hourly irrigation of the oral cavity with weak salt water was practiced. Profuse sweating, perhaps due to reflex vasomotor disturbance, set in, and persisted for about forty- eight hours. The febrile movement was very shght, and both the operation wound and the gunshot wound on the forehead, being redressed on December loth, were found healed and dry under their iodoform dressings. The lesion of the tongue was found granulating and contracting, the perforation of the pillars of the fauces nearly closed, the point of entrance in the posterior pharyngeal wall firmly occluded by a fresh-looking blood- clot. Breath odorless. December 21st. — The flattened ball removed by small incision from the top of the head, where it could be felt beneath the skin. The entire track of this projectile had literally healed without suppuration. The pharyngeal wound found also cicatrized over, the ball being imbedded near and below the left transverse process of the atlas, in close proximity to the vertebral and internal carotid arteries. The head was held inclined to the right side, erection of the spine and its flexion to the left being impossible on account of the intense pain caused by the attempt. This functional disturbance diminished to such an extent within a few months that the con- templated extraction of the small projectile was abandoned. Had the patient's oral cavity been f onl from putrid processes accompany- ing an acnte or chronic oral catarrh, due to dental caries or other causes, suppuration of the pharyngeal wound would have been very probable. The danger would have been very much graver on account of the possibility of ■extension of the suppuration and the likelihood of uncontrollable secondary lisemorrhage. A probing of similar ivoiincls luitJiout a clear and necesmry object in vieiu is ahvays a dajigerous and ijivariably useless step, and should be refrained from under almost all circumstances. TTe may use a clean probe, and the probe may not be the carrier of infection ; but its introduc- tion will break down the blood-clot, the natural barrier provided by the organism itself against infection, and the probe will leave behind an open •channel for the eatrance of possibly fetid oral mucus into the narrow wound. !N'ext in frequency to the inflammations in and about the oral cavity and its adnexa are those due to injuries and other lesions about the anal and uro-genital orifices. m. ENTRANCE, PROGRESS, AND LOCALIZATION OF THE INFECTION. As long as the integrity of the epidermis is j^reserved, no infection from without will take place. The integrity of the epithelial covering of the mucous membranes does not seem to have the same protective power as the 26 188 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. epidermis. This may be explained by the fact that slight injuries of the mucous lining are produced much more easily than those of the skin, and are not readily ascertained on account of the normally moist condition of the parts. As formerly stated, the slightest denudation, not deep enough to cause haemorrhage, and just productive of a slight exudation of serum, offers a favorable point of entrance to the virus in the patulous orifices of the lymphatic vessels or lymph-spaces, thus exposed by the injury. In lacerations or 2)anctured wounds the infective agents are very often deeply inoculated with the point of the injuring article — that, is, they are at once deposited in close vicinity to deep-seated lymph- vessels. In the more superficial forms of injury, the implantation of the virus, occurs only in the neighborhood of more superficial lymphatics, and its. transmission to the deeper lymph-vessels is accomplished by forces which govern the flow of lymph from the pe- riphery to the center. Aside from the normal current set- ting toward the thoracic duct, external forces and the play of the volun- tary muscles have an im- portant part in hasten- ing the flow of lymph. So, for instance, the pressure exerted upon the lymphatics of the palm by the frequent and vigorous grasping of a tool wielded for a long time with great force, will undoubtedly help to propel the con- tents of the peripheral lymphatics toward the larger, more deeply situated lymphatic trunks. Or the vigorous contractions of the muscles during mastication will undoubtedly empty the adjacent lymphatics centerward, their action being aptly comparable to that of a force-pump. What was formerly danoted as external meclianical irritation is nothing but this forci7ig of pus-generating substances into the open lymphatics by friction or other pressure due to exercise. The direction and extent of the spread of the infection by the lymphatics are prescribed by the anatomical arrangement of the lymph-vessels of the region concerned. Thus, on the palmar aspect of a finger, the poisoning will rapidly extend to the j^eriosteum, as the lymphatics all tend that way. In the vicinity of lymph-glands, the infection will promptly extend to them, an intervening lymphangitic streak often clearly denoting the route \>j which it traveled. Fig. 138.- -Bacilli of anthrax and streptococcus (700 diameters). (Koch.) Fifi. 7.— Mixed culture of golden and lemon colored and of white grape-coccus from a case of empyema. Reflected light. Fig. 8.— Common organism of putrescence. Bacillus saprogenes. Reflected light. Fig. 9. -Bacillus saprogenes from a focus of septic compound fracture. Septic»mia. Reflected light. (From Rosenbach.) NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 189 The Tarving intensity of the infection, dependent on hitherto unkuoTvn and yarying fermentative qualities of different cultures of micro-organisms, will also greatly influence the rapidity and virulence of the inflammatorv process. So much is well established that the intensity of the infection depends, _^r-s-f, on the virulence of the invading culture of bacteria ; secondly, on the quantity of fungi absorbed : and, thirdly, on the j^ower of resist- ance — that is, the state of health of the invaded organism. Mechanical Irritation. — Meclianical irritation hy foreign substances imbedded in tissues, such as bullets, splinters of glass, or a broken-off point of a knife-blade, is also a myth in the old meaning of the phrase. They never cause suppuration unless infectious siibstances — that is, microbial filth — be adherent to them at the time of their being deposited in the tis- sues. They may cause pain by pressure upon nerves, or may interfere with the play of a joint or a mtiscle, but. as a rule, never will cause in- flammation or suppuration. Well-disinfected steel nails, driven by mallet through femur and tibia after exsection of the knee-joint, are unhesitat- ingly left imbedded for thirty or more days, never causing any irritation (see Exsection of Knee- Joint, page 319.) Case. — In 1882 a young blacksmith presented himself in the surgical division of the German Dispensary. An angular foreign body could be distinctly felt under the skin on the palmar aspect of the right forearm, midway between elbow and wrist. causing pain by impinging. The body had appeared only since a few weeks. Near the carpus a transverse cicatrix was to be seen, and the patient explained that he was cut there during a drunken brawl two years ago, and that a surgeon had tied an artery and sewed up the wound, which had healed without suppuration. Ever since then he had worked at his trade without any inconvenience until within a few days. From the incision made over the projecting body, a blackened knife-blade, four inches long and five eighths of an inch wide, was extracted, to the greatest astonishment of the patient. The small wound closed promptly. Here we saw a massive, sharp-edged foreign body lie imbedded for two years between the muscles of the forearm without any inconvenience to the patient, until the angular base of the blade had worked out tinder the skin. "Why did it not cause suppuration ? Apparently the blade must have been newly grotmd, or at any rate very clean, when it broke off in the arm of our blacksmith. Had a considerable amount of infection been carried along with it at the time of the injury, its presence would not have been over- looked so long. Dead organic substances, as, for instance, blood, or cubes of animal tis- sues, such as muscle, tendon, or portions of liver or bone, were taken from a freshly killed animal, and introduced into the abdominal cavity of a num- ber of other rabbits under strict antiseptic precautions. In a very large proportion of cases no reaction whatever followed. The animals being killed, it was found that blood was absorbed outright ; that muscle, liver, tendon, and bone were encapsulated ; and that their structttre was gi-adually invaded by granulation tissue — disintegration and final absorption follow- ing after a while, proportionate to the density of the implanted bodies. In 190 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. cases where the ordinary aseptic measures had been omitted, septic purulent peritonitis followed as a rule. Note. — The most remarkable of Dr. H. Tillmann's experiments (Virchow's " Archiv," Bd. Ixxviii, 1879) is that concerning^ a rabbit, in the abdomen of which an entire rabbit's liidney was deposited witliout causing any harm whatever. Tlie animal being killed forty-seven days after the operation, the implanted kidney w'as sought for in vain, as it had disappeared by absorption, the only vestige of its former presence being a spot of tough cicatricial tissue, denoting the locality where the foreign body was attached by exudations. This experimental observation is fully borne out by the experience gained in numberless ovariotomies, where massive pedicles, dead through stoppage of their circulation by ligature, are dropped back harmlessly in the perito- naeum, to be finally absorbed — that is, they will do no harm if a culture of bacteria is not deposited on them by the operator. Chemical and Caloric Irritation. — The common experience that certain acutely irritating substances, as, for instance, croton-oil, oil of cantharides, turpentine, concentrated solutions of corrosive sublimate, and others, brought in contact with living tissues, always would produce suppuration, represented a serious gap in the theory of the microbial origin of suppura- tion. If invariably proved, it would be more than a defect, as it would positively contradict the thesis that suppuration is exclusively and always the result of the development of micro-organisms. The experiments of Councilman,* who introduced under the skin of animals small glass globes filled with sundry irritating substances, and then crushed them, all led to suppuration. Scheuerlen f and Klemperer,J however, in going over Coun- cilman's experiments, showed that his procedure was faulty, inasmuch as suflBcient precautions had not been taken to exclude the introduction of microbes along with the croton-oil, etc. They moreover positively demon- strated by a very large number of successful experiments that, whenever thorough aseptic cautelae were observed, suppuration never followed the in- troduction of even very considerable quantities of the mentioned substances. Small quantities caused some exudation of plasm, and then were absorbed outright. Afterward the fragments of the glass receptacle were found im- bedded in a film of new-formed connective tissue. Larger quantities of croton-oil, for instance, caused a coagulation necrosis of a limited mass of tissue, which was found dense, bloodless, and of a yellow color. These nodes of necrosed tissue were gradually absorbed, suppuration never foUoio- ing the experiment. This fact is in full accord with other incontestable facts of the same character, as, for instance, the absorption of necrosed ovarian stumps in the abdominal cavity if there be no microbial infection present. Caloric irritation, or even an outright destruction of tissues by exces- sive heat, presents a similar state of things. As long as microbial infection is successfully kept away from the exudations in burns of a milder charac- * Virchow's "Archiv," 1883, vol. xcii, p. 217. \ " Archiv fiir klin. Chirurgie," vol. xxxii, p. 500. \ Prize essay, Berlin University, "Zeitschr. fiir klin. Med.," 1885, vol. x, p. 158. XATVEAL HISTORY OF IDIOPATHIC SUPPUEATIOX. 191 ter. and from rhe eschar and exudations iu severer forms, no suppuration will follow. The modern use of the thermo-eautery in the peritoneal cavitv. in joints, and, a5 a matter of fact, in wounds of the most various character and of all anatomical regions, is followed by uninterrupted union in all cases where, at the same time, adequate aseptic measures are emploved. An eschar or a mass of dead tissue, whether produced by ligature, or chemi- cal corrosion, or red heat, will never assume the irritating character of a ''' foreign body,"' in the meaning of the term as presented by the tenets of an older pathology, if the decompiosing action of the presence of micro- organisms is excluded by proper measures. The behavior of superficial iiwus of the slcin is fully iu accord with the facts Just presented. If a bleb be raised, and is left unhroken and dry, its contents will be absorbed, and the epidermis will settle back into its normal relation to the cutis. It will torn into a dry scale, and will peel oS within ten to twelve days, exposing the tender new epndermis. How different is the course of a burn if the epidermis is torn off by acci- dent or intentionally, and the exudations are thus exposed to the invasion of micrococci I If the surgeon do not employ timely disinfection and the application of a protective dressing, suppuration of the exposed ctitis. with all its accompaniment of pain, long-contintted granulation, and a very tardy healing, will follow. rv. DEVELOPMENT OP PHLEGMON. From the moment that a snfficient qtiantity of active ftmgi have estab- lished themselves within the living tissues, remarkable local and general phenomena develop, known under the name of infiammation and septic fever. Our object is not research into, but rather a lucid explanaiiou of. the essence of inflammation, as understood and accepted by contemporary ati- thorities. iBence a brief sketch of the leading features of the process is deemed sufficient. Micrococci find a most favorable pabttlum in dead or devitalized organic substances. The living tissues off'er a decided resistance to the ravages of the micro-organism. The spontaneotis limitation and occasional unaided cure of some forms of suppurative inflammation prove this assertion. Bacteria can not thrive on the products of decomposition : they need for their sustenance dead but uudecomposed albuminoid substances. As soon as the supply of dead animal tissue is exhatisted. the micro-organisms starve and perish. Their spores or seeds are left behind dormant, but will become active if fresh pabulum is offered under favorable circumstances. This explains the fact that fresJi cadavers or animal substances in tJie recent stages of putrescence are much more infectious than those that are in a progressed state of decomposition. The varving intensity of different cases of infection seems to depend in a great measitre upon the varying degrees 192 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. of vitality of different microbial cultures. It seems to admit little doubt that the great majority of dangerous wound infections are brought about by the importation of considerable masses of very active, rapidly proliferating micro-organisms in the shape of "lumps of dirt," as Lister graphically puts it, taken from various sources of recent putrescence, so abundant in all human surroundings. The dry spores floating in the air will be easily taken care of by the living tissues, if pollution of the wound hj gross dirt — that is, masses of organic matter in active decomposition — is avoided. Every injury causing a wound destroys the vitality of those cells that lie in the direct path of the cutting or lacerating object. The blood and lymph exuded from the vessels coagulate, and also represent dead matter. If a number of active micrococci are implanted into the bottom of the wound, they will at once multiply, using the blood-clot and its extensions into the blood-vessels, together with the adjacent dead or devitalized tissues, as a welcome soil for their development. This fermentative decomposition produces from its very beginning certain alkaloids or chemical, extremely poisonous substances, the iJtoma'ines, that are very diffusible. By dint of this diffusibility, the adjacent vasomotor nerves at once come under their toxic influence, as the result of which their strong dilatation ensues, which becomes manifest in the shape of an active hypcrcemia, " rubor. '' Fig. 130. — Bacilli of anthrax (Ti'ii diameters). ( Koch. ) Fig. l-iC. — Formation of spores in anthrax bacilli (700 diameters). (Koch.) The blood passing through the adjacent arterioles and capillaries seems also to become altered ; the red blood-corpuscles become packed and finally stagnate in the capillaries and smaller arteries. The walls of these vessels, including the veins, lose their impermeabilitv, and a number of white and often red blood-corpuscles emigrate into the surrounding tissues, densely infiltrating their interstices, thus producing the characteristic siceUing, " turgor. ^^ As a consequence of the increased blood-supjoly, possibly also of the active chemical process, a marked increase of the local temperature is ob- served — " calor.'' And, if we add that pain of the parts thus affected is NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 193 never absent, we have completed the classical cycle of the four cardinal symptoms of inflammation — " ruior, color, turgor, dolor.'" Note. — The causes of local pain may be several. The initial pain is very likely due to a direct influence of the ptomaines upon the sensory filaments. Direct pressure caused by the dense infiltration may also have some influence ; but the most acute pain is undoubtedly effected by the actual destruction of the nerve-tissue during the advanced stages of suppuration. Stagnation and dense infiltration finally produce a very high degree of tension, leading to compression of larger afferent vessels. The infiltrated portions, devitalized by suppression of the normal circulation, readily suc- cumb to the inroads of the millions of micro-organisms, and actual necrosis rapidly follows. The last stage of textural destruction is the final liquefac- tion of the tissues and infiltrating leucocytes, aided by the exudation of large quantities of lymph-serum from the adjacent unobstructed blood-ves- sels, and thus the formation of an abscess or a cavity filled witli lymph- serum, myriads of dead white blood-corpuscles (pus-cells), and quantities of shreds of necrosed tissues, is accomplished. The veins also participate in the disturbance. Coagulation of their con- tents — thrombosis — takes place, and existing stagnation is materially aug- mented. The deleterious part played by thrombi in the causation of metastases will be later mentioned. When a septic inflammation of sufficient extent and intensity has been well advanced, the great tension of the parts will necessarily cause an over- flow of the most diffusible contents of the focus into the surrounding effer- ent vessels — the veins and lymphatics. The ptomaines, thus entering the general circulation, will at once produce systemic intoxication, manifested by a very marked rise of the body-heat, rigors, sickness, headache, delirium, and general dejection — in short, a deep-going alteration of the nervous system, known as septic fever. V. SPREAD OF SUPPURATION. The way of the extension of septic textural destruction is twofold. It takes place, first, by a direct infiltration of the tissue-interstices by columns and hosts of the immensely prodigious micrococci — that is, by an immedi- ate growth and extension of the microbial colony ; and, secondly, on the way of the lymphatics, openly communicating with the focus of suppura- tion. Into these, bacterial masses, or pus charged with micrococci, are forced by the hydrostatic pressure exerted by the tension within the abscess. If the ]oarts affected are composed of loose tissues, the spread will be rapid and extensive ; if the parts are dense, the inflammation will remain localized as long as the density of the tissues (fascise, for instance) will resist the pressure of the secretions. But, as above mentioned, this very pressure, or tension, involves another great danger. The afferent blood-vessels become thereby occluded, and the resulting stagnation generally leads to extensive necrosis. 194 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. As long as new areas of tissue become infected througli the lymphatics, constant high fever and increase of the local symptoms is the rule. An incision laid through the parts at an initial stage of the process will expose a honeycombed mass of tissue, containing a number of small foci, some of them confluent, and all filled with pus, the interyening substance being discolored, pale, or more or less broken down and softened, or sloughed. In direct proportion with the spread of the infection and the multiplica- tion of supjDurating foci, is the magnitude of necrosing areas, occasionally involying an entire limb. Organs of scanty vascularity, as, for instance, fasciae, tendons, and bone, are the first to succumb. The microbial colony begins to show signs of exhaustion in most cases after a more or less prolonged period of florescence. The parasite becomes less prolific ; its direct ingrowth into the tissues is less and less active, and the life of the white blood-corpuscles, densely infiltrated into the marginal parts of the abscess, is not compromised by their invasion with micrococci. They are not converted into pus, but withstand the attack of the parasites and remain a mass of embryonal connective tissue, that forms a dense wall inclosing the suppurating cavity. This embryonal connective tissue uni- formly i^ermeates all the adjacent parts, among others the lymjihatics and thrombosed veins, forming a more or less effective harrier to the extensio7i of the septic process and to the absori^tion of deleterious soluble substances into the general circulation. This self-limitation of tlie spread of septic destruction is generally marked by a remission of the intensity of the general and, in a measure, of the local symptoms. At this stage, according to ancient notions, the abscess has matured. Note I. — For obvious reasons, the incision of a mahircd abscess is generally followed bv a rapid healing of the cavity. The detachment and liquefaction of the contents of the abscess are well completed, the extent of the process is well rounded off, as it were, by the wall of newly organized connective tissue, and repair can commence under favorable circumstances. Nevertheless, it must be strongly urged that the most dangerous abscesses never ripen — that is, show no tendency to self-limitation — and that the measures ordinarily employed for maturing them, such as vigorous poulticing, only tend to intensify their malignity, and to cause irrepara- ble damage, that an early incision might have averted. A case vividly illustrating the pernicious- ness of thoughtless poulticing is quoted on page 248. Note II. — Not every bacterial infection leads to suppuration, although the rule suffers very few exceptions indeed. One of the exceptions is illustrated by the following : Case. — I. N., laborer, aged twenty- four, was admitted to the German Hospital in March, 1685, with a very painful, hard, and massive swelling of the axillary contents, the skin being oedematous and angry-looking. High fever and a good deal of sickness were observed, so that pus was thought to be indubita- bly present. An incision was declined, whereupon a poultice was ordered, with the expectation that it would hasten the process by stimulating suppuration. For a day or two the intensity of the symptoms increased rather than otherwise, several sharp chills followed with profuse sweat- ing, after which came a marked improvement of all the appearances of the case. The redness and swelling diminished, the fever disappeared, and the patient left the hospital cured, glorying in his triumph of endurance over diagnostic acumen. To explain such cases, it is necessary to assume that, under the powerful stimulation of the local circulation by the cataplasm, the products of bacterial fermentation, bacteria, or even pus itself, are washed away by the lymph-current into the general circulation, where the pto- NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 195 maines provoke constant or explosive symptoms of general intoxication, such as high fever or severe chills ; the bacteria themselves, however, perish, the living oxidized blood forming an unfavorable pabulum for their existence and propagation. In accord with this theory is the well-known fact that wounds of very vascular tissues, such as those of the face, for instance, will heal without suppuration even when there is a good deal of inflammation of their edges, with pain and fever, denoting the presence of a certain amount of septic infection. The poorer the blood-supply of a part, the greater the destruction wrought by an infectious process. If the abscess is not evacuated at the stage of maturity through a fortu- nate spontaneous or an artificial opening, the relief felt by the patient will be a short-lived one. The marginal wall of embryonic connective tissue — that is, the area of gj'anulations — will continue to shed lymph and detached leucocytes into the abscess cavity. The intramural pressure will steadily increase until it rises to such a degree as to overcome, on hydrostatic prin- ciples, the resistance of the soft plugs of living leucocytes, which occlude the orifices to the adjacent connective-tissue planes and lymphatics or veins. One or another of these offering the least resistance, will be forced out of the way, and a new invasion of hitherto unaffected regions results, with a repetition of all the initial local and general symptoms, marking an exten- sion of the process. Note. — The notion that the law of gravity alone regulates the spread of abscesses is an erro- neous one, as it is well known that many forms of suppuration extend in a diametrically opposite direction to the force of gravity. The local spread is prescribed by the direction of the loose connective-tissue planes separating and connecting the different organs, and is mainly influ- enced by hydrostatic law. Perforation always takes place where resistance is the least. The infiltration of the tissues by micrococcal colonies sometimes extends to the close vicinity or into the very walls of larger veins. Thrombosis is the direct result, and, if the microbial invasion includes the thrombus, after the detachment of the slough of the vein and the liquefaction of the throm- bus, a direct communication of the general circulation with the abscess cavity may be established. The slightest external pressure may serve to throw enormous masses of pus and micro-organisms into the general circula- tion at this critical period, causing raj^id death by explosive septicaemia. In these cases the microscojoe will demonstrate the presence of micrococci in the entire blood-mass. In other cases, either spontaneously or in consequence of active move- ments or external manipulations, a portion of a septically infected thrombus may be detached. The blood -current will at once carry it into the right auricle and ventricle, whence it will find its way into one or another branch of the pulmonary artery, to be there arrested in the shape of an embolus. Around this a hsemorrhagic infarction of the adjacent pulmonary tissues will form, within which a new bacterial colony will become established, leading to the formation of a secondary or metastatic abscess. Its appear- ance is always signalized by a severe rigor. Thrombosis of adjacent pulmonary veins, and detachment of portions of the new thrombus, followed by its transportation into the left side of the heart, and hence into distant smaller-sized arteries of the body, will lead to 27 196 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. a repetition of the metastatic process and its febrile accompaniment, until a number of joints, lymph-glands, the liver, in fact, almost all the organs, become the seat of secondary abscesses. This is the classical type of well-developed pijcemia, formerly so common in all surgical hospital wards, but now become a rare phenomenon wherever the leaven of the Listerian spirit has permeated surgical practice. This form of microbial colonization of the entire human body baffles every plan of treatment, and almost invariably leads to the destruction of the organism. It is as good as incurable, hut it can be prevented ; hence it is the moral duty of every physician to do everything in his power to avert this form of mischief. Note. — Recovery of a case of well-developed pt/cemia is so rare that recording the following case seems permissible. The notes were kindly furnished by Dr. A. Caille, with whom the author saw the patient in consultation at his home in Williamsburg : " Henry Huhn, an elderly man. Enormous carbuncle over left scapula ; necrosis of fasciae and subcutaneous connective tissue from clavicle to seventh rib posteriorly, the result of three weeks' neglect (poulticing). "Energetic treatment (by Dr. Caille) with knife and irrigation (carbolic). Well-marked symptoms of pyaemia ; general furunculosis of trunk. "Auffust 16, 1S80. — Consultation with Dr. Gerster, who advised tonic treatment and daily full baths in loeak hichloride-of -mercury solution, together with frequent irrigations with cam- phorated water. Temperatures at this time on an average 102° Fahr. Pulse, 120 to 140. Dysp- noea, chills, and sweats. Improvement noticeable, but slow. In September, suppuration of almost all the lymph-glands took place within one week, without redness or tenderness, so that at one time a tenotomy knife introduced almost anywhere would draw pus. Subsequently exten- sive and painful periostitis and abscess at upper third of right tibia developed. About this time examination of urine revealed a large percentage of sugar. The patient's diet was properly regulated, and his urine was free from sugar five months later. Mr. 11. has since been, and is to-day (December 23, 1886), in excellent health." It will be noticed that a methodical use of a mercuric lotion was advised by the author sev- eral years before Kuemmel's and Schede's experiments brought corrosive sublimate so promi- nently to the notice of the medical world as an excellent disinfectant. The recommendation was based upon the long-known good influence that corrosive sublimate has upon acne pustu- losa of the face. Its application in the shape of a full bath suggested itself by the extension of the affection to almost the entire skin, and by the enormous difficulty in cleansing and dressing the innumerable sores of the patient. Since that time the author has employed the permanent bath in another similar case, to the great relief of the patient and his attendants. Twice daily the bath was charged with corrosive sublimate (1 : 5,000) for an hour, after which the solution was drawn off, and substituted with a weak salicylic lotion. The remarkable relief brought about by the immersion of the entire body was due to the circumstance that, f7-si, the frequent and extremely painful change of dressings could be dispensed with ; and, secondly, that, accord- ing to hydrostatic law, the buoyancy of the immersed body relieved to a very great extent its presszire upon the couch spread in the bottom of the bath-tub. The spread of the bed-sores ceased. Before his attack, the patient had been in very weak health. After three or four seiz- ures by collapse, relieved by increase of the temperature of the bath to 110° Fahr., he suc- cumbed to heart failure. The contents of the preceding pages have in a rough way illustrated the essence of cellular phlegmon, or the suppuration of connective tissue, inele- gantly denoted in text-books as ''cellulitis.'" For obvious reasons lymphatic glands very often become the seat of microbial proliferation. Their direct communication with a numerous set NATURAL HISTOEY OF IDIOPATHIC SUPPURATION. 197 of lymphatics and their filter-like structure naturally lead to ready absorp- tion and detention of noxious substances. In this characteristic is to be sought a by no means insignificant protective quality of the lymphatic glands against general invasion of the body by microbial masses. The difference exhibited by lymph-gland abscesses in comparison with the ordinary forms of phlegmon is due to their anatomical structure and situation. Their strong capsule will resist destruction for a comparatively long time, thus preventing for a while invasion of the vicinal tissues. But the internal tension of a glandular abscess soon becomes very great, and will lead to extensive mortification by compression of vessels. The anatomical situation of many lymph-gland abscesses, their deep seat and close vicinity to large vessels, the pleura, the fauces, and larynx, invest them with additional importance, both as regards the danger peculiar to their locality, and the technical difficulty of their treatment. The skeleton is fortunately a comparatively rare seat of bacterial infec- tion. The fearfully dangerous and destructive character of acute infectious osteomyelitis, or "bone phlegmon," is due to the rigidity and unyielding nature of the periosteum and bone tissue, which lead to rapid occlusion of the blood-vessels, and extensive, often widely disseminated necrosis. The deep situation of the bones renders the symptoms of this form of suppuration ex- tremely violent and dangerous, and increases the difficulties of treatment. Note I. — The so-called habituation of butchers, cattlemen, and anatomists to infection seems to be based rather on structural changes of the skin of their hands frequently exposed to con- tamination, than to a real habituation, such as is, for instance, brought about by vaccination against the small-pox. That the system of these persons does not become hardened or accus- tomed to the septic virus is proved by the fact, that phlegmonous processes will readily establish themselves, and develop in the ordinary way, if the infection occur elsewhere than on their hands. A more plausible explanation of this apparent immunity will be found in the state of the lym, phatics of the integument. Having been the seat of frequent more or less intense attacks of inflammation, they become obliterated and distorted, as it were, by cicatricial changes in and around them. That recent or old cicatricial formations do not possess large-sized lymph-vessels is well known, hence absorption through them of corpuscular elements into the deeper lymphatics will be difficult and scanty. In short, the chronically inflamed state of the skin covering the hands of these persons offers in its infiltrated condition an effective protection against the deep- going or massive implantation of micro-organisms through superficial lesions. Parallel with this state of things seems to be the well-known fact that children subject to frequent attacks of septic tonsillitis or diphtheria rarely succumb to the disease. Penetration by bacterial elements of the dense cicatricial tissue left behind by many preceding attacks is difficult, and absorption of the ptomaines through the scanty lymphatics is very limited. Hence the process soon becomes exhausted through lack of pabulum lo the microbial growth. A cer- tain quantity of viable spores remain imbedded in a follicle, to again develop their activity as soon as a simple catari'hal inflammation of the pharynx will have prepared the soil for their renewed growth. Diphtheria in children who never had been subject to the disease is a much more serious matter. Unchanged tissues with open lymphatics are attacked here. The conditions for local microbial proliferation and invasion of the tissues, and for absorption and systemic intoxication, are much more favorable then, and, as is well known, often lead to unavertable death. The comparative safety of all operations performed within the limits of a preceding but terminated inflammation — that is, within recent or older cicatricial tissue — is very well known to all surgeons. Rearaputations, many joint exsections, almost all necrotomies, rarely give any 198 KULES OF ASEPTIC AND ANTISEPTIC SURGERY. serious trouble, even if the antiseptic measures taken were not very complete. The infection of an amputation wound made through healthy tissues is much more serious, and its avoidance more difficult, as countless lymphatics and large, newly opened, intermuscular, loosely knit connective-tissue planes offer numerous recesses and countless channels for the reception and unimpeded extension of infection. Therefore the statistics of amputation wounds have been very appropriately selected as a uniform and reliable test of the value of the different forms of wound treatment. Note II. — Infection through minute injuries to a gramdating surface by inoculation of active micrococci is the frequent cause of suppurations interrupting the course of repair. Rough treat- ment of a granulating wound by tearing off the adherent dressings will necessarily lacerate the tender granulations matted into the meshes of the fabric, thus causing minimal hcTmorrhage. If an unclean probe, or finger-nail, or nitrate-of-silver stick, previously used on a virulent case, and then applied to the granulations, should carry and deposit some active micrococci into one of these minute lesions, an ulcerative process of the granulations will ensue, and, if the ulcera- tion extend into adjacent tissues, phlegmon will develop. Gramdations should always he covered by " protective ^^ before the application of gauze or other dressings. Conclusions. Suppuration is always undesirable and dangerous, and, if possible, should be avoided by all means. Its essence is textural destruction and death, and systemic intoxication. The i:)hrase " healing by suppuration " is an absurd- ity, is misleading to the student, and should be banished from text-books. As a matter of fact, healing never takes place while active suppuration lasts ; it occurs only after the limitation and termination of suppuration, not by it, but in spite of it. The expression "laudable pus," as applied to the contents of an abscess during one of its stages of spontaneous limitation or maturing, is also mis- leading. Pus is never laudable ; it always is a menace to the health and integrity of the animal organism. Suppuration is a treacherous ally, and its aid should never be invoked by the modern surgeon, or at least should be shunned as long as other ways of curing an ailment remain untried. VI. DIAGNOSIS AND TREATMENT OF PHLEGMON. 