^(frawn From Cohjmfefi > fJniy«r.^ifV HSL Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/rulesofaseptican1888gers THE RULES OF ASEPTIC AND ANTISEPTIC SUHaERY A PRACTICAL TREATISE FOR THE USE OF STUDENTS AND THE GENERAL PRACTITIONER BY AEPAD G. GERSTEE, M. D. PROFESSOR OF SURGERY AT THE NEW YORK POLYCLINIC.; VISITING SURGEON TO MOUNT SINAI HOSPITAL AND THE GERMAN HOSPITAL, NEW YORK ILLUSTRATED WITH TWO HUNDRED AND FORTY-EIGHT ENGRAVINGS AND THREE CHROMO-LITHOGRAPHIC PLATES SECOND EDITION. NEW YORK D. APPLETON AND COMPANY 1888 /rtf Copyright, 1888. By d. appleton and company. 2c^ PREFACE 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 pubhshed, 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 civihzation 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, pysemia, 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. iv PREFACE. The elimination of the accidental disturbances of repair caused by wound infection has depressed the percentage of mortality following am]iutation of the extremities from an average of thirty-five per cent to al)out 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 patient 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 has 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 hernise, 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 be 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 carrying 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 su7'geon''s acts deter- mine the fate of a fresh wound, and that its infection nnd sujpjpiiratioih a/re due to his technical faults of omission or commission. The piinciple 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 blunders 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. y 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 sufficiency of systematic order was 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 through 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 fields 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, the 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 antijpo/rasitic surgery, 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 simple principle of asepticism applied to wound treatment has advanced, so the frequent changes and bewildering vacillation characteristic of the experimental 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. Tet, in the main, he vi PREFACE. lias refrained from quoting other authorities. As reasons for this may be adduced, fii-st, the disinclination to write a bulky text-book, and, further, the knowledge that the interest of the reader is proportionate to the du'ectness and immediate character of the facts and thoughts contained in the work under perusal. As fai' as possible, all important statements will be fonnd borne out by illustrative examples taken from the author's j)ersonal experience. The author is much indebted to the gentlemen composing the house staffs of the German and Mount Sinai Hospitals for the 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 lighting 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 photographing 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 pliototypo- graphic process. Proper credit is given for the lithographic plates co|)ied 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 Pakt I.— asepsis. CHAPTER I. PAGE What are Sepsis and Asepsis! 3 CHAPTER II. Aseptic Wounds — Aseptic Treatment ... 5 I. General remarks ............ 5 II. Rules of surgical cleanliness . . . . . . . . . . 7 1. Hands V 2. The instruments ............ 1 3. Wound irrigation Y 4. Sponges 8 5. Materials for ligatures and sutures ........ 8 6. Drainage-tubes and elastic ligatures 9 v. Disinfecting lotions ........... 10 8. Dressings ............. 11 (1) Types of dressings 11 a. Simple exsiccation. Bismuth, iodoform 11 f>. 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 di'essings 14 a. Gauze ............ 14 (a) Corrosive-sublimate gauze 15 (b) lodoformized gauze . . . . . . . . .15 b. Absorbent cotton, or common cotton batting . . . . .15 c. Sawdust 16 d. Moss 1*7 III. Practical application of rules .......... IT 1. In operating ............ 17 2. Change of dressings ........... 20 IV. Aseptic measures in emergencies ......... 23 Operating bag and kit .25 CHAPTER III. Soiled Wounds. — Antiseptic Treatment. — Difference between Aseptic and Antiseptic Methods. — Illustration of Antiseptic Method ........ 27 Vlll CONTENTS. CHAPTER IV. Special Rtles regarding the Treatment of Accidental Wounds I. Temporary measures . II. Definitive relief . 1 . Contaminated wounds 2. Aseptic wounds 3. Gunshot wounds PAGE 29 29 31 31 33 34 CHAPTER V. Special Application of the Aseptic Method A. General principles .... I. Technique of surgical dissection II. Sutures III. Drainage h. 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 III. 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 anaemia b. Ligatures and final haemostasis 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-joint 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 . V'lII. Laryngeal operations . 1. Tracheotomy a. Superior tracheotomy b. Inferior tracheotomy 2. Laryngofi.'^sure . 3. Extirpation of the larynx regions dislocation, and for deformity due to CONTENTS. IX IX. Goitre X. Amputation of the breast . XI. Abdominal operations 1. General remarks 2. Herniotomy a. Herniotomy for strangulation b. Radical operation for hernia 3. Laparotomy a. Exploratory incision 6. Abdominal tumors . (a) General remarks (6) Special observations . (a) Ovarian tumors (j3) Supra-vaginal hysterectomy (7) X'ephrectomy c. Gastrostomy . d. Colotomy («) Lumbar colotomy (6) Inguinal colotomy XII. Hydrocele, varicocele, and castration 1. Hydrops of the tunica vaginahs 2. yaricocele .... 3. Castration .... XIIL Aseptic operations on the rectum 1. General observations 2. Hemorrhoids 3. Rectal tumors XIV. Aseptics of the bladder 1. Catheterism 2 Litholapaxy 3. Cystotomy a. Perineal section b. Suprapubic section PAGE 107 109 115 115 117 119 128 133 133 133 133 140 140 143 145 146 147 147 148 149 149 151 152 154 154 154 157 159 159 161 162 162 163 Part II.— ANTISEPSIS. CHAPTER VI. Natural History of Idiopathic Suppitration.— Treatment of Suppuration I. The cause of suppuration, 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 V. Spread of suppuration VI. Diagnosis and treatment of phlegmon 169 169 171 171 172 .173 175 176 177 179 184 CONTENTS. 1. General pvlnciples ........ a. Supcrlicial 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 (a) Face (6) Neck (o) Fauces and pharynx .... (j8) Submaxillary and parotid cynanche (7) Acute glandular abscesses of the anterior and lateral cervical regions (5) Glandular abscesses of the temporal, mastoid, and occipital 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 ..... (6) Chronic ulcers of the leg . (c) Acute suppuration of the prepatcUary bursa ((/) Acute suppuration of the knee-joint . (e) Suppuration of the inguinal glands f. Perityphlitic abscesses ..... g. Abscess of the hver h. Lumbar abscesses ...... i. Anal abscess. Fistula in ano PAGE 184 185 185 189 191 194 208 208 209 211 211 217 220 221 223 226 230 239 239 241 242 242 245 246 251 251 254 CHAPTER VIL Erysipelas and Psecdo-Ertsipelas 259 Paet III.— TUBERCULOSIS: ITS ASEPTIC AND ANTISEPTIC TREATMENT. CHAPTER VIII. Natpral History and Treatmknt of Tuberculosis I. Etiology of tuberculosis. Tubercle bacillus II. Complication of tuberculosis with pyogenic or suppurative infection III. Treatment of tuberculosis (ieneral principles Local treatment of tuberculosis .... 1. Cutaneous tuberculosis. Lupus .... 2. Tuberculosis of the mucous membranes 3. Tuberculosis of the lymphatic glands, or scrofula 4. Tuberculosis of tendinous sheaths 5. Tuberculosis of bone. Caries. Cold abscess 6. Tuberculosis of joints. White swelling 263 263 207 267 267 268 268 269 269 271 273 275 CONTENTS. xi PAGE General part . 275 a. Technique of joint exsection . . . . . 275 (a) Septic injection from without .... . 275 (6) Complete removal of tuberculous tissues . 276 (c) Control of haemorrhage .... . 276 (d) Preservation of function .... . 276 h. After-treatment . . 277 Special part . 278 a. Shoulder-joiiit . 278 h. Elbow . . 280 c. Wrist and hand . . 284 (/. Hip-joint . 285 »^ Fig. 2.— The author's Note. — Roller bandages made of a starched fabric known as iodoform duster, with ,,.,.„„ ,. . „ . , . , . screw cap and removable cnnolme, or crown-hnmg, are very useful m corapletmg every bottom tor replenishino-. 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. b. Absoebent coTTOisr, or coMMOisr cottojst battii^g, 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 tliickness. 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 tilled with a large clot, and some oozing from the perforation was noticed. The edges of the perforation wound were snugly fitting around the protruding 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 br.ook 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 batting 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 with 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 pads, 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 alove 100° Fahr. Nov. 19. — The dressings were removed. The swelling, due to the effusion 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 s 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 cliecse-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 TREATMENT. 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 efficient 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 imj^regnated 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 principal employment in hospital practice. m. 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 sjaace 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-cenfc solution of carbolic acid for the recei^tion of the cleaned sponges, from which they ougiit to be handed to the assistants by the nurse. Two more japanned tin 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 in- struments are arranged on an adjacent table in a certain order, which, to prevent confusion and ill-temper, 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 repaid by the cleanliness and sense of comfort that will result. This small inventory will keep long, and may serve again and again at many operations. 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 b v 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. All this having been attended to, anaesthesia 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 (3 X 4 feet) is so placed over the patient's body as to leave exposed only the field of operation. Now the parts are well rubbed otf with a towel ASEPTIC WOUNDS— ASEPTIC TREATMENT. 1!) dipped in corrosive-sublimute 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. S. — Patient made ready for amputation of maimua. 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. 20 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Note. — The employment of copious irrigation during operations requires measures for pro- tecting the person and clothing 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. Ill removing the breast and contents of the axilla, hemorrhage 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 anaesthesia are over, the patients will be found cheerful and contented, feeling no pain or siciiness, 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 tlie other hand, the i)atient 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 dra.inage-tube, together with another vessel holding a few small pads of cotton wrung out of the same solution, should be ])laced on a small table near the bed. An irrigator filled Avith loarm carbolic or mercuric lotion should be suspended from the bedpost or a nail, and a pail for the Fig. 4. — Change of drussiuii's al'ter amputatiou of the thigh. 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 ])us-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- ciari's hands should he carefully cleansed before 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. 5 22 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. If the edges aud vicinity of the wound look normal, the skin pale, not swollen, and not painful to touch, it should 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, ^aneu- 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 indi- cated 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 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 were 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 caus(;d by clogging of the ASEPTIC WOUNDS— ASEPTIC TREATMENT. 23 drainage-tiil)e by a clot. On witlidrawiiig 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) lobe of the right breast. 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-ghind 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 tlie 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 SAvelling discernible. By gently inserting a probe between the corresponding edges of the united wound, entrance into this sac was eflTected, where- upon about two ounces of a yellow, slightly turbid, and very viscid se^um 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 interior 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. IV. 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, liowever 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. wen or the treatment of an incised wound 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 laparotomy, when, possibly, the surgeon's experience is bought with the life of his trusting patient. The attempt of removing 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 ]30ssession of the ability justifying such a grave iindertaking. 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 difficulties, 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 14, 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 antestlietic 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 bouse of a squalid tenement, and a lamp had to be procured. The divested patient'^ pubic and inguinal region was shaved, while anassthesia 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 thetn was poured a quantity of a five-per-cent carbohc 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 bod-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 fortnijiht after the opera- tion, when the wound was found healed throughout by the first intention. ASEPTIC WOUNDS— ASEPTIC TREATMENT. 25 Yet it must be siiid 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 etKer ; 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 bug, witli tin jDans and rubber cloths strapped to it. X Fig. 6. — Interior of operating bag. 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- 26 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. ings, a dressing-forceps for the an^esthetizer, and a razor can be conveniently stuck in behind the bottles. On the other side of tlie 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 Fig. 7. — German instnunent-pouch. Fig. -Interior ot' 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 in 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 seven 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 wcrn strapped to the waist underneath the coat. It contains, besides the instruments held by a com- plete pockot-case, a sharp spoon, a key-hole saw, a flat oblong iodoform dnsling-box of hard rubber, and a set of diverse detachable knife-blades, that can be Htted 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 CHAPTER in. SOILED WOUNDS— ANTISEPTIC TREATMENT.— DIFFERENCE BETWEEN ASEPTIC AND ANTISEPTIC METHODS.— ILLUSTRATION OF ANTI- SEPTIC METHOD. In the prececlino- 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 wounds 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 establislied 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, — For 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 hsemorrhage 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 SURGERY. 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 the 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 tlie operation. Finally, the increasing severity of the symptoms Vv^ill 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 Avill 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 tlie inflamed parts. Frequent, at least daily, change of dressings is proper, accompanied by copious irrigation. Detached shreds of necrosed tissue should be removed witii thumb-forceps and scissors. If new abscesses foi'm, they must be found and opened promptly. 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 fref(uently. Essentially, the so-called " idiopathic " pldegmon, or spontaneous sup- puration (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 imporhuit modifications of the antiseptic procedure, it is deemed expedient to treat of this theme in a special chapter. CHAPTER 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 hasty action and ill-considered zeal. With the comparatively rare exception of injuries to large vessels accompanied by dangerous haem- orrhage, where immediate action is imperative, 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. Berguianii's exjierienco during the Eusso-Turkisli war has shown that most gunshot wounds ai*e aseptic, and that, witli the exception of those cases where shreds of soiled clothing or gun-wads were carried along by the pro- jectile into the bottom of the wound, healing without suppuration can be confidently exjiected if the wound is not infected by meddlesome and un- cleanly surgery. These exj)eriences refer principally to gunshot fractures of the knee-joint. As a matter of fact, it may be safely assumed that an examination by probing or digital exploration, performed on the filthy floor of a public place 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 haemorrhage, 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- 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 the still numerous band, to whom wound infection by dust or filth adherent to hands or a probe be a myth, woe unto him ! Without previous cleansing, immediate probing of the gunshot wound of a vertebra, for instance, accompanied 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 liome. Suppuration, that otherwise might have been avoided, will surely set in, and the patient is doomed. No Fig. 9. — Extemporized tourniquet — " Spanisli windlass. 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 Inrst 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 temporary 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 IL- 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 operating 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 soaj) 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 ivound clean or is it con- taminated'^ Grross 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 comj)rehensive measures at drainage. If the external w^ound be small, it has to be well enlarged, so as to aSoi'd 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. Great 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. Hsemorrhage 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 SURGERY. 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 is 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 sujjported by a splint. On account of their frequency, and their gravity in case of suppuration, scalp-Avounds 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 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 accompanied by a rather scanty secretion of thinnish sero-pus, and very little fever, if any. Case. — P. S., aged thirty -six, was, January 26, 1886, run over by a heavily laden truck, and was at once brought to the German Hospital, where he was anaesthetized about two hours after tlie accident. Under strict precautions the wound was examined. A laceration of the integument in front of and corresponding to the middle of the left leg. four inches long, was found. Compound comminuted fracture of the tibia and fibula. The tibia was broken into four, the fibula into at least three fragments. Severe haemorrhage from the torn tibialis antica artery had caused an enormous infiltration of the leg, which had attained double the size of its fellow, and was quite cold. 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- THE TREATMENT OF ACCIDENTAL WOUNDS. 33 responding to as many recesses, were made. Tlie torn artery could not be found. A large moist dressing was applied, and tlie limb fixed between two well -padded lateral board splints, held together by a pure gam bandage. Moderate 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. Slat. — The patient's temperature had not risen above 100° Fahr., he complained of very little pain, no htemorrhage 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 15th, every fortnight. March 3d. — 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 removed. Consolidation was rather slow, but finally complete, so that tlje 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 wounds, 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 preclude 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 drefssing, 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 prohing or examination teas thoughtfully refrained from. The patient was brought to his home, where, the next day, he was anaesthetized. The temporary splint and dressings were removed, the vicinity of the wound was carefully cleansed and disinfected, and, with the observance of all necessary cautelce., 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 sphnt, 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- 34 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 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. No 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 wounds are asep- tic has been jDointed out by Esmarch, and is now well established. Reyher and Bergmann's experiences in the Russo-Turkish 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 witli a dry dressing, will be sufficient. If the case is complicated by fracture, a suitable splint, preferably plaster of Paris (Bergmann), should 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. Plesh-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 different 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 sharp spiculuni 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 until 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. NoTK. — Recent successes (W. T. Bull) achieved by immediate laparotomy and suture of the wounded intestines 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 SPECIAL APPLICATION OF THE ASEPTIC ME:TH0D. 35 examii)ation of the supci-jaceiit clothing shows a hii-ge defect, reiideriiig tlie 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 wait 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. Note. — Reyher's observations (Volkmann's " Sammkmg," Nos. 142, 143, 18'78) 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. Reyhcr 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 dh't or shreds of clothing into the bullet-track, dilatation, irrigation, and extraction of the foreign body, with sub- sequent drainage, was practiced before the v/ound 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 hemorrhage from the divided popliteal artery and vein on the fifth day ; and the third one of pyaemia. 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 — cleai'ly 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 Peinciples. I. 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- 36 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. tion can be excluded. The large Joints, the tendinous sheaths, and the peritoneal cavity are now safely accessible for curative or even diagnostic 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. Althougli 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 preA^enting infection, the avoidance of accidental injury of important organs and the control of hseni- orrhage first deserve attention. The princi2)le of doing every step of an operation under the guidance of the eye, is the most important discipline of dissection to be 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. Upon this principle is based 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. i'lG. 10. — a, Bellied scalpel for cutaneous iiici.sinn. A, Sliarji-pointcd 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 grasped between two artery forceps, divided between, and safely tied off with catgut. In cut- ting through the fascia, the grooved director used to jilay an important part in for- mer times. Its use has been -Mauiier ol lioldui;^ the knife tor the eutuiieous incLuioii. supplanted by a safer mode SPECIAL APPLICATION OF THE ASEPTIC METHOD. 37 of preparation, known as ciittimj hcttveen kvo 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 hgemorrhage 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. 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, tlie 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 hasty and rough sponging, and everybody preserves an easy 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- r 38 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. ceps or the finger-nail is safer, is, to say the least, very questionable. This advice is born of the fear of unexjoected haemorrhage, 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. 14. — Cutting between two thumb-forceps. 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 are 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 germicides. 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 peritoneum, 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 SPECIAL APPLICATION OF THE ASEPTIC METHOD. 39 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 bending: or breaking. Fig. 15.— Small blunt retractors. Fig. 16. — Medium -sized blunt retractor, a, Actual size. Fig. 17. — Large-sized blunt retractor, b. Actual size. Fig. 19. — Large four-pronged sharp retractor (Volkmann). 40 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. l'O. — Manner of holding the knife for deep dissection. 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 sickUsliaped bistoury in the bottom of a deep wound is always unsafe, as it may lead to unex- pected haBmorrhage 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 ivall ivith 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. ^^ 3 - !^ f~'~—-^\ The funnel shape (Fig. 21, a) is \ / meant by this — that is, that the first \ ,/' / \ incision should be the longest, the \ / \ j 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 ivounds (Fig. 21, ^) are disadvantageous in every way. They result from a too small cutaneous incision, are uncomfortable and Fio. til. — A, Funnel-shaped wound, shaped wound. B, Bottle-' SPECIAL APPLICATION OF THE ASEPTIC METHOD. 