1. General Priticiples. The way to the cure of phlegmonous processes is indicated by the man- ner in which unaided nature occasionally accomplishes it. If the direction in which suppurative destruction progresses should luckily be outward — that is, toward the skin — perforation and spontaneous evacuation of the abscess cavity will occur. If by another lucky accident this perforation should happen at the time of "maturity," or the comparative repose of the destructive process, a complete evacuation of the deleterious contents will take place, followed by a decreasing sero-purulent and bland discharge, and by contraction and final occlusion of the cavity. But nature unaided is a very poor surgeon. Very often destruction does not tend toward the skin ; its natural tendency is to spread in the di- rection of least resistance, that is, along the cellular tissue, and, by the time that spontaneous ojoenings establish themselves, the damage to deep-seated DIAGNOSIS AND TREATMENT OF PHLEGMON. 199 organs may be very extensive. The coincidence of maturity and perforation is also rare. In its absence the perforation will not lead to complete evacua- tion, and the septic process will persistently extend in one or another direc- tion, not relieved by such incomplete drainage. Lastly, natural drainage by perforation will often be located in the most unfavorable place, and will not be ample enough for the escape of large masses of pus and of sloughing tissue. The most direct indications for the cure of phlegmon are offered by a clear understanding of the natural history of its causation and development, as presented in the foregoing pages. One or more properly made incisions, folloiued hy effective drainage, will at once empty the focus of most of its infectious contents, relieving at the same time the dangerous amount of tension. Infected tissues not yet liquefied, and still adherent to the walls of the abscess, must be disinfected by more or less frequent or permanent irriga- tion with a germicidal lotion. Finally, all conditions tending to impede free arterial and venous circulation must be eliminated by projDer position — that is, elevation of limbs, removal of constricting dressings or clothing. The necessity of rest — that is, the avoidance of all mechanical injury — is a matter of course. («) Superficial Suppuration, or Septic Ulcer. — Inspissation of the dis- charges of an infected superficial lesion will, by the formation of a crust, often prevent proper drainage, causing a more or less complete occlusion or retention. The gentlest way of detaching these is by the application of a warm dressing of gauze moistened with a two-per-cent solution of carbolic acid, evaporation of which should be guarded against by an external layer of rubber tissue or oiled silk. After due softening under this warm, moist dressing, the overlapping epidermidal masses, hiding small recesses, should be laid open by cautiously clipjiing away their undermined edges with curved scissors. Tills can he done ivWiout causing the least 'pain. Thorough dis- infection by the lotion contained in the dressings will thus be possible, and the diffusible qualities of carbolic acid will not fail to exert their beneficial disinfecting influence upon the germs scattered through the vicinity of the ulcer. Its yellow coating, consisting of a superficial layer of mortified tis- sues, will be cast off, the angry look of the neighboring skin will disappear, and the remaining healthy granulations will soon be cicatrized over. StreaTcs of lymphangitis extending toward the pertinent lymphatic glands should be well salved with mercurial ointment. But if their cause — the septic state of the ulcer — be removed, they will disappear without special treatment. {b) Cutaneous and Subcutaneous Phlegmon. — This graver form of sup- puration is marked by violent local and general symptoms. High fever, with rigors, the general sense of sickness, headache, and a foul tongue and breath are present. The skin over the focus of infection becomes deeply inflamed, cedematous, and shows dense infiltration, manifested by hardness and pitting. The constant gnawing pain puts sleep out of the question, and the spreading of the affection over new areas of tissue is evident. 200 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Cataplasm or Incision ? The question whether resolution of the gathering by topical applications, hot or cold, should be attempted, or immediate incision should be resorted to, is of great practical importance, and not always easy to determine. The intensity and extent of the process should he herein the main guide. The consideration that an incision is after all the most effective antiphlo- gistic measure, affording relief from tension, evacuating a very large pro- portion of the noxious substances, and permitting the direct application of antiseptics — in short, that it promises prompt success, conserves a large part of the affected tissues, saves much pain and suffering, and averts local and general danger — should stand foremost in the surgeon's mind, whose per- suasive authority ought to gain the patient's consent to an early operation. Especially w^here the rapid spread of the affection and grave general symp- toms make prompt relief urgent, dilatory measures and cowardly tempor- izing are improper. The cataplasm is resorted to not only to allay the patient's paiti and fear, but often serves as a convenient mantle to hide ignorance or indecision. Carbuncle represents the most pronounced form of cutaneous phlegmon, and its treatment, given hereunder, may, with due modifications, serve as a type of the therapy for the entire class of cutaneous suppurations. Out of motives of humanity, and because it offers the surgeon time and deliberation, so necessary for thorough work, aneesthesia is always advisable, — in many cases indispensable. After the usual prejiarations for an anti- septic operation, a free incision should be made through the middle of the inflamed area, penetrating through the skin to the fascia. One or more small foci filled with pus will be thus opened. If their number be great, two or three more parallel incisions should be added. The engorgement or hard infiltration of the adjacent skin will be admirably re- moved by Yolkmann's multiple punctur- ing (Fig. 141). The blade of a narrow, straight bistoury or tenotomy knife is grasped about one third of an inch from its point, and is thrust in quick succes- sion thirty, forty, or, in very extensive cases, a hundred times through different parts of the infiltrated region. The punctures should be evenly distributed. A large quantity of bloody lymph, or occasionally, if a vein be hit, pure blood will escape, and the swelling and hardness will at once be markedly reduced. No attempt should be made to check this escape of blood or serum, as coagulation will soon stop the flow. Thorough irrigation with corrosive-sublimate lotion, packing of the deeper incisions with strips of iodoformed gauze, and an ample moist Fig. 141. — Attitude of the hand for multiple puncture. DIAGNOSIS AND TREATMENT OF PHLEGMON. 201 dressing, held in place by loose turns of bandage, will complete the work. An immediate fall of the temperature, with marked local and general relief, will reward both patient and surgeon. Daily, later on, a rarer change of dressings will lead to a rapid cure. If the patient declines an operation, tojDical applications are in order. Cold, in the shape of iced compresses, or the ice-bag, will be proper where the affection is superficial and accompanied by lymphangitis. On the whole, it may be said that cold is beneficial in the initial stages of most phlegmon- ous affections, and is often very well borne and efficacious in the milder forms. To many it becomes unbearable from the time that suppuration is well established, and often induces a severe chill, the real cause of which, ■however, is always to be sought in the presence of pus. Note. — Cold is badly borne by elderly or run-down subjects, or those prone to Theumatism. Dry or moist heat is very soothing to many patients, and is a power- ful stimulant to the local circulation. Occasionally it undoubtedly averts threatening suppuration, and may aptly be employed as a tentative or initi- atory measure. However, if the local and general symptoms continue to increase, it should not beguile the surgeon into procrastination. Especially if a gathering become so massive as to cause fluctuation, incision should not I)e further delayed. Note. — The main effect of the curious and often incomprehensible combinations of sub- stances entering, at the recommendation of laymen and some physicians, into the composition of poultices, seems to be upon the faith and imagination of the patient. Moist heat is their active property, and, the simpler and cleaner its employment, the better it will be. The nauseous prac- tice of smearing the skin, or, still worse, a wound, with hot linseed dough, is not yet extinct. Even a well-inclosed poultice is not a proper covering to a wound, unless a clean cloth and clean mush be taken for each application. Certainly a mixture of soured linseed with ichor and pus, inclosed in a foul rag, is the worst of all abominations that a decaying era of surgery has left "behind as its legacy. A clean cloth dipped in and wrung out of hot water, covered over with a piece of oiled silk, is the best, the cheapest, and the least unappetizing of all cataplasms. The cataplasm should never be placed in actual contact with a wound. The interposition of a thin, moist dressing will protect the wound from mechanical insults unavoidably connected with the ■change of poultice, and the poultice itself will thus remain unsoiled by the secretions of the "wound. For sjDecial treatment of carbuncle, see i^age 224. Subcutaneous phlegmon, left to itself, or treated by too long poul- ticing, will assume very large proportions. The form of the abscess cavity is rarely globular, but mostly irregular and sinuous. This is partly due to confluence of several smaller abscesses, partly to irregular extension, caused \)j the varying density of the subcutaneous connective tissues. Fluctuation soon appears, and without delay one or more incisions should be placed so as to drain every recess in the most direct manner. Volkmann's punctua- tion of the peripherical infiltration of the skin, a thorough irrigation of the cavity, and a moist dressing, constitute the treatment of these cases. The first incision is made where fluctuation is most marked ; the index-finger of the left hand is then cautiously inserted, and carefully explores the interior 202 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. of the abscess. This examination is very important, and upon its result depends the locating of the drainage-tubes. Counter-incisions are made over the tip of the left index, which pushes up the skin from witliin. AU squeezing of the abscess at this stage of the operation should be carefully avoided. After the placing of the drainage-tubes, and a thorough irriga- tion, no pus should be contained in the abscess. If, therefore, gentle external pressure ^causes the escape of new masses of pus, this is a sign that one or more recesses, communicating by small openings ioith the main cavity, remain undrained, and need further attention. They must be located, and separately incised and drained. If fluctuation persist over one or more places in the vicinity of the cen- tral abscess, it will be found that unopened, independent abscesses require additional incisions, f iG. u^.-Hikcm-Eoser^s method of incL-ing a rj^j^g j.Q^^g|^ tearing and break- ing down of septa of tissue with- in the abscess by the surgeon's finger is unsafe, on account of the unnecessary haemorrhage it provokes, and because it may lead to pulmonary embolism. It is better to make a sufficient number of counter-incisions. TJte squeezing out of abscess- es through an insufficient spon- taneous or artificial opening con- stitutes what may be called sur- gical barbarism. If the opening is too small or improperly placed, the abscess can never be di'ained by the aid of the law of gravity alone. External pressure must be employed to remove its con- tents, and this must be often repeated to prevent refilling of the abscess. As "squeezing out" is a very painful process, the pa- tient will naturally shrink from it, and will let matters go. The abscess becoming nearly filled, only the overflow will escape through the insufficient aper- ture. The result is slow exten- sion of the suppurative process, with continuous fever. Dressings of any kind will only make matters worse, and no relief will follow till another more properly located artificial or spon- taneous opening supply the defect of drainage. Fig. 14-3.— Completed dressing of cervical abscess. DIAGNOSIS AND TREATMENT OF PHLEGMON. 203 Fig. 144.- -Underpadding of safety-pins thrust through* drainage- tubes after incision of cervical abscess. The best proof of the adequate treatment of an abscess is the fact that at change of dressings the cavity is found empty, and all the secretions are contained in the dressings. The frequency of the change of dressings should be regulated by the amount of the dis- charge. (c) Deep - seat- ed or Subfascial Phlegmon. Lymph- Gland Abscess. — Still more serious than subcutaneous suppuration is a phlegmonous in- flammation of the superficial or deep-seated lymphatic glands, or the sub- maxillary or the parotid salivary glands. The danger of these forms of septic tissue-decomposition consists in the great tension which their pois- onous contents attain ; the difficulty of their spontaneous evacuation on account of the massive barriers interposed between them and the surface of the body, and last, but not least, the likelihood of their perforation into the mediastinum, pleura, or peritonaeum, or the erosion of large vessels situated in their immediate vicinity. Deep-seated phlegmon is characterized by the extremely hard and deep- going infiltration of the superjacent tissues, a general and massive cedema of the soft parts, extending far beyond the limits of the inflammatory pro- cess, so that a limb, for instance, attains double its size ; marked functional disability of all organs, even distantly related to the focus of disturbance, and very violent symptoms of systemic septic poisoning. In the beginning the skin covering the affected locality is oedematous but pale ; gradually it flushes up and becomes hard and brawny. Incision and drainage is the sovereign therapy in these cases. No time should be wasted in attempts at an abortive treatment, as every hour of delay may cause irreparable damage. The distant hope of resolution, or the desire to produce "maturing" by poulticing, should not be allowed any weight in the face of the knowledge that extensive necrosis is the unavoida- ble consequence of the raj^idly increasing dense infiltration characteristic of this condition. Relief from excessive tension is the first and most urgent indication, and this can be reached only by an incision. The objection that these abscesses can not be opened safely while they are small, is erroneous, as will be shown directly. But, even if the surgeon should not succeed in opening the small cavity, cutting through the integu- ment and fascia will do material service by averting the greatest danger. 28 204 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. HiUon-Roser^s method offers a safe and easy manner of evacuating these foci. Anaesthesia is, of course, indispensable. A free incision through the skin over the most prominent part of the swelling should expose the fascia, which should also be divided by easy strokes of the point of the knife to a sufficient extent, say an inch or two. After this the knife is laid aside. If a small aspirator be at hand, search for pus can be made by puncturing and aspirating different parts of the swelling. This, however, is not necessary. A grooved director is inserted into the center of the incision, and is briskly thrust into the swelling, or, if large vessels be near, is gradually insinuated by steady rotating pressure. At a certain point resistance will suddenly cease, and a drop of ichor or pus will be seen exuding from the groove of the instrument. A dressing-forceps should now be placed in the groove of the director, and should be pushed into the focus. The grooved director can now be removed, and the forceps withdrawn while its branches are held as wide open as jDOSsible. A gush of bloody pus will follow the instrument. If the opening be too small, dilatation with the dressing-forceps should be repeated once or twice, until it becomes large enough to admit a stout drain- age-tube. Irrigation and a moist dressing complete the procedure. (Figs. 142, 143, and 144). If the incision was delayed too long, the relief of the general symptoms will not be as prompt as after early operations. The presence of adherent necrotic tissues explains this fact. But the spread of the mortification is checked, and the fever will abate as soon as the sloughs become detached and expelled. Very numerous applications have taught the author the great value and safety of this method, wliich, therefore, can be warmly recommended. Fluctuation is a very late symptom in all deep-seated abscesses, and should not be waited for. An explorative aspiration of a doubtful swelling will generally disperse uncertainty, and the production of pus will induce the patient to consent to the incision. The haemorrhage from large, deep-seated abscesses is sometimes copious. It comes from the walls of the abscess cavity, which are very vulnerable ; hence rough exploration, squeezing, or any unnecessary manipulations should be carefully avoided. Note. — It is best in cases of great emaciation to open the abscess according to Hilton-Roser — to insert a large-sized tube, and to desist altogether from exploration and irrigation until a few days later. The cavity will contract, its contents will spontaneously escape toward the point of least resistance — that is, through the drainage-tube— to be absorbed by the dressings, and much blood will be saved in this manner. Phlegmonous Erysipelas. — A combination of extensive phlegmon with true erysipelas is not very common. What is ordinarily known as "phleg- monous erysipelas" is generally nothing but a very extensive subcutaneous phlegmon, mostly with, sometimes without, subfascial complications. The worst cases are directly chargeable to prolonged poulticing, and their treat- ment is rendered very difficult by the frequent occlusion of the drainage- tubes by large tow-like masses of necrosed connective tissue and fascia. DIAGNOSIS AND TREATMENT OF PHLEGMON. 205 Gangrenous phlegmoji (Pirogoff's acute purulent oedema) represents one of the highest degrees of microbial poisoning, where the multiplication of the micro-orijanisms is so rapid and pervad- ing that the establish- ment of innumerable foci throughout all of the tissues composing a whole limb leads to ex- tensive general infiltra- tion. Board-like hard- ness, a dusky hue of the integument, blebs and ecchymoses, and finally, thrombosis of veins and arteries, will end in necrosis of the entire enor- mously swollen and cold limb. Incisions do not yield pus, but only give vent to scanty quantities of turbid ichorous serum. In these cases the prognosis is very bad, and Fig. 145. -Bacilli of malignant cedema or acute progressive phlegmon (TOO diameters). (Koch.) Pig. 146. — Bacilli of malignant cedema in the kidney (700 diameters). (Koch.) the most heroic incisions rarely succeed in saving the member. If too long delayed, even a high am- putation may fail to save the patient's life. (Figs. 145 and 146.) Empliysematous Gan- grene. — The inoculation of the human organism with a specific bacterium (Fig. 134) is generally followed by the development of a dusky, rapidly spreading infiltration, exhibiting on palpation the peculiar crackling, and on percussion, the tympanitic sound of subcutaneous emphysema. The process is accompanied by profound septic intoxication, with delirium, high temperatures, chills, and dejection, and terminates in gangrene of the affected parts. Eesolute measures — that is, timely amputation performed through healthy parts — may succeed in preventing a fatal issue. {d) Acute Infectious Osteomyelitis. — Suppuration of the medullary sub- stance of parts of the skeleton represents one of the most dangerous and destructive forms of phlegmon. Its cause is the establishment of cult- ures of the gold- colored grape-coccus in the capillaries or arterioles of the marrow. The manner in which this infection occurs is still matter of controversy. So much, however, is known that it is most common during adolescence, and that a preceding suppuration, followed by exposure to weather, or certain traumatisms, are common provocative causes. The invasion is marked by a severe chill, followed by a deep alteration of the general well-being. Very high temperatures, with chills, somnolency. 206 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. a dry tongue, foul breath, intense gastric disturbance, bear witness to the gravity of the disorder. The insidiousness of the local and the gravity of the general symptoms lead to frequent errors of diagnosis on the part of practitioners who never have seen this affection, or are careless observers. The favorite locality of the disease is the shaft of the long bones near one or another ejiiphysis, as, for instance, the lower end of the femur. This, together with the upper part of the shaft of the tibia, is its classical seat. No bone, however, is exempt from the disorder. The first local manifestation is a deep-seated, unbearable pain, soon fol- lowed by a general and deep-going oedema of all the soft parts overlying the focus. The skin is pale. As the soft parts covering the adjacent joint are also swollen, and its movement is painful, the erroiieoiis diagnosis of acute articular rheumatism is frequently made. Often the patient is unconscious or quite listless at the time of the phy- sician's first visit, and the local symptoms escape attention. As a matter of fact, typhoid fever or meningitis is frequently diagnosticated, and the affection remains unrecognized until the appearance of a fluctuating swell- ing or, in extreme cases, spontaneous perforation of an abscess disjiel the error. The essential features of the morbid process are identical with those of cellular phlegmon, modified, however, by the peculiar structure of bone. On account of the rigidity of the osseous lamellae inclosing the Haversian canals ; of the cancellous and cortical substances inclosing the medullary tissue, and of the periosteum, the dense infiltration and massive exudation will rapidly heighten the intraosseous tension to such a degree that, the ves- sels becoming occluded, more or less extensive necrosis results. The excessive tension of the noxious exudations penned up within the rigid tissues will cause a copious overflow and absorption of plasm charged with ptomaines, which will not fail to cause a jjrofound intoxication, mani- fested by very grave general symptoms. Cortical osteomyelitis, or what is known in text-books as suppurative periostitis, is the mildest form of the affection, and is most amenable to preventive treatment. The necrosis caused by it generally involves the outer part of the bone only, jDroducing a cortical sequestrum. When the epiphysis is attacked in the vicinity of a joint, perforation and articular suppuration may occur and very seriously complicate the case. Case. — S. C, aged twelve, a somewhat ansemic boy, received, December 19, 1882, a kick from a playmate upon the spine of the tibia, which caused considerable pain for a while, but no discoloration. The next day a severe chill, with intense local pain and an extensive hard swelling of the injured region, set in. The boy became listless and delirious ; he rapidly emaciated ; the swelling extended in all directions. The author saw the patient December 29, 1882, in consultation with the family attendant, who, two days previous to this meeting, had made a small incision corresponding to one of the many points where perforation of the skin threatened. The boy being anaesthe- tized, a free incision three inches in length was made by gradual preparation down upon the anterior surface of the tibia, beginning a little below the patella. Every bleeding DIAGNOSIS AND TREATMENT OF PHLEGMON. 207 vessel was carefully tied at once, and thus clear insiglit and much bloodsaving were ■effected. A large ulcerative defect of the periosteum was found corresponding to a well-circumscribed greenish-yellow spot of the tibia. This defect extended to the cap- sule and into the knee-joint, which was found in open communication with the sub- periosteal abscess, and was distended with pus. Two incisions were made into the joint for purposes of drainage. The popliteal space, thigh, and calf contained a num- ber of burrowing secondary abscesses, mostly subcutaneous, which were also severally incised and drained. The entire major saphenous vein was found in a state of puru- lent phlebitis, its course being marked by a chain of small, angry-looking swellings of the skin, which, on being opened, all yielded pus. As it was probable that the entire vein would suppurate, it was slit up, beginning from the ankle, to within a few inches •of Poupart's ligament, and the remaining parts of the thrombus were turned out. The "haemorrhage from entering branches was checked by packing with narrow strips of iodoformed gauze. A very tardy improvement followed these extensive measures. Jawiiary 10, 1883. — A third incision into the upper recess of the knee-joint, and two more counter-incisions were made into the popliteal space. Large masses of necrosed connective tissue came away at almost each change of dressings, and, although the febrile disturbance had much abated, the boy seemed to steadily lose ground on account ■of the enormous suppuration. The cleansing of the wounds was so slow, the pain and suffering at the unavoidably frequent change of dressings so distressing and enervating to the patient, that, January 14th, amputation was thought of as a last resort. The parents, however, firmly declined the step, and fortunately so, as the boy ultimately recovered, with anchylosis of the knee-joint. A few small shells of necrosed bone came Away from the epiphysis previous to the definitive closure of the wound. Central osteomyelitis is much more destructive to the osseous tissue than the cortical affection, often causing necrosis of the entire shaft. It fre- quently extends to the epiphysis, and involves the adjacent joint. Note. — The excruciating pain felt by the patient is principally due to the tension of the periosteum, separated from the bone by more or less pus. Ordinarily, the extension of suppura- tion by perforation into healthy parts is marked by an increase of the local and general suffer- ing. Not so in osteomyelitis. Perforation of the periosteum, and evacuation into a loose plane of connective tissue, is always marked here by relief of the intense periosteal pain, and often by a, temporary decline of the fever, due to the reduction of the enormous tension which first pre- vailed. With the increase of the tension in the secondary abscess the fever rises again, but the pain never reaches its former intensity. Similar relations obtain in all forms of suppuration where the seat of the morbid process is confined by dense fascia or the capsule of a joint. Submaxillary and parotid cynanche, septic inflammations within the prepatellar or olecranic bursge, and all joint-suppurations exhibit the same peculiarity. As long as the suppurative process is confined within the mentioned closed spaces, the tension and its immediate consequences — necrosis and copious overflow of fever-gen- •erating poisonous material into the lymphatics, causing intense toxic symptoms — are at their acme. As soon as perforation and partial evacuation of incarcerated pus into the meshes of the vicinal loose connective tissue occurs, a relaxation of the intense pain and a temporary remis- sion of the septic fever are observed. Can Necrosis he averted ? — Where the diagnosis is made out early, where the superficial situation of the bone — for instance, the tibia — favors a precise localization of the focus, and where the affection is cortical, a free and early incision may avert, and, as a matter of fact, often does avert, necrosis, or at least will prevent its extension. In the beginning, perhaps, even the ravages of central osteomyelitis could be limited by early trepanning of the medul- 208 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. lary space in one or more places. So much is certiiiu and proved by experi- ence, that prompt incision of the periosteum and trepanning of the affected bone admirably relieves the acuity of the local and general symptoms. Case. — The author has to quote from memory a very instructive case of recent infectious osteomyelitis of the lower end of the humerus observed in 1880 in the surgi- cal department of the German Dispensary, and operated in the presence of Dr. W. Bnlser and other colleagues. A young woman, exhibiting an unusual degree of lassi- tude and a pitiable facial expression of suffering, was led into the place by two of her friends. Her left elbow -joint was semiflexed; it showed a pale, dense, and uniform swelling. Her attendants reported that she had had a severe chill in the morning of the preceding day, and had been very sick ever since then. The thermometer showed 105° Fahr. in the axilla. Extremely acute pain was complained of in the lower end of the humerus. Just above the olecranon. Osteomyelitis being diagnosed, the patient was anaesthetized. A good-sized hollow needle being inserted until its point was caught by the bone at the site mentioned, a drop or two of thick pus appeared in the barrel of the hypodermic syringe. An ample incision was carried along the outside of the triceps tendon down to the bone, whereupon about two drachms of pus escaped. The periosteum was found detached, and, being deflected by an elevator, was found turgid and deep red, except at the place of detachment, where it was broken down and green- ish-yellow. Profuse oozing took place from the exposed bone and periosteum, except- ing an irregular area of bone covering about two square inches just above the posterior supratrochlear fossa. This area was grayish yellow, and did not bleed— in short, was necrosed. The wound was loosely packed with carbolized gauze, and was enveloped in a moist dressing. The patient was taken to her home, whence she was removed the following day to a hospital by her relatives, because she was too sick to be taken care of at home. The author was assured that her mcessant moaning due to the excruciat- ing pain had stopped during the night following the operation. Some years ago the author saw a fatal case of pelvic osteomyelitis in consultation with Dr. H. Kudlich. The patient succumbed to the violence of the initial symptoms — that is, to acute septicaemia. The seat of the disease was the sacrum and os ihum of a very muscular man. Very intense sciatica and liigh fever composed the initial symp- toms. Enormous oedema of the left thigh and inguinal region appeared a short time before death, revealing the nature of the aflfection, which until then had baffled attempts at diagnosis. The pelvis was found occupied by phlegmon extending below Poupart's ligament. The probable source of the infection was a recrudescent suppurative otitis media of old standing. The subject is full of difficulty and surrounded by many drawbacks in all its aspects. The impossibility of an early and precise diagnosis as to location, the depth, and often the inaccessibility of the seat of the disease, will render many cases impracticable for preventive treatment. Secondary abscesses must be incised and drained as early as possible according to rules above given. (e) Chronic Suppuration due to Bone Necrosis. Necrotomy. — The most common seats of acute osteomyelitis and subsequent bone necrosis are the femur and tibia near the knee-joint. This fact may perhaps be explained by the circumstance that the upper epiphysis of the tibia and the lower epiphysis of the femur ossify much later than the other epiphyses of these bones. The active growth and DIAGNOSIS AND TREATMENT OF PHLEGMON. 209 Ir^f Fig. 147. — Necrotomy of tibia. Leg placed on a hard cushion, playing trom the right. Irrigator abundant blood-supplj near the knee-joint seem to favor the importation and deposition there of active micrococci circulating with the blood. ]Slext in frequency of be- ing attacked is the lower jaw near the angle, and the upper end of the shaft of the hu- merus. Note. — Very likely the different arrangement of the nutrient vessels of the bones of the upper and lower extremities has a certain influence up- on the frequency of the location of osteomyelitis near the knee and shoul- der joints. The nutrieiit vessels of the femur and tibia diverge from the knee -joint ; those of the humerrus and the hones of the forea^rm converge toivard the elbow* The direct and abundant blood-supply of the malleoli and the coxal end of the femur seems to cause an earlier consummation of the osteogenetic process at these localities, and also makes them liable to a form of infection peculiar to the infantile period of life — namely, tuberculosis. Tubercular affections of the ankle- and hip-joints are more common in children than white swell- ing of the knee. During adolescence, when the physiological fluxion toward the knee-joint pre- ponderates over that toward the ankle and hip, the tendency to osteomyelitis near and tubercu- losis near and in the knee-joint becomes more pronounced. Similar relations seem to prevail in reference to the upper extremity. During infancy white swelling of the elbow is more common than that of the shoulder and wrist-joints; in adolescence the upper end of the humerus is the common seat of acute osteomyelitis ; in adults the shoulder and wrist are more frequently attacked by tuberculosis and osteomyelitis. Whenever an attack of osteomyelitis terminates in the formation of an abscess and the establishment of one or more fistulse, the acute features of the initial stages of the disorder disappear. The abundant discharge of pus is followed for a while by a gradual decrease of secretion, which again in- creases as the separation of the sequestrum becomes more and more com- plete. This is explained by the fact that, as the dead bone becomes gradu- ally detached, the pus-generating surface of the cavity containing the sequestrum becomes proportionately larger. In the mean time new osseous substance is thrown out by those portions of the adjacent bone and peri- osteum which were not destroyed by suppuration, and thus a more or less perfect involucrum is formed around the sequestrum. After complete de- tachment of the sequestrum, suppuration is generally profuse. Hyrtl, "Descriptive Anatomic," 18Y0, p. 209. 210 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. 148. — Diagram of a transverse section, showing relations of sequestrum, involu- crum, fistula, and skin. If the affection is extensive and no spontaneous or artificial relief is vouchsafed for a long period, a deep deterioration of the general health will follow, characterized by emaciation, anaemia, albuminuria, and in extreme cases by amyloid degeneration of the liver and kidneys. The diagnosis of the presence of a sequestrum can be made by noting' the diffuse thickening of the affected bone, the profuse secretion from one or more fistulae, and by direct prob- ing. If the direction of the sinuses be straight, the silver probe will strike bare and roughened bone-surface. The latter symptom, however desirable for the establishment of a positive diagnosis, is not absolutely necessary to it. Indeed, the cases are quite common where tortuous chan- nels prevent direct probing. Detachment of the seques- trum is indicated by its mo- bility under the pressure of the probe-point, or, when probing is impracticable, by the long duration of the trouble and the increasing or profuse dis- charge. Wlien to Operate. — It may be laid down as a general rule that the best time to perform sequestrotomy is after complete detachment of the dead bone, which can be ascertained either by probing or by the general aspects of the case. Recognition of the necrosed parts and their complete removal are then easy, and will be followed by a rapid cure. This rule, however, ad- mits of important exceptions. Note. — Extensive necroses of the lower jaw are frequently ac- companied by a profuse discharge of fetid pus into the oral cavity. This and the inability to masticate food, do frequently render early relief by operation very desirable. The objection that to perform a complete operation will necessitate the sacrifice of healthy bone is not tenable. Fig. 149. — Xeuber's niethod. Top of involucrum re- moved, skin-flaps turned into the bottom of the bone-cavit\^ Fig. 150. — Schede's method. Diagram showing relations of organ- izing blood-clot. DIAGNOSIS AND TREATMENT OF PHLEGMON. 211 as it may be urged that even an incomplete operation, if it only accomplish the removal of the greatest portion of the sequestrum, will be followed by a decided improvement of the patient's condition. After a while, a secondary operation can be done under more favorable circumstances. Similar considerations may also indicate an early sequestrotomy in other regions. Neckotomy. — Artificial ansemia by Esmarch's band and antisepsis have marked important changes in the technique of sequestrotomy. Control of the hgemorrhage, and the possibility of healing even the largest sequestrot- omy wounds without suppuration, justify a deliberate search after detached foci containing sequestra by thorough exposure of the interior of the affected bones. Long incisions and a free use of mallet and chisel are proper. A compressive antiseptic dressing will insure against secondary hmmorrhage. The formation and maintenance of a moist blood-clot in the wound will bring about rapid filling up of the cavity by new-formed bone, and will terminate in firm and speedy cicatrization. The introduction of the use of Esmarch's band has deprived extensive necrotomies of their chief danger — profuse haemorrhage. The danger of septic disturbances following necrotomy was slight even before the adoption of the antiseptic method, as the densely infiltrated state of the adjoining tissues made absorption of septic matter from the wound difficult, and their rigidity rendered efficient drainage very easy. The chief advantage of the antiseptic method is to be sought in the possibility of effecting a cure with- out the long course of suppuration formerly characteristic of the healing of these cases. Neuber's implantation of skin-flaps was the first step in the direction of accelerating the cure of necrotomy wounds. But Scliede^s methodical and successful utilization of the protective properties of the moist blood-clot is the simplest and most perfect means to the end in view. The indispensable conditions for a successful employment of Schede's method are laid down in the following projjositions : First. Thorough exposure of the seat of the disease by incision and by the use of mallet and chisel. Secondly. Complete removal of the whole sequestrum, or all the seques- tra, and of the entire pyogenic membrane lining the cavities and sinuses, by scooping and scrajjing with the sharp spoon. Thirdly. Thorough disinfection of all the nooks and crevices of the wound by a vigorous use of the irrigator and corrosive-sublimate lotion, and by wiping it out with a clean sponge. Note. — The final flushing and mopping out should always be done with the strongest solution of corrosive sublimate used by surgeons (1 : 500). Residua of this strong lotion are then washed away by a mild solution to prevent mercurial poisoning. Fourthly. The formation of a blood-clot which should fill up the wound to the level of the skin, and its preservation from putrefaction and exsicca- tion by a suitable antiseptic dressing (page 10). Note. — Leaving behind the smallest spiculum of undetected dead bone, or a shred of the pyogenic membrane, will partially or totally compromise the success of this procedure, and no amount of irrigation will avert suppuration. Fulfillment of the second proposition is not difficult 29 212 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. except in the disseminated form of necrosis, where a number of small foci, each containing its sequestrum, and all connected by more or less narrow and tortuous channels, are scattered within a wide area of the affected bone. But even these difficulties can be overcome by the exercise of circumspection and painstaking, favored by artificial anaemia, which renders detection of dis- colored bone and the entrance to bone sinuses comparatively easy. What Chisels to iise. — The chisels generally sold by surgical cutlers have little to commend them for efficient and rapid work. Their shape and size are unsuitable. ''Albert Buck's warranted chisels," as sold by most hard- ware dealers, and generally used by carpenters and Joiners, are well tem- pered and excellent. They should be fastened to an ordinary, smooth, wooden handle, without indentations, to insure the possibility of perfect cleansing. The author has found a set consisting of a one-inch, a half- inch, and a third-inch chisel, and of a one-inch and a half-inch gouge, to answer every purpose. A light wooden mallet, perfectly smooth, its head made of boxwood, can be bought in any house-furnishing establishment, and is much preferable to the small metal mallets of the instrument-makers. The Modem Manner of Performing Necrotomy. — The following descrip- tion may serve as an elucidation of the technique of a sequestrotomy. The parts being well cleansed with soap and hot water, shaved, and disinfected by mercuric irrigation, after Esmarch's band is applied, an incision is car- ried down to the bone over or near the fistulae. The length of the external incision should be proportionate to the extent of bone thickening. The thickened bone should always be attacked where it is most superficial, the site of the incision being determined rather by the question of accessibility than by the location of the sinuses. Where the bone is superficial, as, for instance, the tibia, the incision may be at once carried down to it. "Where there is a thick mass of overlying soft tissues, the incision should be gradual and preparative, and all cut vessels should be at once ligatured. The peri- osteum is pried up on both sides of the cut with an elevator, and, where it is found adherent by cicatricial tissue, is cut away, until the entire affected area is well exposed. Integument and periosteum are held back with a pair of Volkmann's retractors, and the roof of the cavity containing the seques- trum is chiseled away. This can be done very rapidly by a workmanlike use of the mallet and chisel, until the sequestrum is completely exposed. This being done, the sequestrum is lifted out of its bed with a pair of for- ceps. The irregular edges of the cavity are next smoothed off, overhanging parts are removed, so as to j^ermit a careful and thorough ocular examina- tion of all its recesses. Care must be taken not to leave behind any dead bone. The sharp spoon should be used in vigorous strokes to clear away all granulations or softened osseous tissue, until the entire wound-surface pre- sents a bleeding, clean, and healthy appearance. Debris and shreds of granulations are flushed out with a strong irrigating stream, and, to make sure that no detached particles of tissue are left behind, the cavity should be mopped out with a clean sponge. Where the operator is not certain of having rendered the cavity perfectly aseptic, it is safest not to apply suture, but to fill it with a loose jDack- DIAGNOSIS AND TREATMENT OF PHLEGMON. 213 ing of iodoformed gauze, and to swathe the limb in a moist compressive dressing. The dressing should be ample, and should contain externally a good layer of elastic material, as, for instance, ab- The turns of the roller bandage sorbent cotton. Fig. 151. Carpenters' chisels. Fig. 152. Boxwood mallet. Fig. 153. Elevator. Fig. 154. Volkmann's sharp spoon. should be tight and close, to insure a sufficient amount of elastic compres- sion as a safeguard against secondary haBmorrhage. Ample padding will prevent strangulation. After the dressing is finished, the limb is held ver- tically while Esmarch's band is removed. Note. — No alarm need be felt if the finger-tips or toes do not turn pink at once. A momentary lowering of the limb will immediately produce the flush indicative of the hyperaemia due to paresis of the vasomotor nerves. Vertical elevation by suspension or propping up should be maintained for two or three hours, till a firm clot form in the wound. Should some blood permeate the dressings and appear on their surface a short time after the 214 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. operation, then sufficient pressure was not employed. Suitable-sized com- presses of iodoformed and sublimated gauze should at once be laid upon the blotch, and should be firmly held down by a clean elastic or flannel bandage. This additional pressure by the elastic bandage should not last more than an hour. Case. — Herman Albertin, school-boy, aged nine. Central sequestrum of lower end of shaft of humerus and disseminated necrosis of lower epiphysis due to acute osteomye- litis. Necrotomy performed April 12, 1884, at German Hospital, under chloroform. A longitudinal incision five inches long, commencing at the upper third of the posterior aspect of the left humerus, was successively carried through the skin, fascia, and triceps muscle, until the musculo-spiral nerve was exposed and freed from its bed. It was taken up and held aside by a blunt hook. The periosteum was incised, turned aside, and held up by a pair of Volkmann's four-pronged hooks. The posterior face of the thickened shaft of the humerus was chiseled away, exposing an irregular-shaped central sequestrum, three inches long. The overlapping parts of the involucrum were further chiseled off, until the entire sequestrum could be easily lifted out of its place. Two small, round sequestra were removed from the lower epiphysis, and the entire trough-shaped cavity was carefully scraped out with a sharp spoon. A small strip of iodoformed gauze was placed into the most dependent part of the bone defect, and was brought out at the lower angle of the wound. The triceps, fascia, and skin were united by three tiers of continuous catgut suture. A compressive gauze dressing was bandaged around the limb, and the constricting band was removed. The arm was held in vertical suspension for two hours, and after that was placed in the semi-elevated posture on a pillow. The temperature remained normal throughout. The first change of dressings was made April 26th, a fortnight after tlie operation. The dressings con- tained only a small quantity of dried blood. The fillet of gauze being removed, a new dressing was applied. The patient was discharged from the hospital April 30th, with a small, superficially granulating wound corresponding to the place of drainage. He returned for another change of dressing May 12th, when A B tlie wound was found entirely cicatrized over. In cases where the surgeon is reasonably sure of having produced an aseptic wound, either Neuber's method of implantation of skin-flaps or, what is better, Schede's treatment can be employed. Neubefs Method of Implantation. — Neuber's idea consists in the endeavor to cover up with skin, if possible, all the raw surfaces left by the operation. Primary union is the object, and a minimum of uncovered raw tissues is left to heal by granulation. Longitudinal hone defects, such as are caused by the removal of a necrosed por- tion of the shaft, are partly or entirely covered by the turning in of tlie edges of the cutaneous toound till they meet at or near the bottom of the groove in the bone (Fig. 149). It is necessary for this purpose to dissect up laterally the skin on both sides of the incision to a goodly extent, so as to render it movable and easily held in the new posi- tion. One or more wide sutures of catgut are passed through the skin at t/ Fio. 155. — -Simon Nathan's case. A, Fenestra] defect of tibia. B, Bridge removed. DIAGNOSIS AND TREATMENT OF PHLEGMON. 215 the points of reflection (Fig. 149), to retain the flaps in position ; and, where this is not sufiicient, a well-disinfected nail is driven through the edge of the flap into the bone. The groove thus formed is loosely packed with strips of iodoform gauze, and the limb is incased in an aseptic dressing. Note. — Nails are disinfected either by boiling in water or by being passed through an alcohol-flame till they as- sume a dull-red heat. After this they are dropped into the vessel holding carbolic lotion and the instruments. Case I. — Simon Nathau, clerk, aged nineteen, admitted to the German Hospital April 18, 1886. Had been operated on three years ago for necrosis of tibia by Prof. Schonborn, of Konigsberg. A fist- ula remained on the anterior aspect of the leg, that closed up and broke open several times every year. The probe detected exposed but smooth bone. April 22d. — The patient was antesthetized and the tibia was exposed. It was found that the sinus led into an oblong defect (Fig. 155) of the shaft, through which the probe could be passed, so as to be clearly felt beneath the soft tissues of the calf. The length of this defect was a little more than an inch, its width half an inch, and its walls were formed by very hard condensed bone. Apparently the sclerosed condition of this bone and its scanty blood-supply was the cause of the frequent ulceration of the deciduous granulations forming within the track. The bridge of sclerosed bone, together with the adjacent condensed parts of the shaft, were removed by mallet and chisel ; the edges of the cutaneous wound were dissected up sufficiently to admit of an easy adjustment within the gap between the tibia and fibula (Fig. 156). Two stout catgut sutures were passed through both edges of the skin-wound, and were brought out by a Peaslee's needle on the imder side of the calf, where they were firmly Fig. 156. — Simon Nathan's case. Implantation of cutaneous edges into the defect by transfixing catgut suture. Fig. 157. — Neuber's method. Frank Nagengast's case. Implantation of triangular flap into the defect of "the head of tibia. knotted over a piece of stout drainage-tube. Thus the edges of the skin-flaps were well drawn into the bottom of the defect. To somewhat relieve the pressure by the drainage-tube upon the skin of the calf, a nail was driven through one of the flaps into the tibia, and the leg was dressed antiseptically. Slight elevations of the temperature without general or local discomfort were observed on the two successive days, after which the normal standard remained unchanged. The dressings were removed May 216 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 9th, and the skin-flaps were found firmly adherent in their new position. Some cutane- ous ulceration of the skin on the calf had taken place. The nail was removed. The patient was discharged cured June 1st. XoTE. — A sclerosed and ill-nourished state of the involucrum will often lead to a repeated breakdown of the granulations lining an old sinus. Stimulating injections will sometimes effect a cure, but in rebellious cases success can be had only from a thorough removal of the condensed portions of the bone and sinus. Case II. — Frank Nagengast, aged eight, a very anfemic boy. Necrotomy of tibia, November 2, 1885, at Mount Sinai Hospital. Extraction of a large central sequestrum Fig. 158.— Diagram illustrating Schede's method applied to a case like that of Frank Nagengast. comprising the entire thickness of the upper half of the shaft, a narrow extension reaching down to the lower epiphysis. Three small sequestra, together with a lot of softened granular cancellous tissue, were removed from the head of the tibia. The remaining posterior portion of the involucrum was so slender and brittle that it broke into several fragments during the operation. Lateral implantation of the skin by means of transfix- ing sutures by Peaslee's needle. Antiseptic dressing and a lateral splint. First change of dressings November 23d. Healing of the wound by adhesion correspond- ing to the shaft. Sinuses lead- ing into narrow cavity in lower portion of tibia, and a larger cavity in the head of the bone. Fractures united with some sag- ging of tibia downward. De- cemher 17th. — Bloody reinfrac- tion of tibia ; scraping of upper and lower cavities. January 10, 1886.— Lower sinus closed; up- per cavity shows no tendency to heal. February 22, 1886. — Osteoplastic closure of cavity in head of tibia accordirig to Neuber. A triangular skin-flap, containing the insertion of the quadriceps tendon and the periosteum, was raised from the anterior aspect of the tibia. The remaining roof of the cavity was removed by mallet and Fig. 159. — Frank Nagengast's case, a, Triangular skin- flap. B, Skin- flap turned into the cavity ; the dark space to heal by granulation, c. View of necrotomy wound treated according to Schede's method. DIAGNOSIS AND TREATMENT OF PHLEGMON. 217 chisel. Previous to this the capsule of the knee-joint was carefuUy exposed to avoid entering the joint. The granular lining of the cavity was gouged away, and only a shell, consisting of the articular surface and the posterior portion of the head of the tibia, remained intact. The tri- angular skin-flap was turned down into the bottom of this cavity, and there attached by a nail (Figs. 157-161). The remaining uncovered Y-shaped portion of the wound was left to granulate. Under an antiseptic dressing firm union of the flap to the underlying bone took place, and the granu- lating part of the wound was firmly cicatrized over by the middle of April. ScTiecWs Method (Fig. 162). — Schede's plan has the great advantage over Neuber's method that it can be employed successfully under the most vary- ing conditions. Its simplicity and independence of the presence or absence of a sufficient covering hy skin commend it to the attention of the surgeon. The author found Neuber's plan inadequate where much integument had been lost, and was replaced by an extensive cicatrix. Case I, — Frank Hyman, aged twelve, received, in May, 1886, a blow on the left tibia, after which central osteomye- litis developed. August 9th. — Necrotomy. Two large se- questra were removed from the upper half of the shaft, requiring three separate parallel incisions for their extraction, carefully evacuated of all granulations, and disinfected with a 1 rosive sublimate Fig. 160. — Anterior view of Frank ISIagengast's leg after completed cure. The wound was very 1,000 solution- of cor- Simple suture of the cutaneous incisions; a small drainage-tube was placed into the upper angle of the longest incision. All the incisions were covered with strips of disinfected rubber tissue, and the limb was dressed with sub- limated gauze. The first dressing remained un- changed for four weeks, when only a shallow fist- ula remained at the place where the drainage-tube had lain. This was scraped, and it promptly healed. The large cavity became filled with a blood-clot, which organized without sup- puration. The treatment of the osteomyelitic pro- cesses of the femur and their sequelae, nota- bly of necrosis, presents peculiar difficulties of technique mainly due to the deep site of the bone. Long incisions are usually indis- pensable, access to the remote portions of the bone is difficult, and the necessary injury to many muscular branches of the femoral artery, and the difficulty of effect- ive compression of the muscular masses, render the question of after-hsm- orrhage rather serious. It is, therefore, advisable not to deplete the limb by Fig. 161. — Lateral view i Nagengast's leg. if Frank 218 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. an elastic bandage of all its blood before applying Esmarch's constriction. Each cut vessel will then pour out a small quantity ^m^. ■ ■ ^^ blood, and can be readily seen and deligated. J^^^ The safest approach to the hone is from the external IgSi ^ If- as^ject, preferably above, or below the ham-strings. On the inner side, Himter^s canal requires careful attention on account of the femoral artery. The sequestrum is generally located near the posterior aspect of the lower end of the shaft. Should it even occur that the popliteal abscess perforate on the in- ner aspect of the thigh, exposure of the sequestrum from the external side will be safer and more easy. By the free use of the chisel and mallet, sufficient access can be gained to remove the sequestrum. Even the most expert operator will occasionally fail to find a small sequestrum, or will not succeed in its entire removal. The eventual necessity of a repe- tition of the operation should be pointed out from the outset to the patient. Inferior Maxilla. — As a rule, osteomyelitic foci of tiie lower jaw communicate with the oral cavity. This makes the preservation of the aseptic condition of the wound rather difficult, and sometimes, notably in the presence of a neglected and foul set of teeth, an impossibility. Where the process is extensive, an external incision is preferable, as it lessens the dan- ger of the entrance of blood into the respiratory tract, and facilitates complete and clean work. Tig. 162. — Illustrating successive steps of Schede's dressing, a, Necrotomy wound, b, Protect- ive, c, lodotbrmed gauze, d, Sublimate gauze, e, Complete dressing. (Case of Samuel Krongoid. Photographs taken ten days after operation, j DIAGNOSIS AND TREATMENT OF PHLEGMON. 219 Case. — I. Eckert, tailor, aged twenty-three, contracted traumatic acute osteomye- litis of the horizontal ramus of the left side of the lower jaw, after the extraction of a carious tooth, done Xovember 2, 1886. The intense pain of the beginning was relieved by a spontaneous discharge of pus into the oral cavity. The author saw the patient November 23d, when the thickening of the jaw, the profuse secretion, and direct prob- ing put the presence of a sequestrum beyond doubt. Sequestrotomy performed Xovem- her Soth. The mouth had been prepared for a day or two by frequent rinsings with salt water ; the face had been shaved. The back of the anaesthetized patient's head was rested on a low, hard roll made of a blanket. The hair was wrapped up in a hood made of a towel dipped in corrosive sublimate, the chest protected by another wet towel. The skin of the jaw was well soaped and rubbed off with mercuric lotion. Then an incision two inches and a half in length was made along the lower edge of the horizontal ramus. The facial artery was exposed, separated, secured by two pairs of artery forceps, cut through between, and doubly deligated. The periosteum was incised to the entire length of the external cut, and was reflected upward with an ele- vator. Before opening into the oral cavity, a sponge held by a long sponge-holder was thrust into the mouth to the vicinity of the fistula, to receive any blood that might escape that way. An oblong quadrangle of the external lamella of the alveolar process and body of the ramus was chiseled away, exposing a cavity containing three sequestra and amass of ulcerating fetid granulations. The cavity was carefully scraped out by the sharp spoon, irrigated with corrosive sublimate, the soiled sponge in the mouth having first been substituted by a clean one. The opening freely communicating with the oral cavity was plugged with a strip of iodoformed gauze, that reached just within the focus ; the external wound was closed by a number of catgut stitches, a short drain- age-tube being first placed in its posterior angle. December ^(Z.— First change of dress- ings. No reaction ; no fever. External wound was found closed, the drainage-tube was shortened, and was found still containing a dark-red blood-clot. The iodoform plug was left undisturbed, and was removed by the patient's family attendant at the end of the second week. Discharge was scanty throughout. Patient cured December 20th. Bone Abscess. — Circumscribed acute osteomyelitis of minor intensity, caused very likely by infection with a very limited number of micrococci deposited in the medullary substance from the blood, does not have a pro- nounced tendency to induce massive necrosis. Breaking down and emul- sification of the affected parts are tardy, and thus opportunity is given to the surrounding tissues for throwing up around the focus a protective wall of granulations. The extension of the abscess is slow, and the local as well as general disturbance effected by it is of a chronic character. Nightly exacerbations of fever, with occasional chills and sweats, and local- ized, deej)-seated pain of a throbbing nature, gradual hypertrophy of the bone, with atrophy of the pertinent muscles, trophic changes of the skin, as glossiness and local sweats, and increasing emaciation, are the character- istic symptoms of the affection, which extends over months and even years. The marked thickening of the bone, the spontaneous local pain, augmented by pressure on percussion, and the absence of fistula are mainly to be con- sidered as to diagnosis. Therapy consists in doing what is to be done with all abscesses — evacuation and eventually drainage. The consiDicuous thickening of the bone serves as a convenient guide to the purulent focus. After the application of Esmarch's constrictor, a free 30 220 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. incision, made according to the rules described in the paragraph on necroto- my, exposes the bone, the surface of which is generally found covered with osteophytic excrescences, that somewhat impede the raising up of the peri- osteum. All the soft parts being held away by sharp retractors, the thick layer of new-formed bone is pared off with tlie chisel, layer by layer, until the cavity containing pus is exposed. Sometimes a number of discrete or communicating foci are pi'esent, and the surgeon must make sure of not overlooking any of them. It is best, accordingly, to expose the medullary space throughout the entire extent of the thickening. By entirely removing the roof of the cavity, it is converted into a more or less shallow trough, all parts of which are exposed to ocular inspection. The smooth pyogenic membrane lining the abscess is carefully removed to its last shred by vigor- ous scraping and gouging with the sharp spoon, and by subsequent irriga- tion. A final flushing of the wound with a strong (1 : 500) solution of corrosive sublimate will make sure of the destruction of all lingering germs. The wound is sutured and dressed according to Schede's plan, and, if the removal of all diseased tissues and infectious secretions was thorough, rapid and uninterrupted healing under the blood-clot will take place. Case I. — RichcarJ Boss, metal-worker, aged thirty-eight. Chronic painful thick- ening of the shaft of the humerus of two years' standing. Glossy skin, atrophy of the muscles of the arm and forearm, formication, and hyperidrosis, together with paretic symptoms affecting principally the mus- culo - spiral nerve. Nightly exacerba- tions of local pain and hectic emacia- tion. Fehruary 2, 1887.— At the Ger- man Hospital, expos- ure by chisel and mallet of a bone ab- FiQ. 163.— Exposure of thickened humerus containinj? a oentral bone abscess. Elastic constrictor tied above the acromion, and thence passed around thorax into the opposite armpit, where it is secured by another ligature. scess occupying the middle and upper part of the medullary cavity of the left hume- rus. Schede's method of dressing the wound. February 17th. — First change of dress- ings. Wound united by the first intention. Two superficial drainage-tubes were DIAGNOSIS AND TREATMENT OF PHLEGMON. 221 removed. March 6th. — Patient discharged per- fectly cured with im- proving function of the extremity. (Figs, 163, 164, and 165.) Case II. — Samuel Krongold, school - boy, aged twelve, had had, several years ago, com- pound dislocation and acute suppuration of the left elbow-joint, compli- cated with acute osteo- myelitis of the lower epiphysis of the hume- rus, in consequence of which several sequestra had to be removed by the author. Three months ago a painful thickening of the shaft of the hu- merus appeared, causing marked deterioration of the boy's health. February 18, 1887. — At the German Hospital, a central bone abscess occupying the middle portion of the meduUary space of the humerus was exposed and evacuated, and was treated by Schede's method. February 26th. — The first change of dressings took place, and the entire wound was found healed with the exception of the slit left open for drainage at the lower angle of the wound, which was occluded by a Fig. 164. — Cavity chiseled open. Its contents removed with the shai-p bpoon. (Eichard Boss.) fresh - looking blood - clot. March 6th. — Patient dis- charged completely cared. (Fig. 162.) The remarkably short and complete cure of both of these cases is undoubtedly to be at- tributed to the adoption of Schede's plan. Plugging of and introducing drainage-tubes or any foreign substance into the bone cavity are done away Fig. 165. — Eichard Boss's wound treated accordinsr to Schede's method. Photograph taken February i7th, fifteen days after operation. 222 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. with, and organization of the massive blood-clot goes on uninterruptedly to the greatest advantage. Conclusions. Prevention of infection contains the spirit and aim of aseptic surgery ; the object of antiseptic surgery is disinfection and the conservatio7i of infected tissues. The first object is attained by a severe discipline of clean- liness ; the second by the still more severe discipline of early incisioiis and adequate drainage and disinfection. A clear comprehension of the processes determining suppuration must result in the firm conviction that an early and free incision of every focus of septic inflammation is the most conservative form of treatment. It pre- vents local death and general intoxication, the latter only too often the cause of general death. If this conviction will have entered into the "smc- cum et sanguinem " of every physician, public opinion will gradually yield to a better understanding of individual and the public interest. Note. — The change in the surgeon's attitude toward the employment of incisions for septic inflammative processes is characterized by these sentences : Formerly, topical applications were the main reliance, incision only a last and extreme resort. TTie surgeon had to show cause why an incision should be ynade. At present, relief from tension and escape of the noxious substances through incision and drainage is the clear indication to be fulfilled. The surgeon must show cause why an iiicision should not be made in the presence of septic inflammation. 2. Phlegmonous Affections of some Special Regions, a. Face. Floor of the Mouth. Neck. Temporal and Mastoid Regions : Anatomical Arrangement of the Connectire-Tmue Planes of the Neck. — Henke's classical essay is the best guide for the clear comprehension of this subject. He injected the different interspaces of a cadaver with liquid gelatin, and studied the manner of its extension between the several organs by exposing the congealed masses, and examin- ing their relations in situ. The chief interspaces of the neck are classified by Henke as follows : 1. The Capsule of the Submaxillary Salivary Gland. — It forms a completely closed envelope to the gland, from which continuations extend to the superficial and deep cervical fasciae. 2. '•'• Precisceral Interspace.'''' — The connective-tissue plane or interspace situated between the prelaryngeal group of longitudinal muscles (hyo-thyroids, sterno-hyoids, and sterno-thyroids) anteriorly, and the larynx, thyroid gland, and trachea posteriorly. It communicates with the anterior mediastinum. Perforation of a suppurating thyroid gland leads to invasion of this space, with subsequent compression of the trachea. (Fig. 166, 0.) Case. — S. C, aged seventeen. The patient was treated by Dr. C. Lellmann for typhoid fever in the German Hospital. In the third week of the disease severe dyspnoea developed, with a peculiar wheezing sound accompanying respiration. On examination, a diffuse swelling was noted in front of the neck. Incision evacuated an abscess communicating with the interior of the thyroid gland, whence perforation must have taken place. Immediate relief followed. 3. '•'■ Retroviseeral Interspace.''"' — The interspace between the pharynx and oesoph- agus in front, and the vertebral column behind. It communicates with the posterior mediastinum. (Fig. 166, a.) DIAGNOSIS AND TREATMENT OF PHLEGMON. 223 4. '■'■Perivascular Interspaced — The interspace containing the carotid artery and jugular vein. It communicates with the anterior mediastinum along the course of the large vessels, and is important on account of the frequent suppuration of the group of lymphatic glands sit- uated in front of, and externally to the jugular vein. Abscesses of this in- terspace displace the sterno-mastoid mus- cle outward; they extend along the vessels downward, and, left to them- selves, either per- forate through the "deep and the super- ficial fasciae and the skin near the clavi- cle, between the low- er end of the sterno- mastoid muscle and the trachea, or make their way along the vessels into the an- terior mediastinum. (Fig. 167.) 5. '■'■Intermuscu- lar Space.'''' — An interspace situated at their crossing, between the lower third of the sterno-mastoid and the omo-hyoid muscles. This space owes its origin to the sliding of these contiguous mus- cles upon each other, and is limited posteriorly by the scaleni. It contains a group of lymphatic glands, seated near the posterior edge of the lower third of the sterno-mastoid muscle (supraclavicular glands), and communicates inward and upward with the retrovisceral space, and along the subclavian ves- sels with the axillary cav- ity. Supraclavicular ab- scesses usually extend into the arm-pit. (Tig. 168.) {a) Face. — The most serious form of cutaneous and subcu- FiG. 166. — c, Previsceral space. Antero-posterior section. L, Eetrovisceral interspace. (From Henke.) STERNOTHYROID SUBCUTANIAN CAROTID JUGULAR Fig. 167.- -Perivascular interspace. (From Henke.) Transverse section. 224 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. U . — Intermuscular space. Lateral antero-posterior section. (From Henke.) taiieous phlegmon observed on the face is the carhimde. It is characterized by a dense, hard swelling of conical shape, extending far into the subcu- taneous connective tis- sue. It has a dusky red color, and its apex IS marked by one or more yellowish discol- ored spots, which are surrounded by a bluish halo. Septic thrombo- sis extending through the jugular veins into the cranium is to be feared in this affec- tion. The systemic in- toxication is generally very intense, high fe- ver being the rule. In some of the worst cases the intoxication is so deep as to cause symptoms of collapse, with low% sometimes even subnormal, temperatures. In this condition an early and most energetic treatment is urgently indicated, and is almost always followed by elimination of the infectious process. A crucial incision, or, in extensive cases, a number of parallel incisions, carried in length and depth beyond the indurated area, will relieve tension and permit the escape of the contents of many smaller or larger incarcerated foci. The incisions should be packed lightly with strips of iodoformed gauze. In cases of ancemia, where loss of blood would materially increase the danger, tlie actual cautery should be so applied as to convert the entire infected area into a dry eschar. This or the incisions should be enveloped in a moist dressing, which has to be renewed according to the amount of secretions. Note. — The following bloodless treatment applied by Slesarewskij in forty-four cases of car- buncle seems to deserve trial, as it yielded very good results in his hands : Inspissated crusts are first removed, then the diseased surface is sprinkled with from thirty to sixty grains of corrosive- sublimate powder. The dusky halo surrounding the center of the sore is thickly covered with blue ointment, and the whole is enveloped in a compress soaked in carbolized oil (1 : 10), fast- ened with a roller bandage. In case of severe pain, an ice-bag is placed over the dressing. The following day, corresponding to the application of the mercuric salt, a gray, very dense eschar will be visible, which will separate ten days later, and will be followed by rapid healing. Slesarewskij never observed mercuric intoxication during or after the application of this method of treatment. (" Centralblatt fur Chirurgie," 1886, p. 805.) Case. — The author lost, of a considerable number of cases treated by incision, only one by septic phlebitis of the right lateral sinus. Tlie patient, a middle-aged cigar- raaker, was seen in consultation with Dr. L. Weiss, and an enormous carbuncle occupy- ing the riglit side of the upper lip and cheek was found, with extensive oedema of the eyelids and the right side of face and neck, which was due to general thrombosis of DIAGNOSIS AND TREATMENT OF PHLEGMON. 225 \. the pertinent vein?. The patient was semi-comatose, somewhat cyanosed, and had a poor pulse. He had obstinately opposed any incisive treatment for six days, and the case seemed clearly beyond the reach of surgical skill. The incisions caused very little haemorrhage, as most of the divided tissues were necrosed. He died of collapse on the seventh day of his illness. The author has never tried any of the " maturing " forms of treatment in this affection, and would unhesibatingly declare measures which are apt to stimulate suppuration, such as poulticing, to be always risky, and some- times positively dangerous. (J) Neck. — (a) Fauces and Pharynx. — The tonsils and the connective tissue in which they lie imbedded are the most favorite site of superficial and deep-seated septic processes. DipMhei^ia is very likely a microbial affection due to the colonization of micrococci upon the surface and in the follicles of tonsils, that are in a state of catarrhal or scarlatinal inflammation. It is characterized by superficial or deep-going putrid necrosis of the affected tissues, often extending to the pharynx, larynx, velum, pillars, and the nasal mucous membrane, and is generally accompanied by a serious general intoxi- cation. The systemic intoxication is most prominent when parts having an abundant supply of lymphatics, as the pillars of the fauces, the velum, pharynx, and nasal mucous membrane, are involved. The scantier de- velopment of the tonsillar V-H '!"^ •■'■ ^^ ' *"! and laryngeal lymph-ves- sels seems to be the cause of the minor intensity of the systemic symptoms ob- served in affections local- ized in these parts. Char- acteristic intumescence of the deep cervical lymph- glands is a regular conse- quence of the affection of the first group of localities; it is more rarely observed in purely tonsillar or laryngeal diphtheria. An invasion is apt to leave be- hind a certain disposition to re- newed attacks, which is perhaps due to the fact that quiescent spores of bacteria remain imbedded in the recesses of the follicles, to develop their activity whenever a new catarrhal inflammation and exudative process prepares the ground for their multi- plication. But, on the other hand, frequent attacks, and the accompanying formation of cicatricial tissue within the textures of the tonsils, seem to lead to a certain immunity from the graver forms of the disease. As a rule, persons who never had diphtheria suffer more severely than those who have gone through many attacks ; and diphtheria of children for- FiG. 169. — Bacteria from ease of vesical diphtheria with putrescence (700 diameters). (Koch.) 226 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. merly free from the disease is a much more serious condition than the so-called habitual '• follicular tonsillitis." While a first attack is usu- ally, habitual follicular tonsillitis is rarely, complicated with glandular enlargement. The condition of things here is comparable to that which was mentioned as the ''habituation of the hands of anatomists to septic infection" (see page 197, Note I). The disease is highly contagious, hence isolation of the patient is imperative wherever possible. Aided by a sustaining and stimulating general treatment, the disinfec- tion of the local septic state should be most energetically pursued. Accord- ing to the age and disposition of the patient, this will have to be done dif- ferently. In small children of a good disposition, penciliugs of the affected parts with milder or stronger solutions of corrosive sublimate repeated every hour, and, in case of nasal diphtheria, hourly syringing of the interior of the nose, should be practiced. A mixture of corrosive sublimate 0*03, alcohol 25*00 (or one-half grain to the ounce), can be safely used for pencil- ing the tonsils and pharynx. A tepid watery solution of 1: 5,000 for syring- ing the nasal cavity will be well borne. Care must be taken to keep the nostrils well anointed with vaseline to prevent eczema, and never to use a sharp, long-beaked syringe. During the struggles of the resisting child the mucous membrane is easily lacerated, and the haemorrhage and certain infec- tion of the part thus injured are not indifferent in an affection where the least complication may suffice to fatally determine the case. The safest manner of douching the nose is by attaching to the nozzle of the syringe a piece (six inches in length) of soft rubber tubing, such as is used on infants' feeding-bottles, its distal end being first provided with a few lat- eral holes cut into it with scissors. The syringe is filled with the warm lotion, the well-greased flexible tube is introduced into the nostril and pushed back until it is felt to touch the posterior pharyngeal wall, the child's head is inclined forward, and then the contents of the syringe are briskly thrown into the nasal cavity. The immediate reflex closure of the larynx and isthmus faucium will prevent the entrance of considerable quantities of the lotion into these organs, and the energetic stream will aid the detachment and expulsion of crusts, membrane, and liquid secretions. On account of the swollen condition of the mucous mem- brane, the entrance of acrid secretions into the Eustachian tubes need not be feared. The throats of larger children or grown j^ersons can be cleansed by fre- quent gargling with a tepid solution of (1 : 5,000) corrosive sublimate, con- taining one teaspoonful of cooking salt. The principal weight should be laid upon a frequent application of the gargle and a stimulating, nourish- ing, general regime. Whenever the aspect of the malady is very threatening, the appli- cation of the galvano-cautery to the affected parts may be advisable. It is, with cocaine anesthesia, a safe and rational process. That only a portion of the patches are accessible, some of them being beyond the DIAGNOSIS AND TEEATMENT OF PHLEGMON. 