41 unsafe duriiip^ the operation, and after closure offer poor conditions fur natural drainage. They always require a drainage-tube, and, even with a tube, if not absolutely aseptic, become a very hot-bed of suppuration, as the discharges of infected recesses may not find ready egress. Where the incision must be carried through condensed or inflamed 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 upo7i 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 jjoints with a,rtery-f creeps, 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 bleedina: orifice. Fig. 22. Haemostatic needle. Fig. 23. — Manner ot ap]>l^ ing haemostatic needle (E&marcli). like a purse-string. Being tied, it closes the Fig. 24. — Dieffenbach's needle- holder. 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. Thiersch'' 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 42 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. probe-pointed needle is grasped by tbe beak of the forceps, and is cau- tiously insinuated under the plexus or mass to be tied off. Veins and arteries arc 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 haemorrhage 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 u}) the place from which the hgemorrhage 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 liealing 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 hfemor- FiG. 25. —Thiersch's spindle apparatu.s. SPECIAL APPLICATION OP THE ASEPTIC METHOD. 43 rhage issued, and the operation was finished. When the sponge was ex- tracted, it came away, as usual, with some resistance, due to tlie 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. No 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, lefore and while passing 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 equally thick and have sufiicient 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 passed 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 together and pinched up by index and thumb in such a way as to form a continuous ridge, on u RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. 26. the top of which sliould ap])oar the line of incision. A straight needle is thrust transTersel}' 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 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 ai)plication of a mattress suture, illustrated in Fig. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 45 29, combined with a continuous coaptation suture, all done with one piece of catgut. Where silver wire or silkworm -gut are available, tlie quill suture or Lister's button suture will give much satisfaction. Both of these forms of Fig. 28. Interrupted retentive suture. Fig. 29. — Combined mattress suture and Glover's 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 armed with a perforated shot, a S' & « Q-\a Fig. 30. — a. Plate and shot suture. b. Interrupted suture. Fig. 31. — a. Catgut suture from suppurating stitch- liole. b. Calgut 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 projoer 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. m. DRAINAGE. Small aseptic wounds of a favorable, that is funnel shape, do not re- cpiire drainage by rubber tubing. As few stitches should be taken, how- ever, as possible, to permit the escape of the oozing between them. Small 46 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. wounds of bottle shape will do very well with a few threads of catgut placed in one angle for capillary drainage. Larger wounds, especially those with a sinuous cavity, require drainage 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 effected by placing the mesial end of the tube just within the cavity to _ be drained. Drawing (^^'•^^^gi^^^^ ^^^^^-^S^— ^w*"''^ \^ transversely through the \^i^ ' '^^f^-^ 1 ,-^.gfe:^^^'^ cavity does not afford fiG. 32.— Perforated rubber drainage-tube. ^^^^ ^^^^ 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 irrigating stream is thrown into the cavity, to escape through the ojiposite 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 apt to cause irrita- tion. But it is not the tube but the dirt adhering to it that is the cause of the trouble. The ]3ersistence 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 office of the drainage-tube is performed by about the end of twenty-four hours after the operation. But other considerations, notably the unwillingness of disturbing the rest of the wound and of the patient, make it inexpedient to reopen the dressings so soon for the purpose 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 on the sixth or tenth 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 reintroduce 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 difficult 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 cxjiel the tube, or granulations will invade the lumen of the tube through its lateral fenestra, and will simply fill it up completely. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 47 The tube sliould 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 over- balanced by the advantage of their absorbability. Neuber s ''canalization," that is, turning in of a part of the edge of the wound, and fastening it to a deep-lying part of the tissues by suture, still found a limited application in the author's i)ractice, as will be seen in the chapters referring to it. It may be said, on the whole, that rubber tubing has so far not been supplanted by anything better for purposes of wound drainage. B. Application" of Aseptic Method to Diverse Organs and Eegions. i. ligatures of arteries in their continuity. "With due observance of the rules of surgical dissection and of the land- 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 special remark. Free incision of the sheath will be found to facilitate verj much the isolation of the vessel. No fear need be entertained of causing thereby necrosis or suppuration in an aseptic wound. Fig. 33. — Incising the vascular sheath (Esmarch). 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. Isolation of the vessel is best accomplished by gently insinuating into the slit the point of a bent silver probe, while the edge of the cut is held up 48 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. by the monse-tootli forceps. As soon as the point of the probe emerges on the opposite side of the artery, it is followed np 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 piercing of the artery wall by the instrument. Case I. — Carl Toiiipert, 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 lieads of the sterno-mastoid 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 artery 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 the 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 by 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 or slipping of the ligature was observed twice (page 69). 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 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 preserve 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 II. — Herrmann Stinze, fishmonger, aged forty-six, admitted to German Hos- pital January 3, 1880, with aneurism of the femoral artery, situated just underneath Pouparf 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 SPECIAL APPLICATION OF THE ASEPTIC METHOD. 49 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 aneui'ism 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-wouud of left palm, followed by copious haemorrhage, 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 Oatskills severe arterial haemorrhage from pressure-sore over swelling, when bullet was removed and another compressory bandage was applied. Aug. .^O^/i.— Renewed hasmor- rliage. Esmarch's band being applied, the clot was 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. Haemorrhage was arrested by pressure made by a physician who attended to the patient immediately after the attempt. Aug. 23d. — Secondary haemorrhage. Esmarch's band being applied, the wound was dilated, and, the partially cut artery being exposed, was doubly tied and cut through between. Suture. Primary union. Case V. — Alexander Goerlitz, engraver, aged thirty-four. Had chancre eleven years ago, and had been in the habit of folding his legs while at work. Jmie, 1883. — Noticed pulsating swelling in right popliteal space. Sejyt. 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 junction and in the lower cervical triangle was made out by Dr. John Schmidt, who directed the 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. JSTov. 11, 1884- — Patient was presented to the Surgical Society. Pulsation had almost entirely disappeared, and 50 RULES OF ASEPTIC AND ANTISEPTIC SURGEEY. wliat 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 ot 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 VII. — John H. Mttinger, 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 oedematous for three months; marked emacia- tion. Jan. SO, 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 172). Case IX. — Robert Klaile, school-boy, aged fourteen. Congenital arterio-phlebec- tasia of 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. S9, 1886. — Pirogoff'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. Drainage through counter-incision alongside of tendo Achillis. No fever. First change of dressings February 19th. Primary union throughout, except where a narrow strip of the integument had necrosed along anterior part of incision. Dry dressing. Feb. SJfth. — All firmly healed. Patient walks well without support. Note. — In exposing the external iliac artery, the small group of lymphatic glands found underneath the transversalis fascia, just above Poupart's ligament, may serve as an unfailing guide. As soon as these glands come to view, the peritoneum can be stripped up without diffi- culty. In incising a deeply situated perityphlitic abscess, the same glands serve as a good land- mark to prevent the operator from cutting into the fascia of the ilio-psoas muscle, which would divert him under the vessels. II. EXTIRPATION OF TUMORS. In removing tumors three requirements have to be commonly held in view : First, the avoidance of septic infection from without or from within. iSecondly, the complete removal of the neoplasm. Thirdly, its safe removal. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 51 Fig. 34:. — Gluteal tumor belore extirpation. 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 reaion, with several si- nuses leading cown 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- her Jfi 18S6. — 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 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. iifter 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. Xov. 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 insuflicient. Open treatment. Temperature fell off 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 manij^ulation of the tumor. ¥iG. 35. — Gluteal dressiiii;-. 52 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Note. — It is a well-known fact that, in some cases of malignant tumor of slow growth, after operation, a large number of secondarj' 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. Eeasonable 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 haemorrhages do sometimes indicate partial removal. But, wherever possible, comi^lete 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 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 si)eedy' 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. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 53 t"iG. ?AJ. — Axillary tuiuor before extirpation. In removing infiltrating or illy doiined malignant new-growths, the sur- geon's knife should give the tumor a wide berth, and all cosmetic or func- tional considerations not involving present danger should be disregarded, the first object being the complete eradication of the disease. In an ample wound the tu- mor can be handled with the ne- cessary gentleness, and the main attack can be directed upon its adhesions to the surrounding tis- sues. With rare exceptions, sharp re- tractors 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 through- out. The softer the mass of the tu- mor, the more care must be exer- 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. Note. — In former days lipomata used to have a bad reputation. It was said tiiat 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 septicaemia. 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 sJiotild dis- section first be 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 liolding close relations to large vessels, as, for instance, those in the neck, axilla, and in Scarpa's triangle, the greatest safety lies in Fig. 3T. — Axillary wound, united, after e.xtirpation of tumor. 54 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. first exposing these vessels above 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, drained and sutured. Wound 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 : either portions of the tumor adhering to the vessel wall are left behind to cause speedy re- lai)se, or the vein is cut or torn. Fjg. 'M.— iJrc.-s.^ing lor neck vvound.s. 40. — Dres.sing of neck wound completed by rubber-tissue bib and ami-sling. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 55 Wheneve?- the surgeon has succeeded in forminfj a pedicle to a tumor situ- ated in tlie vicinity of largo vessels, cuttimj 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 arter}^, the tips of two or three fingers must be thrust at once into the place from which the haemorrhage 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 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, like in other things, prevention is much easier than cure. Lateral tearing or slitting of a large vein is another accident to which may lead disregard of Langenbeck's rule. 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 an 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 * 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. Fig. 41. — Lateral lig- ature and continu- ous suture of in- jured vein. 56 RULES OF ASEPTIC AND ANTISEPTIC SURaERY. 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 below, was tied and cut across. Likewise were treated a number of larger veins entering the tumor from above. The femoi al vessels were not exposed, but the pulsation of the artery could be distinctly felt, and it was care- Finally, the 42. — Periosteal myxosarcoma of thigh before removal. 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 up from the bottom of the wound. The operator plunged his fist into the pool of blood, and thus succeeded in checking the hsemor- rhage until Dr. 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 tlie 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 tlie limb, which was brought atiout by its vertical suspension in a wire cradle. March 5th. — C'yanosis disappeared. Fiii. i'j. — I'liitcd wound after reiuoval oi luy.xo.sareoma of tliigli. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 57 oedema rnucli dimiuished. Temperature. Iur5°. Circulation of limb good. The wound did well, but, March 18tli, temperature rose to 103° Fahr., and signs of phlebitis of the femoral vein in tiie middle of the thigh appeared in the shape of a cylindrical, painful, and hard infiltration. This and a number of similar attacks were snbdued by the application of an ice-bag. The persistent cedema was combated by elastic com- pression with Martin's bandage, supplemented later on by massage. May 15th. — The patient wjis discharged cured, very little of the oedema being still noticeable. Ill this ease, apparently, a portion of tlie trunk of the femoral vein was drawn into the cone of the pedicle containing the root of the saphenous A'eiu. and was excised along with the tumor. The ligature slipped off, and a wide ga]-) was opened in the side of the femoral vein corresponding to the place of entrance of the sapheua. 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 ha?morrhage when a large branch inosculates between the two ligatures. Such branch must be separately exposed and tied. Case. — March 2T, 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 Gempr. aged twenty-four. The •ation was finished without accident, and, ae- ing to the then prevailing custom, the wound mopped with an eigbt-per-cent solution of cHo- of zinc. April 11th. — A large slough of the vein wall was detached, and fear- ful hfemorrhage ensued, which Dr. Loewenthal, the house-sur- geon, could not check complete- ly by local pressure. When the author saw the patient, be was nearly exsanguinated, though conscious. No pulse could be felt. Without anfesthesia the femoral vein was exposed below the opening in its wall, while pressure by three finger-tips completely controlled the haemorrhage. XoTE. — Thrusting of the fist or of a sponge into the wound will not cheek ha?morrhage effectually m these cases. The tips of the fingers pressed exactly upon the bleediug orifice, and without much force, will always succeed in controlling the vessel. As the vein bled from above, too, Ponpart'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 com- pletely. 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. Deligation and partial exsedion of the axillary vein for ingrowing cancer of the axillary glands has been often performed by various surgeons with ua of thiirh. 58 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. entire success, and can be iindertahen without hesitation whenever un- avoidable. In (Ungating the deep ^jugular vein, avoidance of the jmeumogastiHc nerve will require close attention. AVhen there is enongli space to expose and liberate the vein freely, this will not Ije found very difficult. Low down at the root of the neck however, the decision of the question whether the lipiture encompasses the nerve or not may occasionally be impossible. Case. — Mrs. Catharine Plunkett, aged sixty-four. Extirpation of recurrent hmpho- 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 the 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 impossible 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 symptom. Dec. 31st. — The first dressing was removed, together with the drainage-tubes. Jan. 3, 1887. — She was discharged cured. Having thus gone through the entire subject, we may sum up in the following points : To accomplish a thorougli and at the same time safe removal of a tumor located in the vicinity of large vessels, an adequate, that is, very ample, in- cision is absolutely necessary. a h / Fig. 45.— Outlines of flu] incisions. NoTK. — On the trunk and the exti'cmitie.s, straiglit incision.", with the addition of a transverse extension, will be found most convenient. Where a transverse cut is inopportune, considerable gain in space can be effected by undulatiny the line of incision. In Scarpa's triangle, hut especially about the neck, flap incisions are the most convenient. Fig. 40.— a. T-shaped incision. //. Undu- latmg incision. Methodical dissection, guarded by as many preliminary double ligatures as necessary, will insure a steady and uninterrupted progress of the opera- tion. Loss of blood will be minimal, and the flurry and haste incumbent upon profu.se accidental hieniorrhage will not lead, as it always does, to the disregard of the rules of asepticism. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 59 Aseptic canons arc easily forgotten durinfi^ fi-antic etrorts to ciieck dan- gerous hiuniorrluigc, although it is conceded tiiat avoidance of sup})urati()n is all the more important because of the injury to large vessels. After thorougli irrigation and cleansing, the drainaga of tlio cavity is to be attended to. It should he direct — that is, should reach the surface on the shortest possible route, if necessary through a counter-incision — aiul care must be taken of not letting the square inner end of the tube impinge upon a large artery. Especially must this point be heeded, where the tube consists of hard material, as perforation of the vessel by friction against the hard edge of the tube is possible. Note. — Tlicre are cases on record where the iiiiiomhiate was ulcerated through by friction pressure of the iiiargiu of a tracheotomy caiiiiuUi. The inner eiul of the tube should be placed so as not to touch the vessels. the general direction of the mesial end of the tube being parallel with them. To secure this position the inner end of the tube should be fastened to a suitable i)art of muscle or fascia by a catgut stitch. Cliange of dressings will be required, according to the size of the tumor, on fi'om the sixth to the tenth day, when the tubes can be withdrawn. III. AMPUTATION OP LIMBS. In performing a major amputation, the modern surgeon has to solve three problems : The first is to avoid septic infection of the amputation wound, or, if sepsis of the limb be present, to eliminate it. The second one is to limit hsemorrhage to an unavoidable minimum. The third problem is to secure a good stump. 1. Aseptics and Antiseptics of Amputation. — To the adoption of aseptic and antiseptic measures must be ascribed the remarkable reduction of the rate of mortality after major amputations, now prevalent wherever such measures are practiced. Formerly one third of all cases were directly lost mainly through primary septicaemia, or pygemia, or indirectly by secondary haemorrhage due to ulcerative destruction. At present, deaths from acute and chronic blood-poisoning or secondary haemorrhage are very rare, and limited to cases that come under the surgeon's knife in a neglected or septic state. The total mortality, as computed from nearly 1,000 unselected hospital cases of various surgeons, treated on the new plan, is about fifteen per cent. The author's personal experience embraces forty-three cases of major amputation, mostly done in hos])ital practice. These were : Amputations of the thip;h 22 " " leg V " " foot V " " " shoulder 1 " " " arm 3 " " " forearm 3 Total 43 60 RULES OF ASEPTIC AND ANTISEPTIC SUEGERY. The amputations were performed : For suppurating compound fracture in 2 cases " phlegmon in t3 " " acute and chronic osteomyelitis in 6 " " spontaneous gangrene in 5 " " incurable ulcers in 5 '' " articular tuberculosis in 12 " " phlegmon from uratic arthritis in 1 case " malignant new-growths in 6 cases Total 43 " Of this number were cured : By primary union 16 oases " partial adhesion 14 With suppuration 8 Cured o8 Died 5 Total 43 The five fatal cases were as follows : Case I. — Max LoflFmann, Araputation of thigh at Mount Sinai Hospital for secondary haemorrhage due to phlegmon of popliteal space after exsection of knee. Patient came on table collapsed, and died immediately after ablation (see page 245). Case 11. — Giistav Leuber, aged forty-nine. March 22, 1883. — Syme's amputation of foot, at the German Hospital, for tuberculosis of tarsus. Died May 5, 1883, of gen- eral marasmus, due to pulmonary tuberculosis. Wound nearly healed. Case III. — Carl Frank, aged sixty. Senile gangrene of foot and leg ; amputated at the German Hospital. On account of the collapsed and septic condition of the patient, twenty ounces of a six-pro-mille saline solution were transfused before commencing the amputation. The pulse rallied, and transcondylic amputation was done, but patient died immediately after the bone was sawed oif. Case IV. — Louis Bourbonus, carpenter, aged twenty-nine. Acute progressive gangrenous phlegmon of hand and forearm. Septicaemia with petechial eruption. February ^4, 1880. — Amputation of arm at the German Hospital. Patient died two hours after ablation. Case V. — Catharine Argast, aged fifty-four. Senile gangrene of fore part of foot Septe7nber 18, 1882. — Syme's amputation at the German Hospital. Marastic thrombo- sis of the femoral vein. Died, October 23d. of marasn)us. The author's total rate of mortality wotild be 11 'GS per cent. Excluding the hopeless and moribund cases Nos. 1, 3, and 4, the death- rate will be reduced to 4*65 per cent. Not one of the patients died of acute septicEemia or pyaemia clearly chargeable to the operation. Case No. 2 died of tuberculosis ; case No. 5 (senile gangrene), of thrombosis due to general marasm. Considering the large proiwrtion of amputations of the thigh (twenty- two), and the fact that ablation was done twenty times for acute septic pro- cesses under a vital indication, during a more or less pronounced state of general sepsis, the final results may be favorably compared with those achieved without antiseptics. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 01 To further a better understanding of the methods employed for the maintenance of the aseptic condition during amputation, it will be neces- sary to class all cases requiring ablation in three groups. a. Cleax Cases. — The first r/roup consists, on the one hand, of cases where amputation is indicated for various reasons, such as deformities, tumors, etc., in which the skin of the member is unbroken, and no sub- cutaneous, acute, or chronic suppuration is present ; on the other hand, of injuries requiring amputation, that come under treatment immediately after the accident. These are called clean cases. They require the ordinary aseptic precau- tions, such as shaving, thorough scrubbing, and disinfection of the field of operation, and a careful protection of the hands and instruments of the sur- geons from contact with non-disinfected parts of the patient's body. This is best accomplished by wrapping the whole limb, excepting the field of oj^eration, into a swathing of disinfected towels, which should be fixed in position by safety-pins or a few turns of a roller-bandage. The patient's feet and hands, disirifec- tion of which is difficult at best, should never re- main unnecessarily ex- posed in amputations of the upper or lower ex- '^^^^^^^^^^^^^*^^^^^^™^*^^ tion is to be done near, 's^ \ \ ^^^^^^^B'^^«^ ^'^''^^^KIB^W ■ I 01' ^^ ^^^^ hand or foot, ^^^ these must be. if time permit. "^'^i-Stl^r^u! ^^^^j^^\ subjected to a careful prelim- tation ot thigh. MB^ ^^T^^^ ■ \ inary proccss of cleansing. It consists of a prolonged bath of warm soap-water, and sub- sequent packing in comj)resses moistened with a two-per-cent carbolic solu- tion, and an external wrapping of rubber tissue to prevent evaporation. Large masses of epidermis will be soaked off in this manner, and can be removed by gentle friction with a brush or flannel rag in soap-water. This process must be rejDeated until the skin is perfectly clean, and does not shed epidermis. The part to be operated on is kept wraj^ped in a carbolized towel until nnfesthesia is well under wav, and the operation is about to begin. 10 62 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. Esmarcli's constrictor being applied, and the patient's body protected by rubber sheets, these and the parts of the limb not needing special dis- infection are covered with disinfected moist towels. The parts of the assist- ants are distributed, aud every one takes his place. Now the surgeon unwraps the field of op- eration, and, having once more rubbed it off with corrosive-sublimate lotion, begins to operate. Frequent irrigation of the wound and especially rinsing of the hands of operator and assistants Fig. 48. — Section of femur. Irrigator playing from the left. should not be neglected until the dress- ings are finished and the patient is ready for bed. The other precautionary detail mentioned in a previous chapter should also be carefully adhered to. With the exception of the saw, most instruments required for amputa- tion are easy to clean. The saw is a frequent medium of pyogenic in- fection. Case. — Arnold Bitter, mechanic, aged thirty-four, was amputated at the knee- joint eighteen years ago for a compound fracture of the leg. On account of insufiicient covering, a large adherent cicatrix occupied the under and posterior side of the condyles, which were constantly ulcerated. Ee-amputation of the thigh ahove the condyles, January 8, 1887, at the German Hospital. Drainage and suture. Fever developed on the second day, rising to 103° Fahr. on the third, wherefore the house-surgeon re- moved the dressings, but found nothing to explain the pain and fever. On the fifth day the author inspected the stump, and found firm union of the flaps between each other and to the sawn surface of the bone, the drainage-tubes still filled with fresh, sweet clots, but the extremity of the stump decidedly club-shaped and oedematous, the oedema being of the deep-going, firm variety, characteristic of acute osteomyelitis. The stump was nowhere painful on pressure, except at a point corresponding to the ripper margin of tlie sawn surface of the bone. In a few days pus began to exude from the drainage-tube placed at the time of the operation through a counter-incision into the quadricipital bursa, and the patient's fever subsided. Feb. 9th. — The upper margin of the sawn surface was exposed and a narrow, sharp edge of necrosed bone was detected. This was chiseled away until healthy bone presented ; fistula scraped, wound sutured. Primary union ; patient cured, March 5th. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 63 Ap])arcntly some filtli had been detached from the teeth of the saw when it was drawn across the bone the first few times, and became lodged near the upper margin of the bone section, causing there a circumscribed acute osteomyelitis, ending in necrosis. XoTE. — The proper way to cleanse a saw-blade is to scrub it thoroughly for five minutes in hot water with soap and a stiff brush, held across the blade, then to immerse it in carbolic lotion until used. It is best to do this as the last thing before the operation. Wiping with a towel should he avoided, as a number of linen fibers are detached thereby and remain adherent to the teeth of the saw. 1). Mildly Septic Cases. — The second group contains cases character- ized hij clironic suppuration, due to tuberculosis of joints or bones, or to ulcerative processes of various kinds requiring amputation. Infection of the amputation wound through contact with hands or apparatus that have touched the ulcers or fistulas, or through escaping secretions, occurs very easily in these cases, and special precautions have to be employed to avoid it. A careful examination of the affected parts should be made several days or a week before the time appointed for the amputation. Abscesses should he incised and drained, retentions removed by counter-incision, and the amount of secretion reduced by all known means, as, for instance, frequent irrigation and change of dressings. The field -of operation should be prepared as indicated for the first group. Immediately preceding the operation the suppurating focus or nicer should be irrigated and dressed in bed, and over the usual dressing a piece of rubber tissue should be tightly bandaged so as to overlap it on all sides, the margin of the gutta-percha adhering to the skin. The patient being anaesthetized, Esmarch's constrictor is applied, and the rubbers are arranged in the proper manner to shield the patient's body from drenching with the irrigating fluid. After this the whole surface of the limb, with the exception of the field of operation, is wrapped in clean towels, the carbolized towel covering the site of the operation is removed, this and all hands are finally disinfected, the irrigator is started, and the amputation should commence. It is not very difficult in these cases to exclude suppuration and to secure primary union by the exercise of a moderate amount of care and by intelli- gent attention to important details. Should infection occur on account of faulty management or the in- herent difficulty of the case, the inevitable suppuration will be mostly of a benign character, and well-nourished and well-coapted portions of the wound may even heal by primary union. WJiere amputation lias to he done through ulcerating or suppurating parts of a limh, the surgeon has a still more difficult problem to solve. But even in some of these cases primary union can be achieved. Before com- mencing the operation, the skin surrounding the ulcer or sinus must be thoroughly scrubbed with brush, soap, and water, then the ulcer or sinus is repeatedly washed or injected with an eight-per-cent solution of chloride of zinc, and the granulations are thoroughly scraped off with the sharp 64 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. spoon. Indurated or illy nourished tissues are removed, and all debris is washed away with the irrigating stream of mercurial lotion. After this the ani]ratation is done as usual, good care being taken to provide for ample drainage. . c. Septic Cases of Greater Intensity. — To the third group belong all eases in which an acute progredient septic process of spontaneous or traumatic oridn necessitates ablation of the affected limb under a vital Fu.. 49. — Secui'in,tj of visible ves- sels bj' artery forceps. indication. Profusely sup- j)urating compound fract- ures, rapidly progressive phlegmons of the hand and arm, cases of embolic or other forms of sponta- neous gangrene, compose this class, in which the surgeon has to contend not only with the local trouble, but also frequently with a deep and dan- gerous general intoxication of the system, due to the massive absorption of ptomaines and bacteria. In many of these cases the processes determining phlegmonous destruc- tion have progressed beyond the highest limit of amputation, and securing of an aseptic state of the wound is impossible. No amount of irrigation will here do any good, and the surgeon, having removed most of what is a SPECIAL APPLICATION OF THE ASEPTIC METHOD. 65 source of furtlier infection, has to trust to good luck unci the power of resistance of his patient, aided by ample stimulation and other restorative measures. In these cases the o\)Qn after-treatment is in order. But, even in those instances where amputation can yet be done in healthy tissues, preservation of an aseptic state is an extremely difiBcult matter on account of several reasons. First of all, we havejjrofuse secretion of pus or ichor, containing an extremely virulent culture of micro-organisms, a few individuals of which are sufficient to start up another phlegmon. Nobody who has not tried it can conceive the difficulty of keeping free from contamination in such cases. Another difficulty lies in the limits to our choice of the place tion. Fk;. 50. — Compression of cut surface by sponges placed over the folded flaps. Eemoval of constricting band. of amputa- When we can go high up, far out of the reach of the infec- tion, we should al- ways do it without regard to so-called conservative con- siderations. What is first to he con- served here is the life of the patient, and before this view all objections ought to vanish. But, when the process has extend- ed up beyond the knee or the elbow, how keep free from True, the section tissues ; but, even with the greatest care, contact-in- fection is almost unavoidable. The measures to be employed in these cases are similar to those detailed for the second group, only with this difference : that attention to every step of the prepa- ration should be more rigid ; that, if pos- sible, the filthy part of the preparation contamination then ? may go through healthy should be done by a separate person or persons ; and, finally, that the judicious use of our strongest antiseptics for irrigation (1 : 500 to 1 : 1000 of corrosive sublimate) is justified. The lotion used for rinsing the hands must be repeatedly changed, and everything that 66 EULES OF ASEPTIC x^ND ANTISEPTIC SURGERY. has come in mediate or immediate contact with the focus of infection must be rigidly rejected. Amputation wounds belonging to this group should not be sutured, but require loose packing and moist dressings (open treatment). Our first and second groups coincide with "primary^'' and "secondary," the third with '' intermediate^" amputations of the old nomenclaturCo 2. Hsemorrliage. — Esmarch's apparatus and the animal ligature have un- doubtedly had a great share in bettering the statistics of major amputation. a. Artificial Atst.^mia. — The most important and really blood-saving part of Esmarch's apparatus is performed by the constricting band, used instead of a tourniquet. The theoretical advantages of the use of the elastic roller-bandage, employed for evacuating the vessels of the limb, are offset by some serious drawbacks. It is an undeniable fact that the aerostatic press- ure will effectually prevent the escape of considerable quantities of blood from a limb, the circulation of which has been suppressed by central con- striction. Therefore, the exjDuIsion of all the blood contained in a limb is not an absolute requirement of blood-saving in non -mutilating operations, as, for instance, joint exsections. In amputations the blood contained in the removed limb is an absolute loss, but its quantity can be effectually limited to a very small amount Fir;9. 51, 52. — Esmarch's artery forceps. Fig. 53. — TIalin's artery forceps. Fig. 54. — Showing the difference be- tween a, a good, and 6, a wortli- less, artery for- ceps. On com- pression, points of a remain in contact : those of b gap. by i)revious vertical elevation of the limb. And this loss is abundantly repaid by the agreeable assurance, that no septic material or infectious cell- elements, detached from a malignant new-growth, are thrown into the gen- eral circulation with the blood and lymph which is expelled from the dis- eased limb by the elastic roller-bandage. The retention of a certain quantity of blood in the vessels of the stump affords additional advantages of no mean value. By pressure upon the stump, the smaller and smallest arteries and veins each will pour out a minute quantity of blood, which will greatly aid the surgeon in finding and SPECIAL APPLICATION OF THE ASEPTIC METHOD. 67 Fig. 55. — Manner of tying vessel . ( Esmarch . ) securing them before the removiil of the constrictor. Thus all considerable ostia can be occluded, so that, on detaching the rubber band, no spurting vessels will be observed, and the capillary oozing will easily be controlled by compression of the wound, aided by digital pressure exerted upon the main artery of the limb. Com- pression should not be done by packing the wound full of sponges, and folding the skin-flaps over these. True that their elastic pressure will check haemor- rhage. But, on the other side, most of the small thrombi occluding the vessels, that are continuous with the clot occupying the outer meshes of the sponge, are torn away when the latter is removed, and renewed oozing results. The same objection must be raised against vigorous sjoonging of the wound-surface. Even after oozing has stopped completely, frequent sponging is apt to renew it, and thus to prolong the time required for stanching the haemorrhage. A better way of employing compression is to fold the flaps over the wound, and then to arrange the sponges outside of them. This will insure the good effect of compression without the disadvantage mentioned above (Fig. 50). As soon as all visible vessels have been secured, the wound is compressed, and the constrictor is removed while the limb is held vertically. The assist- ant who removed the constricting band applies digital compression to the main artery. Immediately after removing the rubber band, the skin of the parts that had been subjected to artificial anaemia is seen to flush up, and to remain vividly red for from five to ten minutes. This is the period of excessive hypersemia, due to paresis of the vasomotor nerves. Hyperaemia is all the more lasting and intense, the longer and the tighter was the con- striction. Attention should be devoted by the surgeon to learn the exact amount of tension of the rubber required to just stop, arterial circulation. The band should never be applied before the patient is relaxed, and it should not remain on longer than absolutely necessary. Note. — The rubber constrictor exerts an enormous amount of constant and undiminishing pressure, hence it must be used with discretion. Applying it to the thigh held in flexion may lead to rupture of all flexors if the limb is straightened out afterward. For a number of years, the author has discarded all specially made bands and apparatus recommended by authors and sold by dealers for the production of artificial anaemia. A piece of pure gum-elastic tubing, of the tliicTcness of a mcw?8 index- finger or thumb, and of the length of one and a quarter yard, is all that is necessary. Its application is illustrated in Fig. 56. The limb being held vertically for a few minutes, the elastic tube is j)ut on the stretch, and thus coiled about the limb once or twice, its tension and the number of turns being determined by the relative thickness of the limb, the muscularity, and amount of adipose tissue underlying the skin. To estimate the tension e>s RULES OF ASEPTIC AND ANTISEPTIC SURGERY. required, the feel of the radial and dorsalis pedis arteries may serve respect- ively. As soon as their pulsation disappears, the constriction is sufficient. When the required amount of constriction is secured, the ends of the tube are crossed, a short piece of cord or muslin bandage is passed under the cross- ing, and is firmly tied in a slip-knot. The ends of the tube being released, the rubber crowds up against the cord, and can not slip. (Fig. 57.) This mode of con- striction is very ener- getic, and deserves the preference for very large and muscular ex- tremities. Atiother practical and more gentle tvay of applying elastic constriction is by means of an ordinary pure gum roller or Martin'' s elastic bandage. It is especially suited for emaciated limbs and for operations on wo- men of delicate frame, and children. The manner of ap- plying Martin's band- age is well illustrated in the accompanying cuts. As many turns of the bandage are superimposed tightly around the limb as necessary. The last turn is grasped in the left hand, and is pulled away forcibly from the limb, form- ing a bight, into which is thrust the remain- der of the roller. As soon as the left hand releases the loop, it tightens about the roller, and holds it in place firmly and securely. (Fig. 58.) oU. — Mauner of applying elastic constrictor (rubber tube) for the production of artificial ansemia. Fio. 57. — Elastic constrictor in situ. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 69 /"' b. Ligatures and Final IliEMOSTASis. — The visible lumina of all cut vesselt^ — veins and arteries — are tied with catgut, which is in every way pref- erable to silk. The objections raised against the new material have been entirely disproved by experience. The author never saw one case of sec- ondary haemorrhage from a vessel tied with catgut ; and knows of two cases only, quoted on pages 5 and 56 respectively, where catgut ligatures slipped or gave way. In both, very brittle catgut was used, and the knot was not sufficiently tightened on account of the fear of breakage. Therefore it may be said that improper material was improperly applied in both of these instances. In tying larger ves- sels it is very necessary to grasp and withdraw them from their sheaths for inspection. Arteines will some- times be laterally nicked just a little above the transverse section, and the ligature must be ap- plied above the lateral opening. Large veins must be also well inspected, as it may happen that the lumen of a hastily tied vein may be only partially occluded by the ligature. An ordinary artery forceps can not grasp at once the entire circumference of a principal vein, and the author has repeatedly seen only one half of the vein deligated in the shape of a dog's ear, the remainder of the vein con- FiG. 58. -a. Applying of Martin's bandage as a constrictor. 0. Martin's bandage in situ. Fig. 59. — The wrong way of detaching the skin-flap. The knife should be held vertically. (Esmarch.) tinning to bleed in spite of the ligature. The best way to secure the entire lumen of a large vein is to grasp and withdraw it with one or two forceps 11 YO RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. 60. — Liston's bone forceps The ligature must not be tightened too much imtil its whole circumference is clearly visible, and then to twist it around its own axis, when it will be seen to form a neck wliicli can be easily tied. Atheromatosis of arteries is no valid objection to the application of the catgut ligature. The grasping of vessels affected by it is difficult on account of their liability to slip before, and break after, be- ing caught by the forceps on an atheromatous vessel, or it may cut through it. Vessels imbedded in sclerosed tissues must be secured by a circular stitch. After the removal of the elastic constrictor, local compression of the wound is kept up until the marked hypergemia of the limb begins to wane. Then, an assistant compressing the main artery, the wound is exposed. The glazing of clotted blood is re- moved by irrigation and gentle friction with the tips of the fingers, and the assistant is di- rected to release the compressed main artery. Then any addition- al vessels seen sj)urting should be secured. The hypergemia of the limb will have ceased by this time, and with it the ooz- ing. Note. — Should a larger nutrient ar- tery be divided at the time of the sec- tion of the bone, its bleeding can be readily stopped by the insertion of a short piece of stout catgut into the spurting orifice, where it can be left be- hind without any harm. The employ- ment of wax for the same purpose is unsafe, unless the material is first ster- ilized by boiling. The statement that Es- draiued. march's apparatus is not blood- saving, but, on the contrary, cau.ses undue haemorrhage, is misleading. It may be positively said that skillful management of the application of Esmarch's constrictor will enable the surgeon to perform major operations with an astonishingly small amount of hgemorrhage, and tliat loss of much blood after the removal of the rubber band is due to faulty manipulation. Fig. CI. — Aiiipiitati"! SPECIAL APPLICATION OF THE ASEPTIC METHOD. 71 3. Securing of a Good Stump. — In circular ampututions, as well as in flap operatiourf, an important ot)ject should be to gain abundant covering, and to bring about easy and natural apposition of the wound-surfaces with- out much external pressure. In performing cir- cular amputation, the assistant holding the mesial part of the limb can greatly in- fluence the shape of the stump. As it is desirable to produce a wound of the shape of a hollow cone, multijDle circular sec- tions of not too great dejDtli are commend- able, while the assist- ant successively re- tracts each layer divided by the amputating knife until the periosteum is cut through and pushed well back. The soft parts are inclosed in a two- or three-tailed compress of sublimated gauze, and the bone or bones are sawed off, care being taken on the leg and forearm to complete the sec- tion of both bones simul- taneously. After this the sharp edges of the bone are clipped off with bone- cutting forceps, and the vessels are attended to. Musculo-cutaneous flaps make a very good covering Fig. 62. — Amputation wound of leg, sutured and drained. Keten- tive button sutures. Fig. 63. Dressing of amputation wound of the thigh. to most stumps, and can be very easily adapted. As soon as the haemor- rhage is perfectly under control, suture of the wound can be commenced. T2 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. 64. — Dressing of amputation wound of the leg. The author is using exchisively the interrupted suture, for reasons elsewhere mentioned. If the case was unimpeachably aseptic, and no suppuration is expected, one medium-sized drainage-tube will suffice to carry away the first secre- tions. Otherwise abundant ways of egress must be provided in the shape of several properly dis- tributed tubes. The protruding end of each tube is transfixed with a safety-pin, and cut off on a level with the skin. An ample dry dressing, con- sisting of a few layers of iodoformed and a gen- erous mass of sublimated gauze is snugly bandaged to the stump, so as to reach at least twelve inches above the line of section. If proper care was devoted to the stanching of the hgemorrhage, no great pressure will be required to check the oozing, which is, anyway, moderate after the use of corrosive sublimate for irrigation. The idea of bringing about close apposition of the wound-surfaces by energetic pressure is not to be culti- vated, as it will lead to frequent marginal necrosis of the flaps, frustrating complete j)rimary union. Surface apposition should rather be accomplished by a pro]3er fashioning of the wound and flaps, and the sutures should exert no traction what- evei", but should merely secure contact of the cutaneous edges. For securing contact of the deeper portions of an amputation wound, Lister's lead-plate, or but- ton, sutures are very advantageous. (Fig. 63.) Note. — In former times, when car- bolic lotions were employed for irriga- tion, oozing used to be quite free, and necessitated the use of a good deal of pressure, which was somewhat tempered by the interposition of thick layers of borated cotton between the dressing proper and the outer bandage. Flap necroses were then much more com- mon than nowadays. The sole office of the dress- ings is to lightly support the wound, and to absorb and ren- T . ,, ,. Fig. ()5. - Ainiiutatioii wound -,r,r,i T-ixi T • • i T ^ j_i FiG- 69. — Explaininfic relation of parts March 29, I884.— Ether was admmistered at the jn joi^n Becker' s'"case of phalangeal German Hospital, and, after careful disinfection dislocation. 80 RULES OP ASEPTIC AND ANTISEPTIC SUEGERY. Fig. to. — Arrangement of rubber slieets tor operations about the upper extremity. of tlie patieot's band, reduction was repeatedly attempted without success. The small transverse laceration of the integument of the volar aspect of the finger did not give the least advantage as to examining the interior relations of the displacement, hence a lateral incision was made on the radial side. It was then ascertained that the tendon of the flexor digiti profundus was displaced upon the dorsum of the middle phalanx, and was interposed between the ar- ticulating surfaces. An addi- tional lateral incision on the opposite side of the finger was necessary, and reduction could only be accomplished after a free division of all resisting bands of torn capsular ligament, caught between the flexor ten- don and the articulating surfaces respectively. Suture and catgut drainage ; fixation of the finger on a small volar splint. April Bill. — ^First change of dressings. Primary union. In May the function of the injured joint be- came nearly normal. (Fig. 69.) Case III. — -Joseph Jeretzky, aged eight. Old, irreducible dislocation of basal pha- hmx of index upon the dorsum of the metacarpus. May 19, I884. — Lateral incision. Division of the new-formed cicatricial bands ; removal of an interposed shred of the capsular ligament. Keduction and primary union with perfect restoration of function. Condylar fractures of the elhoiv imtli posterior or lateral displacement of the forearm are a common injury with children. What with the great difficulty of an exact diagno- sis in the presence of a large effusion, and the great differ- ences of opinion of the au- tliors as regards the proper manner of treatment, no won- der that, after elbow-fract- nres, cases of gun-stock de- formity and partial disloca- tion with inability to flex the elbow are not at all rare. Some of the authors adyise putting up of the fracture in extension, others in flexion ; some recommend early pass- ive motion with frequent change of the angle of the elbow; others condemn altogether early passive motion. The author's conviction is that in many instances exact reposition and retention are utterly impossible unless the fragment is cut down upon and sutured or nailed to its original seat. The insertions of the muscles of the i'lG. 71. — Dressintc for wounds of hand and forearm. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 81 forearm about tlie epicondyles must exert a great influence upon the dis- placement of the fragments, hence it seems that flexion would be the better position to counteract the tendency to displacement. But all assertions made to that effect, that, in spite of the presence of a large swelling, reduc- FiG. 72. — Anterior view of gun-stock deformity due to elbow fracture. tion can always be accomplished and. retention maintained, have appeared to the author as a hollow pretense or self-deception. A very guarded prognosis in elbow-fractures is, on the part of the physi- cian, a sign of wisdom and discretion. Where very limited motion and an unfavorable position result in spite of careful treatment, the only means of ■i correction is arthrotomy with subsequent I partial or total exsection. Fig. 73.