227 surgeon's reach in the nasal cayity, is no ralid reason why those that are amenable to this yery effectiye mode of disinfection should not thus be treated. The best way of cauterizing the tonsils and pharynx is the following one : The head of the anaesthetized iDatient is drawn oyer the under j)added edge of the table until it assumes the dependent, or Eose's, position (Fig. 170). The surgeon introduces a bent tongue-depressor, or the bent handle of a tablespoon, well back into the fauces, and instructs the ansesthe- tizer to keep the tongue out of the way by it. This will expose the pharynx in an admirable fashion to permit of the exact and thorough ap- plication of the thermo- or galyano- cautery to the patches thus exposed. If the disease be limited to visible parts of the oral cayity, and all the patches can be thus treated, a rapid improyement of the general state of intoxication will, as a rule, at once follow the procedure. Where only a part of the patches is thus treated, the improvement will not be as complete. The glandular enlargement also requires attention, and should be treated as was explained elsewhere. If the process descend to the larynx, very alarming dyspnoea will grad- ually develop. It should be combated with external hot applications to the throat, and the inhalation of moist, warm air generated in the sick-room. The patient's strength should be carefully husbanded by frequent doses of liquid nourishment, and the avoidance of unnecessary excitement, exposure, and, most of all, strong emetics, the abuse of which has cost many a child's life. In most cases the membrane will get detached piecemeal, or will come away in one or more large masses, and relief will follow, perhaps only to be succeeded by another or several suffocative attacks. As long as there is no lung complication, the pulse fairly good, intubation offers fair chances of success. Where the patient's strength has been consumed by a very long, ceaseless struggle for air, or the depressing use of emetics, the chances are by far more slender. Yet even the most desperate cases sometimes yield unexpectedly good results. When intubation is not feasible, tracheotomy has to be performed. Preventive Treatment of Tonsillitis. — The tonsils are the points where the first patches become visible in most cases, and whence the local infec- tion extends to other contiguous parts. After frequent attacks of tonsillitis, the surface of the tonsils becomes irregularly indented by cicatricial retrac- tion ; the tonsil itself is enlarged, and often yields on pressure one or more 31 Fig. 170. — Rose's position. Head dependent from the edge of the operating table. 228 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. yellowish plugs of a very fetid cheesy matter which were contained within the follicles. Note.— Drs. E. Gruening and S. Cohn called my attention to this fact, which I have repeat- edly verified. These yellowish masses are, as shown by Gruening, swarming with lep- tothrix and other micro-organisms, and the presence of these is undoubt- edly at the bottom of the so-called "disposition " to catch the disease. The reservoir of infecting material is ever there ; the patient carries it constantly with him, and a catarrhal hyperaemia, followed by some infiltration and epithelial erosion, is all that is needed to develop a new attack of ''follic- ular tonsillitis," which may not threaten its possessor with great danger, but is just as contagious to others as any case of diphtheria. One observa- tion like the following Avill carry much conviction. Two children of the same family had attacks of sore throat one after the other. The first, a boy four years old, who has had tonsillitis a number of times, exhibited the usual symptoms of his affection ; the second one, a boy about a year old, and hitherto free from the disease, was carried into the sick-room of the first child by an obstinate nurse, and came down the next day with very alarming systemic symptoms, high fever, and somnolence, exhibiting a small patch on his left tonsil. The first boy recovered in about four days, the usual length of his attack ; by the time that he was well, the baby had died under symptoms of most acute septicaemia. A petechial rash, commencing on the nates and feet, extended upward, and gradually flecked the entire skin. The patch on the tonsil had grown and others had developed, the somnolence turned into coma, and was followed by death. The wet-nurse of this child and the cook of the family, who had kissed the corpse, became seriously ill with diphtheria ; especially the latter, whose condition was critical for three or four days. At the same time, a male servant and two more members of the family contracted sore throats of various degrees of intensity, and the house had to be abandoned. A friend and his wife called in the evening shortly after the child's death to pay a visit of condolence. The next morning one of their children was down with malignant diphtheria, and died in a day or two of septicaemia. Destroying the entire surface of the tonsil, together with the contents of the follicles by the application of the galvano-cautery, would seem to be rational, and has been found a safe and effective measure for lessening the disposition to renewed attacks of diphtheria. It is infinitely safer than a bloody ablation of the tonsils, as the dangers of haemorrhage and diphtheria of the wound-surface are thereby avoided. The smooth, dense cicatrix thus produced offers a very good protection against new infection. In adults, or even in half-grown children amenable to control, the reduc- tion of the tonsil can be gradually accomplished without general anaesthe- sia, the procedure extending over a number of sittings. The throat is pen- cilled with a cocaine solution until local anaesthesia is produced ; then a cold galvano-caustic burner is introduced. It is placed against the part to be treated, the current is turned on, and one fourth or one third of the ton- sillar surface is thoroughly seared. For an hour or so, small pieces of ice should be swallowed by the patient to allay the slight pain. The sittings can be repeated about twice a week or oftener. DIAGNOSIS AND TEEATMENT OF PHLEGMON. 229 Quincy sore throat (peritonsillitis) is a phlegmonous process established in the tonsil itself, or in the loose connective tissue in which it is imbedded. The tonsil is found enlarged, projecting into the pharynx, and displacing forward the anterior pillar and velum. Dysphagia and more or less saliva- tion with high fever are regularly present, and do not terminate until thorough evacuation has taken place. In most cases confluence of a number of small abscesses and simultaneous evacuation is observed. In others, especially when the tonsil itself is the seat of the affection, a number of abscesses develop and open one after another, and retard recovery for a week or two. No local treatment short of incision can effect a substantial improvement, and the different gargling mixtures are only useful in clear- ing the throat and mouth of the foul, sticky slime aggravating the patient's sufferings by exciting very painful reflex movements at deglutition. Hot salt water (one teaspoonful to a quart, about 6 : 1,000) is the best, as it is the most solvent gargle, and can be easily procured. As the exact location of the abscess can not be ascertained easily beforehand, it is wise to wait with the incision until the swelling is well developed. A digital examina- tion of the swollen region is always advisable, as it is not rare that the tip of the finger detects a pitting spot at which incision will release pus. If pitting can not be detected, an examination with the tip of a silver probe will possibly help to ascertain the most painful spot corresponding to the focus to be incised. The relative distribution of the swelling may also serve as a guide in determining the seat of pus. Acute enlargement of the tonsil itself with diffuse oedema of the pillars and palate indicates supjuiration withm the tonsil. Displacement of the relatively normal tonsil inward is a sign of retro-tonsillar suppuration. A combination of both will show the worst association of distressing symptoms. Incising Tonsillar Abscess. — A lancet-shaped pointed bistoury is pro- tected with strips of adhesive plaster to within an inch of its point (Fig. 171), the tongue is depressed with the left index-finger, while the right band thrusts the knife into the base of the swelling through the anterior pillar at the point tero-posterior di- ^^^^^^=^=^" ' kIlI^ - — rection should be ^^^- '^'^^- — Lancet-shaped bistoury wrapped up in adhesive plaster for incision of tonsillar abscess. rigidly adhered to on account of the vicinity of the carotid artery. If the first puncture be unsuccessful, a second one should be made in another likely place, and, as soon as pus appears, the blade should be turned inward, that is, toward the median line, and should be withdrawn, dilating the incision in that direc- tion. A number of fibers belonging to the levator palati will be thus divided, and their retraction will create a patent orifice, favorable to good drainage. Retro-pTiaryngeal phlegmon is a comparatively rare suppuration of the retro-pharyngeal connective tissue, due to septic infection of the glands normally imbedded in it. It is mostly observed in small children. The 230 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. symptoms are those of retro-pharyngeal abscess from tuberculous caries of the cervical vertebrae, but its appearance is much more rapid, accompanied by high septic fever and more acute local distress, causing difficulty of deglutition, regurgitation of food through the nostrils, and alarming dyspnoea. The most characteristic symptom is the peculiarly rigid attitude- of the head, whicli is erect, and thrown back to a certain extent at the same time. The voice is thick and guttural, as though a voluminous foreign body were held in the throat. In some cases the suppuration extends to the "intermuscular space,"" and causes the appearance of a lateral external swelling behind the sterno- mastoid muscle. The transverse diameter of the neck then appears widened. Inspection of the pharynx shows that the posterior pharyngeal wall is dis- placed forward, is densely infiltrated, and sometimes fluctuating. Incision should be done through the oral cavity if the inflammation is confined to the retro-pharyngeal region, but will be more advantageous if done from without and behind the sterno-mastoid muscle in cases where external swelling of the cervical region is noticeable. In the first case, the children should be held as for penciling of the throat, and the person having charge of the head should be instructed to throw it forward at a given signal, so as to favor the escape of pus and blood outward from the oral cavity, and prevent its entering the larynx. If lateral swellings appear, proper incision from without will afford efficient drainage, and at the same time will help to avoid the dangers accru- ing from the entrance of \n\s into the larynx.^ The manner of incision is best illustrated by the subjoined cases. Of a large number of cases treated at the German Dispensary, and a few seen at consultations in private practice, only two have terminated fatally, and in both serious haemorrhage occurred a few hours after the incision. Case I.— S. P., aged eighteen months, seen May 17, 1883, with Dr. L. Weiss. Retro-pharyngeal and submaxillary abscess developed during the florid stage of a violent scarlatina with diphtheria. Dysphagia and dyspnoea. Small lateral incision through the skin and fascia parallel to, and behind the posterior margin of the left sterno-mastoid muscle. Successful search for pus with a stout hypodermic needle, carried inward and a little backward toward the retro-pharyngeal space. Insinuation of a grooved director along the hollow needle, followed up by the introduction of a small pair of dressing forceps, which were withdrawn half opened. Escape of about one and a half ounce of pus and introduction of a drainage-tube. Two hours after incision copious secondary hteraorrhage set ic, and rapidly terminated in death. Giving away of the wall of a sloughing vessel must be assumed to have caused this issue. Case II. — Henry W., aged four and a half months, a healthy child, developed, March 4, 1883, fever and dysphagia, due to the presence of a number of .small abscesses situated in the retro-pharyngeal connective tissue. Several of these were incised by Dr. A. Jacobi, with apparent relief of short duration. New foci appearing, the incisions were repeated March 6tli and 8th. March 9th. — Dysphagia became complete and dyspnoea alarming. Although the incisions through the retro-pharyngeal space con- tinued to bleed, increasing the danger by the addition of haemorrhage to the other symptoms, the extension of the process to the connective-tissue plane of the large DIAGNOSIS AND TEEATMENT OF PHLEGMON. 231 vessels and the alarming dyspncea left no alternative but death from sufEocation or an incision of the abscess from without. March 9th, at 2 P. M. — This was done, evacuat- ing about half an ounce of pus. A drainage-tube was introduced into the bottom of the cavity, and, to limit the oozing, a compressory dressing was applied. At If. P. M. — Scanty but continuous hemorrhage set in from the drainage-tube. This being removed, the cavity was plugged with strips of iodoformed gauze, and the bleeding edges of the incision were seared with the thermo-cautery. At 8.30 P. M. — The child died of acute anemia. March 10th. — Post-mortem examination by Dr. A. Seibert in the presence of Dr. L. Bopp and the author. On the neck, close to the posterior edge of the left sterno- mastoid, a cutaneous incision was found one inch in length, its edges marked by a dark-red, bloody infiltration. A probe entered the refcro-pharyngeal space, where it could be felt with the finger placed in the oral cavity. A skin-flap being raised and turned upward, a couple of intumescent, dark-red lymph-glands, situated near the an- terior edge of the sterno-mastoid muscle, were exposed. The sterno-mastoid muscle was cut away at its lower insertion and was turned upward. The vascular sheath was opened, and the deep jugular vein and carotid artery were carefully examined and found intact. A wall of tissue one third of an inch in thickness was found interposed between these vessels and the track occupied by the silver probe. The prevertebral interspace was found distended by a dark, massive, and soft clot, extending upward to the base of the cranium, and downward to the level of the third tracheal cartilage. Cervical vertebrae normal. Doubtless it was a case of hsemophilism. (A case of retro-pharyngeal infiltration, simulating the symptoms of abscess, was seen by the author in the German Hospital, in which acute infectious osteomyelitis of the second cervical vertebra was the cause of the trouble. Henry Ludwig, bartender, aged twenty-one. February 16, 1885. — High fever set in with a chill and stertorous breathing. The face was slightly cyanosed and the voice had a thick sound cliaracter- istic of retro-pharyngeal swelling. The patient held his neck rigidly, and in moving supported it by his hands. A typhoid condition prevailed. The house surgeon of the German Hospital made a free incision into the swelling occupying the retro-pharyngeal region, but no pus escaped. In spite of weight extension, sudden death occurred, March 20th, from compression of the medulla. Post-mortem examination revealed a far-gone destruction of the second, third, and fourth cervical vertebrse. The odontoid process was detached, and had fatally compressed the medulla.) Acute infectious osteomyelitis of the lower jaio occurs either in the adult after traumatism, such as for instance fracture of its entire thickness by- violence, or injury to the alveolar process caused by the extraction of teeth ; or spontaneously in the adolescent. The latter form is quite frequent, and results generally in more or less extensive necrosis and the formation of abscess. Perforation usually takes place toward the oral cavity, though oc- casionally invasion of the submaxillary capsule or the vascular intersjDace is observed. Early incision will allay pain, relieve the fever, and will prevent the extension of suppuration. The treatment of necroses of the mandible was disposed of elsewhere. (y8) Submaxillary and Parotid Cynanche. — Both the submaxillary and parotid salivary glands are inclosed in complete and very dense fascial en- velopes. On account of this anatomical peculiarity, and in the case of the submaxillary gland, the vicinity of the tongue and larynx, purulent inflam- 232 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. matious of these organs present some peculiarly grave features worthy of special attention. Human saliva normally contains a chemical substance akin to the pto- maines or to snake poison, that, like the latter, seems to play an important part in the process of digestion. Whether an undue development of this albuminoid substance, or exclusively the direct absorption of septic matter from the oral cavity is at the bottom of the septic inflammations of the sali- vary glands, is not known — suffice to say, that occasionally one or the other of these glands becomes the seat of supjiurative inflammation. Their resist- ant envelope leads to incarceration of ichor and pus, to the development of enormous tension and its deleterious local and general effects — which are dense infiltration and necrosis of the contiguous soft parts, with dysphagia and suffocative attacks, and a highly septic fever. Sublingual or Submaxillary Cynanche {Ludwig's Angina). — A painful, deep-seated, hard swelling of the submaxillary region apjjears, and is quickly followed by chills and high fever, the swelling rapidly increasing in extent and hardness, and the skin over the submaxillary gland turning dusky red. As long as the patient is up, his head is held rigidly in one position, the eyes moving in wide circles if he wants to see an object out of his range of vision. Or, if he be unsuccessful, the entire body is turned round slowly to bring the desired object within sight. The mouth is held slightly open, the tongue is dry, the floor of the mouth somewhat oedematous. Speech is difficult, as can be seen from the painful twitchings of the patient's face whenever he has to say something. After a while he will seek the bed. The face will appear slightly oedematous and cyanosed, the eye has a dull and stupid expression, the dry tongue is found lolling out of the mouth, and saliva escaping alongside of it. The floor of the mouth is very oedematous, and by this time the entire submaxillary region will have become swollen and as hard as a board. The labored snoring respiration of the patient gives warning of the extension of the oedema to the soft palate, fauces, and the vicinity of the larynx. The temperature indicates very high fever, and the patient is unable to allay his burning thirst, as swallowing will have become impossible. At this stage oedema of the glottis may cause asphyxia in some cases, requiring immediate tracheotomy. In other cases extensive slough- ing of the involved parts of the neck will supervene, and fatal hgemorrhage may be caused by erosion of large vessels. The grave sei^ticasmia alone, or the extension of septic thrombosis to the cranium or right auricle, may end in death. All dilatory measures, such as hot or cold applications, will be useless, or positively injurious, and the patient's salvation depends on a quick appreciation of the true character of the trouble, followed by prompt and energetic action. Case I. — It was observed by tbe author during his military service in Garrison Hos- pital No. 2 at "Vienna, Austria, in November, 1872. During convalescence from a severe form of typhoid fever, symptoms of sublingual cynanche appeared in a young soldier treated in the division for internal diseases. Fomentations being employed, the swell- DIAGNOSIS AND TREATMENT OF PHLEaMON. 233 ing assumed alarming proportions. Suddenly oedema of tlie glottis appeared, and the case was transferred to the surgical division. The left side and frontal region of the neck were found densely infiltrated and very hard, and tracheotomy had to he per- formed under unusual difficulties by regimental surgeon Dr. Fillenbaum. A number of abscesses were encountered, and purulent perichondritis was found to be the immedi- ate cause of the oedema of the glottis. Tracheotomy relieved the dyspnoea, but the patient died soon afterward of septicaemia. Case II. — Jacob H., farmer, aged twenty-one, admitted to the German Hospital January 19, 1886, presented a circumscribed red swelling of the left submaxillary region, that had appeared with high fever two days before admission. Face cyanosed, expression dull, breathing stertorous; the mouth half open, tongue protruding, floor of mouth oedematous. Temperature, 104"5° Fahr. Immediate incision according to Hil- ton-Roser's method in ansesthesia. About half an ounce of thin ichorous pus escaped. The incision was enlarged with a probe-pointed knife, and drainage and a moist dress- ing were applied. In the night a short suffocative attack appeared. January 20th. — Temperature, 101° Fahr. Cyanosis and oedema of the floor of month appreciably diminished. Improvement continued, no necrosis following, and patient was discharged cured February 6th. Case III. — William B., clerk, aged twenty-two. Sublingual cynanche, character- ized by protrusion of tongue and very high fever. The family attendant had treated the case for ten days by poulticing, and April 3, 1884, had incised the swelling in the submaxillary region. Relief followed, but in the night alarming dyspnoea, due to arte- rial hsemorrhage, supervened, that rapidly distended all the interspaces of the left side of the neck, and threatened suffocation. Afril 5th. — Early in the morning trache- otomy was hastily performed by the author, who found the left side of the neck enor- mously swollen, and some bloody serum oozing out of the small external incision and from the oral cavity. The source of the latter bleeding was found in a sloughy per- foration of the floor of the mouth. As hsemorrhage had ceased, only a drainage-tube was placed into the external incision, and a moist dressing was applied. The patient was doing well April 7th, when he was seen by the author the last time. Later on, the family attendant informed the author that another external htemorrhage had occurred during the process of detachment of the numerous sloughs, requiring deliga- tion of a spurting, probably the facial, artery. Patient recovered Case IV. — C. S., watchman, aged thirty-two. Sublingual cynanche of thirty-six hours' standing. Extensive hard infiltration of anterior and left side of neck. Dys- phagia, dyspnoea, tongue protruding. May 5, 1886. — Incision by preparation at Ger- man Hospital. The thickened capsule of the submaxillary gland being divided, a small cavity containing about a half drachm of ichorous pus and debris was exposed and drained. It just admitted the tip of the index-finger. Immediate improvement of all symptoms. Patient was discharged cured May 20th. Parotid Cynanche. — This may develop iudepeiidently or complicated with orchitis during and after acute infectious diseases, such as typhoid and scarlet fever, small-pox, or the measles, or may be the direct continuation of an attack of mumps. It is not as alarming in rapidity of development as the sublingual form, but is apt to be much more tedious on account of the gradual breakdown of the lobulated structure of the parotid gland. One lobe after another succumbs to the suppurative process, and an intermina- ble series of abscesses make their appearance. Generally perforation out- ward is the rule ; occasionally, however, perforation into the spheno-max- 234 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. illary fossa, and extension into the intermuscular planes of the neck, with all its dangers, ensues. Necrosis of the interlobular septa is a common occurrence. On account of the necessity of avoiding the temporal artery and facial nerve, long incisions are imj^racticable. They must be small, and several should be made to afford sufficient drainage. Case. — II. S., merchant, aged fifty, commenced to suffer about Christmas, 1885, from a furuncle of the external meatus. This led to suppuration of the lymphatic gland normally found in front of the meatus, and, under a poulticing treatment, to an involvement of the parotid gland. The patient was seen by the author January 11, 1886, and exhibited a large, non-fluctuating, very dense swelling of the right parotid region, with a temperature of 104° Fahr. His right eye could not be closed entirely (paresis of the facial nerve), and he was unable to separate the jaws to the slightest extent. Besides, repeated chills, sleeplessness, and the intense pain radi- ating to the diverse branches of the trigeminal nerve, had demoralized the man com- pletely. A vertical incision placed just in front of the external meatus by careful preparation released a large mass of pus. The relief was very great, and the patient left the house five days later to be treated at the author's oflBce, where he repaired daily for many weeks longer, as the involvement, and breaking down of new lobules of the parotid gland made frequent irrigation and constant drainage a necessity. He was discharged cured March 28th. By October the paresis of the orbicularis palpe- brarum had disappeared. (y) Acute Glandular Abscesses of the Anterior a.nd Lateral Cervical Regions. — They are caused by absorption of active micro-organisms depend- ent on inflammatory processes of the oral and nasal cavities, the pharynx, larynx, the lower jaw, and the mastoid region. They have to be well dis- tinguished from cold or chronic abscesses of the same region. Their onset is sudden ; pain and fever rapidly develop, with deejD-seated dense infiltra- tion, and gradually the corresponding side of the neck becomes oedematous. Inflammations in the oral cavity, the tongue, the larynx, and the lower jaw produce an involvement of the glands in the 2}erivascular space. They can be felt somewhat in front of the sterno-mastoid muscle, extending upward toward the angle of the jaw, and are commonly known as "submaxillary" glands. Affections of the temporal, auricular, and mastoid regions, and of the pharynx, nasal cavity, and oesophagus, on the other hand, are generally followed by intumescence or suppuration of the glands situated in the in- termuscular space. They can be felt behind the posterior margin of the sterno-mastoid, and their suppuration is apt to extend in the direction of the supraclavicular space. The question of when to incise these abscesses should not be made de- pendent upon the presence of fluctuation, as the worst and most virulent cases will have wrought infinite mischief long before the appearance of fluctuation. In very virulent cases, marked by violent general symptoms and rapid local spread, incision should be made at once after Hilton-Eoser's method, as relief from tension is the most urgent requisite to prevent slough- ing and possible erosion of vessels. Anaesthesia is indispensable. Where the symptoms are less violent, the spread less rapid, maturing of the abscess may be awaited in case the joatients are very averse to an incision. DIAGNOSIS AND TEEATMENT OF PHLEGMON. 235 But the responsibility for the consequences of delay should be declined by the physician. Case. — Lonis Lebowitsch, aged twenty-seven, presser. December 15, 1886. — Pain- ful hard swellings developed in the pretracheal and both submaxillary regions with a severe chill. Previous to this the patient had been suffering from a " sore throat " for a few days. The family physician advised poulticing, wliich, as usual, was enthusiasti- cally attended to by the patient's female relatives. The swellings continued to grow in size; fever and sleeplessness were unabated. December 25th. — Suddenly an enormous increase of the swellings in front and on the left side occurred, with dyspncea and dysphagia, which induced, December 29th, the patient's transfer to Mount Sinai Hos- pital. Following a hasty summons the author found the patient sitting up in bed, his head held erect, the neck increased to double its circumference, its skin red, swollen, and shining like a large-sized sausage. Boggy fluctuation everywhere. Most intense thirst with absolute disability to swallow even fluids ; wheezing, long-drawn respira- tion with considerable dyspnoea, which became augmented to an alarming degree by the reclining posture. Examination of the fauces revealed a swelling of the retro- faucial soft tissues, and almost complete contact of the slightly intumescent tonsils. Two incisions, one behind the posterior margin of the sterno-mastoid muscle, the other a little below the thyroid gland, released about a quart of a dark-red gory liquid, streaked with pus. This was followed by an immediate disappearance of the dyspnoea, and the patient was able at once to allay his thirst by copious drafts of water. A digital ex- amination of the cavities opened by the incisions showed them to communicate freely. The pulsating carotid could be distinctly felt, lying exposed behind a large, roundish mass of blood-clot, freely projecting into the lateral cavity, and seemingly attached to the pharyngeal wall. Two stout drainage-tubes were placed in the incisions, the remaining clots were washed out by gentle irrigation, and a large, moist dressing was applied. The fever fell at once from 103° Fahr. to 100° Fahr., but rose the following day to 103° Fahr., as the incisions were clearly insufficient for the drainage of the enormous cavity. More- over, there was still considerable oozing present, and therefore it was deemed proper to anaesthetize the patient again, for the sake of a thorough exploration, drainage, and possibly prevention of further haemorrhage. A fluctuating place just above the clavicle was incised, and was found communicating by a narrow channel with the upper cavity. Both of the lateral incisions were now united by preparation, the external jugular vein being first secured by double ligature and divided, and thus by this long incision the interior of the large abscess was exposed to view. The cavity extended from the clavicle to the base of the cranium. In it lay exposed the carotid artery and the jugu- lar vein, to the upper portion of which anteriorly a large, firm, and irregular clot was found adhering, indicating where the haemorrhage had come from. The loose clots were all cleared out, hut the one adherent to the jugular was left undisturbed. Copi- ous oozing from the abscess walls was observed, and checked by a loose packing of iodoformed gauze, preceded by thorough irrigation. The patient was discharged cured on January 27, 1887. The preceding case vividly illustrates the dangers of protracted poultic- ing in deep-seated lymphatic abscesses. Sloughing of the wall of an adja- cent large vein caused a most serious complication by secondary haemorrhage. Arterial heemorrhage would have undoubtedly produced rapid suffocation. (8) Glandular Abscesses of the Temporal, Mastoid, and Occipital Re- gions. — Suppurative processes located in the external ear will occasionally 32 936 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. extend to one or more lympluitic glands, subfuscially situated in front of the external meatus of the ear, and in close vicinity to the parotid gland. They produce very violent general and local symptoms, and require early attention, as a subsequent involvement of the parotid gland is very apt to occur. Suppuration of the mastoid cells is the most common form of extension of a purulent otitis of the external or middle ear. Its symptoms bear great resemblance to those of acute osteomyelitis, and require prompt attention on account of the ])ossibility of necrosis and the involvement of the meninges, brain, or lateral sinus. Where intense swelling indicates the presence of purulent periostitis of the mastoid process, a free incision of all the soft parts down to the bone will often give great relief. But, where the interior of the cancellous structure of the mastoid process is the seat of the disease, noth- ing short of a free opening of its interior will avail. Formerly, this opera- tion was done with the aid of the trephine, an instrument the penetration of which is somewhat beyond the supervising control of the surgeon. At present mallet and chisel are used for this purpose with greater advantage. The chisel should be held tangentially to the external surface of the mastoid process, thin layers of bone being pared off in succession, until the suppurat- ing focus is freely exposed. Thus injury to the lateral sinus can be safely avoided. Coj^ious irrigation with a luarm solution of corrosive sublimate and a moist dressing are advisable. The cases in which early operating has prevented necrosis will heal very promptly. Necrosis will retard the cure considerably, and may require a second or even a third operation for the removal of sequestra. In neglected cases spontaneous perforation through the periosteum will occur, and an external abscess, located posteriorly to the sterno-mastoid muscle, will appear. The tendency of its extension is toward the "inter- muscular space," that is, downward into the supraclavicular fossa. Occasionally the process extends backward and upward upon the occiput. Case I. — Fred. Biitlis, bnker, aged eighteen, admitted to ear department of German Hospital, December 17, 1883, with purulent catarrh of the middle ear and suppuration of mastoid cells. Wilde's incision and extraction of some sequestra from the external meatus were practiced by Dr. J. Simrock. A phlegmon of the left occipital region, starting from a sinus below the mastoid process, having set in, patient was transferred, March 25, 1884, to the surgical department. March, S6th. — High fever and violent headache with vomiting. Several incisions laid open an irregular cavity situated be- hind the ear and extending downward toward the neck. On pressure, a large quantity of pus oozed out of a recess between exuberant granulations near the lower anterior angle of the parietal bone. These being scraped away, a sequestrum, about one square inch in circumference, and comprising the whole thickness of the skull, was extracted. Pulsation of the bottom of the cavity thus exposed was clearly discernible. Healing progressed without interruption, the purulent discharge from the middle ear ceased, and patient was discharged cured, April 17, 1884, with a deeply indented scar. In October, 1886, he presented himself, complaining of epileptic seizures that had appeared in July, 1886. DIAGNOSIS AND TREATMENT OF PHLEGMON. 237 Case II.— E. N., merchant, aged twenty-five. Had been suffering from purulent otitis media for a long time. Suppuration of the mastoid cells, and formation of an external inframastoidal abscess, led to incision, which was done by Dr. E. Gruenmg, under whose care the patient had been for some tinie. A phlegmonous inflammation of the neck following, January 22, 1882, a consultation was called, when a number of deep incisions back of the sterno-mastoid muscle were made, and the abscesses were drained. The probe felt bare bone in the mastoid notch. Subsequently a considerable quantity of bony grits passed away witb the secretions, and the carbolic lotion injected into the drainage-tubes entered the oral cavity. End of March, the patient was dis- charged cured, and remained well until September, 1886, when he was seen by the author suffering from dementia. b. Mammary and Retro-mammary Abscess. — Excoriations and fissures, so common upon the nipples of nursing women, are the portals through which infection enters the multitudinous lymphatics of the mammary gland. A preparatory treatment of the nipples during the last period of pregnancy is the best preventive of the formation of fissures. It should consist in molli- fying, and removal by bathing in warm soap-water, of the thick layers of effete epidermis, usually present around the openings of the lacteal ducts. The tender epidermis thus exposed will be hardened, and will become fit to resist the manifold injuries unavoidable during lactation. Should rhagades develop, a thorough disinfection with corrosive-subli- mate lotion (1 : 1,000), followed by touching of the fissures with a well- sharpened stick of nitrate of silver, will in most cases lead to a cure of the painful disorder. Nursing should be either stopped and the milk removed with the breast-pump, or, if continued, should be only permitted with a nipple-shield, until the fissure is closed. Disregard of these precautions will frequently lead to suppuration. A large proportion of the inflammatory processes of the breast are non- suppurative, the intumescence, redness, and occasionally smart fever being set up by a retention of the thickish milk of first lactation. Sometimes fluctuation will be felt, and, if an incision is made, no pus — only milk — will escape. Absence of an infection by micro-organisms must be assumed in these cases, which, as a rule, get well without suppuration by simple topical treatment, consisting of the application of moist heat and methodical com- pression. Hence, not all cases of acute mastitis terminate in abscess. Winckel saw, in the Dresden Lying-in Hospital, ninety-one out of a total of one hundred and thirty-six cases of mastitis get well without suppuration. Therefore, topical treatment with the ice-bag or cold-water coil (by both of these the secretion of milk is materially reduced), or, if opposition to these be encountered, tepid or warm applications, aided by support and gentle compression of the breast, should be first tried. Should, however, fever and the local symptoms persist or increase, and fluctuation become apparent, incision and drainage are the measures to be applied. Abscesses of the mammary gland proper are either suhcutaneous, then generally located about the nipple ; or are more deep-seated, that is, intra- 238 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. glandular. A third form of breast abscess is the suppuration of the loose connective tissue found heliind the gland : retro-mammary abscess. Its location in the vicinity of the nipple and the early appearance of well-defined fluctuation will readily characterize the subcutaneous abscess. When the deeper parts of the glandular tissue proper become the seat of an abscess, general swelling of the breast-gland is most prominent. The skin of the mamma becomes red and oedematous, and one or more jjitting points can be soon detected. But the hreast is freely movable as a 2vhole upon the pedoralis fascia. In retro-mammary suppuration the breast is immovable, and firmly attached at its base. The glandular tissue is soft and normal, unless a combination of mammary and retro-mammary suppuration be present. Deep fluctuation can be detected by careful palpation. Incision of the more extensive abscesses of the breast should ahvays be done under ancesthesia, as the unavoidable pain associated with thorough work is too great to be endured ; and the measures must be thorough to give a prompt result, as nothing is more unsatisfactory than an insufficient or improperly placed incision. Suppuration is not limited thereby, new points of fluctuation develop, and the interminable process, with fever, sleep- lessness, and the drain upon the system, lead to serious emaciation and lamentable demoralization of both jiatient and physician. Antiseptic pre- cautions, consisting of a thorough scrubbing of the surgeon's hands and of the patient's breast with soap and brush, and subsequent rubbing off with corrosive-sublimate lotion (1 : 1,000), should never be neglected. There are microbial cultures of various intensity of virulence, and the touch of an unclean finger may intensify an otherwise comparatively bland form of sup- puration, or may add the poison of erysipelas to that of simple suppturation. All incisions penetrating the glandular tissue should be placed radially, so as to avoid injury to the lacteal ducts as much as possible. A place of fluctuation being marked, the knife is rapidly thrust into the abscess, if the thickness of tissues to be cut through is not too great. In the latter case, Hilton-Eoser's method is safer and preferable, on account of the possibility of haemorrhage from a deep-seated vessel. XoTE. — Billroth recounts a case in which he caused uncontrollable and very serious haemor- rha<'e by cutting a large branch of the external mammary artery. The loss of blood was alarm- in"', and so beyond control that, after having unsuccessfully tried a number of the usual measures, he finallv injected the abscess cavity with a quantity of turpentine oil, that happened to be •within reach. The bleeding was stopped, but a formidable gangrenous phlegmon brought the patient very near the grave. She recovered, however. As soon as the well-dilated dressing forceps is withdrawn, the index of the left hand is slipped into the cavity, and a gentle exploration of its interior is carefullv made. Wherever a recess extends toward the skin, the tissues are raised upon the tip of the left index-finger, the skin and fascia are incised, and the dressing forceps is introduced along the grooved director in the well- known manner. In this way a number of short counter-incisions can be made with very little haemorrhage. Stout drainage-tubes, reaching just within DIAGNOSIS AND TREATMENT OF PHLEGMON. 