— Lateral view of Bernhard Loebel's elbow. Fig. 74. — Normal aspect of lower end of hume- rus. A A. Transverse diameter, b b. Line of fracture. In Bernhard Loebel's case. Case I. — Bernhard Loebel, aged two, October 27, 1886, injured his elbow by fall- ing oif a chair. The arm was put up by a physician in the flexed position in plaster Fig. 75. — Showing relative positions of frag- ments in Bernhard Loebel's cass. Fig. 76. — Anterior view of lower end of humerus in Bernhard Loebel's case. of Paris, and remained in this dressing for a fortnight. JDec. 7, 1886. — The elbow- joint showed very marked gun-stock deformity. It was held at an angle of about 82 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. one hundred and forty degrees. Flexion could be carried to about one hundred and ten degrees; extension not beyond the angle first mentioned. The forearm was dis- placed inward and backwai'd, and the tendon of the triceps described a well-pro- nounced concave line. An abnormal mass of bone could be felt in the bend of the elbow externally, behind and below which the head of the radius could be made out with some difficulty. A posterior incision midway between the abnormal mass of bone and the olecranon opened the joint, and the periosteum was raised by means of the knife and elevator on both sides of the incision until the lower end of the humerus could be turned out for inspection. It was found that the deformed callus consisted of the external epicondyle, capitellum, and a small portion of the trochlea that had been broken otf obliquely, and was tilted and pulled forward by the action of the flexors so as to present its articular aspect forward, part of the fractured surface looking back- ward. In this position bony union had taken place. The elongation of the outer half of the articular end of the humerus accounted for the gun-stock deformity; the pres- ence of the large mass of bone dis- placed forward by tilting of the frag- ment explained the inability to flex. The lower end of the humerus was pared off horizontally with the knife, care being taken to remove a little more from the external than from the inner half of the lower end of the humerus, in order to preserve the "carrying point." The capsule and skin were united by suture. One drainage - tube was inserted. The arm was put up in extension in a couple of lateral pasteboard splints. No fever followed. Dec. mh. — First change of dressings. In anaesthesia the tube was removed, and the arm was flexed to an acute angle and put up in this position in two lateral pasteboard splints. Dec. 19th. — Pas- sive motion was practiced in anaes- thesia, and the arm was fixed in the straight position. Dec. 23d. — Passive motion without ether. Fixation at an acute angle. Dec. 29th. — Free passive motion to normal limits. Splints abandoned and active move- ments commenced. March 3d. — Outline of elbow almost normal. Flexion and extension normal. Case II. — Willie H., aged elev- en. Very pronounced gun-stock de- formity due to fracture of the elbow- joint sustained two and a half years ago. The treatment hud been conducted by a surgeon of good repute. Flexion could be carried to a right angle, extension to about one hundred and thirty degrees. Fig. T7 shows the boy's arm in full extension. June 17, 1887. — Arthrotomy done at Mount Fio. 77. — Gun-stoek deformity due to T-lracture of the lower end of the humerus. Willie 11. 's case. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 83 Sinai Hospital revealed a very curious condition of things. The broken-off external condyle and capitellum occupied a position similar to that observed in the preceding case. The ulna was dislocated backward and inward from the fragment representing the tro- chlea, which was attached by callus to the an- terior aspect of the lower end of the humerus. Apparently a T-shaped fracture of the lower end of the humerus had taken place. The ar- ticular surface had a most grotesque shape. The cartUaginons surfaces of the trochlea and sig- moid incisure were coated with a dense mass of connective tissue. The broken-off coracoid process was attached to the fragment of the trochlea. The articular sui-face was pared off to approximate the shape of a normal hume- rus, and the wound was drained, sutured, and the arm put up in a pasteboard splint. Normal union by primary adhesion of the wound took place, but an annoying complication, consisting of paralysis of the forearm and hand^ was noted. This untoward event was probably caused by the fact that the pad of Martin's bandage, used for producing artificial anaemia, had been placed over the inner aspect of the arm^ exerting undue pressure over the nerves. June 19th. — The compressive dressings were removed, the drain- age-tube was withdrawn, and the wound re- dressed. July Sd. — The patient was discharged from the hospital with healed wound. Local treatment of paralvsis by galvanism and mas- sage was commenced. July 22d. — Flexion and extension of forearm and fingers re-established. Aug. 1st. — Function of elbow be- coming normal. Aug. 19th. — Muscular power fully restored. (See Fig. 78.) Habitual luxation of the s]ioulder-joi7it, a very annoying and rebellious comi:)laint, may also be cured by arthrotomy and partial exsection of the redundant capsular ligament. (See case on page 8, Note 2.) Fict. 78. — Eesult after exsection of elbow- joint for gun-stock deformity. Willie "ll.'s case. V. OPERATIONS FOR DEFORMITIES. 1. Knock-Knee and Bow-Leg. — Operative exposure of the medullary tissue of the long bones is a dangerous procedure unless suppuration can be ex- cluded from the wound. By the successful employment of the aseptic method the danger of osteomyelitis can be virtually excluded. McEwen's osteotomy is one of the safest and most useful procedures of the newer surgery. It has almost entirely displaced purely orthopedic methods. For knock-knee, after division of the soft parts by a short longitudinal incision, the cancellous tissue of the lower end of the femur is divided by a properly shaped chisel, called osteotome. For bow-leg, the osteal section is carried through the upper end of the shaft of the tibia and fibula. The 84 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. operation is doue under artificial anaemia ; and the dressings are aj)plied, and the limb is put up in a contentive dressing — preferably plaster of Paris — before the removal of the constricting elastic band. New-formed bone is thrown out into the gap caused by the correction of the position of the bones, and bv the end of three or four weeks firm union in a normal position is the result. Case. — Leopold Heymann, clerk, aged nineteen. Very marked bow-legs, the dis- tance between the internal condyles of the femora being three and a half inches. JSfo- remher 15, 1883. — Double osteotomy of the thighs at Mount Sinai Hospital. Plaster- of-Paris splints. Dec. IJ^th. — Change of dressings. Wounds healed by primary union; bones firmly consolidated. The knees were in contact, but the curvature of the tibiae, which represented a great part of the deformity, was still very marked. Undoubtedly osteotomy of the shin-bones would have given a better result. The patient declined further operative interference. 3. Bony Anchylosis in a vicious position. Case I. — Lina Frieberger, aged fif- teen. Bony anchylosis of right and pseud- anchylosis of left maxillary joint, prob- ably due to acute osteomyelitis of right ascending ramus. The teeth were in ab- solute apposition, and no solid food could be taken. Marked facial hemiatrophy. In childhood a suppurating affection of the right cheek was noted. April 3, 1886. — Exsection by chisel and mallet of the left maxillary joint (hemiatrophy of the same side). Tlie operation did not relieve the functional trou- ble ; the joint was found pseud- anchylosed, the cartilages gone, andthecapitellum nearly absorbed. The wound liealed by primary inten- tion. April 29th. — Exsection of right maxillary joint, which was found firmly an- chylosed. The semilunar incision was obliterated, the capitellum, coronoid process, and temporal bone forming one solid mass. Immediately after its removal the teeth could be separated to tlie distance of an inch and a quarter. Primary union. Perfect restoration of func- tion noted in January, 1887. K Fio. 79. — Arrun.i?eraent of nails in Maggie Schweizer'.s case. Fig. 80.— Final result in Maggie Schweizer's case. Cross-inarks indicate places where nails were driven in. (Page 85.) SPECIAL APPLICATION OF THE ASEPTIC METHOD. Case II. — Maggie Sclnveizer, aged fifteen. Bony anchylosis of knee-joint at a riglit angle, in consequence of infantile acute osteomyelitis of tibia, with suppuration of knee- joint. January 23, 1886. — At the German Hospital, excision of the patella and of a wedge-shaped piece of bone, with preservation of the epiphyseal lines of femur and tibia. Transverse cutaneous incision, as for knee-joint exsection. Division of the bones by the saw, after peeling off of the periosteum. The sawed surfaces were brought together, and their fixation was secured by three steel nails, which were driven diag- onally through the tibia and femur in the horizontal plane — that is, from the lateral aspect of the extremity. The locking of the femur and tibia was so firm that the limb could be raised and handled like a solid staff. The application of the dressings was thereby made a very easy procedure. Pull plaster-of- Paris splint. No reaction and no fever were observed. Fei. 23d. — First change of dressings. The nails and two drain- age-tubes inserted at the operation were removed. The bones were found firmly united. Over a small aseptic dressing a light silicate-of-soda splint was applied, and the patient was directed to walk on crutches. March 15th. — Discharged cured with light silicate splint. May 10th. — Presented herself to author, walking excellently with the aid of a raised sole. Shortening, two and a half inches. 3. Deformed Callus. Case I. — William Paradies, laborer, aged thirty-eight. Deformed callus of the lower end of the tibia following a supra-malleolar fracture of the leg. Radiating pain issuing from the site of the deformity, due to pressure on the in- tegument, which was tightly stretched over the protruding edge of the upper fragment. March 7, 1887. — The deformed bone was exposed and chiseled away on a level with the surface of the dis- tal fragment. Suture ; no drainage. Primary union. March 21st. — Patient discharged cured fi'om the German Hospital. Case II. — Ernst Langer, carpenter, aged forty-five. Deformed callus of fibula. August 29, 1885. — At the German Hospital, in- cision and exsection of the callus by chisel and mallet. Apposi- tion and fixation of the fragments by a strong catgut bone-suture. Primary union. Discharged cured, September 26, 1885, with firm consohdation. 4. Club-Foot and Pes Valffus. — On account of its sim- Fig. si.— Defoi-med 1 i n 1 ji J? callus 01 low- phcity and the excellent results reported both irom er end of tibia. abroad and at home after its practice, Phelps's operation diel/^'^" seems to deserve extended trial. It consists in the com- bination of tenotomy of the tendo Achillis with a free division of all the soft tissues situated on the mesial side of the planta pedis, the incision penetrating down to the bone and, if necessary, into joints. The idea of dividing all resisting tissues underlies the plan of procedure. The incis- ion includes the tibialis anticus tendon, the tendons of the tibialis posticus, flexor digitorum communis longus, flexor hallucis longus, the belly of the flexor digitorum brevis, of the abductor hallucis, the plantar fascia, the long plantar ligament, the deltoid ligament, the nerves, and, if unavoidable, the vessels. The incision need not be a very long one. It commences just in front of the tip of the inner malleolus, and extends downward, according to the age of the patient, for about an inch or two. All the ]3arts named above can be easily reached from the wound Avith a tenotomy knife, unless they 13 86 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. are in tlie direct line of section, when they are diyided with the scalpel. Preservation of the integrity of the plantar artery is very desirable, on acconnt of the avoidance of satnration of the dressings with blood. The tiG. 8:i. — Group illustrating an operation about the foot or ankle. operation being done with the aid of Esmarch's band, all the tissues can be readily identified as they are gradually exposed step by step. The internal plantar artery can thus be seen and doubly tied. The main trunk of the artery sweeps in a long curve outward to the ex- ternal side of the sole, and is out of the line of sec- tion. Should it be divided accidentally, and the blood soil the dressings at once, it is proper to re- move them, to reapply Esmarch's band, to enlarge the incision, and to find and deli- gate the cut ends of the vessel. In extreme cases of adults, where the bones have acquired a definitely vicious shape, osteotomy or wedge- shaped excision of the neck of the astragalus must be added to the teno-myotomy performed in the planta. The author was surprised to see Fig 8.3.— Drossini,' fm- \Vf)UiRls of ankle and foot. the ease with which even great de- formities could be corrected after the division of all tissues mentioned above. Of course, the wound is a wide gaj), which is widened still more by the cor- rected position. Its healing is accomplished by the " organization of the SPECIAL APPLICATION OF THE ASEPTIC METHOD. 8' moist blood-clot" (Schede's method). As soon as the wound luis been well cleansed by irrigation, a piece of rubber tissue, ])reviously kept immersed in a five-per-cent solution of carbolic acid for twenty-four hours, is placed over the gap. This is covered with a few strips of iodoform gauze and an ample dressing of sublimated gauze. While the foot is held in the cor- rect position by an assist- ant, the sur- geon applies over the asep- tic dressing a silicate-of- soda splint, and over this a plaster-of- Paris splint. While the j)laster is setting foot is held with force in somewhat overcorrected posi- tion, which will allow for the slight giving, way of the asep- tic dressing. Then Esmarch's band is removed, and the feet are held in the vertical posture for an hour or two after the operation. After disappearance of passive hyperaemia they are placed on a pillow in the horizontal posture. In a fortnight or so the plaster-of-Paris shell is cut away ; the silicate splint thus exposed is finished off by a few turns of crinoline bandage soaked in silicate, and as soon as it is dry the patient is allowed to walk with the aid of crutches. In about four weeks after the operation the silicate shoe is split on top, and the dressings are removed. In many cases the wound will be found cicatrized over by this time. Should this not be the case, however, the aseptic dressing and silicate shoe must be reapplied. When the wound is perfectly healed, the silicate splint can be replaced by a well- fittinof laced shoe. Fig. Elevation of the feet after Phelps's operation. XoTE. — The silicate shoe must not include more than about one third of the leg not to prevent treatment of its debilitated muscles by massage and electricity. in order The fear that the severed tissues will not grow together properly is un- founded. Schede had the opportunity of ascertaining by autopsy the exact re-establishment of the physiological relations of the cut tissues. The best proof of the fact is, however, the restoration of the function of the cut parts. The results exhibited by Phelps at a meeting of the New York State Medical Society at Albany surpass everything the author has seen accom- plished by any surgeon for the cure of this deformity. 88 RULES OF ASEPTIC AND ANTISEPTIC SURQERY. Case. — Hiirr.v Epstein, sdiool-boy, aged twelve, siittering from chronic interstitial nephritis as a consequence of scarlatina. General condition poor, on account of lack of exercise, due to disaltility trom club-feet. The patient was walking on the outer edge of the plantas. The urine contained granular and hyaline casts, and twenty per cent of albu- men. March lit, 1887.— At Mount Sinai Hospital, double Phelps's operation was done under chloro- form, wliich was borne excellently, the operation lasting forty-five minutes. No fever, no reaction followed, llarch SSth.— The plaster shell was cut away, and the patient commenced to hobble about in the ward on crutches. April 10th. — The old water-glass splints were removed, and were replaced by a new set, which were worn until June. After this the patient was fitted with a pair of lacing shoes. Case II. — Aaron Meyer, oysterman, aged twenty-nine, far gone and very painful p3s valgus of both feet. Oct. 12, 1885. — At Mount Sinai Hospital, exsection of a bony wedge by chisel and mallet from the internal aspect of the head of the astragalus, the scaphoid, and calcaneum of the right foot. Area of the base of the wedge about one square inch. The remnants of the neck of the astragalus and calcaneum were divided entirely by the osteotome, and the foot was broken into shape by manual force and put up in an aseptic dressing and plaster-of-Pai"is splint. Nov. 1st. — Dressings rerac>ved, wound presenting a strip of shallow granulations. Dec. 1st. — Discharged cured. Feb. 1st. — Foulis's operation on the left foot, which showed a lesser degree of deformity than the right foot before operation. The talo-navicular joint was incised, and its entire cartilaginous covering was removed by scraping with a scoop. Fe/K 2Ut. — First change of dressings; primary imion. Feb. 27th. — Patient discharged cured. In March, 1887, patient presented himself for examination. Firm anchylosis of the talo-navicular joints of both sides, and very good function had been secured, the patient attending to his accustomed business. Fig. 85. — Appearance of wounds four weeks after Phelps's operation. Harry Epstein's case. VI. PLASTIC OPERATIONS. Aseptics liave greatly improved the results of plastic operations, and especially erysipelas has been almost entirely banished from facial wounds made for plastic purposes. In performing any operation about the face it is necessary for the surgeon to protect himself and the patient from two sources of infection. One is the oral and nasal secretions, the other the patient's head, notably his hair. The latter should always be enveloped in SPECIAL APPLICATION OF THE ASEPTIC METHOD. 89 a cap extemporized from a good-sized towel or comjjrcss wrung out of cor- rosive-sublimate lotion. The accompanying illustrations show the manner of folding the towel about the head. It should be lirnily fastened by a narrow roller-bandage encircling the forehead and occiput. Whenever vomiting occurs, a careful cleansing of the soiled skin and a ciiange of towels are indicated. Where there is no great tension to be over- come, fine catgut (No. 0) makes excellent sut- uring material for facial wounds after plastic operations. Where the tension is great (which, how- ever, should be reduced to a minimum by the proper shaping of flaps and free dis- section), silver wire, or silkworm t gut well soaked in car- bolic lotion, will be well employed for retentive purposes. Sutures of coapta- tion are best made with fine catgut. Hare - lip pins were never used by the author, as they are unnecessary, and offer no advantages over the sutur- ing material more generally employed by surgeons. Where the wounded surfaces can be completely closed by suture, no dressings whatever are needed. A thick layer of iodoform dusted over the line of union will soon unite with the oozings into a paste, which on becoming dry will form an excellent and un- irritating protection to the wounds and suture-points. Daubs of collodion, or the application, after hare - lip operations, of strips of ad- hesive plaster to the face, are especially unpleasant and irritating to infants. They Fig. 87.— Applying aseptic cap. Second step. create uneasiness, and excite the little patients into crying fits, and the distortion of the face resulting from frequent crying is certainly not conducive to the uninterrupted rest and union of the wounds. Fig. 86. — Applying aseptic cap. First step. 90 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. 88. — Aseptic cap in situ. Cancer of lip. Retentive sutures should never be removed too soon — that is, before the seventh day. The smaller catgut sutures will be absorbed by that time. Where an uncovered de- fect is unavoidably left be- hind, on account of lack of integument or some other reason, Schede's procedure is the best means of preventing supjDuration. A strip of rub- ber tissue is laid over the de- fect, and is suitably inclosed in an aseptic dressing. The blood-clot, which will form under the rubber tissue, will, if it be well protected from desiccation and decomposi- tion, rajDidly become organ- ized. In plastic operations performed about tlie soft and hard palate the con- dition of the teeth should be well attended to previous to the undertaking. Decaying teeth should be removed, and an unwholesome state of the gums and mucous membrane should be corrected by the diligent use of the tooth-brush and a 1:1,000 solution of permanganate of potash as a mouth-wash. Urethroplasty will fail almost in- variably if ammoniacal urine is per- mitted to pass over the line of union. Acid urine is not deleterious to the wounds. Where chemical examina- tion has established the presence of ammoniacal decomposition of the urine, frequent washings of the blad- der and the urethra with weak so- lutions of permanganate of potash (1 : 4,000 or 5,000) and the internal administration of boracic acid will suitably prepare those organs for the operation. To prevent the soiling of the wound by ammoniacal urine, a soft Nelaton catheter should be passed into the bladder and fixed by a proper bandage to prevent its escape. Daily antiseptic irrigation of the bladder should be continued all the time while permanent catheterism is used. As soon as the wound is firmly united, catheterism may be stopped. Fk;. b'.i. — Dressiiifi' for cxcisidu of the upper jaw. SPECIAL APPLICATION OF THE ASEPTIC METHOD. til Periiwal plastic opcrntions on tlie female require a ])revioii.s thorough disinfection of tlie vulva and vagina by mercurial irrigation, which should be kept up during the entire time of the operation. Here, too, dressings are annoying and unnecessary. Catheterism, temporary confinement of the bowels, and frequent irrigation, with subsecjuent dusting with iodoform powder, will afford all the security needed against infection. Aside from the care for the production and maintenance of the aseptic condition during and after the operation, another imj)ortant requirement must be fulfilled. This is a thorough and complete apposition of the entirety of the wounded surfaces hy several tiers of catgut sutures, and a correct union of the mucous membranes of the vagina, and of the rectum if necessary. A slovenly manner of suturing will lead to the formation of hollow spaces, which will become filled by blood-clot ; and, if the sutures of the mucous membranes be also inexact, contact of the vaginal or rectal discharges with the unprotected clot will lead to its inevitable putrescence, and to partial or general suppuration. An exact, deep and superficial suture is the best protection of perineal operative wounds against infection. Note. — The stitches holding tlie mucous membrane together should never pass through the epithelium. They should be entered and brought out just below the epithelial lining. This will prevent inversion of the edges, and the stitch-holes will be also protected from infection by the ridge of proti'uding mucous membrane. On account of the great vascularity of the face, facial wounds will often heal without suppuration, even if very indifferent asepticism was observed. Not so in other parts of the body, notably about the extremities, where suppuration is much more easily produced, and is generally followed by sloughing of the flaps. Strict asepticism, avoidance of tension by sutures and of pressure by dressings, are imperative conditions of success in plastic operations done on the extremities. Fig. 90. -Maas's operation. Primary plaster-of-Paris dressina;s. On the right leg, the defect to be covered ; on the lei't leg, flap detached from calf. " Case I. — Abraham Strecker, aged seven. Circular, extensive skin defect of the right leg, due to old compound fracture: extensive ulceration of frontal part of the cicatrix; oedema of the foot, caused by contraction of the circular cicatrix. Dee. 7, 92 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. ISSo. — At Mount Sinai Hospital, plastic repair of the frontal part of the defect by Maas's procedure. Each thigh and foot was first incased in a plaster-of- Paris splint, then the cicatrix was disinfected with an eight-per-cent solution of chloride of zinc and pared off Fig. 91. — Maas's operation. Secondary plaster-of-Paris dressings fixing relative position of extremities. Flap attached to its new habitat. with the scalpel. After this a properly shaped, generous skin-flap was raised from the posterior aspect of the left leg. Now the extremities were superimposed in such a manner as to bring the flap over the vivified surface of the right leg, wherewith it was brought in contact on its raw surface. A second- ary plaster-of-Paris dressing applied over the primary plaster splints secured the limbs and the flap in their new relative position. The exposed raw surface of the pedicle of the flap was wrapped in an envelope of rubber tissue to prevent its desiccation ; the flap was lightly attached to its new habitat by a few catgut sut- ures. The edges of the flap were dust- ed vrith iodoform, and the defect of the calf was inclosed in an aseptic dressing. With the exception of a small portion of the end of the flap which necrosed, primary union throughout was achieved. Dec. 21st. — The pedicle of the flap was cut, and the limbs were released from their confinement. Rapid cicatrization of the remnant of the original and of the defect of the calf followed, and, January 30, 1886, the boy was discharged cured. The oedema of the foot had disappeared. Case II. — Adolph Carstens, school- boy, aged eleven. Fel. 17, 1887.— Av the German Hospital, Maas's operation for a large skin defect of the anterior aspect of the tibia, due to severe traumatism. The case was managed exactly like the foregoing one, with this additional circumstance, however, that it became necessary to pare off an area of the anterior aspect of the tibia by chiseling, corresponding to Fif.. 02.— Maas's op- eration, final resiiit. Cicatrix is marked with ink. Fig. 93. — View of ci- catrix of the phicc whence the skin-iiap was taken. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 93 the size of the flap, in order to remove the condensed cicatricial tissue underlying the extensive elevated ulcer. Thus, a well-vascularized base was secured for the skin-tiap. March 5(Z.— The pedicle was divided, and, April 10th, the patient was discharged cured. VII. ASEPTICS OF THE ORAL CAVITY. Long after the principles of tiie aseptic treatment of external wounds had become recognized, the proper management of the wounds of the nor- mal openings of the resiDiratory, digestory, and uro-genital tracts was still a mooted question. It was a comparatively easy thing to produce in these regions an aseptic condition for the time of the operation. But how to protect the wounds from the inevitable soiling by the continuous discharges pertaining to these several apertures, was first shown by Billroth, who suc- cessfully employed iodoform as an effective preventive of putrefaction in the oral cavity. If a fresh wound of the oral cavity is rubbed off with iodoform powder and packed with gauze saturated with iodoform, this dressing will become matted together with the tissues of the raw surface, and will form an effective protection against infection by septic influences. The secretions will innocuously pass over the surface of the gauze, and the penetration of active germs to the wound will be prevented by the air-tight and closely adherent packing. The course of oral wounds treated in this manner differs widely from that observed under other forms of treatment. Diphtheritic and phlegmonous processes, formerly so common in wounds freely communicating with the mouth, have become things of great rarity. The terrible odor which could not be kept down by however frequent irrigations with any kind of deodor- izing lotion until the necrosed layer of tissues was cast off, is now generally absent. By the time that the packing of iodoformed gauze becomes loose, healthy and vigorous granulations will have sprung up, and the wound will progress toward its uninterrupted healing without pain and without fever. As long as the packing is firmly adherent, it should not be disturbed. Its forcible extraction would certainly cause a good deal of pain, and would be followed by haemorrhage and inflammation. The superficial layers of iodoformed gauze, becoming soiled by secretions or food, can be daily renewed. Another important point to be observed in operations about the oral cavity is the control of hgemorrhage. The abundant blood-supply of this region is apt to be the source of copious haemorrhage, dangerous in itself, but especially perilous on account of the possibility of the entrance of blood into the air-passages. This accident may, on the one hand, cause instant death from suffoca- tion ; on the other, it may produce catarrhal or septic pneumonia by decom- position within the bronchi. Hemorrhage from oral wounds can be controlled in two ways. They may be employed separately or combined. 14 94 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. 94. — The author's tracheal tampon cannula. The first one is by preliminary ligature of one or both lingual arteries ; the second, by the exclusive use of the actual cautery and galvano-caustic wire loop. Where the operation must needs extend to the floor of the mouth, deli- gation of the lingual arteries will be insufficient, and the use of the actual cautery point or loop often impracticable. In such a ca,se, preluninary tracheotomy and the employment of a tampon can?mla will be the only safe means of preventing the entrance of blood into the bronchi. Although White- head's speculum is an excellent instrument to render the oral cav- ity accessible, yet it will be unsatisfactory in operations to be done on the floor of the mouth. Here sec- tion or even partial excision of the lower jaw may be unavoidably necessary to afford ample space for complete excis- ion of a malignant tumor, and to make accurate h^emostasis practicable. Where most or all attachments of the tongue to the inferior maxilla must be severed, a strong loop of silk should be drawn through the stump of the tongue near the epiglottis, to be brought out by the mouth and attached by a strip of adhesive plaster to the cheek. This precaution will enable the nurse or attendant to instantly clear the epiglottis should the stump of the tongue ever slip back upon and occlude the entrance to the larynx. In the more extensive cases of oral surgery, especially after removal of the tongue, nutrition will have to be carried on for some time by the stom- ach-tube, which can be left in for several days, or can be daily introduced by the mouth or nostril. Early operations for cancer of the tongue will give better results in every way than late ones. But even of the latter it can be said that, as a rule, the patient's life will be prolonged by them, and will be made more tol- erable. Every oral operation should be preceded by a careful preparation of the mouth by extraction of carious teeth and frequent washings with a germi- cide lotion, preferably a 1 : 1,000 solution of permanganate of potash. Pres- ent stomatitis should be first got rid of by all means. Case I. — Mr. David S., wholesale butcher, aged fifty-four. Strong smoker. On the inner aspect of the right clieek, opposite a carious and sharp-edged molar, where an opaline mucous patch had existed for some time, an elevated ulcer of the size of a silver dollar had established itself, and was steadily extending. The submaxillary lymphatic glands were intiimescent. April 30, 1884- — Extirpation of the growth from SPECIAL APPLICATION OF THE ASEPTIC METHOD. 95 a transverse incision extending backward from the angle of tlie mouth. Tlie outer skin was saved and brouglit togetlier by a line of stitches. The intumescent submax- illary glands were also removed. Uninterrupted recovery followed, but a small fistula remained behind, corresponding to the middle of the incision of the cheek, which, how- ever, closed after a few applications of the thermo-cautery. The contraction of the cheek was successfully overcome by the insertion and wearing of wooden wedges, which were abandoned in the fall of 1884. During the summer a relapse of cancer had developed in the deep-seated submaxillary glands of the right side and in the submen- tal gland. September S5, 1884- — The glandular swellings were extirpated from both mentioned regions. The complete removal of the submaxillary glands necessitated excision of two inches of the deep jugular vein. The wound healed by the first inten- tion; the patient took his first walk twelve days after the operation. He remained free from the disease until September, 1885, when a rather rapid swelling of the sub- maxillary glands of tlie left side was observed. Apparently the infection had extended to the opposite side of the neck by way of the diseased submental gland. The original site of the epithelioma in the cheek remained intact by relapse. October 22^ 1885. — An attempt was made to remove the glandular swelling of the left side of the cheek, but it had to be abandoned on account of the wide extension and infiltrating character of the new growth, January 31, 1886. — Patient died of extension of the disease to the cerebrum. Had the first operation been undertaken at an earlier date, the respite secured to the. patient would have been much longer. Case II. — Katie Jobs, aged thirteen. Mucous cyst of the left under side of the tongue, deeply imbedded in the lingual tissues, and extending back to the hyoid bone. March 21^., 1883. — Deligation of the left lingual artery from an external incision above the hyoid bone. Whitehead's speculum being inserted, the tongue was transfixed and secured by a strong fillet of silk. By this it was withdrawn, and the cyst was easily extirpated from its bed by means of scissors and forceps. Care was taken not to grasp the cyst with the mouse-tooth forceps, which served only to hold aside the muscular tissue of the tongue. Minimal haemorrhage was observed. The wound was stitched with fine silk throughout its entire length, a few threads of catgut being inserted into its upper corner for drainage. Both wounds healed by primary union, and, April 7th, the patient was discharged cured from the German Hospital. Case III. — Adolph Bottger, cooper, aged forty-two, a strenuous smoker and hard drinker, had contracted an epithelioma of the right anterior margin of the tongue, ex- tending well forward to the gums of the canine tooth, and involving the intervening part of the floor of the mouth. No intumescence of the lymphatic glands could be made out. A^igust 28, 1883. — At the German Hospital the right lingual artery was deligated, and the right half of the tongue was excised by the aid of forceps and scis- sors. A morphine injection had been administered before the operation, and anaes- thesia by chlorofoi-m was not carried to insensibility. Hemorrhage was very moder- ate. In excising the floor of the mouth the bleeding was somewhat profuse, and a large number of spurting vessels had to be tied. The resulting wound was packed with iodoformized gauze. No fever or inflammation followed, and the power of deglu- tition was re-established on the third day. The patient left the bed on September 9th, and October 9th was discharged cured. In February, 1884, the disease returned on the inner aspect of the gums. March 10th. — Three inches of the alveolar process of the horizontal part of the lower maxilla were excised, together with the entire cicatrix. Cure was delayed by necrosis of the remaining portion of the body of the jaw. April 30th. — The sequestrum was extracted. May 20, I884. — Patient was discharged cured. 96 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. May i7, 1886. — The patient returned with a far-gone relapse, starting from the left submaxillary stump. May 19th. — Exsection was performed. Violent delirium tremens set in immediately after the operation, followed by death in collapse. Case IV. — Fritz Osterwald, shoemaker, aged sixty-three; strong smoker; cancer of the right margin of the tongue well back near the anterior pillar of the fauces, with considerable involvement of the floor of the mouth, February ^, 1886. — Deligation of the left lingual artery, followed by excision of the corresponding half of the tongue and floor of the mouth in morphine-chloroform anaesthesia at the German Hospital. Access was gained to the oral cavity by a semicircular incision following the under side of the lower jaw, from which the attachments of the muscles were raised together with the periosteum. The mucous membrane was cut through, whereupon the tongue and floor of the mouth could be drawn out from under the maxilla and turned out upon the front of the neck. Hsemoi'rhage was rather free in spite of the preliminary liga- ture of the lingual artery ; and, though the patient was not fully ansesthetized, alarm- ing asphyxia suddenly took place, apparently due to the occlusion of the glottis by a blood-clot. Efforts to dislodge this were unsuccessful, therefore hasty tracheotomy had to be performed, resulting in re-establishment of respiration. After this the excis- ion was completed without further mishap. More than half of the tongue was re- moved up to the epiglottis, together with the left side of the floor of the mouth and the anterior faucial pillar. The wound was packed with iodoformized gauze. Nutrition was carried on by stomach-tube. No fever followed, but, February 15th, symptoms of iodoform mania necessitated the removal of the original packing, which was replaced by corrosive-sublimate gauze. Feh. 18th. — The restless patient was taken to his home, whence he was transferred to Bellevue Hospital, where he died a maniac on February 28th. The foregoing case illustrates the dangers from the entrance of blood into the larynx, and the greatest drawback of iodoform when used on elderly- individuals — namely, its tendency to produce acute mania. From this instance the author learned the lesson of never risking a rather bloody opera- tion in the oral cavity without preliminary tracheotomy and the use of a tampon cannula. The anxious moments spent in opening the suffocating patient's trachea will never be forgotten. Case V. — Victor Jeggi, silk- weaver, aged fifty-three, a very moderate smoker, admitted August 20, 1885, to the German Hospital with hngual cancer, involving nearly one half and principally the right side of the tongue. No glandular swelling. Aug. 22., 1885. — Both lingual arteries were deligated, and two thirds of the entire length and width of the organ were excised with very little haemorrhage in mixed (morphine- chloroform) anaesthesia. The wound was packed with iodoformed gauze. Deglutition returned on August 28th. The wound healed very rapidly, so that, September 5th, ])atient could be discharged nearly cured. He presented himself, February 21, 1886, with a relapse in the floor of the mouth, but delayed operation until March 30th, when the disease had assumed formidable proportions. Preliminary tracheotomy being done, the author's tampon canula was inserted. The middle portion of the lower jaw was excised, and the remnant of the tongue was removed together with the entire floor of the mouth by means of the thermo-caustic knife. The stumps of the severed arteries did not retract (atheromatosis), and were successively tied. The wound was packed with iodoformized gauze, and nutrition was carried on by the stomach-tube. April 2d. — The patient vomited, and undoubtedly some of the ejecta found their way into the bronchi. April 3d. — Catarrhal pneumonia set in with a chill and a temperature SPECIAL APPLICATION OF THE ASEPTIC METHOD. 97 of 104° Fahr. April 6th. — The critical condition changed for the belter, and by April 15tb the patient left the bed. To avoid vomiting produced by the frequent introduc- tion of the stomach-tube, this was carried in through the nostril and left in situ with evident comfort to the i)atient. The wound contracted rapidly, but in the middle of May relapse appeared in the pharynx, which ended the patient's existence in June, 1880. The presence of the tampon cannula in the trachea, effectually shutting off the possibility of the entrance of blood into the air-passages, made this otherwise very bloody and formidable operation comparatively easy and safe. Case VI. — Mr. Joseph T., wholesale liquor-dealer, aged sixty, a smoker, had been suffering for twelve years from opaline patches of the tongue, two of which, situated on the left side of the organ, developed, toward the end of 1886, into epitheliomata. The otherwise well-nourished patient suffered also from chronic interstitial nephritis, as evidenced by the presence of albumen and hyahne and fine granular casts in the urine. Feb. 10, 1887. — The left lingual artery was deligated under chloroform anaes- thesia. The tongue was secured by a strong fillet of silk, and was withdrawn from the mouth. A straight Peaslee's needle was then carried into the bottom of the deligation wound, and was thrust through the middle of the base of the tongue just in front of the epiglottis into the oral cavity. One end of a platinum wire was passed through the eye of the needle, withdrawn through the wound and disengaged. The same needle was reintroduced by the wound into the oral cavity, emerging this time just alongside of the left anterior pillar of the fauces. The other end of the wire was brought out by the needle through the external wound. Thus, one half of the base of the tongue was included in a loop, and, the wire being connected with a galvanic battery, was singed through without loss of blood. After this the tongue was divided longitudi- nally by the thermo-cantery in two unequal halves, and finally was severed from its connections with the floor of the mouth by the same instrument. A few spurting arteries had to be tied off during this last step of the operation, which was completed within the time of forty minutes. The haemorrhage was really insignificant, to which circumstance is to be mainly attributed the rapid recovery of the patient. The oral wound was packed with iodoformized gauze, and the external incision was dressed in the normal manner. The temperature remained normal throughout, and feeding by tube was discontinued on the third day. The mouth was irrigated every hour with a 1 : 1,000 permanganate of potash solution, until February 18th, when the packing came away. The wound appeared clean, and rapid contraction was manifest. Fe^. 25th. — The external wound was firmly healed. March 8th. — The oral wound was closed. Note. — la preparing iodoformized gauze for use in wounds of the oral cavity of elderly subjects, care must be taken not to sprinkle too much of the chemical upon the gauze. The surplus of iodoform should be rinsed out of the meshes of the fabric, which should be tinged just a very faint yellow color. VIII. LARYNGEAL OPERATIONS. 1. Tracheotomy. — The belief that tracheotomy is an easy operation is by no means justified by the author's experience. Occasionally, on a slender neck, and when there is competent assistance to be had, it is a simple enough procedure. But in most cases, especially on children, it calls for the best qualities of an experienced and cool surgeon. The necessity of tracheotomy having become manifest, three require- ments are to be fulfilled. First, infection of the wound has to be avoided ; 98 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. secondly, unnecessary hfemorrhage has to be guarded against ; and, tliirdly, the trachea has to be properly incised, and the cannula properly introduced and secured. The risks of the operation are not inconsiderable, hence intubation of the larynx, a much simpler, easier, and more physiological procedure, must be declared to be far preferable to tracheotomy where its application is proper, as in croupous laryngitis. For the removal of foreign bodies and in cases of tumor of the larynx, tracheotomy will remain the proper measure. Avoidance of infection of the wound from within or without is an ever important matter in all laryngeal op- erations. But it is especial- ly important, and also more difficult, in cases where the operation is done in the pres- ence of an infectious process, as, for instance, diphtheritic croup, where the extension of the septic condition to the external wound signal- izes a very grave complication of the otherwise precarious state of the patient. The aseptic rules laid down in preceding parts of this work obtain to their full extent in laryngeal operations. Infection from within must be guarded against by careful cleansing of the external wound and rubbing iodoform powder into all its recesses before incising the trachea. As soon as the cannula is inserted, the external wound must be well mopped out with a sponge soaked in corrosive-sublimate lotion. Then it is dusted with iodo- form, and lightly packed with iodoformized gauze. In all cases of croup the external wound should not be sutured, as sutures favor re- tention. A small slit compress of iodoformized gauze is slipped in under the flange of the can- nula before its fastening by the two lateral pieces of tape. By slipping in over the gauze com- press a slit piece of rubber tis- sue or oiled silk, the dressings and the patient's shirt will be protected from soiling by the sputa. A narrow roller bandage passed several times over and under the outer opening of the cannula will give additional security against accidents. Fig. 95. — Arrangement of the patient for tracheotomy. Same in situ. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 99 Note. — Unruly children will sometimes attempt the forcible removal of the cannula. In 1880 the author performed tracheotomy on a boy twelve years old, who, on regaining conscious- ness, at once tore out the cannula from the wound, breaking its fastenings to the flange, which remained attached to his neck. The family attendant, an elderly gentleman, attempted the re-introduction of the instrument. Finally, during the violent struggles of the patient the cannula slipped into place, whereupon respiration, which had been labored before, suddenly ceased altogether. The author reached the bedside by this time, and at once removed the cannula from the asphyxiated child's neck, restoring respiration. It was found that the cannula had been introduced upward into the oral cavity, instead of downward into the trachea. Another tracheal tube was properly introduced, and peace was once more restored, but the boy died sub- sequently of septicaemia, due to the wide extent of the diphtheritic affection of the pharynx. Hcemorrliage, always characteristic of an overhasty and bungling opera- tion, can be guarded against by observing the rules laid down in the chaj)ter on the technique of surgical dissection. Nothing will retard the perform- ance of tracheotomy as effectively as the disregard for haemorrhage. And every drop of blood spilt unnecessarily will proportionately diminish the chances of recovery, not to mention the danger of suffocation from the entrance of blood into the langs. Note. — The author once assisted a colleague who in his anxiety to open the trachea cut the isthmus of the thyroid gland. The formidable haemorrhage following this step only increased the doctor's haste. He plunged the knife into the pool of blood and fortunately opened the trachea. The patient aspirated a large quantity of blood, and would have surely been suffocated but by the timely turning of his body face downward. The patient, a boy of seven years, recovered. As soon as the skin, platysma, and superficial fascia have been amj^ly divided, the two groups of longitudinal muscles situated in front of the larynx are exposed. Sharp retractors are inserted and the bleeding vessels are attended to. A faint white mark indicating the median line where the muscles meet, is incised, and the muscles are taken up and raised by the retractors as the wound deepens. Thus far everything is easy. The most difficult part of the operation consists in the proper treatment of the isthmus of the thyroid gland. The surgeon must decide whether to approach the trachea from above or below the isthmus, and this decision depends upon the length of the neck and the size of the isthmus. In long, slender necks, the trachea is easily exposed below the isthmus ; in short, fat necks, with a massive isthmus, the upper operation is more appropriate. a. SuPEEiOR Tracheotomy. — Having chosen the upper o]3eration, the surgeon must find his way to the upper part of the trachea, situated just behind the isthmus, without injuring the thyroid capsule and its compli- cated plexus of large and turgid veins. To accomplish this, Bose's method affords an easy way. The deep cervical fascia divides into two layers just above the superior margin of the thyroid gland, these two layers forming the main body of the thyroid capsule. The point of division corresponds exactly with the upper margin of the cricoid carti- lage, which can be easily identified by touch. The nail of the left index-finger is placed against the margin of the cricoid, the pulp of the finger looking downward, whereby the thyroid gland is protected, and the fascia is opened by a short transverse 100 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. 97. — Diagram showing relations of deep cervical fascia, a, Thy- roid body. Just above it, corre- sponding to cricoid cartilage, bi- furcation of deep cervical fascia. iuoision directed against the upper edge of tlie cartilage. As soon as this is done, a bhint liook can be iiitrodiu-ed through the ti-ansverse slit behind the thyroid gland, AAhii-h then can be drawn down with some force, exposing the two or three upper rings of the trachea. The author never saw this method fail, and, in employing it, never was compelled to cut the cricoid cartilage for want of space to limit the incision to the trachea. (See Fig. 97.) b. Infekior Tracheotomy. — When the lower operation is decided on, the two layers of the deep cervical fascia are successively incised ietween two forceps, and thus the trachea will be readily exposed. Incision of the trachea should be done by the scalpel used for the first part of the operation, and rather by cutting than by puncture, as the latter may injure the poste- rior wall of the cylinder. Before cutting it, the trachea should be allowed first to adjust itself in its normal position, so that the in- cision should be placed exactly in the me- dian line. Grasping of the trachea while the incision is being made, but especially haste in opening the organ, may lead to very serious mistakes. It may happen that the trachea is not incised at all, or, what is still worse, the incision is placed laterally or even posteriorly on the tilted wind-pipe. Case I. — Mary R., aged five. May jf, 1882. — Tracheotomy performed by a col- league for laryngeal croup. The cannula could not be kept back in the wound, and the patient was found by the author suffocating, the instrument lying on the outside of the neck. Examination showed that the tracheal incision was placed to the left side and posteriorly, the trachea being twisted and bent while the cannula was in situ. An anterior tracheal incision was made, and in this the tube was retained without trouble. The child died of pneumonia. Case II. — Hermann Mollenhauer, aged two and a half. Croupous laryngitis. March ^7, 1881. — With the assistance of the family attendant. Dr. Hase, superior tracheotomy, on account of imminent suffocation. The trachea was exposed without trouble, but in cutting it open too hastily it tilted around its axis, and the point of the knite shaved off a segment of the first tracheal ring. The tilting of the trachea was not noticed at first on account of the necessary haste ; but, as soon as it was discovered, the trachea was properly incised, and the child ultimately recovered. As soon as the proper number of rings are divided, the lips of the in- cision should be taken uji by two small, sharp retractors. (See Fig. 18, page 39.) Hasty crowding in of the cannula is reprehensible, and may cause serious or fatal mischief by detaching and pushing membrane down into the deeper parts of the tracheal tube. Drawing asunder the tracheal wound will afford ample opportunity for free breathing, for ejection of blood and membrane or mucus, and will give the surgeon a welcome chance to inspect the trachea and to extract semi-detached membrane or a foreign SPECIAL APPLICATION OP THE ASEPTIC METHOD. 