239 the cayitj, are nest introduced, and the abscess is well washed out with the mercuric lotion. Oozing from the abscess walls, which is sometimes con- siderable, will also be checked thereby. After this the breast should be grasped and gently compressed between the extended hands as a test, ivliether all recesses had been duly emptied or not. The appearance of additional masses of j^us will be a proof that something was overlooked, and renewed search must be instituted to find and drain the OTerlooked recess. XoTE AND Case. — The observance of this simple rule led to the recognition of a very interesting and rare form of suppurative mastitis. Mrs. C. F., primipara, admitted to Mount Sinai Hospital two weeks after her confinement, with abscess of the breast. Had very little fever. She was anaesthe- tized December 20, 1886, and, four fluctuating spots situated just above and near the nipple being incised, the finger was slipped into one of the incisions, and found the irregular and tortuous cavities communicating with each other. A large number of smaller cavities occupying the upper half of the mammary gland were entered, and the intervening bridges of tissue were broken down with the finger. Haemorrhage was very scanty. The cavity was washed out, and, gentle pressure being applied, an additional large mass of thick pus escaped. A long incision uniting the two most distant primary incisions, and passing through the entire width of the gland, was now made. It exposed the cavity, which was found lined with necrosed shreds of glandu- lar tissue. The abscess walls exuded on firm pressure from hundreds of invisible openings separate drops of creamy pus. A portion of the indurated wall of the cavity was pared off, until seemingly healthy tissue was encountered. Pirm pressure being repeated, the same exuda- tion of pus from innumerable pores of the cut sui'face was observed. The section had a deep- yellow tinge, and presented the density of fibromatous tissue. The lower half of the breast-gland was normal and secreted milk. An iodoform dressing was applied, and remained undisturbed until December 2'7th, when the patient complained of pain and exhibited some fever. The dressings being removed, a new abscess was found and incised near the upper margin of the long incision. The old abscess cavity was granulating, but its walls still exhibited the peculiar appearance of a large number of distinct pus-drops on pressure. The wretched general con- dition of the patient, and the presumably interminable suppuration to be expected under the circumstances suggested exsection of the affected parts of the breast as the most rational measure. This step, however, was strenuously opposed by the patient, and she left the hospital uncured. Apparently we had in this case a form of purulent mastitis where the supjouratiye process was jDrimarily located in the lacteal ducts, the intersti- tial connective tissue assuming the character of shrinking fibroid or cica- tricial tissue, as in non-suppurating interstitial mastitis. The contraction of the interstitial tissue led to closure of the lacteal ducts and to retention ; this to perforation of the lacteal ducts and extension of the supjDuration into the interstitial tissue ; this, finally, to the formation of a large number of disseminated abscesses and necrosis. Throughout, the case exhibited un- usual characteristics : well-circumscribed localization, low fever with appall- ing destruction of tissues, and their curious permeation with canals, that could be nothing but lacteal ducts, filled with creamy pus. As drainage and disinfection of the infected lacteal ducts were imjDossible, ablation of the diseased part of the gland was clearly the proper way to terminate the process. Retro-mammary abscesses usually point near the lower margin of the breast-gland. They should be treated like other deep-seated abscesses, by 240 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. incision and drainage, care being taken to establisli the latter in the most dependent position. When tlie operation is completed, safety-pins are thrust through the pro- jecting ends of the drainage-tubes near the surface of the skin, and they are trimmed off short. A small ring of iodoformed gauze is placed underneath the safety-pin around the drainage-tube, to prevent its being overlapped by the edges of the wound, and a moist antiseptic dressing is applied. In the absence of fever and pain, and if the dressings remain unpermeated by secre- tions, they need not be changed before three or four days, when the drain- age-tubes can be either wholl}^ removed, or one, having previously been somewhat shortened, can be left in the most de- pendent incision till the following change of dress- ings. Where shreds of ne- crosed tissue are still ad- herent to the walls of the abscess, secretion will be somewhat more copious, and permeation of the dressings will require daily changes until the necrosed parts come away. During this time, however, if drainage be adequate, all the pus secreted should be contained in the dressings, and none in the tooutid. After detachment of the necrosed parts, secretion will become scanty and watery in character, and removal of the tubes will be followed by rapid closure of the wound. In cases where drainage is inadequate, fever and pain will persist, and secretion will remain profuse. The dressings will need frequent I'euewal, they will be rapidly soaked with pus, and the wound itself will contain more or less of it. This can be easily ascertained by gentle pressure, which will cause a copious flow of pus. Frequent irrigation is a very imperfect substitute of proper drainage ; therefore, the making of a well-placed incis- ion should remedy the shortcoming. c. Empyema. — Infection of the pleura by pyogenic organisms, either through metastatic processes or by direct extension from the bronchi and lungs ; from without by injury, or from purulent affections of the vicinal regions, as, for instance, perinephritic or liver abscess, leads to the forma- tion of empyema — that is, an accumulation of pus within the pleural cavity. The diagnosis of the affection is based upon the fever, dyspnoea, the absence of respiratory murmur, the dull percussion sound, rigidity of the affected side of the thorax, flatness of the intercostal depressions, and more or less marked oedema of the integument over the site of the accumulation. Probatory puncture with a hypodermic needle will usually yield pus. Fig. 17; -Dressing for mammary abscess, or empyema. DIAGNOSIS AND TREATMENT OF PHLEGMON. 241 The proper treatment consists of timely incision, disinfection, and drain- age under antiseptic cautela3. Management of Recent Cases of Empyema. — The thorax of the ansesthe- tized patient is cleansed and disinfected, and an incision is made, from two to three inches in length, in the eighth intercostal space, parallel with the ribs, and a little back of the axillary line. The skin and muscles are grad- ually divided down to the pleura, which is then incised. The sudden gush of pus is checked and moderated by the pressure of the tip of the finger, as too sudden evacuation of the tense accumulation may lead to rupture of ves- sels, or, in the case of empyema of the left pleural cavity, to fatal embolism of the pulmonary artery. In these cases the heart is displaced to the right side, and any clots that may have formed within the right auricle could be easily detached by a sudden change of the heart's position. This accident has occurred once to the author. However, it did not take place on the operating-table, but happened several days after the operation. Case. — Helen Muller, aged eleven. Empyema, with two fistnlse, of six years' standing. Great emaciation ; retention of fetid pus; the heart displaced to the right side. February 27, 1883. — Exsection of two ribs, multiple incisions, and drainage of the fetid abscess. Daily irrigation produced a marked remission of the fever, and everything seemed to progress favorably, when, March 6th, while playing in bed, the child suddenly became cyanosed, and fell back dead. No post-mortem examination could be had. Death was doubtless caused by embolism of the pulmonary artery. The pleural incision should be ample, as otherwise voluminous fibrinous pseudo-membranes may clog the exit of pus. A large-calibered drainage- tube, reacMng just within the pleural sac, is inserted, and is at once secured with a stout safety-'pin, to prevent its being lost in the abscess. This occurred in one case treated at the German Hospital, and a good deal of trouble was experienced in finding the lost tube. Case. — Fridolin Jaehle, laborer, aged forty-three, saccated empyema of eight weeks' standing. February 9, ISSJf. — Posterior incision in the eighth intercostal space ; evacu- ation of a large quantity of pus. A drainage-tube was inserted, but slipped out of the fingers, and was lost in the cavity. The incision was sufHciently enlarged to admit two ■fingers, and then a sort of a diaphragm could be felt separating two intercommunicat- ing cavities. A counter incision was made in the mammary line, and the lost drainage- tube was extracted therefrom. Drainage-tubes properly fastened with safety-pins were inserted, and the cavity was irrigated with carbolic lotion. Moist dressings were ap- plied. April 18th. — Patient was discharged cured. Washing of the pleural cavity with warm mercuric solution (1 : 5,000) thrown from an irrigator should be done, until the fluid returns in a limpid state. Then a final flushing with corrosive-sublimate lotion of the strength of 1 : 1,000 should follow, and good care should be taken to drain off the last vestige of the solution by turning the patient so as to bring the incision nethermost. A very ample moist dressing should envelop the patient's thorax. As long as the temperature remains normal or slightly elevated, and the dressing clean, no change is necessary. Usually, however, the dressings 242 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. will be soiled within twenty-four hours, and then they must be changed. But irrigation should not be employed so long as the patient's temperature is normal. Only, if renewed fever appear, or the secretion assume a fetid odor, will repetition of the irrigation be necessary. In fresh empyemata, especially of children, one irrigation thoroughly done at the time of the operation loill he found siifficient. But in some favorable cases of adults the same smooth course of healing may be observed. The discharges will gradually diminish, they will lose their purulent character, and will become watery and scanty. As soon as this is observed, the drainage-tube should be removed, and within four or six weeks from the operation the cavity will be healed by renewed adhesion of the costal and pulmonal j)]eura. The lung will dilate to its normal extent, and the universal adhesion of the pleural surfaces will gradually give way to constant attrition, until the mobility of the lung and the normal state of things are re-established. Case. — Henry Fennell, furniture-dealer, aged thirty. Empyema on left side of four weeks' duration. February 1, 1880. — Communication with a larger bronchus spon- taneously established, giving rise to uncontrollable fits of coughing, which have ex- hausted the patient to a dangerous degree. February 6th. — Incision, drainage, and irrigation with a five-per-cent solution of carbolic acid. The cough stopped at once; the fever fell off. February i7«^.— Discharge very scanty and watery ; drainage-tubes were removed. February 19th. — Sudden rise of temperature, with chill. February 20th. — Pleuritic serous effusion on right side. March 1st. — Effusion on right side begins to be absorbed. Left lung dilated to nearly its normal compass. March 6th. — Exuda- tion in right pleura has disappeared. March i^f A.— Patient was discharged cured. Lateral curvature of the spine is a prominent symptom of long-continued empyema, and is very hard to cure. The moderate amount of lateral curva- ture that goes along with recent empyema disappears with the restoration of the function of the compressed lung. Old Empyema. — Cases of inveterate empyema loitli or loithout sinus throw much greater diflBculties in tlie way of the surgeon's efforts to close the cav- ity and fistula than recent cases. The retraction and consolidation of the lung, and its envelopment in more or less thick coats of pseudo-membrane, frustrate all attempts at closure of the thoracic cavity. The unyielding lung can not expand, while the contraction of the partially yielding walls of the thorax, accomplished by lateral curvature, by a close crowding to- gether of the ribs, and a corresponding flattening of the affected side of the chest, has its limits. Thus a secreting hollow space is maintained within the chest that can not be obliterated by the unaided efforts of nature, and ultimately the patient's strength and life will be sapped. The injection of irritating fluids, or the packing of the cavity with strips of lint or gauze, are of no avail, and the only means of effecting a cure is multiple exsection of the ribs according to the plan of Estlander. The rationale of this plan is to do away with the rigidity of the thoracic wall by removing suitably long sections of as many ribs as are found to be corresponding to the cavity. Thus the limbered thoracic wall may be depressed, and can be brought into actual contact, or nearly so, with the DIAGNOSIS AND TREATMENT OF PHLEGMON. 243 Fig. 173. — Cicatrix in a case of Estlander's operation for inveterate thoracic fis- tula. (John Springer's case. ) opposite or pulmonal surface of the cavity, where it Avill be fastened down and retained by cicatricial adhesions that will form before the reconstruction of the exsected ribs. In due course of time the at- tached lung may even regain a large proportion of its former functional capacity by distention and aeration, and the more or less complete re- establishment of lung capacity is manifested by the disappearance of lateral curvature. Case I. — John Springer, clerk, aged twenty-one. Em- pyema of left side with thoracic fistula. Profuse secretion of pus, escaping through an insufficient incision. Exten- sive burrowing of pus under latissimus dorsi and serratus muscles. The process was of one year's standing, and had caused lateral curvature and far-gone emaciation. Aitgust S5, 1879. — Incision and drainage of the external abscesses and of the left pleural cavity at the German Hospital. Exsection of the eighth rib became necessary, as the inter- costal space was too narrow to permit of a safe adjustment of the drainage-tube. The operation brought on alarming collapse, which was over- come by energetic stimulation. The extei-nal ab- scesses healed, and, though the secretion from the pleural cavity became much diminished, no tend- ency to a diminution of the capacity of the sac could be noticed. By New Year, 1880, the pa- tient's general condition had become excellent, and, no improvement being visible regarding the heal- ing of the thoracic fistula, January 3, 1880, Est- lander's operation was performed. By an ample vertical incision, commencing in front of the axil- lary space in the pectoral fold, the third, fourth, fifth, sixth, and seventh ribs were exposed. Their periosteum was slit up longitudinally, and sections of from two to four inches of the ribs were re- moved, the removed pieces being proportional to the entire length of the sevei'al ribs. As soon as the ribs were removed, the thoracic wall could be well depressed into the hollow of the cavity. In order to retard the new formation of bone, the external wound was packed with carbolized gauze, and healed by granulation. The pleural hollow began at once to diminish in size, and April 11, 1880, patient was discharged cured. He has re- mained well ever since that time, and presented. Fig. 174.— Result after Estlander's April 23, 1887, when the accompanying photo- X?iT spt'!"Tjot"ng;rl; g'-^Pb^ were taken, the following status : A scarcely case.) noticeable trace of lateral curvature ; the respira- 33 244 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. tory excursions of both sides of the thorax identical. All exsected ribs had re-formed and occupied a normal position. Eespiratory murmur could be heard all over the left side of the thorax. (Figs. 173 and 174). Case II. — Miss Eva C , aged thirteen and a lialf. Thoracic fistula of two and a half years' duration, leading into a small cavity holding about three ounces of fluid, tliat had resisted all efforts at cure. May 13, 1881. — Exsection of sixth and seventh ribs at Mount Sinai Hospital. September 20th. — Patient was discharged cured. In August, 1882. the healed fistula came open, with pain and fever. September 26, 1882. — A sequestrum two inches in length, consisting of a portion of the seventh rib, was extracted. The wound healed promptly, and the girl's health remained sound. The author's rather incomplete record of all forms of empyema of chil- dren embraces twenty-two cases. All of these recovered with the exception of two — one died of basilar meningitis ; the other of pulmonary embolism. Of the nine cases of adults, four were cured by simple incision ; two by multiple excision of ribs ; one, a case of perforation of a tubercular lung cavity into the pleura, died of fatal haemorrhage into the pleura ; and two cases were discharged improved, but not cured. To conclude, it may be said that the earlier the operation, the safer it is, and the better the results achieved by it. d. Phlegmon of the Palmar Aspect of the Hand, of the Arm, and Axilla. — The hand, on account of its exposed situation, is the most frequent place of small or more serious injury. The necessity of the continned use of a slightly injured hand, and its contact with septic matter, lead to phlegmo- nous affections of different degrees of intensity. More serious traumatisms, like incised or lacerated wounds of the hand, become in numerous cases the seat of septic inflammation, in consequence of the improper and uncleanly primary treatment they receive from laymen and some physicians. Neglect of thorough cleansing and disinfection of a small wound often leads to direful consequences, that perhaps the most skillful and incisive therapy can not remedy. Of the manifold curious practices commonly employed for stanching hpemorrhage and dressing injuries to the hand, only two may be mentioned. Fii'.'it comes tlte u.se of styptic solutions. They are unnecessary, because digital compression of short duration is capable of stanching ev^en profuse arterial hemorrhage. The second practice is the favorite closure of soiled wounds about the hand with strips of adhesive plaster or a suture, loitliout preceding disin- fection. Some of tlie Avorst forms of palmar phlegmon observed by the author were due to similar ministrations by lay or medical advisers. Case I. — John McG., liquor dealer, aged thirty-nine. April 30, 1886. — Chopped off the tip of his index-finger wnlh a hatchet, and was attended to immediately by a medical quack, who strapped the injured part with a structure of neatly-arranged strips of adhesive plaster without previous cleansing. The wound was a smooth and clean-cut one, and offered the most advantageous conditions for the avoidance of infec- tion. Severe pain, swelling, and fever supervened on the following day, but, at the advice of the medical attendant, the dressing was left on undisturbed for four days. DIAGNOSIS AXD TREATMENT OF PHLEGMON. 245 May -5, 1886. — The patient came under the care of the author, who found the wound and its neighborhood tightly compressed by the adhesive strapping, and a phlegmon of the sheath of the flexor and extensor tendons of the index extending into the inter- muscular planes of the ball of the thumb. A number of incisions exposed the necrosed tendons, and resulted in a tardy cure after their expulsion. He was discharged cured July 10th. Case II. — S. A., laborer, aged thirty-five. Presented himself in January, 1881, at the German Dispensary with an incised wound of the palmar aspect of the thumb, and an extensive subaponeurotic phlegmon of the palm and forearm. The hsemor- rhage had been unsuccessfully combated by the patient himself with applications of cobwebs and varnish. Finally, the aid of a druggist was sought, who soaked a piece of lint in perchloride-of-iron solution, and hermetically sealed the wound therewith. Phlegmon set in promptly, and rapidly extended to the palmar bursa. The styptic dressing remained undisturbed, but the palmar swelling was treated with diligent poulticing. At the German Dispensary various incisions were done in anaesthesia, fol- lowed by a tedious after-treatment consisting of repeated counter-incisions until cure was effected. The removal of the styptic lint, intimately matted together with living and necrosed tissues, was exceedingly troublesome. The function of the thumb was partially restored. Dorsum. — On account of the loose arraagemeut of the subcutaneous connective tissue of the dorsal region of the hand, its phlegmonous affec- tions present characteristics similar to those of any other subcutaneous phlegmon. The presence of a large number of hair-follicles farors the localization of septic processes in the cutis, which lead to the formation of typical furuncles or rarely a carbuncle. Palmar Aspect. — The peculiar features of the phlegmonous processes of the palmar aspect of the fingers and hand depend upon the anatomical pecu- liarities of that region. On the fingers we find, instead of tlie longitudinal and loose arrangement of the subcu- taneous tissue of the dorsum, a dense net-work of short, thick fibers, inclosing a num- I)er of small acini of fat. The main direction of the course of these fibers is from the cutis down to the periosteum, or to the slieath of the ten- dons, to which they are close- ly attached. The direction of the lymphatics coincides with that of the connective tissue. Upon this centripetal course of the lymphatics depends the pronounced tendency of digital inflamma- tions to penetrate to the bone or the tendons. The well-known tendency to necrosis and the formation of cutaneous, tendinous, or osseous sequestra is, on the other hand, caused by great tension due to the rigid and dense Fig. 175. — Transverse section of terminal phalanx, show- ing aiTang-ement and direction of connective-tissue fibers. (From Vogt.) 240 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. arrangemeut of the subcutaneous conneciive tissue. (Fig. 175.) The manner of the extension of phlegmonous inflammation within the tendinous sheaths of the pal- mar aspect of the hand is also pre- scribed by their special arrange- ment. Fig. 176 shows the sheaths of the flexors of the thumb and lit- tle finger in open communication with the common palmar bursa, through which pass all the flexor tendons of the fingers to and un- der the ligamentum capsi transver- sum, and hence to the forearm. The sheaths of the flexors of the index, middle, and ring fingers represent separate and closed re- ceptacles, which terminate on the level of the metacarpo-phalaugeal joints. For a short distance be- yond these sacs the tendons pos- sess no sheath proper, but are im- mediately inclosed by loose con- nective tissue. We see corresjiond- ing to these three closed sacs three pointed extensions of the common pal- mar bursa, into which the tendons enter after passing through the sheathless part of their course. (Figs. 176 and 177.) Thumb and Little Finger. — Upon this arrangement is based the great im- port of the suppurations of the thumb and little finger, mentioned by the old- est medical writers, and well known to the common people. While gatherings of the index, the middle, and ring fin- gers often perforate s])ontaneously near or on the level of the finger-balls (where the blind end of the closed tendinous sheath coincides with the thinnest por- tion of the palmar aponeurosis), suppu- rations of the thumb and little finger are very apt to, and as a matter of fact often do, extend at once into the palmar bursa. The knowledge of this peculiarity is of the greatest practical importance. Fig. 176. — a, Blind endings of sheaths of the in- dex, middle, and ring fingers, b, c. Sheaths of thumb and little finorer openly communicating with palmar burr^a. (From Vogt.) % / Fir,. 177. — Common palmar bursa injected, and showing extensions toward thumb and little fineer. ( From Vo^t. ) DIAGNOSIS AND TEEATMENT OF PHLEGMON. 247 Aside from the acuteness of the symptoms, phlegmonous affections located on the palmar aspect of the hand and fingers present some jiecu- liarities, the diagnostic significance of which must be mentioned. Redness of the shin is generally absent, to appear only when the process has worked its way uj) to the skin. Oedema is moderate, and is often overlooked by in- experienced observers, who are misled by the oedema and redness of the dor- sal soft parts to look there, and not on the palmar side, for the focus of the disturbance. The subjective symptoms are very distressing, high fever and intense pain being the rule. Treatment. — Prevention of phlegmon by guarding against the infection of large or small injuries of the integument is very profitable. Small excoriations and shallow cuts should be cleansed and touched with acetic- acid. Punctures should be well sucked and bled and sealed with an acetic acid eschar ; or, if there be the least suspicion of infection by an unclean sharp-pointed object, dilatation of the small hole, thorough wiping out of the track with sublimate lotion, and drainage by means of a few short pieces of catgut laid into the bottom of the puncture are to be employed. Li this latter class of cases a moist dressing is appropriate. In the presence of an inflammation that is evidently gathering mo- mentum, all attempts at an abortive treatment are risky, as the deceptive relief afforded by hot ap]3lications is very apt to induce patient and physician to be tardy with the application of the best and surest antiphlogistic : the knife. By the time that the unbearable suffering finally compels energetic treatment, suppuration requires a long incision, and necrosis of a phalanx or tendon may be established. At first it might have teen prevented by a much smaller incision — in fact, hy a mere puncture. The cases where a timely deep puncture with a tenotomy knife released one or a few drops of pus to the most intense relief of the patient were very numerous in the author's dispensary experience, and he can not recommend this truly con- servative procedure in warm enough terms. Instead of a terribly painful and tedious illness ending in more or less of destruction, rapid healing of the small wound under the moist dressing will be the rule. And, if we consider that local anaesthesia by cocaine or the ether spray (both more effective if combined with artificial angemia) has deprived incision of all its terrors, hesitation and poulticing become a culpable offense against the dictates of common sense. The diagnosis of the exact locality of beginning suppuration is easily made by the aid of the unmistakable sensations of the patient. Gentle pressure by a probe upon different points of the affected region, made to cover successively and in a methodical way the entire area in the shape of a spiral, will soon detect the most painful spot. If one or two repetitions of this process confirm the result of the first search, no hesitation need be felt. The point thus found is marked by a shallow scratch or otherwise, the finger or hand is anaesthetized, and the tenotomy knife is boldly thrust down to the periosteum. If a few drops of pus escape only, this will 248 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. siiflHce ; if more, the ])uncturc should be at once proportionately enlarged, thoroughly irrigated, and covered with a moist dressing. As the affection generally extends to the periosteum or tendon, the incision should always be carried down to one or the other, and should be longitudinal to avoid injury of vessels or tendons. Subfascial phlegmons of the palm should be also promptly and suffi- ciently incised. The adjoining diagram (Fig. 178) will be found very useful in pointing out the small area which should be avoided on account of the superficial pal- mar arch. It is situated between the first and last strokes of the capital M that marks the palm. After the aponeurosis has been cut through, any point of the jialm can be reached from the lines marked out on Fig. 178, by Hilton-Eoser's method. Incision is advisable even at the risk of cutting the palmar arch, as the haemorrhage thus caused can be easily stopped by ligatur- ing the vessel in an ample incision, and Es- march's band will effectively prevent undue loss of blood during the operation. There is no region of the human body where senseless poulticing of phlegmons has done more harm, and timely incision can do more good, than in the palm. Case. — M. M., saddler, a^ed sixty-five, had in the latter part of August, 1885, a boil of the face, which he was in the habit of dressing himself. At the same time he infected a small scratch of liis right forefinger, from which developed a felon. The family attendant ordered poulticing, which was Icept lip uninterriij)tedly for more than three iceelcs. Not one incision had been 7nade, and when the author saw the patient, September 28, 1885, about twenty-four hours before his death from septicaemia, the hand and entire arm presented a terrible condition of phlegmonous destruction. Not one tendon, no joint, was free from suppuration, and a number of phalanges were necrosed ; the skin was extensively detached and repre- sented a boggy bag, from which pus flowed copiously through a number of smaller and larger defects due to sloughing. Diplitheria of the throat, tongue, and mouth had also developed the day before the consultation, and the wretched general condition of the patient put any operative measure out of question. The inquiry, liow such a state of things could come about, drew the reply that " there were plenty of openings, they seemed to discharge f reel i/ and nicely, and therefore surgical interference was refrained from." Neglected cases, where the suppurative process has attained wide pro- portions, should be treated on general principles laid down regarding the management of complicated abscesses. All recesses should be found out, separately incised, and drained. Where in the course of a long-continued U R Fig. 178. — Straight lines marking the places where incision.^ can be safely made. The space between the first and last strokes of the capital M, markiuir the palm, should be avoided. (From \ ogt.) DIA&NOSIS AND TEEATMENT OF PHLEGMON. 249 process the soft tissues have been more or less permeated by the septic poison, and multiple small abscesses with a sanious discharge have estab- lished themselves, the enormous swelling will render efficient drainage very difficult or even impossible. Vertical suspension on Volkmann's arm-splint tvith continuous irriga- tion will often do here very effective service. Its detail is as follows : After the proper incisions are made and the requisite number of drainage- tubes have been inserted, the arm is enveloped in gauze, is loosely attached to the splint (Fig. 179) by a roller bandage, and is suspended from the ceil- ing or a suitable frame. One or more irri- gators filled with a very weak sublimated or salicylated lotion being also suspended, their nozzles are connected with one or more of the uppermost drainage-tubes. A rubber blanket is so arranged beneath the suspended limb as to catch all the drippings and to conduct them into a bucket placed alongside the bed. The flow of the irrigating fluid is regulated by pushing a match-stick or a straw into the nozzle of the irrigator. In this manner, ac- cording to necessity, a free current or the escape of the fluid in drops can be effected. If the entire limb require irrigation, the use of many irrigators can be obviated by a simple contrivance recommended by Starcke. A tin tube, open at one end, and provided with a number of nipples, is connected with a large irrigator. On the ni^Dples rubber tubes are slipped, and are conducted to the several drainage-tubes, with which connection is es- tablished through short pieces of glass tubing. (Fig. 180.) Continuous immersion in a weak antisep- tic lotion is a very simple and effective sub- stitute for permanent irrigation, although it precludes the advantages of vertical suspen- sion. The lotion should be changed from three to four times daily, and its tempera- ture is to be regulated by the patient's sen- sations. Some will have it warm, others will prefer a cool bath. By placing one or two alcohol lamps underneath the tin vessel containing the bath, an even temperature can be maintained. Case I. — Hugo B., laborer, aged twenty-eight, admitted, March 11, 1886, to the German Hospital with extensive phlegmon of the palm, consequent npon an injury to the middle finger. The corresponding metacarpo-phalangeal joint was destroyed. The house-surgeon exarticulated the third finger, and made a number of incisions in the Fig. 179 Volkmann's arm-splint for vertical suspension. 250 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. palm, liberating a good deal of pus. By March 12th the temperature had been some- what lowered, but an ominous swelling of the forearm appeared. March 18th. — A number of incisions were made on the flexor side of the arm into the suppurating tendinous sheaths. Moist dressings and elevated posture. Continuous high fever. March S5th. — Renewed incisions on dorsum of forearm, exposing the extensor tendons. Swelling of the arm and axil- lary glands. High fever. TJie affection proving un- controllable, on account of the uniform purulent infiltration of the soft tissues, continuous immersion of the limb in a 1 : 5,000 solution of corrosive sub- limate was resorted to, and was constantly employed during the montlis of April and May. No mercurial toxic symptoms wiiatever could be observed during this period of time. The swelling of the axillary glands disappeared a few days after the commence- ment of this treatment, and a tardy disappearance of the febrile symptoms followed pari passu with the detachment of a number of gangrenous muscles and tendons. Toward the end of May all the sloughs were detached, and the little finger was removed on account of necrosis of the phalanges. During June and July a number of small abscesses devel- oped on the hand and along the arm, and were successively incised. End of July all incisions were healed. Active and pas- sive motions and massage restored a part of the motion of the wrist, the thumb, and index. The patient, of whose limb and life we had despaired, was discharged cured and in a florid condition August 20th. Case II. — A. W., laborer, aged thirty-two, admitted, August 17, 1886, to German Hospital. August 7th. — Sustained an injury of the left forearm. The profuse hsem- orrhage was stopped with a tourniquet. The physician left this instrument in situ, and ordered to tighten the screw in ease of renewed loss of blood. The patient, fol- lowing tlie advice of his physician, tightened the tourniquet as directed. August 9th. — The forearm swelled up considerably, and assumed a bluish cast; at the same time several chills and high fever set in. Increasing swelling. A homoeopathic practitioner of Newark made a few superficial incisions, and, seeing no improvement therefrom, proposed amputation. On admission the patient presented a pitiable condition of sep- tieaeniia. Temperature, 105'8° Fahr. The pulse was hardly noticeable, respiration very frequent, tlie patient cyanosed and somnolent, liis body covered with cold per- spiration. The entire left arm was enormously swollen, the skin of the forearm exten- sively discolored, and fluctuation was noted in many places. On account of the collapsed condition of the patient, only a few incisions were made to relieve the pus and to reduce Fig. 180. — Continuous irrigation by means of Starcke's tube, in vertical suspension. DIAGNOSIS AND TREATMENT OF PHLEGMON. 