101 body. It will iilso solve the question whether tracheotomy has accomplished its end or not by the relief from dys})noea. The apncea, or seeming cessation of breathing, often observed imme- diately after the incision of the trachea, is apt to alarm beginners. It is due to the habituation of the patient to exist on a very small allowance of oxygen. The first deep and free breath taken through a newly-made tracheal incision gives the patient more oxygen than ten or fifteen labored inspirations could give before the operation. As soon as the cannula and dressings are in place, the patient is brought to bed, and a sponge, hollowed out in cup shape by the curved scissors, is attached with a safety-pin or two to a suitable piece of bandage, is wrung out of hot carbolic lotion (two per cent), and is tied down loosely Just over the orifice of the cannula. It should be cleansed at frequent intervals in the same lotion. Close attention to the cleanliness of the interior of the cannula is a constant duty devolving upon the nurse. It should be done by chicken or pigeon wing-feathers dipped in carbolic lotion. The little patients should be encouraged to drink as much as possible, prefer- ably milk. The first dressings can remain undisturbed for three days ; on the fourth day they and the cannula are changed. The patient is laid out flat on a table as for tracheotomy, and everything possibly needed should be at hand and readily arranged in a pan. Two shai'p retractors, thumb-forceps, scis- sors, a clean cannula, and a change of dressings will be needed. The bandages are cut, and they and the cannula are simultaneously removed with the outer compress of gauze. The deeper packing should remain unchanged till it becomes detached. The fresh cannula is slipped in at once, and usually with- out much difiiculty if the procedure be not unduly delayed. The packing of iodoformed gauze will become loose on about the fourth day, and should then be removed. If the wound is found clean and granu- lating, no repacking will be required. As soon as the patient can breathe freely through the fenestrum of the outer tube, the external opening of the cannula being occluded, the instru- ment should be removed, as it is apt to cause pressure-sores and trouble- some granulations within the trachea. The author's experience embraces thirty-eight tracheotomies performed for various reasons. Twenty-two were done for croupous laryngitis on chil- dren. Of these, five recovered ; seventeen died. The superior operation was employed seventeen times ; the inferior, five times. One of the children died of suffocation caused by the ill-advised action of the father, who inflated the patient's bronchi through the cannula with a large quantity of burnt alum. The others died of extension of the pro- cess to the lungs, or of septicaemia. Of the remaining sixteen tracheotomies done on non-croupous cases, two concerned children, fourteen referred to adults. The following table will elucidate the causes for which the operation was performed : 15 102 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Recovered. Died, Asphyxia from entrance of blood into trachea 1 1 " " malignant goitre 2 " " arterial haemorrhage into a cervical abscess 1 " " chloroform 1 Dyspnoea from cicatricial stenosis of bronchus 1 " " " " pharynx 1 " " foreign body in trachea 1 " " " " larynx 2 " " laryngeal tumor 3 1 Preliminary tracheotomy 1 Total 9 7 Of the two cases operated on for the entrance of blood into the larynx, one recovered (see Case IV on page 96) ; the other, where haemorrhage came from a suicidal gunshot wound of the base of the skull, died of the cerebral injury. In two cases the operation was done for threatening asphyxia by growing malignant goitre. Both died : one from collapse ; the other from coma, produced by acute alcoholism or traumatic delirium (see Cases I and II on page 109). In one case asphyxia caused by haemorrhage into a cervical abscess neces- sitated the operation. Patient recovered (see Case III on page 217). In two cases tracheotomy was done without success for deep-seated ste- nosis of the air-ducts. One concerned a man of forty, in whose left bronchus post-mortem examination revealed a syphilitic cicatricial stenosis. The other bronchus was found compressed by acute swelling of a bronchial lymphatic gland. The other case was that of Fred. Peckary, aged one, who exhibited symptoms of a growing tracheal stenosis, principally obstructing expiration. The case came, March 6, 1886, under the author's care by the kindness of Dr. Boldt. Tracheotomy was done at the German Hospital without relief. The child died of pneumonia March 10th. On autopsy a brass trousers-button was found imbedded in old cicatricial tissue between trachea and oesophagus, midway between the cricoid cartilage and the bifurcation. An open communication existed between the two tubes. The button was held in place by a rim of cicatricial tissue in the oesophagus, and projected downward with its free lower margin like a valve into the lumen of the trachea. Thus inspiration found no impedi- ment, but on expiration the valve was raised, and expiration-stenosis was the result. In one case syphilitic stricture of the fauces indicated the operation. Patient survived. In four cases the trachea was opened on account of the presence of laryn- geal tumors. Three survived, and one died of septic pneumonia, due to aspiration of the intensely fetid secretion of the ulcerated tumor. Preliminary tracheotomy was done once successfully before extirpation of the cancerous tongue (see Case V on page 90). In one case the trachea was opened on account of acute asphyxia occur- ring during chloroform anaesthesia. Case. — Undersized boy, aged nineteen. November IS, 18S/>. — At Mount Sinai Hos- pital removal of an enormous congenital teratoma of tlie occipital region under chloro- SPECIAL APPLICATION OF THE ASEPTIC METHOD. 103 form. The growtli had become sarcomatous, and extensive involvement of the cervical glands of both sides was present. The patient had to be placed in the prone position, and this and his generally weak state, together with the encroachment on the trachea by the glandular swellings, produced asphyxia toward the end of the operation. As arti- ficial respiration did not seem to produce any effect, tracheotomy was performed at once, and respiration was restored. While the pedicle of the tumor was being de- tached, it was noted that respiration had again ceased. The cannula was found outside of the tracheal wound, from which it was allowed to slip by the assistant intrusted with the narcosis. It is fair to state that death was very likely due to exhaustion or collapse induced by the shock of the formidable operation upon the much emaciated patient. He was a lad of nineteen, but looked like a very sickly child of ten. In one case increasing stenosis, caused by the presence of a dispropor- tionately small tumor, indicated the operation. Case. — Julius Meyer, peddler, aged thirty-nine. Previous history pointed at the lodgment of a foreign body in the oesophagus with dysphagia, which spontaneously disappeared. Gradually, however, increasing dyspnoea supervened. The laryngoscope demonstrated the presence of a small irregular tumor in the larynx, the size of which did not seem to explain the intense dyspnoea. Tracheotomy was done December 18, 1886, at Mount Sinai Hospital. On incising the trachea above the thyroid body, a granuloma occupying the posterior and lateral aspect of the larynx just below the vocal chords was exposed. Surrounded by this mass was found the point of a wooden skewer^ one inch in length, its ends being Imbedded in the mucous membrane. The cricoid cartilage was divided, the body was extracted, and the granuloma was excised. Dec. 27tJi. — Tracheal tube was removed. (For continuation, see Case III on page 104.) The following history of the removal of a foreign body from the larynx of a child concludes the series of the author's non-croupous cases of trache- otomy : Case.— Clara V., aged five and a half. May 22, 1881. —k foreign body entered the larynx of the patient, causing intense fits of coughing and transient attacks of chok- ing. A number of unsuccessful attempts at endolaryngeal removal of the body were made the same day. Finally, the body became lodged in the right bronchus, where its presence was made out by the sibilant noise heard near the bifurcation and the absence of normal respiration sounds over the entire right lung. A short, hacking cough, moder- ate dyspnoea, and noisy respiration served as constant reminders of the impending danger. June IJ^th. — During a coughing spell, sud- denly an alarming asphyctic attack set in, followed by dysphagia, Fig. 98.— Min- aphony, hoarse, croupy cough, and distressing dyspnoea. Marked moved '^ from larnygeal stridor and diminished respiration sounds over both lungs larynx by tra- pointed to the lodgment of the foreign body in the glottis. Inferior Exa°df size. tracheotomy being performed, the dyspnoea at once disappeared. The (Clara V.) foreign body, a headless and armless miniature doll of porcelain, five eighths of an inch long and three eighths of an inch wide, was found firmly wedged in the glottis, whence it was extracted through the wound without diflSculty. The wound was treated openly, and the child recovered. (See Fig. 98.) 2. Laryngoflssure. — Fission of the larynx for the removal of tumors or a foreign body was performed three times by the author. In one case of recurrent diffuse papilloma a very good final result was secured. In another lOi RULES OF ASEPTIC AND ANTISEPTIC SURGERY. one, done for epithelioma, speedy relapse followed. In the third case the presence of a foreign body and inflammatory granuloma required the step. The body and new-growth were removed, but the perichondritic inflamma- tion maintained fora very long time such an intense swelling of the laryngeal mucous membrane that the tracheal cannula had to be worn until June, 1887. Case I. — Mrs. 0. Lehmann, twenty-four, epithelioma of both vocal cords. April 11, ISSJj,. — At the German Hospital, laryngofissure and extirpation of both vocal cords and the adjacent mucous membrane were done. April 15th. — Cannula removed. April 30th. — Wound healed. Relapse manifesting itself soon afterward, excision of the larynx was done in the summer of the same year by Dr. F. Lange. who took charge of the service at the German Hospital after the expiration of the author's term. Case II. — David Popplewell, machinist, aged forty-two; recurrent papilloma of the larynx, that had been treated endolai'yngeally by Dr. Gleitsmann, who kindly directed the patient to the author. July 9, i555.— Laryngo fission at the German Hospital. Removal of the posterior half of right vocal cord; excision of several disseminated papillomata and searing of their base by the thermo-cautery. August 5th. — External wound healed; voice much improved. Case III. — Julius Meyer, jieddler, aged thirty-nine ; recurrent stenosis after trache- otomy (see case on page 103) done, December 18, 1886, for the removal of a foreign body and granuloma from the larynx. January 27., 1887. — Laryngofissure. Moderate return of the new-growth about the defect of the mucous membrane in which the end of the wooden splinter had been found imbedded. The probe was introduced into this aper- ture, and penetrated downward and backward to a distance of three fourths of an inch, thin pus exuding from the sinus. Intense swelling and hypersemia of tfie entire mucous membrane and submucous tissue were noted. Perichondritis was diagnosticated, and a tracheal tube was left inserted in the wound. The patient readily recovered from the operation, but subsequently could not get along without a cannula till June, 1887. To prevent the entrance of blood into the bronchi the author tried the use of a tampon cannula in each one of the preceding cases. It had to be abandoned, however, as, taking up too much space, it cramped the operator. It was found quite satisfactory to press into the lower angle of the laryn- geal wound a small sponge, leaving enough space below it for the admission of air. 3. Extirpation of the Larynx. — There is no doubt in the author's mind that partial or total extirpation of the larynx for malignant new-growths, if clone early, is the correct treatment, and will be successful in direct proportion to the readiness and thoroughness with which it is done. This view is in full accord with the accepted principles of the treatment of malignant neoplasms of all other regions of the body. The large rate of mortality recorded so far after extirpation of this organ is due in a great measure to the fact, that the step was resorted to mostly in otherwise hopeless and desperate cases, in which endolaryngeal therapy had utterly failed to give relief. The earlier the operation is done after due establishment of the diagnosis, the less mutilating it need bo. Unilateral extirpation of the larynx is far less dangerous than the total removal of the organ, and, as a number of suc- cessful cases testify, even a fair degree of phonation, together with unim- paired deglutition, may be preserved by it. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 105 Case I.* — Paul ILilin, barber, iigcd titty. Novemher^ 1870. — Increasing dysphagia. Dr. E. Gruening diagnosticated an elevated ulcer of tlie size of a half-dollar coin, occupy- ing the depression bounded by tbe right side of the base of the epiglottis, the right side of tlie base of the tongue, and the right wall of the pharynx, a site corresponding to that of the glosso-epiglottic and aryteuo-epiglottic folds, and more particularly to that of the sinus pyriformis. The mucous covering of the epiglottis was seen to be tliickened and congested. The cervical glands did not appear to be affected. No evidence of syphilis could be elicited, either from the history or from the physical examination of the patient, excepting a moderate degree of onychia, characterized by roughening of the finger-nails. In the course of the treatment it became evident, however, that this hitter trouble was due only to the fact that, in pursuing his trade, his fingers were much ex- posed to the action of soap-lather. Anti-syphilitic treatment was lustituted and continued for some time with apparent benefit, the patient regaining to a certain extent the ability to swallow. The improve- ment was, however, merely temporary ; the dysphagia returned, and the patient soon began to suffer from the inanition thus engendered. Preliminary tracheotomy was performed January 18, 1880, at the German Hospital. March 5, 1880. — Unilateral exsection of the larynx was done with the able assistance of Drs. Gruening, Bopp, Lefferts, and Dr. Degner, the house-surgeon, to whom great credit is due for the skill and patience exhibited in the difiicult and tedious after-man- agement of tbe case. An incision was carried from tbe median line of the byoid bone along its upper margin outward .to the extent of three inches, exposing the right lingual artery, which was ligated. A second incision was carried downward from tbe starting-point of tbe first, in the median line, to the opening for the cannula, exposing the anterior surface of the hyoid bone and larynx, and the flap thus formed was dissected up with all the underlying soft parts and turned outward. Trendelenburg's tampon-cannula bad been fitted into the trachea. Tbe right half of tbe hyoid bone was then exsected, a double ligature placed around tbe superior laryngeal artery, and the same divided. The crico- thyroid ligament was cut across, a pair of bone scissors inserted into tbe larynx, and the thyroid cartilage divided in the median line. Trendelenburg's tampon cannula did not fulfill tbe requirements owing to a leak in the inflated bladder, so that blood man- aged to find its way into tbe trachea. An attempt to make it serviceable by winding layers of moistened gauze around the cannula was unsuccessful, and during the rest of the operation it became necessary to fill out the lower part of tbe larynx with small sponges. The interior of the larynx was now exposed and showed an oval tumor, of about the size of a pigeon's egg, situated in tbe substance of tbe right false vocal cord, involving the posterior half of the true vocal cord and tbe small cartilages belonging to it. The right half of the thyroid and the whole of the arytenoid cartilage were now dissected up and removed, together with the whole epiglottis. The pharynx being thus exposed to view, its entire right side was seen to be diseased, and was removed, together with tbe right tonsil and the lower half of the right pillars of the palate. Tbe base of tbe tongue, likewise involved, was dissected up on the right side with tbe scalpel, on the left with the tbermo-cautery. Tbe haemorrhage was insignificant, and tbe patient rallied promptly after tbe operation. One of Tiemann's excellent soft-rubber tubes was introduced into tbe oesophagus, the wound thoroughly cleansed with a ten-per-cent solution of zinc chloride, and tbe whole cavity packed with moistened balls of carbolized cloth. The edges of the hori- zontal incision were then united by catgut sutures. * " Archives of Laryngology," vol. i, No. 2, June, 1880. 106 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. The oesophageal tube was remarkably well tolerated, and the patient's nourishracRt was satisfactorily effected through it during the whole course of the treatment. The dressing was changed once every twenty-four hours. On the fifth day after the operation the patient was well enough to sit up in a chair for an hour. Three days later he could ascend a flight of stairs in being removed to another room, and a week later he spent most of his time out of bed. By the 1st of April, twenty-six days after the operation, he took a walk in the garden, and his weight had increased by Q^ pounds. The large cavity contracted rapidly, and finally became a canal, bounded on one side by the remaining half of the larynx, on the other by a smooth cicatrix uniting the skin with the mucous membrane of the posterior wall of the pharynx. On the 29th of April the patient made a first attempt to speak. When the tracheal tube was closed, he could converse with a hoarse, dull voice, quite audible, and easily imderstood at a distance of from two to three yards. His ability to swallow has in a measure been recovered, but he preferred to use the oesophageal tube, to which he had become accustomed. By the 5th of May he had gained 14| pounds in weight. The patient continued well until February, 1881, when he contracted an acute pleurisy, to which he succumbed rather suddenly on account of fatty heart. The speci- men of the larynx gained at the post-mortem examination showed absence of any sign of a relapse. The tumor was found to be an adeno-sarcoma. Case II.* — Henry O., porter, aged fifty-seven. Rebellious hoarseness of five months' standing, with increasing difiiculty of deglutition. Marked loss of flesh and power. March 16, 1885. — When the patient was directed to the author by Dr. S. W. Gleitsraann, a deep-seated, nearly immovable, hard, glandular swelling of the size of a hen's egg was noted in the left submaxillary triangle. Endolaryngeal inspection revealed the presence of a smootli, pale tumor, the size of an almond, commencing in the left glosso-epiglottidian fold and extending through the substance of the left vocal cord into the ary-epiglottidian fold, to terminate in the arytenoid cartilage with a knob- like protuberance. March 18th. — Chloroform being administered, the diseased glands were removed. The sterno-mastoid was found partly involved, and this, together with a piece of the internal jugular vein of about one and a half inch in length, was removed in one mass. Then inferior tracheotomy was performed. The wound healed kindly, except where the tracheal tube was located, and April 27th, under chloroform, the left half of the larynx was removed. A tampon cannula, made by George Tiemann & Co. after the author's directions, was inserted and suitably distended so as to pre- vent the entrance of blood into the trachea. After this an incision, commencing at the upper notch of the thyroid cartilage and extending to the lower margin of the cricoid cartilage, laid bare the larynx in the median line. To this was added another incision, commencing in the upper angle of the flrst cut and extending horizontally to the anterior margin of the left sterno-mastoid muscle. The crico-thyroid ligament was split to admit a strong pair of bone-pliers for the division of the thyroid cartilage ; but it was found impossible to perform this act, as the strongly inclined position of the cartilage did not permit an effective handling of the instrument. Therefore, access was gained througli an incision in the thyro-hyoid ligament from above, and in this manner an exact division of the calcified cartilage was successfully eff'ected. After, this the epiglottis was cut through lengthwise, the left half of the crico-thyroid. liga- ment was divided, and the" superior thyroid artery was included in a double ligature and cut through. The most difficult part of the operation consisted of the dissection of the lateral portions of the larynx and pharynx, closely adherent to the carotid artery * " Annals of Surgery," .January, 1886, p. 20. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 107 by cicatricial tissue, caused by the extirpatioQ of the submaxillary glands. Shallow incisions, running parallel with the course of the carotid artery, were cautiously made one after another, and the difficult task seemed almost completed when suddenly a powerful jet of arterial blood welled up from the bottom of the wound. The bleeding point was easily secured in a pair of artery forceps, and then it was ascertained that the trunk of the superior thyroid artery (doubly ligated further below prior to this) had been cut away on a level with its inosculation into the carotid. A catgut liga- ture was applied around the main trunk above, another below the artery forceps, and when the instrument was removed a round hole in the side of the carotid became visi- ble. The remaining adhesions, corresponding to the lateral portion of the pharynx on the left side, could now be easily dissected out. The tampon cannula was removed, and it was found that no blood whatever had entered the trachea. A soft tube was in- serted into the oesophagus, the wound was loosely packed with iodoformed gauze, and an ordinary tracheal cannula was left in the lower angle of the tracheal wound. Finally, the horizontal incision was closed by a number of catgut sutures. The duration of the operation was one hour and three quarters — the anaesthesia throughout undisturbed. Microscopical examination of the new-growth by Dr. L. Waldstein gave the diag- nosis of alveolar sarcoma. The subsequent course of the wound was very satisfactory and free from fever or suppuration, the patient's only complaint being a rather profuse secretion of saliva. Nutrition was carried on by the oesophageal tube, the patient consuming considerable quantities of milk, eggs, and an emulsion composed of beef-tea and crushed boiled beef; finally, a generous supply of good whisky. From May 10th on, the oesophageal sound was introduced twice daily for purposes of nutrition. On May 13th the tracheal cannula was abandoned. On the same day the innermost layers of the iodoformed gauze packing became detached, and were replaced. The entire wound was found to be in a vigorous process of granulation, and was considerably contracted. May 15th. — The patient swallowed a small quantity of coffee. May 27th. — Sutures were removed ; wound firmly united. Increase of body weight four and a half pounds. May 31st. — Patient was discharged cured from the hospital, good deglutition being noted. June 12th. — Removal of a small, suspicious gland from the left supraclavicular space. March 13, 1886. — Removal of an enlarged lymphatic gland from left suprahyoid region. Since then the patient remained well, attending to his laborious occupation. He could speak with a very audible hoarse intonation. The right vocal cord performed its function normally. In March, 188V, relapse appeared in the cicatrix about the insertion of the stump of the epiglottis, for which subhyoid pharyngotomy was performed, April 22, 1887, at the German Hospital. A portion of the cicatrix, together with a section of the base of the tongue, was removed. The external wound was united by three rows of superimposed catgut sutures. Deg- lutition was hardly disturbed by the operation; the external wound healed by adhe- sion, and, May 3d, patient was discharged cured. In both of the preceding cases decided alleviation of the patients' wretched condition and an undoubted prolongation of life were achieved. IX. GOITRE. The aseptic method and an improved technique of dissection have materially reduced the formidable perils of the surgical treatment of goitre, justly dreaded by old-time practitioners. lOS RULES OF ASEPTIC AND ANTISEPTIC SURGERY. In goitre encroaching upon the trachea, the question must be iirst de- cided whether the growth is cystic or parenchymatous. If cystic, various forms of treatment offer a fair chance of cure. The cyst can be tapped and injected with tinctnre of iodine, like a hydrocele ; or it can be exposed by dissection, incised, and its walls sutured to the skin, like the sac in hydro- cele operated on by Volkmann's method (Schinzinger). Case. — Lena Kaiser, aged thirty-five. Cystic goitre of the thyroid body. It was as large as a child's fist, and the source of much discomfort to the patient on account of the severe dyspnoea it produced. November 23^ 1882. — At the German Hospital, exposure of the capsule of the goitre. A plexus of much-distended veins was included in two sets of double mass ligatures, between which the capsule was cut into. The parenchyma of the gland was divided, and the sac of the cyst being exposed was incised and attached to the skin by two continuous sutures. The cavity was packed with carbolized gauze. Decemher 22d. — Patient was discharged cured. Where the presence of a number of contiguous cysts is made out, their enucleation will be appropriate. The procedure is not difficult, and offers the additional advantage of the possibility of primary union and a speedy cure. Case. — Hannah S., servant, aged thirty-one. January 16, 1886. — At Mount Sinai Hospital, extirpation of four contiguous cysts of the thyroid body. Flap incision; the thyroid capsule was cut into between two rows of mass ligatures ; after this the cysts were shelled out without difficulty. The wound was drained and sutured. Primary union. Patient was discharged cured February 21st. Parenchymatous goitre may be treated with some hope of success by the methodical injection of tincture of iodine in cases in which the tumor is soft and vascular. Should this plan fail, or when the tumor is very dense and hard, excision must be performed. Total removal of the thyroid gland is apt to produce a deep alteration of the general condition denoted '' myxmdema,'''' or ^'cachexia strumipriva" (Kocher), characterized by idiotism, loss of sexual power, and general dense edematous infiltration of the subcutaneous connective tissue ending in death. Hence, a portion of the glandular tissue ought to be always left behind to perform its function, so necessary to the healthy state of the nervous system. The principles laid down for the safe removal of tumors (page 50) should guide the surgeon in exsecting thyroid swellings. Hsemorrhage from the large veins of the capsule is to be avoided by the timely use of Thiersch's spindles and of double ligatures. Dissection should be systematic and de- liberate, and especial care should be devoted to the preservation of the re- current laryngeal nerve, which will be found behind the lateral lobe of the thyroid gland in the groove separating the trachea from the oesophagus. Case. — Rosa Rosenfeld, cook, aged twenty-four. Parenchymatous hyperplastic goitre of the body and right thyroid lobe, causing severe dyspnoea. October 9, 1884- — At Mount Sinai Hospital, extirpation of the right lobe and body of the gland from a spacious flap incision. A pedicle was formed toward the left lobe, and, being first liga- tured, was cut off. In dissecting up the right lobe, which was found to be insinuated between the trachea and oesophagus, the recurrent laryngeal nerve was separated and SPECIAL APPLICATION OF THE ASEPTIC METHOD. l(i<> drawn aside. Drainage, suture, and aseptic dressings. The wound healed, witli the exception of the drainage-tracks under the first dressing, which was changed on Octo- ber 19th Some hoarseness due to paresis of the right vocal cord persisted for five months, but ultimately disappeared. Tracheotomy for goitre is one of the most formidable tasks the surgeon may be called upon to perform. It was twice the author's duty to under- take this procedure for extreme dyspnoea caused by malignant tumor of the thyroid gland. One case was complicated by mitral insufficiency and acute broncho-pneumonia, and ended fatally. In the other one the sujDra-sternal portion of a very large fibro-sarcoma of the thyroid gland had to be first extirpated before access could be had to the trachea. This case also ended lethally. Case I. — Rosa Guttmann, widow, aged thirty-six. Large and growing originally parenchymatous, later sarcomatous, substernal goitre of five years' standing. Mitral in- sufiiciency and severe acute broncho-pneumonia. Dr. S. Kohn, who referred the patient to the author, diagnosticated paralysis of the right vocal cord. November 11, 1879. — Patient was admitted to German Hospital in a very exhausted condition. After copious stimulation tracheotomy was performed. Only a very small amount of ether was admin- istered for the cutaneous Incision. Division of the goitre by the therrao-cautery was tried, but had to he given up on account of the slowness of the process and the great hfemorrhage from the enormously distended veins. The expedient of at once taking up and firmly retracting the divided tissues by large, four-pronged, sharp hooks, proved more efficacious in checking haemorrhage. With a few rapid strokes the trachea was exposed and opened, and, a large-sized soft catheter being introduced, respiration be- came well established. But a few minutes afterward patient expired. Case II. — Elizabeth K., aged sixty-two. A very fat woman, with a small pulse, suffering from extreme dyspnoea due to the presence of a very large and hard supra- and infra-sternal fibro-sarcomatous goitre. August 23, 1882. — Extirpation of the supra-sternal part of the swelling with subsequent tracheotomy, for which a specially constructed cannula with a long tube was used. Relief of dyspnoea. Copious stimula- tion was employed by the family attendant to such an extent that in the night of August 24th the patient became boisterously drunk, and died in a soporous condition under the symptoms of acute alcoholism. X. AMPUTATION OF THE BREAST. In preantiseptic practice the rate of mortality observed after amputa- tion of the breast, mainly due to accidental wound comjjlications, was nearly as high as that of major amputation of the limbs. The notable depression of the death-rate that has taken place since is directly due to cleanlier methods. The absence of a proportionate decrease of the death-rate, caused by re- lapse of the malignant growths for which the operation is performed, is to be attributed to the tardiness of the general practitioner in advising and urging early removal, and the unwillingness of the patients to heed timely advice. In view of the fact that over ninety per cent of all mammary tumors are carcinomatous, the benefit of the doubt belongs to the view which urges Ifi 110 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. to removal. ^1 probatory incision at least slumld he insisted on in every case of solid chronic intumescence of the breast that remains uninfluenced by proper local and general treatment directed against syphilis or chronic infam mat org mastitis. Particd operations are admissible only where the youth of the patients, the smoothness and mobility and slow progress of the tumor justify the assumption of a benign growth, such as adenoma or adeno-fibroma, or where probatory puncture leaves no doubt of the presence of a simple re- tention cyst. In these cases the operation proposed by T. G. Thomas is very appro- priate, and gives satisfactory results both as to the completeness of the re- moval and the cosmetic effect. The incision is laid in the pectoro-mammal fold, and the breast-gland is raised from the pectoral fascia sufficiently to enable the surgeon to incise it on its posterior aspect. After the enucleation of the tumor the breast is replaced, and, the wound being drained, the skin is united by an exact suture. The cicatrix remains hidden under the overlapping breast. Case T. — Miss C. L., governess, aged twenty. Adenoma of left breast of the size of a hen's egg. December 12, 1884.- — At Mount Sinai Hospital, Thomas's operation. December 22d. — First cliange of dressings. December SJfth. — Dis- charged cured. De- cember 12, 1886.— No relapse ; very fine lin- ear cicatrix. Case II. — Miss Tillie G., aged six- teen. Adeno-fibroma of left breast of the size of a small apple. Fio. ;»;».— i 1 laiiiuiary ulaml Ix'iuir tli-tac'liud from below, the surgeon inserts liis left liaud under tlic hreiist to complete the upper section. SPECIAL APPLICATION OF THE ASEPTIC METHOD. HI Decemher SO, ISSG. — Tliomas's operation at Mount Sinai Hospital. December 30th. — Dressings changed. January 4, ISSl. — Wound firmly united. Whenever amputation of tlie breast is performed for malignant tumor, the operation must he radical, or at least as radical as possible. No regard wliatever sliould be paid to cosmetic considerations, the object of the measure being the extirpation of a deadly disease, which, if not eliminated, is sure io till. A wide berth should be given to the visible limits of the disease, and the knife should take away at least an inch and a half of apparently healthy skin. The axillary fat and glands must be invariably removed in mass, whether intumescence is to be felt or not. If the axillary vein be attached to degenerated lymphatic glands, the attached segment must be included in two ligatures, and the intervening piece cut out together with the adherent mass. The technique of breast amputation is simple. After marking by a shallow cut the extent of the two semi-elliptic incisions that should include the part to be removed, the infe- rior margin of the breast-gland is exposed. The pectoral fascia be- ing incised, the mamma is gradu- ally dissected up from the thorax till its upper limit is reached. The surgeon's hand is slipped in under the breast, and the upper incision completes its detachment, except where the lym- phatic vessels, pass- ing along the pecto- ral fold from the breast to the arm- pit, form a sort of a pedicle. The bleed- ing vessels are secured as they are cut, and the pectoral wound is covered with a towel wrung out of corros- ive-sublimate lotion, to remaiii under its protection during the removal of the axillary contents. The incision is extended well up the arm into the axilla, and the skin is dis- sected up for about an inch to each side of the cut. The fascia is divided where the incision can be made boldly upon the edge of the pectoral muscle anteriorly, and the latissimus dorsi posteriorly. Proceeding from this latter incision, the loose connective tissue is divided by blunt dissection with a thumb-forceps and the handle of the scalpel, until the axillary vein is exposed to view. With this the most important step of the operation is accomplished. Seeing the vein will prevent its accidental injury, and from Fig. 100. — Eeraoval of axillary contents. The surgeon holdini;; the detached breast serving as a handle. 112 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. this on, in most cases, dissection will be directed mu ay from instead of toward the vein. The loose fat can be easily detached from all its lateral adhesions. Fig. 101. — Sutured wound after amputation of breast. Counter-incision through latissimus for purposes of drainage. The vessels and nerves which traverse the adipose tissues can be distinctly- felt and seen as they are successively approached. If necessary the long thoracic artery and vein, and sometimes the subscapular vessels, should be Fio. 102. — Completed dressing after breast amputation. taken up and cut between two forceps. The nerves ought to be preserved. During the dissection of the axillary contents, the breast serves as a suitable handle. Breast and axillary contents are removed in one mass. Thus the intervening lymphatic ducts are certainly taken away together with the SPECIAL APPLICATION OP THE ASEPTIC METHOD. 118 mammary gland and the axillary lymphatic gland.s. After due irrigation, a counter-incision is made on the external aspect of the latissimus-dorsi muscle. The knife should divide the skin and fascia only ; then a dressing- forceps is thrust through the muscle into the most dependent part of the axillary wound, when it is made to grasp the end of a stout drainage-tube, which is drawn out through the counter-incision, to be transfixed with a safety-pin and clipped off even with the skin. After this the pectoral wound is united. Lister's button suture, or a quilled suture, or any other of the known forms of retentive suture, is applied to relieve tension. After another irrigation, the fine catgut sutures of coaptation are put in until the wound is closed. The wound is once more flushed out with mercuric lotion, and is covered with the dressings, care being taken to make them the thickest about where the drainage-tube issues forth. The dressings are secured by roller-bandages, and the arm is either included in the turns of the bandage, the uhia first being well joadded, or, being left out, is supported by an extra sling. Ordinarily, the dressings are changed and the tube is removed on . the tenth day after the operation, when the retention sutures are also extracted should they not have been absorbed by this time. A smaller dressing secures the parts against injury. Five days later another change of dressings may take place, wlren the drainage opening will be found closed by a plug of granulations. After this a covering of cerate or lead plaster, with a little pad of cotton secured by a strip of adhesive plaster, will be all that is neces- sary until cicatrization is complete. It is remarkable how soon the arm regains its power of abduction in cases that remain free from suppuration. Of fifty operations for tumors of the mammary gland, forty-eight were done on women mostly past middle life ; two were performed on men. The male cases were as follows : Case I.— A. B., aged seventeen. Growing adenoma of right mammary gland. August 4, 1883. — Extirpation of the tumor ; axilla was not interfered with. Uninter- rupted primary union. Case 11, — George Eckert, blacksmith, aged sixty. Large, very hard epithelioma of the right mammary gland, starting from the nipple, which was unrecognizable in the ulcerated mass. Axillary glands inV^olved. AjjtU 27, 1886. — Amputation of breast and evacuation of axilla at the German Hospital. Large portions of skin and of the pectoralis major and minor muscles had to be removed. Primary union followed, except where the skin could not be brought together. June Ith. — Discharged cured. In two cases of adenoma of young girls, the tumor alone was removed. In fiye instances (Mary Hauser, adeno-cystoma ; Emma Bockhold, cysto- sarcoma ; Albert Baron, adenoma; Sarah S., cysto-adeno-fibroma ; Frida Meissner, adeno-fibroma), the mammary gland alone was amputated, the axillary space remaining intact. The remaining forty-three cases consisted of thirty-eight cancers and five sarcomata. In each of these the entire breast and all the axillary contents were removed. lli EULES OP ASEPTIC AND ANTISEPTIC SURGERY. Cancer 38 cases Sarcoma ti " Adenoma 3 " Adeno-fibroma 2 " Adeno-cystoma 1 case Total 50 cases Of this number, forty-one times healing hy primary union was observed. Five cases suppurated in consequence of infection of one or another kind at the time of the operation ; three cases healed by granulation, as it was impossible to cover the defect caused by the operation. A fourth granulat- ing case died of erysipelas, contracted outside of the author's care (Julie Schmalz, scirrhus) while the wound was not yet healed. Of the cases healed by primary adhesion, one died of continuous throm- bosis of the axillary and innominate vein, with subsequent embolism of the pulmonary artery. The sudden change took place shortl}'^ after the first change of dressings, made eight days after the operation. Case. — Clara Halm, spinster, aged tliirty-two. Novernber SO, 1883. — Amputation of left breast, with evacuation of axilla for small-celled adeno-carcinoina; suture; no drainage. Deceraber IJ^tTi. — First change of dressings; entire wound absolutely healed. On Christmas eve the patient was selling crockery over the counter. April 4, 1885. — Typical amputation of right breast at the German Hospital for the same affection, together with excision of relapsing cancer in the shape of a small node in the cicatrix of the left side. Patient was doing excellently till April 12th, when the first dressings were changed, and the wound was found faultlessly healed. Immediately after the dressings were completed, the patient became faint and cyanosed; breathing labored, pulse scarcely to be felt ; the left deep Jugular vein was permanently distended. Hydropericardium and hydrothorax developed with oedema of both arms, and the patient died April 20th, sixteen days after the operation, having had normal and later subnormal temperatures throughout. Autopsy revealed continuous thromiosis of left axillary and anonyma vein, the thrombus extending into the right auricle and the pulmonary artery ; bilateral hydrothorax, hydropericardium, and a hsemorrhagic in- farction of the connective tissue in the posterior mediastinum. The only unusual circumstance that attracted the author's attention immediately before the second and fatal operation was the fact that, a hypo- dermic injection of morphia being administered, extensive ecchymosis ap- peared shortly afterward at the site of the injection, suggesting a morbid alteration of the patient's vascular system. Thrombosis and embolism were observed in another case, which, how- ever, ended in cure. Case. — Mary Lier, school-teacher, aged fifty-seven. Suffering from old pulmonary emphysema and chronic bronchitis. Face slightly cyanosed. Scirrhus of right breast; nipple retracted, discharging dark, tar-like serum. Novemher IJf.^ 1575. —With the kind assistance of Dr. F. Lange, amputation of right breast and evacuation of the axilla were fjerformed. Anaesthesia by ether was very bad. Feverless course of healing. Novem- ber 19th. — Drainage-tube was removed. November 23(1. — Apoplectiform seizure, fol- lowed by aphasia and agraphy, which, however, gradually disappeared. December 20th. — The wound was entirely healed, and patient could again speak Bohemian, her SPECIAL APPLICATION OP THE ASEPTIC METHOD. 115 motlier tougue. Gradually she reg'aincd lier German and English, and in 1882 author heard from her as being able to write again. One of the sui)purating cases died of acute catarrlial pneumonia and carcinosis of the lungs, twenty-two days after the operation, the wound doing well at the time under process of granulation. Case. — Mary Volkmer, housewife, aged forty-seven. Soft adeno-cancer of both breasts, the large tumor of the left mamma causing much distress. March 17, 1881. — At the German Hospital amputation of left breast and evacuation of the axilla were done. "Wound was united in part only on account of extensive loss of integument. Suppuration of axillary space followed, but the fever resulting therefrom subsided directly after drainage was re-established. Nevertheless, patient appeared to be very ill. April 8th. — Catarrhal pneumonia set in, to which she succumbed. April 9th. — On post-mortem examination general carcinosis of lungs and liver and catarrhal pneumonia were found. In computing the three fatal cases, that of Julie Schmalz, who died of erysipelas contracted under the care of another physician before perfect cicatrization had taken place, can Justly be excluded. Accordingly, of the remaining forty-nine cases, two died directly in consequence of the opera- tion, none, however, on account of septic processes established in the wound. Thus, the author's rate of mortality from accidental wound infection in amputation of- the breast would be ; from other causes beyond the in- fluence of the surgeon, a trifle more than four per cent (4*08). XI. ABDOMINAL OPERATIONS. 1. General Remarhs. The relation of aseptics to the surgical treatment of the peritoneal cavity is in some quarters a subject of hot controversy to this day. On one side we see the advocates of a more or less complicated antiseptic apparatus, including the spray, achieving very good results, and basing success upon the strict enforcement of their cautelse. But, on the other hand, we notice a most successful laparotomist maintaining that antiseptics are unnecessary, or even harmful, and that he is accustomed to flush the peritoneal cavity with "water from the tap," teeming with millions of bacteria, and yet his results vie with those of the most scrupulous Listerian. Both sides to the controversy have abundant and incontrovertible facts to support their positions, and the contradiction seems to be hopelessly in- surmountable. It certainly is extremely bewildering to the student and beginner. Yet this contradiction is unreal, and let us say, on one side, also disin- genuous. The physiological peculiarities of the peritonseum, most notably its enor- mous absorbent power, endow it with the quality of neutralizing the deleteri- ous effects of limited quantities of pyogenic or septic micro-organisms, a quality not possessed to such an extent by any other part of the human organism. 116 RULES OF ASEPTIC AND ANTISEPTIC SURGEEY. Grawitz * has bi'onght experimental proof of the fact that the normal peritonaeum will at once absorb into the circulation moderate quantities of active pyogenic cocci, where they will be widely scattered through the blood and perish. Note. — This fact goes very far to explain Lawson Tait's position, who, however, althougli disclaiming antiseptics, devotes most scrupulous care to asepticism — that is, to the cleansing of hands and instruments. His instruments are few, and selected with a view to simplicity. His sponges are put into carbolic hfio7i for disinfection. The water used for the immersion of his insti'uments is sterilized by boiling. Most of the bacteria contained in his '' water from the tap " are innocuous — that is, non-pyogenic ; and those that have the power to cause suppuration are too few to produce serious trouble. They are simply absorbed and killed off by the great germicide, the blood. The limit of the quantity of pyogenic cocci required to produce acute purulent peritonitis varies with the size and state of health of the animal used in the experiment. A large dog's peritonaeum would resist a much greater quantity of infectious pus than that of a small dog or rabbit. And a healthy animal would neutralize more septic material than a debilitated one of the same kind and weight. The presence in the peritoneal cavity of a larger quantity of stagnant bloody serum than can be readily absorbed within an hour, will suffice to produce purulent peritonitis on the addition of a very small number of cocci. If the fluid is absorbed or artificially removed by drainage before the cocci have a chance to vastly multiply, no peritonitis or only adhesive forms of the inflammation will develop. Therefore, it is rational to employ drainage in cases where large surfaces, denuded of peritoneum, have to be left behind in the abdomen. Denudation of the surface layer of the peritoneal endothelium by caloric, or mechanical or chemical influences, is also conducive to the development of purulent peritonitis. It favors exudation of serum, and diminishes or de- stroys the power of absorption inherent to the normal peritonaeum. Should even a minute quantity of pyogenic cocci be introduced into the peritoneal cavity under these circumstances, purulent peritonitis may readily develop. The practical conclusions to be drawn from the preceding facts are as follows : 1. Although the normal peritonaeum will tolerate a greater quantity of infectious material than most surgical wounds, yet all precautions regarding the cleansing of hands, instruments, sponges, and other apparatus used for laparotomy should be employed, as septic infection of the peritonaBum is much easier to prevent than to cure. 2. Unnecessary denudation of the upjiermost layer of the peritonaeum should be avoided as much as possible. 3. Corrosive solutions, as, for instance, of carbolic acid or mercuric bi- chloride, are not to be used on the peritonaeum. As soon as the peritoneal cavity is opened, Thiersch's solution should be employed for rinsing the * " Charite Annalen," xi. Jalirg., page 770. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 117 surgeon's hands, immersing tlie instruments, sponges, towels, and, if necessary, for irrigation. 4. A careful toilet, that is, removal of all exuded serum or blood, should precede closure of the abdominal wound. 5, Where large denuded surfaces have to be left behind, and a good deal of oozing is to be expected, drainage must be employed. NoTK. — If the drain-tube is brought out from a dependent part of the peritoneal cavity, as, for instance, through DougUis's cul-de-sac, the secretions will escape spontaneously by the operation of the law of gravity. Whenever the drainage-tube is brought out above the symphysis, the scrum collecting at the bottom of the cavity must be removed either by hourly mopping out with a stick, armed with a pad of absorbent borated cotton, or by exhausting with a long-nozzled syringe, introduced to the bottom through the hollow of the drain-tube. G. Should it become evident that the mode of drainage employed is in- sufficient to remove a copious gathering of secretions, febrile symptoms, tenderness, and tympanites developing on the first few days after the opera- tion, a saline purge may be employed in preference to the accustomed opium treatment (Tait). Its object would be to favor rapid absorption of the effused serum in an analogous manner seen with the administration of cathartics for the rapid removal of hydropic accumulations from the abdomi- nal cavity. 7. If purulent peritonitis be undoubtedly established, reopening and irrigation of the peritoneal cavity with a hot 1 : 5,000 solution of corrosive sublimate may be taken into consideration, provided that the patient's gen- eral condition should warrant such a procedure. 2. Hernioto7ny, In the main, the success of herniotomy depends upon the condition of the strangulated gut at the time of the oj)eration. With aseptic pre- cautions, as long as the gut is not necrosed, herniotomy is fraught with very little danger. From the moment that intestinal gangrene has set in, the preservation of asepticism becomes extremely difficult. Contact alone with the decayed gut is infectious. Laceration of the friable intestinal wall is very likely to occur on employment of the least amount of force, and usually leads to further contamination by escaping intestinal contents. In addition to this, the general condition of patients with intestinal necrosis is mostly wretched. Systemic intoxication, and the tendency to heart-failure induced by constant vomiting, vastly increase the perils of anaesthesia and haemorrhage, and the prognosis is thereby rendered all the more doubtful. The free exhibition of anodynes, especially in the shape of hypodermic injections in the presence of strangulated hernia, is very often followed by fatal consequences. The most acute symptoms are blurred or blotted out entirely, and a false sense of security is apt to lull the apprehensions, and to betray patient and physician into undue procrastination. Out of the thirty-one cases of herniotomy performed by the author both for strangulation and for the radical cure of the complaint, eight died. IT 118 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. Sis out of this number exhibited necrosis of the gut, and all of these died. Of the remaining two, one, whose gut was sound, died of acute nephritis, presumably due to the use of ether as an angestbetic ; the other one of general tuberculosis of the peritonaeum. Case I. — A. Schlesinger, aged seventy-three, strangulated left inguinal hernia of twenty-four hours' standing. Ap?