251 tension. Aside from the large abscesses, a uniform ■purulent infiltration of the tissues was found. August 18th. — Nuuierous incisions were made in anaesthesia, the entire forearm exhibiting a state of ichorous inliltration. Necrosed portions of the skin and of various muscles were ablated, and a number of drainage-tubes were inserted. The arm was kept continuously immersed in a tepid bath for four days without an appreci- able improvement of the local or general disturbance. August SOth. — The arm was vertically suspended, and continuous irrigation by a weak mei'curial lotion was estab- lished and kept up until September 18tli. This change was followed by slow but unmistakable improvement, interrupted by occasional rises of temperature due to retention. The entire integument of the volar side of the arm was lost by necrosis, and the defect had to be covered by a number of skin-grafts. The patient was dis- charged cured November 29th, with slight mobility of the wrist and the metacarpo- phalangeal joints. By these means many a limb can be saved. The detachment of slough- ing tissues should be facilitated by the use of scissors and forceps, and the rule should be upheld not to sacrifice any part of the hand that is viable. Even the most sorry-looking, shapeless, and immovable rudiments of this useful organ will be of great value to the patient afterward. Should all these means be of no avail in checking the progress of sup- puration, amputation will have to be considered as a last life-saving remedy. Case. — Ernst B., shoemaker, aged sixty-nine. Had been for years attended to at the German Dispensary for a chronic fungous affection of the wrist. In the fall of 1885 a phlegmonous inflammation started from one of the many fistulse present, grad- ually involving the entire hand, wrist, and part of the forearm. A large number of incisions had been made, but the trouble crept steadily from one joint to another, and along the tendons, until the hand presented one swollen, shapeless, festering mass. Felriiary 13. 1886. — Amputation of the forearm was done at its upper third. Primary nnion followed throughout. Joints of the Upper Extremity. — Injury and infection of the metacarpo- phalangeal or first interphalangeaJ joints frequently take place during a rough-and-tumble fight, when the fist of a fighter hits the incisors of his antagonist. The author has treated four cases of this kind within the last seven years. In one, syjjhilis followed a very obstinate suppuration of the first interphalangeal joint of the right index. But often enough secondary suppuration of the finger-joints is caused by extension of a neglected subcutaneous or tendineal phlegmon. Note. — A very acute phlegmon of the elboiv-joint came under the observation of the author at Mount Sinai Hospital. A compound dislocation was freshly admitted, and was reduced and dressed so-called " antiseptically " by a junior member of the house staff. Suppuration followed promptly, the sutures had to be removed, a number of incisions had to be made, and a tardy cure was effected, resulting in bony anchylosis of the elbow at an acute angle. (See case of Samuel Krongold, page 207.) Suppuration of the finger-joints usually terminates in anchylosis. In many cases this untoward result can be prevented by exsection and subse- quent careful treatment by passive and active movements. However, this operation should never he undertaken before the phlegmonous process has terminated, and suppuration has assumed a bland character. The author's 34 252 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. results achieved by this little operation are very satisfactory, and the jiro- cedure can be warmly recommended. As a rule, a more or less movable Joint results, which certainly is preferable to a stiff finger. In one case double exsection was successfuUy done after a felon of the thumb, involving the metacarpo- phalangeal and interphalangeal joints. To this end, how- ever, preservation of the tendons is a necessary condition. Case I. — Frank P., liquor dealer, aged thirty-six. Seen January 15, 1885, with Dr. H. Balser, on account of a phlegmon of tlie right index and palm, caused by open injury to the metacarpo-phalangeal joint. The injury was sustained, January 1, 1885, during a fight by violent contact with the antagonist's teeth. The process had lost its virulent character, and subperiosteal exsection, by two lateral incisions, was done January l(ith. The cure was uninterrupted. The flexor profundus tendon had sloughed away, hence only the first phalanx could be actively bent. Patient discharged cured February 22. 1885. Case II. — S. L.. baker, aged twenty-nine. Seen in December, 1882, in consulta- tion with Dr. H. Kudlich. Recent phlegmon of thumb, suppuration of tendineal sheath of flexors and of both the joints of the thumb. Lecemler 12th. — Three in- cisions released the tension. After the cessation of the acute stage of the inflamma- tion, December 29th, exsection of metacarpo-phalangeal and interphalangeal joints was done. Uninterrupted cure ; good function preserved. Phlegmon of the olecranic bursa is characterized by very acute local and general disturbance due to the great tension maintained by the dense cap- sule of the sac. Free incision supplemented by Volkmann's punctuation of the infiltrated skin of the vicinity is promptly followed by relief and a rapid cure. Siqjpiiration of the cubital or axillary lymphatic glands is a very com- mon complication of limited or extensive septic inflammatory processes af- fecting the hand and arm. Ttvo forms of suppuration have to be distinguished: One of an acute char- acter, terminating in the formation of one more or less extensive abscess, the result of confluence of several foci. A spontaneous or artificial evacua- tion generally leads to rapid cure. Another more chronic and very obstinate form, in which a group of lymphatic glands is attacked in succession, leading to the formation of a series of deep-seated abscesses and a number of sinuses. This form is gener- ally observed in poorly-nourished subjects. The individuality of the glands is not destroyed rapidly as in the more acute form, but their slow and gradual destruction is accomplished by a tedious ulcerative process. Long before the glandular ulceration is terminated, cicatricial contraction of the sinuses leading through healthy tissues will occur, and cause retention. This is followed by an exacerbation of the local and general symjitoms, and results in the formation of a new abscess and sinus. The interminable suppuration often leads to serious deterioration of the general condition, marked by emaciation, night-sweats, and loss of appetite. As these cases represent an aggregation of a large number of septic foci imbedded in dense tissue, one or even more incisions will not be adequate for efficient drainage, and in spite of them the process will continue. DIAGNOSIS AND TREATMENT OF PHLEGMON. 253 Extirpation of the entire group of affected lymph-glands by careful preparation is their best therapy. As rupturing of one or more of the broken-down glands, and soiling of the wound by their contents, can not always be avoided, closure by sutures is best omitted. Thorough irrigation with corrosive-sublimate lotion, a loose packing with moist gauze, and a moist dressing are appropriate. Case I. — Emma Epple, servant, aged seventeen. Admitted to German Hospital March 31, 1886. As the consequence of a "run-around" treated by poulticing, sup- puration of the lymphatic glands of the left axilla developed. The arm-pit was filled with a densely infiltrated large mass of intuniescent and very painful glands. The continuous fever and sleeplessness had produced an alarming degree of anasmia and ■debility, characterized by night-sweats and loss of appetite. As no fluctuation could be made out, and presumably all the affected glands were in a state of suppuration, extirpation of the entire glandular mass was advised, and carried into effect April 3d. Dissection of the tumor from the axillary vessels was rather difficult, and, one of the tenacula lacerating one of the brittle glands, a few drops of pus exuded into the -wound. After thorough irrigation with corrosive-sublimate solution, the wound was closed by suture, and an antiseptic moist dressing was applied. Previous to this a sepa- rate incision was made at the most dependent portion of the cavity for the reception of a stout drainage-tube. A sharp chill and much pain followed the next day after the operation. Undoubtedly, infection of the cavity by contact with the escaped pus had taken place. The dressings being removed, pus was seen oozing out of the drainage- tube. Daily change of dressings and irrigation of the cavity with mercurial lotion was followed by rapid improvement, and the patient was discharged cured, May Yth. Case II. — 0. H., butcher, aged sixty-two. Slightly cut the dorsum of his left middle finger, October 15, 1885, with a butcher-knife. A phlegmon developed, and was treated by the patient himself with poulticing till October 27th, when spontaneous ■evacuation took place. For a few days previous to this date, intumescence of the cu- I)ital lymphatic glands was noted. Octoler 28th. — The patient came under the author's •care with an angry swelling of the region of the cubital glands. Incision was proposed and declined. After a couple of wretched nights the patient consented to incision, which was done under chloroform, October 31st. A small amount of pus came away, and a drainage-tube and moist dressings were applied. The momentary improvement soon gave way to renewed attacks of pain and swelling, apparently due to succes- -sive suppuration of several glands. Much difficulty was experienced in keeping the drainage-tube in situ, the external wound showing a great tendency to cicatrization, while the slow ulceration of the glandular tissue was still progressing. An extirpation •of the glandular mass would have been more serviceable in this case than a simple incision. After a tedious and troublesome course of treatment, the case was finally ■discharged cured, December 27th. e. Suppurative Affections of the Lower Extremity : (a) Ingkown Toe-JSTail. — The most common cause of this distressing affection is the improper care of the toe-nails. Sweating feet, in combina- tion with lack of cleanliness, improperly trimmed toe-nails, and narrow-toed shoes, offer the best conditions for the development of ulcerative processes near the anterior edge of the nail. Whenever the nail is trimmed off too short, the adjacent skin will overlap its angle (Fig. 181). The epidermis be- ing macerated and soft from the profuse sweating, a small amount of friction between the edge of the nail and the skin will be sufficient to cause an exco- 254 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. 181. — a, Wronij way of trimming toe-nail, b, The right way. riation. The pyogenic germs, so abundantly present in the fetid epidermidal masses of sweating feet, will not only come in contact with the raw surface, but will be rubbed into the open lymphatics by each successive step taken by the individual. An ulcerative inilani- mation of the parts will result, which offers poor conditions for natural drain- age. Retention of the septic secretions leads to chronic suppuration, and to the extension of the process backward toward the root of and also under the nail, until more or less of it becomes undermined and detached. Exuberant granulations, subject to frequent ulcer- ative destruction, spring up from the hyi^ertrophied and infiltrated overlap- ping skin, and, if unchecked, the disorder terminates in the loss of the nail. Occasionally an ingrown toe-nail is the starting-point of phlegmon or ery- sipelas of the dorsum of the foot. The initial stages of the mischief can often be successfully met with careful local treatment. Disinfecting baths, sprinkling of alum and salicylic powder (alum, usti, | ij ; acidi salicyl., ^ ss ; bismuthi subnitr., | ijss) into the stockings, which should be daily changed, and the packing of salicylated or iodoformed cotton or a small piece of heavy tin-foil under the edge of the nail, frequently result in alle- viation, if not a cure, of the affection. More inveterate or extensive cases in persons unable to devote the neces- sary care and time to the treatment of this trouble will be best cured by operation. After careful scrubbing and disinfection, the toe is rendered anaemic by constriction of its root with a piece of rubber tubing. Local anaesthesia is produced by either an injection of a cocaine solution or the use of Richardson's ether-spray. The point of a bistoury is (Fig. 183) placed against the exuberant tissues adjoining the nail, and is thrust through the margin of the toe. It is carried forward until the integu ment is separated in the shape of a longitudinal flap. Then the knife is reversed and carried back well be- yond the matrix of the nail, where the flap (c) is cut off. The pointed blade of a straight pair of scissors is placed under the an- terior margin of the nail (Fig. 182, A, b) just beyond the limit of the disease, and, being thrust under it, cuts through the nail in an autero-posterior direc- tion well back of the matrix. One blade of a stout pair of dressing-forceps is next insinuated into the slit in the nail and under the loose segment. This, Fig. 18^. — Operation for ingrown toe-nail. A, B, Line of section through the nail and matri.x. DIAGNOSIS AND TEEATMENT OF PHLEGMON. 255 being firmly grasped, is evulsed with an outward rotating motion. Good care must be taken not to leave behind any shreds of the cut-off matrix. Any granulations are scraped away with a sharp spoon, and the wound is well irrigated with mercuric lotion. A strip of rubber tissue well soaked in carbolic lotion, aud just large enough to cover the wound, is placed next to it ; over this comes a strip of iodoformed gauze and a small disinfected sponge, the latter to exercise elastic pressure for the prevention of undue haemorrhage ; finally comes a light, compressive moist dressing, fastened by a roller bandage. While the patient's foot is held elevated, the rubber band is removed. The first dressing can be left on for a week or even two weeks. Being moist, it will peel off easily when removed, aud, accordiug to its size, the wound will be found either partly or entirely cicatrized over. Care must be taken not to compress the toe too much, as necrosis of the skin by pressure may develop and retard the healing. The author has treated several hundred of these cases in the manner de- scribed with the best results, the majority being patients of the German Dis]oensary, who walked to and from the institution during the time of treatment. (5) Chhoxic Ulcers of the Leg. — Neglected excoriations or abrasions of the skin belonging to the lower third of the leg are the most common starting-point of ulcerous processes. Varices due to stagnation of the venous circulation render the progressive invasion of new areas of tissue by micro- cocci, ever present in the putrescent discharges, especially easy. Conse- quently, ulcerative destruction develops. The successful treatment of this condition must be based upon an elimination of the causal factors. Pre- vention or elimination of decomposition by antiseptics, and an improve- ment of the circulatory conditions by elevation of the limb or its elastic compression, form the cardinal points of our therapy. The affected limb is carefully cleansed with soap and a soft flannel rag until all the crusts of inspissated secretion and epidermis are removed. This process will be greatly facilitated by packing of the parts in strips of lint saturated with vaseline or unsalted lard the night previous to the cleansing bath. Plain water should never be used on account of its irritating quali- ties and its liability to cause eczema. After the bath the soap-suds should be simply wiped off with a soft toweL The ulcer is well mopped with a 1 : 1,000 solution of corrosive sublimate, or, where the stench is very intense, with a 4 : 1,000 solution of permanganate of potash. Iodoform powder is dusted over the ulcer, and a suitable patch of rubber tissue is placed next to it. The eczematous skin in the vicinity is well anointed with vaseline or an astringent salve, and a regular antiseptic dressing is snugly bandaged on to the ulcer, the roller bandage extending from the toes to the knee-joint. This dressing need not be removed before two or three days, the frequency of renewal being dependent upon the quantity of the discharge. As soon as cicatrization is well advanced, a simpler dressing, consisting of a strap- ping of mercurial plaster covered with a pad of absorbent cotton, held down by a Martin's elastic bandage, can be substituted therefor, and the patient 256 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. may be permitted to abandon the recnmbent posture and take moderate exercise. When cicatrization is completed, a well-cleansed elastic bandage will suffice to prevent renewed ulceration. It is most convenient to have two elastic bandages, to be worn alternatingly. Under this simple treatment most ulcers of the leg, even those surrounded by callous edges, will develop healthy granulations, and will heal kindly. Due regard should be paid to the general condition of the patient, as on it may depend to a great measure the rapidity of the cure. A marastic state of the system should be improved by suitable nutritious diet ; the deterioration of the general health of those addicted to the immoderate use of alcohol should be remedied by a proper regulation of their habits. In cases of very extensive loss of integument, skin-grafting will give very gratifying results. If this should fail, circumcision of the callous ulcer by a deep cut carried through the fascia, according to Nussbaum, may be tried. The incision should be placed about one third of an inch from the edge of the sore. (c) Acute Suppuratiox of the Peepatellary Bursa. — Servant-girls and scrub-women, in short, persons frequently subject to house-maid's knee or simple synovitis of the prepatellary bursa, are frequently victims to phlegmonous inflammation of the same organ. The symptoms are those of a subcutaneous phlegmon, heightened by the circumstance that, the phleg- monous focus being encapsulated, great tension is apt to develop. Extensive necrosis and serious septic intoxication must result if no timely relief is afforded. Dense, hard infiltration and a deep-red flush of the prepatellary region, with oedema, high fever, and marked sickness, are present. The general intumescence may cause errors in diagnosis, as inexperienced observers are apt to look for the source of the trouble within the knee-joint. This mis- take can be avoided by noting that in septic bursitis the point of the most intense swelling, redness, and pressure-pain is over the patella, whereas in gonitis pressure over the juncture of the femur and tibia laterally of the patella is most painful, and the patella can be distinctly felt floating on top of the exudation within the knee. A free incision into the bursa, together with Volkmann's multiple puncture of the inflamed skin, is the proper treatment. The cavity should be well irrigated with corrosive-sublimate lotion, loosely packed with strips of iodoformed gauze, and inclosed in a 7noist dressing, which should be daily changed. (d) Acute Suppuration of the Kxee-joint is one of the most formi- dable types of phlegmon. On its prompt recognition and energetic treat- ment may depend the safety of limb and life. It should be well distin- guished from the more bland, so called, " catarrhal'" (Volkmann) inflamma- tions of the synovial membrane, due to tuberculosis or to rheumatic and gonorrhoeal influences ; and also from metastatic suppuration complicating pyaemia. It is generally caused by infection of the joint from without through accidental or surgical wounds, or by its invasion of a suppurative process DIAGNOSIS AND TREATMENT OF PHLEGMON. 257 established in the vicinity, as, for instance, acute osteomyelitis or a subcu- taneous or bursal phlegmon. Idiopathic acute suppuration of the knee- joint is very rare indeed. The invasion is marked by one or more sharp chills, very high fever, and a sudden painful intumescence of the Joint. The limb is rotated out- ward, lying on its outer aspect, is flexed at an obtuse angle, and its 2Dosition is carefully maintained by the patient, as the constant pain is terribly in- tensified by the least change of posture. General oedema and reddening of the integument soon follow, the septic intoxication frequently j^i'oducing delirium and a typhoid condition. The intra-articular tension increasing, perforation of the capsule, gener- ally upward through the bursal extension of the joint beneath the quadri- ceps tendon, occurs, and is marked by a temporary remission, of the in- tensity of the local and sometimes of the general symptoms. One or more subfascial or subcutaneous abscesses, located on one or both sides of the quadriceps, appear, and rapidly extend upward and outward until perfora- tion of the skin permits the escape of the enormous mass of pent-up pus. Occasionally the matter joerforates backward into the popliteal space, this way being marked out by the bursse situated beneath the popliteus muscle, which are frequently in open communication with the knee-joint. In this case the abscess will extend downward along and beneath the muscles of the calf. Spontaneous perforation will not bring about complete and lasting relief, as the drainage is and must be inadequate. Profuse suppuration and a con- suming fever, with frequent chills and colliquative sweats, will in a short time so depress the patient's condition, that amputation will have to be thought of as the last resort for saving life. The treatment should be that of deep-seated phlegmon, modified by the requirements of the anatomical peculiarities of the knee-joint. The cavity of the knee-joint naturally consists of three distinct recesses : one below, the other above the patella ; the third is an extension of the suprapatellar space, and is known by the name of the bursa of the quadriceps. In flexion, where the knee-pan is firmly held down to the condyles, the infra- and supra-patellar spaces become practically non-communicating. Andrews of Chicago, to whom we owe a most excellent treatise on the subject of injuries to the joints, mentions a case * of traumatic suppuration of the infra- patellar recess of the knee-joint, where, by means of continued flexion and thorough disinfection and drainage of the same space, general infection of the joint was eifectually prevented. To effect adequate drainage of a phlegmonous knee-joint, each of these recesses must be separately incised and drained. A double incision of each of these spaces will be much more effective than a single one, as it will permit more thorough irrigation. In very infectious cases two additional incisions will drain away pus retained in the reflection of the capsule from the vicinity of the crucial ligaments. * Ashhurst's " Encyclopedia of Surgery," vol. iii, p. 723. 258 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. The first incision should be made in the suprapatellar space on the inner side, where the capsule is the most ample. Haemorrhage is generally profuse, hence it is best to penetrate the tissues gradually, and to secure each bleeding vessel as soon as it is cut. As soon as the joint is entered, a dressing forceps is thrust through it to the corresponding point of the other side of the joint, where the second incision is to be made through the tissues raised by the pressure of the forceps. The point of the forceps emerging from this incision, a stout drainage-tube is grasped with it, and drawn into the Joint just far enough to clear the synovial membrane. A similar piece of drainage-tubing is inserted into the first incision, and the protruding ends of the tubes, being transfixed with safety-pins, are cut off on a level with the skin. The infrapatellar and submuscular spaces are treated similarly, and, if necessary, the lateral poaches of the joint are also in- cised and drained. The cavities are thoroughly flushed out with corrosive- sublimate lotion, a large moist dressing is fastened on, and the limb is secured to a posterior splint to insure rest and painlessness during unavoid- able changes of posture of the patient. Wherever perforation of the capsule and formation of a circumarticular abscess has occurred, this must be sepa- rately incised and drained. In the great majority of cases, resolute and comprehensive measures of this kind will be rewarded by prompt improvement. Daily change of dress- ings and irrigation should be practiced until the disappearance of all the inflammatory and febrile symptoms. As soon as the discharges become scanty and serous, the drainage-tubes can be withdrawn one by one. Where the affection is due to osteomyelitis, anchylosis will result as a rule, espe- cially in grown individuals. In children, prompt and adequate drainage frequently results in preservation of mobility. Case I. — Charles Hundertmark, aged four. Acute suppuration of knee-joint caused by a blow upon head of tibia. May 31, 1875. — Three incisions — one on each side into the suprapatellar space, a third one into the quadriceps bursa. Daily change of moist carbolized dressings and irrigation. Rapid improvement. June l5th. — Drainage aban- doned. July Jfth. — Perfect recovery noted, with free active use of the joint. Case II. — John S., grocer, aged nineteen. Acute suppuration of knee-joint, with terrible pain and typhoid symptoms. The patient was brought to the German Hos- pital .January 10, 1880, by Dr. Schwedler, who administered chloroform during the transfer, to allay the patient's suffering from the jolts of the carriage. Immediate typi- cal multiple incisions and drainage. The index-finger detected a roughened place on the articular surface of the inner condyle of the femur. Undoubtedly on account of the osteomyelitic process, the febrile symptoms receded very slowly. Permanent irri- gation of the joint rendered the frequent, terribly painful change of the dressings unnecessary. A few small sequestra belonging to the cancellous tissue of the femoral epiphysis came away on the twenty-tliird day. Patient was discharged cured, March 20th, with firm anchylosis. In exceptionally neglected cases, where the process has assumed the character of a general purulent infiltration, incisions and drainage, supple- mented with continuous irrigation, will not be followed by as prompt im- provement as is desirable. The continued high fever, the formation of DIAGNOSIS AND TREATMENT OF PHLEGMON. 259 new abscesses, will certainly bring about a fatal termination, unless the limb is amputated clearly beyond the limits of the disease. So-called con- seryatiye measures — as, for instance, exsection of the joint — are entirely inadmissible and dangerous under these circumstances. They will fail to remove from the affected parts the elements of contamination, as the most rigid antiseptic measures of the ordinary kind are here utterly inadequate. The phlegmonous process will attack the newly-made wound-surfaces, and the patient's life will be placed in the greatest jeopardy by secondary hasmor- rhage. The following case forcibly illustrates the weight of these remarks : Case. — Max LofFmann, butcher, aged twenty. Admitted, October 25, 1885, to Mount Sinai Hospital. October 12th. — The submuscular recess of the knee-joint was accidentally incised with a filthy butcher's knife. Some synovia escaped from the small puncture ; after the accident the patient walked home. Suppuration of the knee- joint set in the following day, with rigors and general dejection. The wound was dressed by a Jersey City practitioner with an adhesive-plaster dressing placed over the incision. The patient was admitted to the hospital in a highly septic condition, large quantities of thin, ichorous pus escaping from the joint on shght pressure. Immedi- ately the patient was anaesthetized, and typical incision and drainage were done. The synovial lining of the joint was coated with a greenish-gray adherent and putrid mem- brane, in looks identical with the membranous coating in pharyngeal diphtheria. A number of small, purulent foci were opened by the incisions made for drainage of the joint. ' A moist dressing and dorsal splint were applied. In spite of frequent irriga- tion, no remission of the high fever or local pain following, amputation of the thigh was proposed, in view of the visible failing of the patient's strength. This, however, was resolutely declined by the patient and his widowed mother, who begged for an attempt to save the limb. The author, against his better judgment, performed exsec- tion of the knee-joint, November 6th. Esmarch's band was applied to the upper third of the thigh without the previous use of the elastic roller bandage, and a continuous stream of corrosive-sublimate lotion (1 : 1,000) was kept playing upon the wound during the entire opei-ation, which was rapidly but carefully performed. Care was taken to operate in healthy parts, and all the involved tissues w-ere removed. The wound was drained and closed in the usual manner, and the dressed limb was fixed upon a dorsal splint. Suppuration of the wound followed, requiring frequent changes of dressing and irrigation, the secretions retaining all the while their peculiar thin, ichorous character noted from the outset. On the afternoon of November 18th, pro- fuse arterial hsemorrhage occurred from the wound, which was temporarily checked by the house-surgeon with the application of Esmarch's baud. Being hastily sum- moned to the hospital, the author found the patient blanched and collapsed. About twenty ounces of a 6 : 1,000 watery solution of cooking salt were transfused into his median vein, and resulted in a notable improvement of the pulse. Amputation of the thigh was quickly done as a last resort. The patient, however, expired before the removal of Esmarch's band. Post-mortem examination revealed a sieve-like perforation of the popliteal vein and a large oblong defect of the popliteal artery, both of which were found exposed and surrounded by a massive blood-clot. The walls of the cavity containing the clot consisted of broken-down and necrosed tissues. There is little doubt that an early amputation might have saved the patient's life. (e) StfPPUEATiOF OF THE Ingtjikal Glan'ds. — Two groups of lym- phatic glands have to be distinguished in the inguinal region — one situated 35 2(J0 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. below Poii})art's ligament, tiie other above it. The subingiiinal group is frequently the seat of phlegmonous inflammation, due to absorption of sep- tic material from sores caused by the pressure of ill-fitting shoes, ulcerated bunions, ingrowing toe-nail, and excoriations of the lower extremity from scratching in eczema. Their treatment by incision does not require special elucidation. Should, however, their excision become necessary, the rules laid down for the removal of tumors from Scarpa's triangle (pages 52 and 55) should be heeded. Acute suppuration of the sui)rainguincd glands is caused most generally by ulcerative or suppurating processes of the generative organs. Their treatment is subject to the principles accepted for glandular abscesses of other regions, and may be dismissed with the remark that the hest loay to incise them is not parallel, hut at a right angle with the direction of the fihers of FotijMrfs ligament. The edges of the incision will gap asunder, and afford very good drainage even without the use of a tube, and, later on, the edges of the cut will not exhibit the tendency to become inverted, which is the source of much trouble in the after-treatment. Interminable chronic suppuration of the suprainguinal glands fre- quently indicates their bodily extirpation. The safest way of accomplishing their removal is as follows : Two semi-elliptic incisions should include all the fistulous openings leading into the glandular swelling. They should be gradually deepened until a comparatively healthy part of the swelling is exposed. Here the capsule is incised, and the mass is carefully dissected out with the tip of a pointed scalpel. Blunt dissection should be resorted to only where it is evidently easy, as in using much blunt force the glands may be ruptured, and their contents soil the wound. This injunction is important, as intentioncd or unintentional injury to the peritonoium may become unavoidaMe. Should the epigastric vessels be in the way, they must be cut and deligated. Attention ought to be paid also to the seminal cord, which occasionally enters into very close relations with inguinal glandular swellings. /". Perityphlitic Abscess : Up to within a recent period of time it was the prevalent belief that peri- typhlitic suppuration was located retroperitoneally, and most generally in the iliac fossa, whence it found its way to the surface by pushing aside the peritoneal reflection corresjDonding to Poupart's ligament. Willard Par- ker's method of incising perityphlitic abscess was based upon this view. It Ctin not be denied that the development of most circuniappendicular abscesses seems to confirm tliis view, and that the rules laid down by Par- ker for the treatment of this grouj) of suppurative processes have yielded, and continue to yield, very satisfactory results in very many instances. Still, it must be said that the exceptions to Parker's type are considerable in number. Formerly they were classed as cases of general or localized "idio- pathic peritonitis." Their treatment was non-surgical, and their issue very uncertain and often fatal. DIAGNOSIS AND TREATMENT OF PHLEGMON. 261 Vv"e owe the better understanding of the elements of this phenomenon to Treves and Weir, but principally to McBurney, who demonstrated that in the vast majority of instances the formation of abscess in the right iliac fossa was due to intraperitoneal inflammatory processes, mostly of the ver- miform appendix, and commonly accompanied by ulceration, necrosis, and perforation of this viscus. The frequency of the location of perityphlitic abscess near the parietes of the right iliac fossa is explained by the fre- quency of the sujDerficial sifiis of the appendix in this region. In these cases the type of development so well described by Parker will prevail. But in a very large proportion of instances the vermiform appendix, either con- genitally or in consequence of acquired peculiarity, occupies a deep situa- tion, and in these cases an aj^pendicular perforative process is sure to cause a deep-seated intraperitoneal abscess, more or less distant from the surface, hence infinitely more grave and dangerous both as regards its deleterious possibilities and the difficulty of diagnosis and surgical management. As soon as it became clear that widely different intraperitoneal forms of suppu- ration might be caused by extension from the appendix, and that their man- ner of development was wholly unforeseen and unaccountable, a violent oscillation in therapy w^'as initiated by those who proposed, in all cases where the appendix was suspected of causing trouble, a bold exploration by abdom- inal section, and the extirpation of the appendix, or evacuation at all haz- ards of the purulent collection, wherever it might be found, and all this without delay. Though this bold course of therapy has, in spite of its experimental character, yielded very good results in the hands of various surgeons, and although its adoption was absolutely necessary for establishing a clearer understanding of the nature of the morbid process in question, neverthe- less it must be remembered that a vast proportion of perityphlitic abscesses do not need operative invasion of the free peritoneal cavity for their success- ful care, and that a sweeping advice to the general profession to open the peritonaeum in every case where appendicular trouble is suspected is, for ob- vious reasons, fraught with much unwarrantable danger. Formerly it was considered purely accidental whether an intraperitoneal abscess would appear here or there, and the variability of the surroundings and location of these abscesses was deemed so irregular and erratic that, to the author's knowledge, no attempt was ever made to study the question whether a certain order of development did not prevail even in those forms of perityphlitic abscess which could not be classed with the well-known inguinal type described by Parker. If some light could be thrown upon the detailed nature of these seemingly erratic forms of circumappendicular abscess, instead of the crude general advice to •'•perform laparotomy,*' more precise, hence safer, methods of treatment would suggest themselves. Let us first emphasize the fact that all intraperitoneal abscesses are of visceral origin, and that perityphlitic abscess in particular is due to inflam- matory processes located in the vermiform appendix. Though not always, this form of abscess is mostly established within the peritoneal sac. 262 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. The proof of this assertion has been so manifolil that it is only necessary to refer to the niuueroiis cases of early a])pendicitis reported by McBurney and other observers, in which, on laparotomy, the free appendix was found to be tightly distended by a copious exudate, and more or less erect by dint of its extreme distention; its walls thickened, hypersemic, occasionally exhibiting unmistakable signs of circumscribed necrosis with perforation imminent. This distention was uniformly produced by occlu- sion toward the gut. Occasionally decay had j)rogressed to actual perforation and the formation of incipient abscess, surrounded by a protective barrier of recent adhesions of the vicinal serous surfaces. The appendix was invariably found to be the starting-point of the trouble, and the affection, with rare exceptions, always intraperitoneal. Asiile from the numerous instances in which the intraperitoneal and appendicular character of perityphlitis was established by positive observation, the following case may serve to show that the retroperitoneal space back of the iliac fossa is not the seat of abscess in typical cases of perityjihlitis. In the spring of 1887 I>r. Lellmann, then on duty in the German Hospital, requested the autlior to operate on a case of perityphlitis pertain- ing to his service. The operation was delayed twenty-four hours on account of a mis- understanding, and the next day — a dense, painful tumor being found in the right iliac region — incision according to Parker was done, in spite of the circumstance that the size of the swelling had somewhat diminished since the previous day. The peritoneal lining of the iliac fossa was easily stripped up two inches beyond the external iliac ves- sels, so that the tuuaor was freely raised with it from the underlying tissues. No sign of inflammation was found, and, as the case was mending, it was not deemed prudent to incise the peiitonfeum. The very deep wound was drained and closed, but no pus appeared. Simultaneously with the healing of the incision the tumor disappeared, and the man was discharged cured within a fortnight after the operation. We need not do more than hint at the causes of appendicular inflamma- tion. Let us first mention the impaction of foreign bodies entering from the gut, acute or chronic forms of catarrhal or ulcerative (typhoid) enteri- tis, transmitted from the colon and leading to simple hypertrophy or to ulceration, both of these causing irregular constriction mostly in the vicin- ity of the attachment of the appendix. Another not infrequent cause of stenosis is the doubling upon itself and fixation of the appendix in this posi- tion. Stenosis by flexion is thus produced.* With the establishment of hypertrophy and stenosis a loss of contractile power is associated, leading to more or less complete retention and to the inspissation of fecal matter, which finally assumes the shape of one or more globular concrements. As long as the communication with the colon is fairly open, no local symptoms need prevail. As soon as the stenosis becomes considerable, the well-known signs of appendicitis make their appearance. If they are due to a passing state of catarrhal hyperaemia, their acuteness will vary in proportion with the intensity of the stenosis. Thus, with the cessation of causal intumescence and the elimination of the stenosis maintained by it, all trouble may seem- ingly or really disappear. A case reported by Shrady f aptly illustrates this train of symptoms * F. W. Murray, " New York Medical Journal," May 24, 1890, p. 564. ■f George F. Shrady, Meeting of Practitiouers' Society of New York. " Medical Record," April lie, 1890, p. 479. DIAGNOSIS AND TREATMENT OF PHLEGMON. 263 A physician had had four distinct attacks of appendicitis, in all of which the ques- tion of operation arose. Dr. Shrady had seen the patient at New York in three of the attacks, all of which were well pronounced, while the fourth occurred in Paris, where the patient was seen by a distinguished surgeon, who made a like diagnosis. There also the question of an operation came up. Each attack was attended with all the usual severe symptoms which would appear to usher in the formation of an abscess; there were dullness, tenderness, more or less rigidity, and some oedema in the neighbor- hood of the caecum. In each attack the advisability of operation was freely discussed. The patient was willing to take the risks, but in each instance the symptoms gradually disappeared, and he recovered. He asked Dr. Shrady, should he survive him, to ex- amine his appendix, which was done when death occurred, some time subsequently, of another cause. The appendix teas found perfectly sound. There was not the slightest appearance of any inflammation around it ; it was not even thickened. "Where ulcerative processes have led to the formation of a permanent cicatricial contraction, the appendical trouble is apt to persist even after the cessation of the causal disorder of the intestine. Passing states of local intumescence are then more likely to lead to complete occlusion of the com- munication between gut and appendix, with serious consequences. But even in these cases temporary improvements are possible with the diminu- tion of the acute swelling of the cicatricial mass. Before attempting a practical classification of the phases of appendicitis and of the localities in which circumappendicular suppuration is to be ob- served, this fact has to be pointed out : that, unfortunately, the acuteness or mildness of the local or general symptoms is not an invariable index of the ultimate gravity of a given case. Sometimes fatal cases will set in with a very deceptive mildness of appearances. On the other hand, a very alarm- ing beginning may be followed by resolution or a tractable state of affairs. Hence it must be insisted on that, in reference to this trouble, all thera- peutic advice has only a conditional value — to be weighed and accepted or rejected by the surgeon in each separate case. a. Acute Appei^dicitis (without Tumor). — {a) Simple Appendicitis {no Tumor). — Anatomy teaches that in the supine body the attachment of the vermiform appendix can be found directly underneath a point located two inches from the anterior superior spine of the ilium, on a line connecting this bony prominence with the navel. Whenever acute and persistent pain appears in this region, accompanied by fever and retching, the pain being markedly increased by palpation of this area, trouble of the appendix can be confidently diagnosticated. In women, bimanual palpation ought to ex- clude the joresence of an inflammatory process of the displaced uterine ap- pendages. Though the local and general symptoms may be very alarming, tumor can rarely, if ever, be detected in the early stages of the affection. Meteorism is also absent. In view of the impossibility of foretelling whether, in a given case, spontaneous evacuation of the contents of the appendix or perforation is to take place, and in the latter case whether a superficial or a deep-seated abscess is to develop ; and, considering the fact that laparotomy followed by excision of the appendix has yielded uniformly good results if done be- 264 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. 183. — Incising peritypbilitic abscess. fore the access of perforation, it is safe to follow McBurney's advice, which recommends laparotomy and removal of the appendix whenever severe .symptoms persist and increase for more than forty-eight hours. The steps of the operation are these : A longitudinal incision, four or five inches long, parallel with and just outside of the outer margin of the right rectus muscle. Having opened the peritonaeum, the appen- dix is found, which will be rendered easy by first ascertaining the location of the caput coli. The mesentery of the appendix is included in a double ligature of stout catgut and divided. Then the root of the appendix is secured by two ligatures, between which the viscus is cut off. The mucous lining of the stump is either seared with tl.e thermo-cautery, or, after careful disinfection, is touched with a few drops of iierchloride-of-iron solution and dried off. Then the stump is dropped back and the external wound is closed. Case.— Miss F. L., aged tsveiity. Has had altogether sixteen or eighteen attacks of appendicitis within two years. Characteristic local pain, irregular fever with tem- peratures reafhing 104° Fahr. ; no tumor. Uterine appendages normal. April 20, 1890. — Laparotomy. The free appendix is found very nmch thickened, its distal half distended and bent upon itself, containing a quantity of fetid serum. It was removed. Uninterrupted recovery. {b) Perforative Appendicitis {no Tumor). — Sudden increment and ex- tension of the local pain followed by symptoms of collapse, such as profuse cold sweating, a thready pulse, anxious expression, pallor, frequent vomit- ing, and the appearance of meteorism are indications that perforation and infection of the peritona?um have taken place. This rarely occurs before two or three days after the ince])tion of the trouble. The violence of the symptoms will depend on these factors. If the extent of the perforation is small, and only a small quantity of the infectious contents of the appendix has made its way into the peritonaeum, a limiting barrier of protective ad- hesions may be thrown about the infected area within an hour or so. In this case the alarming features of the case will somewhat subside and a tumor is ai)t to develop. If, on the other hand, the perforation is large or multiple, a considerable volume of infectious material will suddenly escape. Lively peristaltic action will widely distribute it, and more or less extensive local or, in the worst cases, general septic peritonitis will be established. The absence of tumor in conjunction with very acute local and general symptoms represents an extremely grave combination of things, its meaning being a generalizing peritonitis. In these cases the prognosis is very doubt- ful, and it will be extremely difficult to save the patient, even by the most resolute measures. If laparotomy is immediately done, the focus laid open. DIAGNOSIS AND TREATMENT OF PHLEGMON. 285 wiped out clean, the appendix removed, and the cavity packed and drained, some chances may still be present for the patient's recovery. But where, on account of delay, numerous and widely disseminated abscesses have established themselves in the more remote parts of the peritoneal cavity, the patient's death is nearly certain. Prolonged exposure, the impossibility of a sufficient evacuation and drainage of the foci which are found, finally the overlooking of distant foci located in the loins, in front and behind the liver, will sufficiently explain this fact. Cass I. — William Sachse, aged fortv-eight, liquor-dealer. Was treated since September, 1889, in the internal department of the German Hospital for alcoholic neuritis. No habitual constipation. March 23, 1890. — Sudden chill. Temperature, 105° Fahr. Slight amygdalitis. No abdominal symptoms. The temperature remained high, although the patient's bowels were well purged with calomel on March 25th. Had a chill in the preceding night, another one in the afternoon, complaining the first time of belly-aclie. ^7^A.— Pain well marked in ileo-ca^cal region. Was transferred to surgical service. Temperature, 104-4° Fahr. Meteorism, intense pain in the ileo-cgecal region, but no tumor and no dullness. Vomited only once. Laparotomy at 3 p. m. McBurney's incision. Peritoneum filled with turbid serum. Omentum widely adher- ent to caecum, in front of which an adherent and very much thickened and elongated vermiform appendix was found. On freeing this, a large, irregular abscess cavity was opened, which did not anywhere approach the parietes, and which was situated below and behind the cfecum, its walls being formed everywhere by intestines. At the root of the appendix a large perforation was seen, with three globular fecal concrements lying in front of and outside of it. The appendix contained three more globular con- crements of the size of a small marble. The appendix was isolated, tied, and cut off. Another large abscess situated in the median line, and a third one in Doug- las's pouch, were opened, irrigated, and drained. Hasty partial closure of incision after packing and drainage of the abscesses on account of collapse. In the night the temperature rose to 106° Fahr., and the patient expired toward midnight. Post- mortem examination revealed three more abscesses, one situated high up behind the liver. Case II. — David Danziger, tailor, nged twenty-two. General peritonitis due to perforative appendical trouble of six days' duration. Laparotomy January 29, 1889, at Mount Sinai Hospital. Seven abscesses were opened and drained. Patient seem- ingly improved, the quality of the pulss improving. Vomiting ceased, but he collapsed suddenly thirty hours after the operation and died. Post-mortem examination re- vealed three perihepatic abscesses. i. Acute Appbistdicitis with Tumor ; Perityphlitic Abscess. — AVhenever perforation of the free appendix occurs, the invasion of the peritonaeum is regularly signalized by the usual symptoms of perforative peritonitis. As before mentioned, a circumvallation by adhesions will form in those cases in which only a small quantity of infectious material has escaped. This seems to be the usual course of events. Occasionally, hov/- ever, the inflamed parts of the appendix will first become adherent, and then be perforated. In these cases the alarming intermezzo possessing the typical aspect of perforative peritonitis will be missed, and the abscess will develop without a tendency to meteorism and collapse, and with a gradual but steady growth of the mainly local symptoms. The complex of symp- '2m RULES OF ASEPTIC AND ANTISEPTIC SURGERY. toms has little of the character pertaining to peritonitis, and resembles that of an ordinary abscess. Bv contiguous extension, which is mostly slow, these abscesses may as- sume very large proportions. Neglected for a long time, especially if they are limited by intestines only, their secondary rupture, followed by a chill and further extension, or even their generalization, may occur. This, however, is not common in the early stages of the process. The only case of this kind observed by the author occurred nineteen days after the incep- tion of the trouble. Case. — IT. I)., clerk, aged twentv. Subject to alvine sluggishness, contracted, after a more than usually severe spell of constipation, a deep-seated, hard, painful, perity- phlitic swelling. Cathartics failed to relieve the bowels, and, high fever with vomiting having set in, the author was consulted. Jlay i, 1878. — Typical swelling of a cylin- drical shape was made out in the right groin, and a number of repeated large injec- tions of tepid water into the gut were employed without success. 3d. — The peritoneal symptoms, notably vomiting, became very distressing, wherefore this therapy was aban- doned and opium treatment begun. At the same time an ice bag was placed over the swelling. The change effected a decided improvement in the subjective symptoms, but the swelling continued to increase and the fever remained unrelieved, 17th. — Spon- taneous evacuation of a large, formed stool occurred. 19th. — The general condition becoming very poor, incision was urged, but was firmly declined by patient and parents. Suddenly, in the night of the same day. perforative symptoms developed. The patient died. May iOth, of septic peritonitis. Post-mortem examination demonstrated an in- ternal perforation of the abscess, and putrid septic peritonitis. Had the patient con- sented to the operation, the case might have turned out differently. Perforation took place on the nineteenth day after the invasion. Tlie presence of a tumor, which alicay.< indicates the existence of protective adhesions, implies a certain amount of temporary security, and, under certain circumstances, may justify a .9hort delay of the operation. Types of Acute Perittphlitic Abscess. — Although the classification of perityphlitic abscess according to location can not be made with geomet- rical precision, yet it will be found that most cases can be naturally massed in a series of roughly defined groups. The small number of intermediate or transitory forms does not vitiate the practical value of this grouping, upon the right understanding of which must be based some important variations of the operative technique. It is the author's wish to firmly maintain the importance of the prin- ciple that every intraperitoneal abscess should, if possible, be opened and drained without invading the normal peritoneal cavity — that is, through ex- isting planes of adhesion to the parietes. With few exceptions, all perity- phlitic abscesses have .such an approachable side. To study, to ascertain, and to utilize them is the duty of the conscientious surgeon. It is idle to state that safely incising and draining an abscess through a laparotomy wound — that is, through the free peritoneal cavity — is an easy or indiffer- ent matter, Xo competent person will believe it. DIAGNOSIS AND TREATMENT OF PHLEGMON. 267 1. Ilio-inguinal Type {Willard Parher^s Abscess). — The normal situa- tion of the caput coli and appendix vermiformis near the parietes of the right iliac fossa has the consequence that the great majority of circumap- ])endicular suppurative processes will naturally establish themselves so as to have for one of their limiting walls the parietal peritonaeum of that region. This has led to the erroneous belief that perityphlitic abscess is normally located behind the peritoneal lining of the iliac fossa. This situation involves the great practical advantage that the abscess can be permitted to assume certain proportions so as to render its incision sim- ple and free from the danger of invading the normal peritoneal cavity. Therefore, when an immovable tumor develops in the right iliac fossa soon after the inception of the malady, it is safe to wait a few days until the ab- scess has assumed a certain size. On the fourth, fifth, or sixth day it may be safely incised. Searching for pus with a hollow needle is superfluous when the abscess is superficial — that is, immediately beneath the parietes ; dangerous if it is deep-seated, as the gut might be thus injured or the healthy peritonseum infected. Case. — Francisca Bertrand, aged forty-five. Was taken ill with fever early in July, 1882, and developed a deep seated, painful swelling in the left iliac fossa, with high fever and peritonitic symptoms. On the afternoon of August 5th probatory puncture brought out some pus, wherefore, with the aid of the family physician, Dr. Assen- heimer, incision was jjracticed by Hilton's method. A large quantity of pus escaped, and a drainage-tube and antiseptic dressing were applied. In the following night very acute peritonitis set in, to which the patient succumbed August 6tli. No doubt the retiection of the peritoneum was injured, and part of the pus must have entered the peritoneal cavity. The only safe way of opening these abscesses is by methodical and care- ful dissection, layer by layer being divided by an ample incision placed through the longer axis of the tumor. The vicinity of pus will become manifest by the discoloration and condensation of the tissues. When the abscess is opened and the bulk of its contents has escaped, a gentle ex- ploration by the index-finger is advisable to detect recesses or a foreign body. But all rough treatment of the walls of the cavity by scraping, tearing, or rude squeezing is reprehensible, as it may lead to inward rupt- ure. For the same reason search for and removal of the ulcerated or necrosed appendix from the abscess is to be avoided as unnecessary and dangerous. Two drainage-tubes are slipped into the cavity and fastened in the usual manner. They will facilitate irrigation without causing un- due distention. A daily change of dressings will be required for the first week or ten days. As soon as the discharge becomes scanty and serous, the tube should be removed. The ilio-inguinal type is undoubtedly and fortunately the most common form of perityphlitic abscess, and its time-honored therapy as laid down by Parker will have to be retained as safe and successful. In sixteen cases of the ilio-inguinal group operated on by the author ac- cording to Parker's plan, only one terminated fatally, by erysipelas. The 268 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. patietit Avjis under treatment for hip-joint disease when, unfortunately, the complication with perityphlitic abscess set in. Case. — Ernestine S., servant-irh'l, aged nineteen. Admitted March 2, 1880, to the German Hospital, with the diagnosis of hip-joint disease, tlie symptoms of which were indubitably present. Emaciating fever, and the characteristic fle.xion and adduction of the tiiigh, together witii swelling of the gluteal and infrapubic regions, seemed to ad- mit of no doubt. Examination under ether, however, revealed a fluctuating swelling of the right groin, which yielded pus on puncture, and was incised. A large quantity of pus and the stem of an apple or pear were evacuated. Another incision below Pou- part's ligament establislied drainage of an abscess communicating with the perity- phlitic gathering. The lower extremity was put into Buck's extension, and the cavities were daily irrigated. Operative measures, directed against the profuse discharge from the lower incision — that is, drainage or exsection of the hip-joint — were contemplated, when the girl contracted erysipelas, and died of it in May, 1880. Post-mortem exami- nation established the fact of hip-joint sui)puration, a communication of the perity- phlitic abscess with the joint being found, by way of the iliac bursa. See Case XI, page 129, for necrosed appendix contained in inguinal hernia. 2. Anterior Parietal Type. — Next in frequency to the ilio-iuguinal form of perityphlitic abscess is the type according to which the bulk of the puru- lent collection is found immediately behind the anterior abdominal parietes of the right side. Frequently this is associated with a more or less appar- ent ilio-inguinal tumor, and might be looked upon as its extension. The swelling is generally found behind the right rectus muscle, its shape verti- cally elongated, its upper limit occasionally extending beyond the level of the navel to the hypochondrium, its jiroximal margin to or beyond the me- dian line. When an unmistakable continuation of the tumor can be traced into the right iliac fossa, the abscess can be safely opened above Poupart's ligament, as in the preceding grou}). But occasionally the upper extension will require a separate incision. Case I. — Abraham Jacobson, tailor, aged twenty-two. Perityphlitic abscess of six days' duration, the iliac tumor extending inward and upward to the inner margin of the rectus muscle, the space above Poupart's ligament feeling em{)ty. Norem'ber 19, 1888. — Typical incision at Mount Sinai Hospital, a little below and to the inward of the anterior superior spine ; drainage. Retention of pus in the upper pocket, hence, November 26th, second direct incision. Rapid improvement. January 17th. — Dis- charged cured. Case II. — David Frank, butcher, aged forty-two. Perityphlitic abscess of eight days' duration ; tumor extended upward along the line of the rectus muscle to within a hand's breadth of the costal margin. Decemher 8, 1889. — Incision two inches and a half to the inward of the anterior superior spine. Evacuation of about a quart of jms ; depth of abscess, twelve inches; though the wound was doing well, surgical delirium set in, and the patient was transferred to his home December 2-4th, where, as his family attendant reported, he soon recovei-ed entirely. When it is found that the iliac fossa is normal and entirely void of re- sistance, and a circumscribed tumor can clearly be felt some distance from the ilium and Poupart's ligament, it is necessary to ascertain where to make DIAGNOSIS AND TEEATMENT OF PHLEGMON. 269 a safe incision. If the extent of the tumor is great, a direct incision might be confidently made. But if the superficial extremity of the tumor is small, it will be safer to first open the peritoneal cavity in the median line by a small incision, and digitally explore the exact relations and extent of the adhesion. Having thus located the abscess, the exploratory cut is closed, and the abscess is incised by a direct route. Case I. — Miss Evelyne H., school-teacher, aged twenty-three. Perityphlitic ab- scess of two weeks' duration. Small tumor to the riglit of median line, underneath right rectus muscle. Iliac fossa empty. Per vaginam^ tumor was felt adherent to anterior abdominal wall, and with it bimanually movable backward and forward. March 7, 1890. — Exploratory laparotomy in median line below the navel. Just to the right of incision, partly solid, partly fluctuating mass could be felt, its walls being evidently formed of intestine, among which the empty appendix was seen firmly attached. By passing the finger aronnd the attachment of the tumor to the anteiior abdominal wall, it was found that the iliac fossa contained healthy intestine, and that the tumor was in no wise cimnected with it. Fixation of tumor by fingers in abdomen ; puncture through abdominal wall ; fetid pus. Closure of laparotomy wound by suture. It was sealed with a strip of rubber tissue moistened with a little chloroform. Incision of abscess along the line of puncture ; evacuation of five ounces of pus. Uninterrupted recovery. Discharged cured, April 10, 1890. Case II. — Mark Beermann, hat-maker, aged nineteen. Perityphlitic abscess of seven days' standing. Somewhat movable tumor underneath right rectus muscle on a level witli umbilicus. Iliac fossa normal. Novemter 30^ 1889. — At Mount Sinai Hos- pital, median exploratory laparotomy. Location of adhesion, which was very limited, was established by digital exploration. Closure of laparotomy wound. Incision and drainage of abscess. Discharged cured, J.-muary 11, 1890. Case III. — Perityphlitic abscess of the anterior type may extend to and heyond the median line, whea it icill hold close relations with and may perforate into the bladder. Henry Marks, aged seventeen, suffered from habitual constipation and fre- quent attacks of colic. In June, July, and August, 1878, severe attacks of colic were noted and overcome by tJie use of purgatives. August 25th. — Dr. L Weiss, the family attendant, made out typhlitis and ordered a laxative, whicii, however, failed to relieve the patient. Thereupon opium was methodically exhibited until September 6th, when the patient had a spontaneous and copious, formed evacuation. Septemler 7th. — The temperature rose to 104° Fahr. ; the external swelling in the right groin became very marked. 10th. — The author saw the patient in consultation with Dr. Weiss. A uni- form puffy swelling was found occupying the right groin, and was extending beyond the median line of the abdomen. Frequent urinatiim distressed the patient a good deal, who exhibited the usual hectic symptoms of long-continued suppuration. Deep fluctu- ation was made out, and evacuation of the abscess was determined upon. The trans- versalis fascia being gradually exposed, it was found infiltrated and firmly attached to the underl^\ing tissues. A probatory puncture made in the bottom of the wound, close to the OS ilium, gave pus, wliereupon the abscess was freely incised, and a large quan- tity of matter was voided. No foreign body could be found. Digital ex])loration dem- onsti-ated a long sinuosity extending toward the median line to a pocket occupying the prevesical space, A drainage-tube was placed in the main abscess, another one was carried into the prevesical space, and the wound was dressed with carbolized gauze, The patient's wretched condition at once commenced to improve ; appetite and sleep returned, and the profuse night-sweats disappeared. 20th. — The drainage-tubes be- came disarranged, and were found slipped out of the wound Difficulty was experi- 270 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. CDced in replacing them, and symptoms of retention, witli renewed p.iii! and fever, set in again. 2Jd.—The author again saw the patient, and replaced tiie tubes. A consid- erable quantity of pus was found in the prevesical pocket. From this date on uninter rupted improvement was noted, and the patient got up October 10th. October 20th, the tubes were withdrawn, and October oOth the fistula was closed. In this case iniiniiu'iit perforation of tlie bladder wall was prevented by timely incision. 3. Posterior Parietal Type. — Whenever perforative processes occur in an appendix located near the posterior parietes of the peritoneal cavity — for instance, near the right sacro-iliac synchondrosis of the lumbar region — the resulting abscess will naturally have a deep situation. Cases w\\\ occur in which incision of such an abscess can not be made unless it be done through a laparotomy wound. But there can be no doubt that in a certain proportion of these cases a safe incision may be made from behind. Case I. — Tames Solomon, school-boy, aged thirteen. April i5, 18S9. — Perityphli- tis of five days' standing. In consultation with Dr. W. Morse, an indistinct, very deep- seated, and painful tumor was felt in the region of the sacro-iliac juncture «.f the right side. By April 22d the tumor had considerably enlarged, and seemed to lie just be- neath the right rectus muscle. At Mount Sinai Hospital laparotomy was done the same day over tlie site of the swelling, which was found to hold no connection what- ever with the anterior abdominal wall, but wns firmly adherent to the posterior wall of the pelvis. The ascending colon formed the outer wall of the tumor. The appen- dix could nowliere be found, and was undoubtedly imbedded in the mass of the tu:nor. The anterior wound was closed, and a long, hollow needle was thrust into the region of the tumor from behind, entering the pelvis a little to the inward of the line of the pos- terior superior spine, its direction being downward and forward. Pus was gained at great depth, and tlie abscess was incised and drained from there by a rather long and deep incision. All the febrile symptoms disappeared, and the boy was discharged cured, June 8, 1889. Case II. — Sanniel Gross, tailor, thirty-three years old. Was laparotomized at Mount Sinai Ho.spitai, January 27, 1889, for internal obstruction of six days' standing. Fecal vomiting was present, with enormous tyiupanites due to intestinal paralysis. The cause of the obstruction was found in a very long and much distended appendix vermiformis, the apex of which was firmly attached to the under surface of the right half of the transverse mesocolon. Tlirough the loop thus formed about three leet of the ileum had slipped ami had become strangulated. Corresponding to the attaciiment of the apex of the appendix a massive swelling was felt, occupying the spa'i-e beliind the colon, and, when the adliesiou was severed, pus welled up from a small aperture correspondin r to the site of the attachment. This led into an abscess cavity wliich was carefully evacuated. The appendix being removed, the intestines were reidacecl with considerable difficulty. The patient died an hour and a half after the operation.* Case III. — Mr. M. C, aged sixty-two. Had been suffering from habitual and very obstinate constipation for years. In May, 1880, profuse diarrhoea set in, and ccuid not be controlled by any of the usual dietetic and therapeutic measures. A grave deterio- ration of the general condition developed, and the patient lost very much flesh in spite of forced feeding. August 31st. — Fever set in, and the presence of a painful swelling in the iliac fossa was made out. September 3d. — The author saw the case in consulta- * For complete history, see " New York Medical Journal," May 4, 1889, p. 478. DIAGNOSIS AND TREATMENT OF PHLEGMON. 211 tion with Dr. W. Balser and Dr. L. Conrad. A large fluctuating swelling occupied the right half of the pelvis, and tympanitic percussion sound was noted in tlie lumbar re- gion. Two incisions were made — one above Poupart's ligament, another in the lum- bar region — and an enormous amount of gas, pus, and fecal matter was evacuated. Profuse secretion and diarrhoea continued, and tlie patient died September 22d. Fost- moi'tem examination revealed a tight cancerous stricture of the ileo-csecal valve, and an enormous dilatation of the lower portion of the ileum, which resembled thick gut. Large masses of impacted fecal matter were found in this poucb, which was adherent to the posterior parietal peritonaeum, and was freely communicating through a number of ulcerous defects with the abscess caviiy. 4. Rectal Type. — It is a good rule never to neglect to examine the rec- tum of a patient suffering from perforative appendicitis. A long appendix may become fixed and perforated in the small pelvis, and an abscess is then apt to develop in close vicinity to the rectum, whence it can be safely opened and evacuated. The objection that faeces might enter the abscess has thus far not been verified by experience. Case. — August Petry, clerk, aged eighteen. Was admitted, November 10, 1887, to the German Hospital with symptoms of perforative peritonitis. General tympanites prevailed, and a tumor could not be felt anywhere, but intense pain v/as complained of on pressure in the right iliac fossa. The poor state of the patient forbade operative in- terference, and opiates and stimulants were exhibited. By November 13th the patient had fairly rallied. An examination of the rectum disclosed the presence of a fluctu- ating swelling corresponding to its anterior wall. An incision evacuated a large mass of pus, and a drainage-tube was placed into the cavity and brought out tlirough the anus. The tube was not borne well. It excited tenesmus, and was repeatedly ex- pelled. As the patient was doing very much better, and the tumor had disappeared, it was left off without ill consequences. The patient was discharged cured November 27, 1887. 5. Mesocodiac Tyi^e. — To characterize that most serious form of circum- appendicular abscess, the walls of which are composed entirely of aggluti- nated intestines, and which hold no immediate relation whatever with the parietes of the abdominal cavity, the term '' mesocoeliac " was chosen (from at KoiXCai, the intestines, and iv fiea-io, between). The abscess is found occupying, as it were, the middle of the peritoneal sac. Hence, to reach and evacuate this form of abscess, the free peritoneal cavity must be opened, and the collection of pus must be reached by separating the adherent coils of gut which inclose it. We owe the development of the teclmiqiie of the evacuation of these abscesses mainly to McBurney, whose procedure is as follows : A longi- tudinal incision, as for simple appendicitis, is made parallel to and along the outer border of the right rectus muscle. The abnormal cohesion and resistance of the implicated intestines will point out the site of the abscess. The protruding normal coils of gut should be packed away under a pro- tective bulwark of sponges held in situ by the assistants' hands, so that, if the abscess is opened unawares, no pus should soil the healthy peritonteum. Two of the nearest coils are now gently and cautiously separated by gradual traction, exercised by the operator's fingers, until a small quantity of pus is 272 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. seen exuding. It is desirable to let the pus escape slowh', so as to have am- ple time to sponge it away as it pours out ; otherwise the whole tield might be overwhelmed and contaminated by a sudden flood of matter. Note — It seems that exhausting the abscess through a small aperture bv means of a syringe would be an improvement upon the mopping up by sponges. As soon as the bulk of })us has been removed, the cavity is wiped out clean with sponges dipped in an antiseptic solution, and now the adherent intestines are still more separated to permit the surgeon to inspect its in- terior. If the appendix is loose and easily to be got at, it can be removed, but, if it is found closely adherent and very brittle, it is better to remove only so much of it as will come away easily. A good-sized drainage-tube is placed into the bottom of the cavity, which is, in addition, loosely filled with strips of iodoform gauze. These and tlie rubber tube are brought out near the lower angle of the wound, and the abdominal incision is closed in the usual manner. If the case is progressing well, the packing can be with- drawn on the third day, as by that time protective adhesions will have formed between the adjoining coils of gut. The drainage-tube is to be removed as soon as the secretions become serous and scanty. c. Chroxic or Relapsixg Appendicitis axd Perityphlitic Ab- scess. — It was shown how simple catarrhal conditions of the mucous lining of the appendix may lead to more or less complete occlusion of the exit of this viscus. The retention of the secretions will then cause distention and the train of symptoms characteristic of appendicitis. With the diminution of the catarrhal swelling of the mucous membrane, a restitution ad inte- grum will take place.' Usually the symptoms produced by this form are mild and tractable. Bland laxatives and opiates, rest in bed, with some form of local applications, generally bring about a lasting recoverv. Where ulceratvie ])rocesses, prolonged inflammation, or the doubling of the appendix upon itself, have caused the formation of cicatricial mat- ter — hence permanent stenosis of greater or less intensity — the recurrence of severe obstructive symptoms will be more frequent, the intervals between the attacks shorter and shorter, and the tendency to the formation of adhe- sions more pronounced. Tims the ver}" chronicity of the process will yield, in its tendency to the formation of adhesions, a certain protective charac- ter. Should perforation occur, these adhesions fulfill a most important function in preventing general septic peritonitis. The number of relapses of appendicitis may be very great ; in one of the author's cases sixteen were counted. With the increase of the cicatricial stenosis, the formation of concretions, and the loss of contractile power of the appendix, tlie tend- ency to ulcerative or gangrenous lesions becomes more and more pronounced, and finally culminates in perforation. As we have no means of ascertaining the exact condition of the ajipen- dix, frequent recurrence and increasing severity of the disorder clearly justify an attempt at its removal. The term " attempt " is used here purposely to signify that such endeavors may occasionally be baffled by intricate and DIAGNOSIS AND TREATMENT OF PHLEGMON. 273 close adhesions, which a prudent surgeon may prefer not to disturb for fear of lacerating the gut. It may be said, however, that, should the first attempt fail, a second one may be crowned with success.* All surgeons admit the occurrence of the spontaneous evacuation of peri- typhlitic abscesses into an adjoining part of the gut. Occasionally perfora- tions into the bladder, rectum, or even the pleura, have been observed and described. If such an evacuation into the gut is followed by a perfect oblit- eration of the cavity and fistula, no relapse will occur. Should evacuation be imperfect, ins23issation of the retained pus and a temporary dormancy of the acute signs of the process will result, until some local irritation again provokes rapid intumescence, followed by evacuation of the surplus con- tents of the abscess. This process may be repeated a number of times, as a result of which a thick mass of cicatricial matter will be deposited around the focus. Cases of this order demand surgical interference. Case. — Miss Caroline D., aged fourteen. Bad had within two years three attacks of perityphlitis with well-marked ilio-inguinal tumor, which never disappeared com- pletely. On April 24, 1888, Dr. L. Arcularius presented her to the author, who ad- vised an operation. A small immovable tumor could be felt occupying the iliac fossa. On May 1, 1888, an incision was made, and a small cavity of the size of a chestnut was laid open. Its walls consisted of a massive deposit of cicatricial matter, its contents of a putty-like mass of inspissated pus, surrounded by a coating of deciduous granulations. "When all the soft matter was scooped out, a narrow sinus was traced to a depth of an inch and a half beyond the bottom of the cavity. The wound was packed, and was kept open witli considerable difficulty during the entire summer, small quantities of feculent matter escaping from time to time. In the course of the following winter the tumor gradually shrank away, the discharge dried up, and, the tube being removed, per- manent healing took place. Had the outer opening been permitted to heal, recurrence of the abscess would have probably followed, as closure of the communication with the gut came about with a great deal of hesitancy. The same state of affairs may and does often prevail in abscesses that are evacuated by the surgeon, and in which the outer opening shows a more pronounced tendency to clos- ure than the sinus leading from the abscess cavity to the gut. Thus the presence of a however minute fecal fistula that has not healed soundly may bring about a number of recurrences in the tract of the old abscess. It stands to reason to say that inadequacy, both as regards the quality and dura- tion of drainage of the abscess cavity, has a most important influence upon the retardation of the closure of the fecal sinus. Hence the tendency to relapses will be very pronounced in cases where evacuation of the primary abscess took jolace spontaneously. Case. — Frank Kennedy, printer, aged twenty-five. Had suffered since childhood from a number of attacks of smart pain in the right groin accompanied by fever. In the early part of 1885 he acquired an oblique inguinal hernia of the right side, and w.is * I take the Ubcrty of referring to a verbal communication of Dr. F. Lange, who informed me that he once had to abstain from removing the appendix through an anterior incision. Later on the organ was successfully removed through a posterior wound. 274 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. ordered to wetir a truss, the pressure of which, if the pad became displaced outward, caused iuteuse suftering, so tliat he had to abandon its use from time to time. In June, 1885, during a severe attack of lever, an abscess broivC open two inches and a half below the anterior superior spine. Since then healing and reopening of the sinus had occurred four times. On March 3, 1886, a dense deep-seated tumor could be felt in the right groin, independent of the hernia, which could be easily replaced. Follow- ing the existing sinus, the center of the indurated mass was laid open by a large incis- ion running parallel with Poupart's ligament. At the depth of two inclies a globular stiiootli-walled cavity was exposed, within Avhich, imbedded in frail granulations, a stratitied coprolithon of the size of an unshelled almond was found. A channel of the diameter of a goose-quill was seen leading from this cavity inward and downward, into which could be slipped twelve inches of a slender drainage-tube. When water was thrown in through this tube, diluted fecal matter regurgitated. Under the microscope this matter w^as seen containing granules of amylum and fat with fat crystals arranged in the shape of sheaves. The wound was kept packed with gauze till March 25th, and was healed, seemingly from the bottom, by April Uth. On November 15, 1886, the fistula reopened, and the proposition was made to the patient to expose the site of the fecal sinus from within by laparotomy, and to deal with it by extirpation of the appen- dix or enterorrhaphy. He declined to take the risk, and preferred to wear a tube per- manently. Sparse quantities of a feculent, orange- colored serum continued to escape from time to time until the end of 1888, when the tube could not be replaced once, and was abandoned. As it seems, permanent healing tlien took place. The proposition made to this patient, to close his fecal fistula by laparot- omy and an ai)propriate dealing with the involved gut, contains the essence of a plan the adoption of which might be necessary in order to bring about the speedy cure of an apparently interminable, most disagreeable, and loath- some ailment. But the necessity for the adoption of such extreme measures must be very rare indeed. On the whole, it may be said that the recurrence of an evacuated peri- typhlitic abscess is comi)aratively rare, and that, if it is due to the presence of a fecal fistula, its lasting cure can in most instances be effected by pro- longed and efficient drainage of the outer wound. Another cause of prolonged suppuration within and around an incised perityphlitic abscess is the formation of one or more extraperitoneal bur- rows and cavities, located between the several layers of the abdominal wall, which are the direct consequence of inadequate measures at drainage. The primary cause of the abscess may be eliminated, the perforative aperture of the appendix or gut may long since have permanently closed, and yet frequent relapses of suppuration will keep the patient confined to the bed. How to deal with a case of this kind may be seen from the following history : Mrs. E. T., aged thirty-two. "Was operated for perityphlitic abscess by a prominent gynecologist of this city in the latter part of the summer of 1887. Four weeks after the operation the drainage-tube was withdrawn, and the wound healed promptly, but a reaccumulation and evacuation of pus soon followed, and symptoms of recurrent re- tention were observed on an average every four or six weeks until January 13, 1889, when, by the same practitioner, bloody dilatation was done with the confident expecta- tion of lasting success. These hopes, however, remained unfulfilled. Up to March 1, DIAGNOSIS AND TEEATMENT OF PHLEGMON. 275 1889, three more recrudescences occurred which were closely observed by the author. Each time symptoms of retention were present, though a large and long drainage-tube was constantly in situ, reaching to the bottom of the wound. Circumscribed swellings occurred then once above, another time to the inner side of the sinus, and pus was seen welling up on pressure from tlie drainage-tube. It was decided to tind and remove the cause of this distressing condition by an operation, which was done March 11, 1890, in the presence of Dr. Lange and Dr. Bull, of this city. The tract within which had lain the drainage-tube was exposed to its bottom by an incision nine inches long, and run- ning parallel with Poupart's ligament. Carefully examined, it was found to be soundly and firmly closed at the bottom, no manner of communication existing with the gut, though it was evident that only a thin layer of tissue separated the cavity from the peritoneal sac. On the lateral aspect of the smooth lining of the old drainage track, and not far from the bottom, two minute apertures were seen inosculating, into which the probe passed for a distance of two and four inches, respectively, the longer track leading toward the navel, the shorter upward toward the crest of the ilium. When these narrow tracts were slit up, each of them was found terminating in a small pocket containing granulations and pus. These sinuses were located within the ab- dominal parietes, between the muscular and peritoneal layers. Unavoidably, the peri- toneal cavity was opened in two places, but, as no tumor could be felt within, these apertures were not enlarged. However, a long probe was passed into Douglas's cul- de-sac through one of these apertures, where a finger placed in the vagina could dis- tinctly feel its rounded point. The very large wound was purposely left open, and the dressing consisted in an iodoform-gauze packing, which was renewed every twenty-four hours in the beginning, later on at longer intervals. Uninterrupted heal- ing followed, though it took a long time on account of the size of the wound. June 3d. — The patient was discharged cured, and has remained well ever since then. Conclusions. — 1. Mild, presumably catarrhal, forms of appendicitis, require no operative measures, but dietetic and medicinal treatment by opiates, laxatives, rest, and local applications. 2. The more severe and persistent forms of appendicitis may render ex- cision of the appendix advisable, especially if frequent recurrence, with increase of the violence of the symptoms, is observed. 3. Most perityphlitic abscesses hold close relations with one or another of the abdominal parietes. The location of the parietal adhesions of the abscess is to be first ascertained, if necessary, by exploratory laparotomy, and the abscess is to be then incised and drained through the area of adhe- sion, thus avoiding infection of the sound peritonaeum. 4. Perityphlitic abscesses that possess no parietal adhesions and have a mesocoeliac situation between free coils of intestine must be reached by laparotomy through the uninvolved peritoneal cavity. Precautions have to be taken not to infect the normal peritongeum. 5. Eecurrence of suppuration in the groin, following spontaneous or artificial evacuation of a perityphlitic abscess, may be due either to the per- sistence of a small fecal fistula, or to the presence of secondary intraparietal sinuses caused by inadequate drainage and retention. In the first case prolonged and efficient drainage is to be employed for a long time before resorting to artificial closure of the fecal fistula by lapa- rotomy and enterorrhaphy or otherwise. 37 278 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. In the second case all sinuses and pockets have to be found by free and careful dissection, and, when they have been slit up and scraped, the wound is to be treated by the open metliod to effect a sound cure. g. Abscess of the Liver. — The diagnosis of hepatic ab.-cess is based upon the presence of a painful and growing intumescence of the liver, ac- companied by more or less intense fever, which gradually assumes a hectic character. In the beginning the swelling ascends and descends at respira- tion ; but later on, when the liver becomes attached to the abdominal wall, this mobility disappears. Probatory puncture with a fine aspirating needle can be safely made, and will generally dispel any doubt. As soon as the diagnosis is secured, incision has to be made. Where adhesion of the hepatic swelling to the abdominal wall is estab- lished, or, even more so, where the suppurative process has involved the integument, a free incision can be safely made. A large-sized drainage-tube should be inserted into the cavity, and frequent irrigation should be em- ployed. The wound is covered with an ample moist dressing. The incision of hepatic abscesses located in the unattached liver require some si^ecial precautions. The abdominal wall opposite the tumor is incised under a strict observance of the rules laid down for laparotomy, so as to expose the liver. The incision is packed with iodoformed gauze, and a dry dressing is applied. In three days firm adhesions of the liver to the abdominal wall will be established, when, the packing being removed, the liver is punctured, and, pus being found, is freely incised and the cavity evacuated and drained. Ji. Lumbar Abscesses. — The significance of acute lumbar abscesses de- pends upon their causation and upon the locality from which they take their origin. The majority of lumbar abscesses are caused by purulent affections of the kidney or its pelvis — as, for instance, by renal calculus or pyelitis — but in a com})arative]y large number of cases no affection of the kidneys or their adnexa can be recognized, and traumatism of one or another kind must be assumed as the causative agent. Contusion and a sudden and unexpected strain of the back were stated to the author by patients as causative factors. The beginnings of lumbar abscess are always obscure and insidious. A deep-seated unilateral pain in the small of the back is first complained of. One or more chills or a low form of hectic fever set in. The patient's back is bent upon the affected side, and is more or less tender. Loss of vigor and emaciation become more and more evident, until a distinct tumor, marked by dullness on percussion, can be made out in the space between the crest of the ilium and the twelfth rib. The way of extension of the abscess is prescribed by the quadratus lumborum muscle, the outer edge of which serves as a landmark for finding and incising it. The presence of pyelitis or pyonephrosis, ascertained by examination of the urine, is very significant, and possible doubts as regards the nature of the trouble may be dispelled by one or more probatory punct- ures with a well-disinfected hollow needle and the aspirator. A good-sized caliber should be selected, as grumous or flocculent pus is apt to clog a DIAGNOSIS AND TREATMENT OF PHLEGMON. 277 Fig. 1S4. — Lange's position for renal and perinepiiric operations. small-sized needle, aud a negative result may be arrived at in the presence of a large collection of matter. Case. — Mr. I. A., brewer, aged twenty-two, developed lumbar pain and swelling of the right side without any known cause. April 17, 1881. — High fever accompanied the seizure, and, though no fluctuation could be felt, the diagnosis of perinephritic abscess was made. April 21st. — In the presence of Dr. Heppenheimer, the family phy- sician, four probatory punctures were made with an aspirator needle without positive result, and, unfortunately, the contemplated incision was deferred until the next day. when perforation into the pleura and rapidly fatal pyothorax developed. Had a larger-sized needle been used, pus would have been found, and the fatal termination might have been averted by timely incision. Early incision can never do any harm where perine- phritic abscess is suspected, and will be of some use even if pus be not found at the first attempt. On account of the deep situation of the abscess, and tiie necessity of exploring its interior for sinuosities, which may require separate drainage, an ample incision is advisable. It should be done in anaesthesia under strict antiseptic precautions, and by gradual dissection. The patient is brought into the position recommended by Dr. F. Lange for nephrotomy. A roll made of a blanket is slipped under the lumbar re- gion, and the body is placed semi-prone upon the affected side, as shown in the accompanying cut (Fig. 184). The vicin- ity of the swelling is carefully cleansed and disinfected, and the surrounding parts of the body are protected with rubber cloths and towels in the usual manner. A lon- gitudinal incision two or three inches in length is made, commencing about an inch below the last rib, and extending to near the crest of the ilium, and is gradually deepened until the abdominal muscles are all divided. Frequently pus will be reached before the edge of the quadratus lumborum muscle is exposed. Should this not be the case, a grooved director may be inserted un- derneath the external margin of this muscle, and, being pushed downward and toward the median line, will soon enter the abscess. A.& soon as pus is seen to appear in the groove of the instrument. Fig. 1 -Incising perinephritic abscess. 278 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. 186. — Arrangement of drainage-tubes for perinephritic or any other deep-seated and large abscess cavity. a dressing-forceps is insinuated into tlio ctivity, and is withdrawn while licld wide open. Blunt dilatation of this kind can be repeatedly practiced until the aperture is large enough to admit the index-finger for exploration. Should the abscess contain urinous matter or stones, or should the septa of the calices of the renal pelvis be recognized by touch, the causation of the process by perforation outward from a sujipurating kidney will suffer no doubt. If found, stones may be then extracted, and the cavity, being well washed with boro-salicylic lotion, is drained by the insertion of one or more stout rubber tubes. Note. — A very efficient mode of draining is the following one : A number of fenestra are cut into the sides of a large-calibered rubber tube, which is placed well within the cavity. An- other smaller-sized tube of the same length is pro- vided with a couple of fenestra near its mesial end, and is inserted into the abscess alongside of the larger tube (Fig. 186). A stream of lotion inject- ed into the smaller tube will enter the bottom of the abscess, will wash out its recesses, and will carry away secretions and debris through the many fenestra of the larger tube. Safety-pins thrust through the distal ends of the tubes will prevent their being lost in the abscess. An ample antiseptic moist dressing should envelop the entire lumbar region, and the patient should be brought to bed. Aside from lumbar abscesses of renal origin collections of pns must be mentioned that depend upon an extension into the circumrenal tissue of purulent processes originally established elsewhere. Peri- typhlitic abscess, empyema, perimetritic suppuration, and finally cold abscesses due to spinal disease, belong to this order. Lumbar abscesses, the rela- tion of which to purulent af- fections of the kidneys is un- likely or doubtlessly absent, admit of a much better prognosis. They are frequently referred by the patients to traumatisms, and, properly incised, heal very promptly. Ca.se. — A. F., pawnbroker, aged twenty-fonr. sustained, in May, 1885, in jumping and slipping, a severe strain of the left side of the small of the back, which was fol- lowed by sharp pain and stiffness for a few days. It subsided spontaneously, but left behind a soreness of varying intensity. May 20^ 1886 — Fever set in with intense lum- bar pain, but swelling came on very slowly. Though looked for, it could not be made out until July 10th, wlien Dr. E. Schwedler ascertained its presence. The kidneys. Fig. 187. — Dressing tor kiinbar or hepatic absces DIAGNOSIS AND TREATMENT OF PHLEGMON. 279 gut, and spinal column were found normal. July 12th. — Incision by gradual dissection was practiced under ether. The abdominal muscles being dialed, the edge of the quadratus lumborum was exposed. Probatory puncture in the bottom of the wound had to be done five times before pus was found high up close to tlie edge of the twelftli rib, beneath the quadratus muscle. This was drawn aside, and the cavity was opened by Hilton-Eoser's method. About au ounce and a half of odorless pus escaped, and digital exploration showed that it had been contained in a small, smooth-walled cavity. Drainage and antiseptic dressings being applied, the wound was irrigated and dressed, daily ; later on, at longer intervals. The patient was discharged cured, September 6th. i. Pyonephrosis, Renal Abscess, and Calculous Kidney. — As an exhaust- ive study of the pathology and diagnostics of the yarious forms of suppu- rating kidney would far transcend the limits of this work, it must he sutfi- cient to review the conditions requiring surgical interference. Whenever cicatricial contraction, of pressure from Avithout, or the impaction of concretions within a ureter impedes or prevents the free exit of the secretions of a normal or diseased kidney, dilatation of the pelvis, or in the later stages of the whole organ, must follow. A tumor will then make its appearance in the lumhar region, the contents of which may vary in character. If a suppurative nephrosis be present, pus will be found intermixed with urinary elements, which will be more or less in propor- tion with the amount of glandular tissue still performing its physiological function. The longer the retention persists, the more of the secreting ele- ments will perish, and finally the kidney will represent a pus-bag contained within the fibrous capsule of the organ. If the causative factor be the pres- ence of calculi, these will be found floating in the retained fluids. Impediments to the exit of urine from a normal kidney will be charac- terized by accumulations lacking purulent elements. When all the secret- ing tissue has perished, a simple hydroneplirosis will be established. The presence of calculi in the pelvis and calyces of the kidney will generally produce very distressing symptoms, such as local pain, hsematuria, and pyuria, with fever and emaciation, though the pertinent ureter may be perfectly pervious. Finally, discrete pyogenic or tubercular abscesses of the glandular kid- ney-tissue occur, causing all the signs of a deep-seated abscess, w^hich may require operative interference. The diagnosis must be based on the subjective symptom of pain and objective signs characteristic of the various forms of kidney trouble, as fever, pyuria, haematuria, the presence of a painful tumor, and of serum or pus withdrawn by the aid of the aspirating needle. {a) Nephrotomy. — The incision of the kidney for the purpose of the evacuation of retained serum, pus, and calculi, is a safe operation often possessing the dignity of a life-saving procedure. It is performed as follows : Note. — Aspiration of the diseased kidney should always be looked upon as a diagnostic and not a curative expedient. The complete exhaustion of the purulent contents of a kidney pre- ceding nephrotomy may be the source of serious embarrassment, as it is much more difficult to find an emptj-, hence collapsed cavity, than one well distended by pus or serum. 280 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. The anaesthetized patient is brought into Lamjc's jmsition, which can not be too warmly recommended for its eminent advantages. (See Fig. 184, page 277.) Contrary to former usage, the patient is put with the belly on a tirm roll in tlie semi-prone position, so as to have the diseased side not uppermost, but occupying the lowest level near the edge of the table. The kidney will be pushed well up into the loin by the pressure of the subjacent roll, and will be rendered more accessible. Finally, it will be held without further external aids within easy reach. The patient's body being well protected in the usual manner, a transversely oblique incision, commencing two inches from the spine, and carried midway between the crest of the ilium and the costal margin, is gradually laid through skin, fascia, and muscles, until the fascia containing the circumrenal fat is exposed. With this incision extended far enough outward, ample space can be made for the removal of the kidney, should this become necessary, and injury to the pleura (in the absence of the twelfth rib) need not be feared. After the fatty capsule is incised, masses of loose fat will be seen bulging into the Avound, which must be held aside by sharp and later by large, blunt retractors (see Figs. 17 and 19, page 40). A second fibrous septum, interposed between the superficial and deep portions of the circumrenal fat, will then be encount- ered. When this is divided, the posterior and distal aspect of the kidney will come in view. The question will arise now whether the pelvis or the parenchymatous portion of the kidney should be incised. As it has been observed that wounds of the pelvis do not heal as promptly as those made through the renal parenchyma, the incision should be made through the latter, unless it be found that a large stone is occupying the pelvis. A thermo-cautery knife completes the incision, which need not be larger than sufficient to admit the index-finger, with which the interior of the cavity is explored after most of the liquid contents have escaped. If no calculi are found, a stout drainage-tube is inserted and brought out through the wound. If stones are present, they are extracted by means of force])s, the scoop, or the hooks used by Lange. Preceding this, further dilatation of the renal incision may be required to gain room for the difficult process of extracting irregularly angular stones. This completed, tlie drainage-tube is inserted, and the cavity is flushed with Thiersch's solution. The external wound is lightly filled with iodoform gauze and inclosed in an ample dry dressing. The drainage-tube is to be brought out through a central slit in the outer dressings, and is connected with a longer tube carried under the })atient's bed, where its end rests in a suitable vessel containing a few ounces of car- bolic lotion. Thus the necessity for a frequent change of dressings will be avoided, should much urine escape tlirough the Avound. As soon as the quantity of urine thus voided becomes small, the rubber tube attachment can be left off. The dressings are to be changed every second or third day ; the tube is to be retained for a very long time. The tendency to the formation of a permanent fistula is strong in these cases, except where cal- culi were extracted from an otherwise normal organ. But, with a scantily dischariring fistula, life mav be verv tolerable indeed. DIAGNOSIS AND TREATMENT OF PHLEGMON. 281 Nephrotomy was performed by the author eleven times, with two deaths. In seven cases tuberculous pyonephrosis necessitated the operation, w^liich gave the patients eminent relief, freeing them from the presence of large and distressing accu- mulations of pus in the pelvis of the kidney. Once the kidney was incised for an enormous hydronephrosis. In June, 1890, four years after the operation, the patient was still wearing a cannula in a scantily discharging sinus. Of the two fatal cases nephrotomy v/as done in one for calculous kidney, in which perforation into the pleura and hence into a bronchus had taken place. Both the thoracic cavity and the kidney were incised, but the patient died of a septic pneumonia four days after the operation. The other case concerned a man whose left kidney had been extirpated for the cure of a urinary fistula remaining after nephrotomy done for pyonephrosis due to cicatricial obstruction of the corresponding ureter. One month after the heal- ing of the nephrectomy wound, renal suppression took place on the right side. The patient was admitted to Mount Sinai Hospital in a urtemic condition. Though nephroto- my was promptly performed, the kidney did not recover its functional capacity, and the man died within twelve hours after the operation. (See case of Moses Oohn, page 283.) {h) Xeplirectomij. — When a kidney has become totally disorganized through suppuration, or has lost its functional ca2:»acity in consequence of the atrophy of the secreting tissues, as, for instance, in liydrouephrosis ; or, finally, where obliteration of a ureter has brought about an incurable uri- nary fistula of the kidney, extirpation of this organ may come in question. Before proceeding to remove a seemingly useless or disorganized kidney it is very desirable to ascertain whether another kidney be jDresent or not. All the methods of examination hitherto proposed for the establishment of the presence of two kidneys, and the diagnostication of their condition by the catheterism of the ureters, have been found unsatisfactory and unreli- able. Hence, if there is any doubt of the presence of two kidneys which can not be eliminated by the ordinary means of physical examination, nothing remains but an exploration through either an abdominal or a lumbar section. Lumbar nephrectomy is performed as follows : Without regard to a pre-existing sinus, the external incision is made as described in the chapter on nephrotomy. When the surface of the kidney is reached, the organ is separated from the surrounding fatty tissue by blunt dissection, most con- veniently done by the tip of the index-finger. Occasionally a more resist- ing band will have to be severed by a touch of the knife or scissors. As soon as the kidney is well separated, it can be brought out of its niche by traction, unless its size is very large, when subsidiary incisions will have to be added. Even then occasionally manoeuvres will have to be made resem- bling the development of the infantile head from the vulva — that is, the kidney will have to be tilted and brought out with its end on. This being done, the vessels and ureter are separated and tied each by itself with stout catgtit, and the pedicle is cut oif at a safe distance from the ligatures, which are also cut off short. Tlie wound is well irrigated, and, if any oozing be present, is packed with iodoform gauze. Secondary sutures maybe then employed, which can be closed after the removal of the packing on the third day. A drainage-tube will be needed after the suture is completed, to prevent retention. If no considerable oozing prevail, the 2b2 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. wound can be at once sutured, after a good-sized drainage-tube was slipped into the bottom of tlie cavity. In separating the kidney, the i>eritonfeum mav be accidentally injured. In this case the rent ought to be at once closed by suture, if possible ; if not, a strip of iodoform gauze ought to be stuffed temporarily into the rent, until the kidney is removed, when the peritonaeum can be more conveniently stitched. The after-treatment by packing and secondary suture will be the safer procedure in all those cases where unavoidable contamination of the deep cavity bv pus, escaping either from a pre-existing sinus or in consequence of the rupture of the wall of an intrarenal abscess, had taken place. Though not commonly, yet it occurs that, in consequence of long-contin- ued inflammation, the fibrous capsule has entered into such an intimate and firm union with the condensed and shrunken circumrenal fat, that the enu- cleation of the kidney becomes a very difficult and hazardous undertaking. In these cases the proper mode of procedure is this : After having exposed the kidney, the fibrous cai)sule is split open along the outer edge of the organ, which now can be readily stripped out of its fibrous coat. On devel- oping the gland, the rather stout pedicle is secured in an elastic ligature, and cut off. If need be, the section of the pedicle can be carried through the renal tissue, in order to prevent slipping of the ligature. The wound is drained and packed, and tlie ligature is brought out near the inner angle of the wound. The sloughing pedicle will come away in about ten days, when the size of the wound can be reduced by secondary suture. Case I. — Solumon Posner. aged thirty-seven, an emaciated, anxious-looking tailor, had been suffering from cystitis since January, 18S8. Two years previous to this had had an attack of renal colic of the left side. Frequent and very painful urination with blood and pus, no renal elements, but a trace of albumen in filtered urine. Intermit- tent attacks of high fever. No pain on pressure in the loins. Koteinber 2^ 1888. — Temperature 102"" Fahr. Suprapubic cystotomy at Mount Sinai Hospital. The interior of much congested bladder-wall studded with miliary tubercle, and bleeding at the slightest touch. T-tube inserted, outer wound packed. Two hours after opera- tion, profuse capillary haemorrhage from the bladder was observed. It was checked by tamponade of the viscus with iodoform gauze. The fever continuins, and a jjainful tumor having developed in the left loin, this was aspirated December 14th, when muco- pus was withdrawn, December 21st. — By nepthrotomy done in chloroform anaesthesia a large quantity of pus was evacnated. A drainage-tube was inserted into the pelvis of the kidney, from wliich no urine ever escaped. DecenJier 25th. — Forty ounces of urine were collected from the bladder. The fever subsided somewhat, but there was an exacerbation every evening. As there was good reason to suppose that the other kidney was fairly healthy, and in view of the fact that the patient's strength was being steadily sapped by the nightly fever, nephrectomy was performed January 25, 1889. The very large kidney was exposed by an ample T-shaped incision. Its sepa- ration was very difficult, and though the eleventh and twelfth ribs were resected, lack of space led to the injury of tlie peritonaeum. After the development, deligation, and removal of the organ, the peritoneal rent was closed by suture. Wound packed, no external suture. The pelvis of the kidney was lined with closely adlierent cheesy Miasses ; the cortical and pyramidal substance stndded with a large number of smaller and larger caseous abscesses. The rather collapsed patient rallied well, and the tem- DIAGNOSIS AND TREATMENT OF PHLEGMON. 283 perature fell off and did not range after this above 100° Fabr. January 27th. — Passed tbirty-six ounces of urine in twenty-four hours. Up to February 4tb every- tbing went well, so that the patient sat up on the afternoon of that day, and retired aftcT a bearty sup|)er at 8 p. m. The evening observation gave temperature 100^ Fabr. ; pulse, 90; urine, thirty-six ounces. At 11 p. m. suddenly stertorous breathing set in, the pulse ran up to 120, the patient was comatose, with insensible conjunctiva, and a deeply flushed face. There bad been no vomiting or headache. Urine was still seen dripping out of the catheter placed in the patient's bladder. Tbe wound was exam- ined and found in good order. Death ensued at 5.15 a. m. No autopsy could be se- cured. As tbe assumption of urgemia was hardly justified, it is probable that a throm- bus found in tbe stump of the renal vein became detached and gave rise to pulmonary embolism. Case II. — Rosaly Cronn, bousewife. aged fifty-six, began in 1883 to have rigors, paroxysmal pains in the left hypogastric region with painful and frequent voiding of turbid urine. These attacks recurred every few months for four years till 1887, when a tumor made its appearance. August, 1888. — A large quantity of pus was evacuated by an incision made in tbe left loin. General condition was soraewbat improved, but a discharging sinus remained behind. October 8, 1889. — On ber admission to Mount Sinai Hospital a dense resisting and painful tumor could be felt in the left loin. A probe introduced into tbe existing lumbar sinus led down toward this swelling. The woman was poorly nourisbed ; her urine contained pus, blood, and a little albumen, but no casts. October SI, 1889. — Neplirectomy . The sinus led into tbe small, shrunk- en and lobulated kidney. Tbe swelling felt before tbe operation was accounted for by a dense cicatricial deposit in which tbe organ lay imbedded, A number of calculi were struck by a needle thrust througb the kidney, wliicb was found converted into a cicatricial bag. The fibrous capsule was divided, and the organ was stripped out of it. Tbe very sbort pedicle was ligatured in mass and tbe kidney was cut away. A cylindrical calculus was found caught in tbe ligature, but was easily with- drawn from tbe stump. The peritonaeum was accidentally rent during the first attempts to separate tbe organ. The rent was stopped up with a strip of iodoform gauze which was left in situ ti'l the dressings were changed on tbe fourth day. Octo- ber 23d. — Tbe temperature had not risen above 100° Fabr. Patient had passed twen- ty-four and a half ounces of urine in twenty-four hours. It contained granular hyaline and blood casts. General condition was good. October 24th. — Urine forty-two ounces ; temperature normal. From October 28tb on the casts disappeared from tbe urine, but slight quantities of pus were still observed. November 16th. — The ligatures and stump came away. Secondary suture had to be done twice to hasten tbe closure of the large wound. Discharged cured, December 15, 1889. Cask III.— Moses Cobn, tailor, aged forty-two, had had within tbe last four years a number of severe attacks of renal colic, accompanied by rigors and turbid ui-ine. Three weeks before his admission to Mount Sinai Hospital another attack set in with vomiting, repeated chills, and severe pain in tbe left loin. The fever continued till his admission, November 12, 1889, when the temperature was 101°, the iirine abso- lutehi normal, but in tbe left loin a painful tumor was felt, which could be v/ell sepa- rated from the somewhat enlarged spleen. November Hth. — By an exploratoi-y puncture sanguino-purulent, urinous smelling serum was withdrawn. The kidney was exposed, and was found considerably distended. From an incision about twelve ounces of matter were evacuated. The kidney was drained so as to catch the dis- charges in a vessel placed below tbe bed. The patient's condition was immediately improved in every way, but the same quantity of urine continued to escape from tbe drainage-tube as from tbe bladder, averaging about twenty ounces from every side. 38 284 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Apparently the left ureter was completely blocked, and, as there was no improvement noticed until December 14th, it was decided then to explore the left ureter. A slender elastic bougie was passed into the urett-r, and was arrested at a distance of five inches, the channel aiipeariug to be impassable. Thereupon the kidney was re- moved, though it was apparently healtliy. December 15th. — Patient did well; passed twenty-five ounces of urine in twenty-four hours; temperature normal. December 20th. — Passed forty-six ounces of urine containing traces of albumen and a little pus. February ^th. — Secondary suture. February 16th. — Patient was discharged cured and in excellent health. March 13th. — lie was readmitted with obstructive symptoms of the hitherto unaffected right kidney, which, however, yielded to treat- ment. Discharged at his own request, March 21st. March SJ^th. — He was readmit- ted with absolute renal sup[)ression, which was not influenced by medication, where- fore nephrotomy was performed, March 28th, on the uraemic patient. The evacuation, of much urinous pus was of no avail ; the intoxication was too far gone, and led, in spite of diligent attention, to his death, March 31st. A number of small renal calculi were extracted, and proved the mechanical nature of the obstruction of the ureter. The autopsy revealed softened and nmch swollen parenchyma of unusually liglit color, the ureter obstructed by calculous detritus. Case IV.— Oscar llettler, barkeeper, aged twenty-seven, has suffered from acute attacks of pain in the right lumbar region since three years, the pain radiating to the glans penis. Ten days before admission to the German Hospital, fever set in with much sweating. February 5, 1889. — On admission, marked anaemia, a movable tumor in the right loin and urine containing much pus. February 11th. — Dr. W. Meyer, then on duty, evacuated a considerable quantity of pus by nephrotomy. February 13th. — The author took charge of the patient. In spite of free drainage he continued to fail. March 8tli. — High and constant fever set in, the temperature rising to above 103° Fahr., and a careful physical examination did not reveal any complication by involve- ment of other organs. March IJ^th. — Nephrectomy was done. It was an easy, short, and comparatively bloodless operation, from which the patient rallied well. During the first twenty-four hours thirty ounces of urine were voided. The high tempera- tures continued unchanged. March 23 A ^"^^ washed away by the lymph-serum in the _ _ y^_^ *Af ^^ ^^•^*i^ shape of single cells or in coherent epi- ^£^'«i^^>o '^Jf&l ce^ thelial flakes. Loss of the epithelial in- %{^.^'Vb^ ^"q ^ * vestment is often followed by the exuda- v5 <«% £ f (; |.JQj^ Qf jj croupous membrane, beneath Fig. 235. — Vertical section through mu- i • i i £ ■ 1.1 ecus membrane, showing first coioiii- which clumps of gonococci are to be sccn zation of jronococci (700 diameters), ^j^ proccss of activc proliferation. Gono- (trom Bumm.) ^ '■ cocci can be found occupying at this stage the interstices of the subepithelial tissues, their columns extend- ing inward along the lymphatics, whence, according to various authors (Kammerer), they may be transported to the endocardium, the joints, and the synovial sheaths of tendons. With the deeper invasion by the gonococci goes pari passu the dense infiltration of the in- fected tissues with ,_ . , _ t/^ — , - ■ ■ - - ^ -^ss leucocytes, the ex- :'-" .-f ' %= v=/ . ': - ^A, tent of which serves ^=^v, '-' - T'-'^n ■ ' -' • . ^t^J as a gauge oi the m- fg: ^^ y - ,,, ,-.«, -;-; i-"-/- ->r-^i^'^"^K ;--^:-- ,-•■-,•..,, tensitv of the mfec- ifm/f /i'^^^w^ 3 ^-i^"^^is. P - ^4. iJ/'S^'aa tious process. ^M^ ^ ^^^^ §)fi ^ I f ^^ ' At the acme of % ^ ., , Fig. 236. — Invasion of epithelium by gonococci (TOO diameters). the process, general- (From Bumm.) ly reached about the end of the second or third week, a regeneration of the lost epithelial layer commences. Complete restitution of the epithelium signalizes the termina- tion of the malady, which, however, is attained only in favorable cases under favorable conditions. Generally primarily unaffected parts of the mucous membrane become involved by spontaneous extension of the infective pro- cess, or by the improper use ^ ^^i; X *^^.. _ of instruments; or portions " ■ ' • ' ■' - - ••••"•"-■ • — ■ - ■ which have recovered suc- .- 4/, 'J_/. U' x^--^' ^/ - -'^ cnmb anew to gonococcal de- 'Q'^lf r^S^ .-^ struction. ^i^cc'^ "'^'^/"Iv*^ "^^^^ regeneration of the