-il IS, 1885. — At Mount Sinai Hospital, the hernial sac was exposed under ether anfesthesia, A knuckle of gut could be felt within the sac, con- taining a cubic, friable body that was easily crusheJ, whereupon the gut was replaced in the abdominal cavity without any difficulty. The wound was sutured and dressed. Duration of the operation, twenty minutes. The wound healed by primary adhesion, but ursemic symptoms, with suppression of the renal secretion and vomiting, developed on tlie second day. The scanty urine was found contaiuing blood and a large amount of albumen. April 22cl. — The patient died in uremic coma. Inquiry elicited the fact that, preceding the day of the patient's illness, he had largely consumed of a dish of potato soup. The toothless old man had bolted some of the potato, a piece of which having made its way into the hernia caused strangulation. The other fatal case, not due to necrosis of the gut, was as follows : Case II. — Mrs. Henrietta Bolz, housewife, aged sixty, an ill-nourished, emaciated person, who said that she had been suffering from belly-ache and constipation for two months, and that she has had severe and continuous fever that caused her present emaciation. She also noted that she had lost most of her hair. Forty-eight hours pre- vious to her admission, irreducible femoral hernia of the right side was diagnosticated by a medical man. Vomiting, no fever, and great tenderness over the abdomen were found, and it was deemed proper to explore the hernia. Accordingly the operation was done, May 7, 1887, at the German Hospital, xifter incision of the sac, this was found to contain a portion of adherent omentum, together with a very much congested knuckle of small gut. The strangulating band was incised, the gut withdrawn, and, being in a viable condition, was replaced. The protruding portion of omentum was liberated, tied, and cut off. In replacing it, extensive adhesions of the stump to the parietal peritonaeum could be felt inside of the abdominal cavity. The sac was excised and the wound closed and dressed in the usual manner. May 12th. — Change of dressings. The wound was found united, but the general condition of the patient had remained the same as before the operation. Gradually considerable ascites developed, the patient continuing to complain of much colicky pain ; the vomiting and lack of appetite, together with rebellious constipation, seemed to Justify the assumption of a general morbid condition of the peritonasum, namely, either tuberculosis or a neoplasm. May 2Gth. — The peritoneal cavity was reopened at the site of the cicatrix left by herniotomy, and extensive tubercular degeneration of the entire peritonaeum, with dense infiltration of the omentum and almost universal agglutination of the intestines, were found. The parietal peritonaeum and the gut were literally covered with a mass of miliary white nodules. With a view to relieving the obstruction caused by the multiple adherence of the bowels, a protruding part of the thick gut was attached to the wound by a number of catgut stitclies, and the external incision was packed with iodoformized gauze. May 28th. — The bowel was found well united with the parietal peritonaeum, and an artificial anus was established by incising the gut and sewing the mucous mem- brane to the skin. Sufficient stools followed, but the patient died, March 31st, of exhaustion. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 119 The case is interesting on account of the coincidence of tuberculosis of the peritonaium with strangulation of a femoral hernia of old standing. Of course, successful herniotomy could not avert impending death. Twent^'-three (including those subjected to the radical operation) of the author's total of thirty-one herniotomized patients recovered. a. Herniotomy for Strangulation. — If gentle and not too prolonged efforts at reduction, first without then with ansesthesia, do not succeed, herniotomy should be done forthwith. The mode of procedure is as follows : The patient's inguinal region is shaved and scrubbed off with soap and hot water, and is disinfected with mercuric lotion. Towels wrung out of corrosive-sublimate solution are arranged about the field of operation, and a free incision is made over the hernial swelling down upon the sac. The in- cision should extend well above the ingui- nal or femoral ring, and should freely ex- pose the place ivhere the hernia emerges from the abdominal toall. By doing this the surgeon will be enabled to divide the constricting band un- der the guidance of the eye, and without the necessity of in- serting the probe-pointed knife into the inguinal or femoral canal, a cir- cumstance that may, even in the hands of a cautious and expert surgeon, lead to cutting or laceration of the intestine, especially if it be very brittle, or necrosed, or adherent. Case III. — Philip Trumann, aged two years and three months, was presented to the author December 11, 1881, with a soft, fluctuating, scrotal swelling of the left side, which, however, could not be by pressure reduced in size. Congenital hydrocele was diagnosticated nevertheless, as the tumor showed transparency. Puncture with a hypodermic needle brought out intestinal contents. There were no signs of strangula- tion, therefore cold applications were ordered, and the child's mother was told to return the next day. By December 12tli all symptoms of strangulation, with rather high fever and inflammation of the swelling, had developed. Herniotomy was done at the German Dispensary. In opening the sac, the gut was inadvertently incised. It was found that local peritonitis of the sac, with extensive fresh adhesions, presumably due to escape of fecal matter through the puncture-hole, had taken place. The gut was detached everywhere by the finger-tips, the parts were well disinfected by free irriga- tion with a two-per-cent solution of carbolic acid, and the slit in the intestine was closed with a Lembert suture of catgut. The strangulating band was then cut, and, the intestine being replaced, the wound was sewed up, drained, and dressed. Un- FiG. 103. — Patient ready for herniotomy (or for any other operation about the genital region). 120 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. lO-i. — llerniotomy. Cutaneous incision. interrupted recovery followed. Januanj IS, 188£.— The patient was discharged cured. The sac is carefully opened between two forceps, and, if possible, at a place where there is no adhesion to the gut. After free division between two thumb - forceps, a careful inspection of its contents, gut or omentum, or both, should be made. This will be very much facilitated by taking up the edges of the incision made into the sac with a num- ber of artery forceps, which will serve as handles to unfold it to a funnel, which can be easily looked over. (Fig. 105.) Generally the gut will appear deeply congested, purplish, or brownish red. As long as it is turgid, and is seen to contract on pinching, it may be assumed to be viable. But it still remains to be ascertained whether the points of strangulation be alive or not. To do this the strangu- lating hand or hands must he first cut to a sufficient extent. Attempts to with- draw the gut before the strangulation is completely removed may lead to very seri- ous consequences, es- pecially where necro- sis of the strangulated portion of the intes- tine is present. Case IV. — J. Schrank, saloon-keeper, aged fifty - nine. Left inguinal stran- gulated hernia of five days' standing. Herniotomy, March 8, 1886, at the German Hos- pital. The sac contained a large mass of adhering omentum, and a knuckle of deeply congested small intestine. It was tliouglit tliat the strangulating band, corresponding to the internal abdominal ring, had been sufficiently incised, and a very gentle and -Jlcrniotomy. The opened liernial sue is held ai)art for inspection by a number of artery forceps. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 121 unsuccessful attempt wjis made to withdraw the gut. The tip of tlie index was rein- serted as a guide, and, the constriction being completely divided, the gut was easily withdrawn. At the same moment a considerable quantity of fecal matter was seen to escape. It was found that necrosis of the neck of the strangulated knuckle of gut had taken place, and that it had been torn or cut during the preceding efforts at liberation. The intestine was still further extracted, and was attached to the skin by a few silk sutures. After careful disinfection, the neck of the sac was loosely packed with strips ofiodoformized gauze, and the wound was inclosed in a moist dressing. The collapsed patient died two hours after the operation. In cases like the preceding one, the classical practice of invaginating the tip of the index into the inguinal canal or femoral ring, for the purpose of cutting the strangulating band, is dangerous, as it may lead to injury of the brittle gut. The author has found the gradual division of all tissues from without inward much safer, although it must be admitted that the division of the fibrous tissues located above the place of strangulation is extensive, and often practically converts herniotomy into laparotomy. With a few exceptions, the author has always employed open division of the strangulating bands of tissue, and never had reason to regret it. In some of the complicated cases he was thereby enabled to at once gain a very clear insight into the relations of the hernia, and in a great measure the ultimate success of the operation was attributed to that advantage. Case V. — Fred. Bormann, laborer, aged thirty-three, had been treated at the Ger- man Hospital without success during several days for internal intestinal obstruction marked by the usual symptoms. On closer inspection, slight oedema of and somewhat indistinct resistance at the right inguinal region was noted. January 17, 1884-. — An incision was made exposing the external inguinal ring, which was seen to be normal. The incision was further extended, and, when most of the fibrous layers surrounding the inguinal canal had been divided, a small but well-defined tumor could be seen and felt occupying the inner aspect of the abdominal wall near the internal orifice of the inguinal canal. The abdominal wall was completely divided, and then a small hernia, located between the parietal peritonaeum and the abdominal wall, was exposed. The sac being incised, a knuckle of small gut was found contained within it. The place of strangulation was at the neck of the sac. This was completely slit open, the gut was reduced, and, the neck of the sac being closed by a purse-string ligature, it was cut away entirely. The incision in the abdominal wall was closed by three tiers of catgut sutures. Primary union followed. February 16th. — Patient was discharged cured. Case VI. — Mr. M. S., aged thirty-six. Left inguinal hernia, that had been repeat- edly incarcerated, but was reduced each time. April 8, 1885, it came down again, and, after prolonged and very energetic efforts, the physician in charge succeeded in replacing it, but the symptoms of strangulation, notably vomiting and absence of alvine evacuations, persisted. April l"2tli. — Herniotomy at Mount Sinai Hospital. No ex- ternal tumor could be seen, but on palpation a dense resistant swelling could be felt in the inguinal region within the abdominal wall. The region of the external abdom- inal ring was freely exposed by an ample incision, and the abdominal wall was divided above Poupart's ligament. The hernia which had been reduced in mass was then reached, and was pushed out through the inguinal canal. The remaining portion of the intervening abdominal wall was divided, together with the place of strangulation, 122 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. and, the sac being tied and cut away, the abdominal wound was closed with three tiers of strong catgut sutures. The wound healed kindly. May 15th. — Patient was discharged cured. It may be said, then, that open division offers great advantages, espe- cially with regard to the avoidance of injury to necrosed or very brittle gut, and that its only drawback — tlie increased size of the incision — is vastly overbalanced by the security gained therefrom. If the gut be found ne- crosed, it can be safely withdrawn from the ample aperture, and establish- ment of an artificial anus can take place after securely packing the neck of the protruding knuckle of intestine with a sort of embankment of iodo- formized gauze. This packing of gauze serves as a diaphragm against infec- tion of the peritoneal cavity. Out of nineteen cases of herniotomy done for strangulation, undoubted gangrene of the gut was joresent at the time of operation in four. In two of these the necrosed part of the gut was injured within the inguinal canal by the unavoidable manipulations in liberating the intestine. In those cases where external or open section was used, the integrity of the much-decayed gut was preserved. In these latter cases the gangrene ex- tended to the free part of the gut, and was taken notice of before dissolving the strangulation. In the former cases, however, in which the gut was inadvertently injured, gangrene was limited to the exact locality of the con- striction, and was diagnosticated only after the mishap. The practical lesson to be drawn from this experience is that open incis- ion of the inguinal canal should be done whenever very acute strangulation has existed for more than four or six hours. All the patients upon whom necrosed gut was found died either of col- lapse, shortly after the completion of the ojoeration, or of jjeritonitis due to infection extending from the place of strangulation. On one of them resection of the necrosed part of the gut was practiced, with subsequent suture. The patient died of peritonitis. Case VII. — Catharine Ilile, housewife, aged sixty-one, a very fat woman, having a large incarcerated umdilical hernia, was operated September 24, 1881, at her rooms in the presence of the family attendant. Dr. Arcularius. Open section of constricting bands, circumscribed necrosis of the neck of the protruding mass of transvez-se colon. Exsection of six inches of thick gut and of a triangular piece of meso-colon, and sub- sequent enterorrhaphy with fine catgut ; closure of abdominal cavity. Peritonitis developed during the following night, and, September 25th, patient died with enormous tympanites. Immediate exsection of the necrosed gut has little to commend it. The dangers of infection of the peritonaeum are almost insurmountable, the com- prehensive preparations required for enterorrhaphy are usually not made, and, the work being extemporized, generally lacks exactitude. In addition to this, the general condition of the patients is commonly so bad, that undue prolongation of aneesthcsia itself would be very dangerous. Therefore, in these cases, the estnbUslnnent of an artificial anus is the only proper thing to do. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 123 To young physicians the decision of the question, whether the gut be alive or necrosed, may offer a good deal of difficulty. The responsi- bility is great, and uncertainty about a point of such importance extremely perplexing. Where necrosis is fairly established, the shriveled, parchment- like appearance, the yellowish-gray color, the absence of reflex motion on pinching, and the great fragility will at once characterize the condition. But where necrosis is just developing — that is, where thrombosis of the terminal vessels with bloody infarction has gone so far as to surely com- promise the integrity of the gut, but the signs of necrosis are as yet unrec- ognizable — decision may be very difficult indeed. The causes producing intestinal necrosis are not identical in different cases. Local, well-circumscribed necrosis, limited to the extent of the strangulating ring, and very often found in femoral hernia, is due to local anemia produced by the pressure of the constricting band« In other cases the local pressure exerted by the constricting band upon the neck of the hernial contents may be insufficient to destroy the vitality of the intestine in actual contact with the constricting tissues. But press- ure that would be hardly sufficient to cut off arterial supply, will often com- press to such an extent the veins leading aivay from the strangulated gut as to completely arrest circulation. Venous engorgement and gangrene of the convex portion of the intestinal knuckle are then inevitable. The decision whether a portion of intestine, subjected to prolonged acute anaemia by local pressure, is viable or not, is comparatively easy. In many of these cases, absent circulation is often restored to the bloodless parts under the eyes of the surgeon. As soon as the constriction is relieved, minute red streaks are seen to sjjring up across the formerly pale, bloodless area ; they increase in number, and finally the parts in question assume a rosy hue and a normal appearance. Sometimes, however, recovery of circulation is tardy. In these cases, after amply dividing the strangulating band, a catgut thread should be passed through the mesentery of the questionable looj) of intestine, which then should be temporarily replaced in the abdominal cavity. The time required for restoring the circulation of the gut is usefully employed in attending to such other procedures as may be indicated under the circum- stances. Dissection and removal of adherent omentum, or the dissection of the hernial sac, will thus occupy some time, by the end of which the loop of intestine can be withdrawn from the belly for examination. If the con- ditions be found satisfactory, the thread should be removed, and the opera- tion finished in the usual way. Case VIII. — Theresa Wagenglast, cigarmaker, aged thirty -nine, contracted, April 11, 1887, strangulation of a femoral hernia of old standing, situated on the left side. April 15th. — Admitted to German Hospital with incessant vomiting, induced mainly by the administration of calomel. Immediate herniotomy. A considerable portion of adherent omentum presented, and was tied oft" in several portions and removed. After tins a very small knuckle of gut became visible, which showed an ansemic area corresponding to the locality of constriction. Eecovery being tardy, a 1-24: RULES OF ASEPTIC AND ANTISEPTIC SURGERY. tliread of catgut was passed thi'ough the mesentery, and the knuckle was replaced in the abdomen through the well-divided femoral ring. In the mean time the sac was excised. After the completion of this step, requiring about fifteen minutes, the gut was re-extracted for examination, and circulation was found fully re-established. The gut being replaced, the neck of the sac was closed with a purse-string suture, and was pushed well up in the femoral ring. Drainage and suture of the external wound. April loth. — The drainage-tube was removed. April 29th. — Patient was discharged cured. Where impending gangrene from venous engorgement is to be feared, the decision is generally more difficult than in the preceding class of cases. Where immediate solving of the momentous question is impossible, the benefit of the doubt should always belong to the assumption that necrosis is to be expected. In these cases the neck of the hernial sac should be well divided to secure the best circulation possible, and the loop of gut should be so attached to the skin by a couple of sutures passed through the mesen- tery as to leave the questionable spots exposed to view. Thorough disin- fection by wijiing with sponges wrung out of Thiersch's solution, a light packing of iodoformized gauze around the neck of the knuckle, and a mnist aseftic dressing (the gut being covered by a protective strip of rubber tissue) should be applied. If the gut decay, this will take place outside of the peritoneal cavity. Should it recover, the fact will be manifest within one or two hours after the operation. The gut should be then well disinfected, liberated by gentle manipulation from its newly-assumed position, and replaced in the abdominal cavity. Case IX illustrates the consequences of the replacement of the gut of doubtful vitality. It was the author's first herniotomy. Case IX. — John Philip lores, waiter, aged fifty-three. Very acute strangulation of twelve hours' standing of an old, right inguinal hernia. October ^7, 1878. — Herni- otomy in presence of Dr. L. Bopp, the family physician. Two knuckles of deeply- injected small intestine, aggregating to the length of ten inches, and a mass of dark- blue omentum were found in the sac. But, as the gut seemed to be turgid and viable, it was replaced. The omentum was pulled out, tied and cut off, and the stump was replaced. Septic symptoms set in immediately after the operation, with high fever and very great debility. October 29th. — Unmistakable signs of peritonitis, notably enormous meteorism, appeared. The restless patient disarranged the dressings during his tossing in bed, and, while vomiting, the adhesions of the wound gave way, and a large loop of intestine prolapsed. Necrosis of a portion of the prolapsed gut was evident. As much of it as was normal was replaced, the decayed part of the gut was incised, and fixed near the external wound. The patient died shortly afterward. It must be added that, according to then prevailing notions (1878), the sac and its contents were washed with a strong solution of carbolic acid (5 : 100) before the gut was replaced. Superficial ei'osion of the intestinal peritonaeum may have had its share in precipitating both gangrene and peri- tonitis. Necrosis of the vermiform appendix was observed by the author once with fatal termination. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 125 Case X. — Henrietta Baulnnd, aged forty-seven. Right femoral hernia of forty- eight hours' standing. April 18, 188 Jf. — Herniotomy at the German Hospital. Vermi- form appendix was found attached by its apex to the side of the sac ; a knuckle of small intestine was embraced in the loop formed by the vermiform appendix, and then doubly incarcerated. Manipulation was very difficult, on account of the narrow space and tlie complicated state of things. The gut was slightly torn, but no intestinal con- tents escaped. Two Lembert's sutures being applied, the strangulation at the neck of the sac was relieved and the gut was liberated. The middle part of the vermiform appendix was found necrosed, and, a ligature being applied above this part, the appen- dix was cut away. The gut was returned. The patient got on very well until April 25th, when perforative peritonitis developed. April 27th. — Patient died. No autopsy could be secured. However desirable thoroughness and deliberation may be in herniotomy, undue prolongation of anaesthesia is an evil fraught with especial danger in cases of long-contintied strangulation, on account of the cardiac debility present. When the patient's vitality has been much lowered by continuous vomiting, loss of sleep, and septic fever, even a brief anaesthesia may be sufficient to precipitate fatal collapse. Habitual users of alcohol and obese individuals are very poor subjects to endure anaesthesia in the presence of necrosis of the gut. Case XI. — Albert P., drayman, aged thirty-five, moderate but steady consumer of beer and whisky. Incarcerated right inguinal hernia of seventy-five hours' duration. The swelling was mistaken for acute orchitis, hernia being thought of by the family attendant only after fecal vomiting had set in. March 19, 1887. — Herniotomy at the German Hospital. Extensive gangrene of the small gut was found. Ether anaesthesia was very bad, the patient struggling all the while during the operation. If ether was crowded, respiration became irregular, the face pallid, and syncope threatening. Arti- ficial anus was established, and the case was finished with all possible expedition, anaesthesia lasting altogether for thirty minutes. Deep collapse following, the patient did not rally in spite of copious hypodermic stimulation, and he died two hours after the completion of herniotomy. It is plausible to assume that in similar cases herniotomy performed with the aid of local anaesthesia would offer better chances of success than if it be done in general ether or chloroform narcosis. The last one of the eight fatal cases died of acute septicsemia induced by diphtheritic enteritis of the strangulated knuckle of gut. Case XII. — Charles Etzler, baker, aged thii-ty-five. Very acute strangulation, of fifty hours' standing, of an old right inguinal hernia. The patient had had no medical care until a few hours before his admission to the German Hospital, when Dr. H. Kudlich was called in. He was requested to stop the violent fecal vomiting caused by a very large dose of Eochelle salts taken in the morning of January 31, 1884. Herniotomy on the evening of the same day. The large scrotal hernia contained a good-sized portion of adherent omentum and a massive conglomerate of several knuckles of small gut, bound together by firm cicatricial adhesions of old date. Free external Incision of the abdominal wall until the neck of the hernial sac was completely divided. The gut looked tolerably well preserved and was replaced ; the omentum was freed by dissec- tion, and, being tied off in several portions, was cut oflf. The stump being replaced, the sac was tied and cut off; then the abdominal wall was sutured by several tiers of 18 126 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. strong catgut in physiological order. The outer wound was drained, sewed, and dressed as usual. February 1st passed off without any outward symptom, the vom- iting having ceased immediately after the operation. February 2d. — A severe chill with much belly-aclje set in, but no raeteorism appeared until February 4th, the thermometer indicating all the while 105° F. The patient's condition grew steadily worse, with deep coma, jaundice, and petechial patches on the legs. February 5th. — The sutures gave way during a vomiting spell, and a loop of healthy-looking gut pro- lapsed. It was not replaced. Shortly after the patient died. Post-mortem examina- tion revealed a slaty discoloration of the mentioned bunch of coherent gut, which, being incised, appeared to be covered on its mucous side with a large number of round and contluent whitish-gray adherent patches of membrane, which involved the intes- tinal wall to varying depths, some of them being visible through the peritoneal covering. No peritonitis. The author is at a loss for an explanation of this rare form of di23h- theritic affection of the bowel. Seven of the successful operations for strangulation w^ere done on in- guinal (one preperitoneal, Case V), four on femoral, hernise. Cured 11 patients Died 8 " Total 19 In dividing the strangulating band in femoral hernia, the incision should be directed inward toward Gimbernat's ligament. But, where the space is very narrow or the condition of the gut doubtful, free incision of the fascia lata parallel to the large vessels, and preparatory exposure of the femoral canal, would be more proper. To incise the strangulating bands sufficiently to enable the surgeon to withdraw additional portions of gut for examination does not insure facile reposition by any means ; and forcible crowding back of the congested and vulnerable intestine through an insufficiently wide orifice may lead to its rupture. Therefore, the dilatation must be very ample to permit easy reposi- tion without the use of undue force. As long as the sac is not closed, and communication is open with the peritoneal cavity, irrigation of the wound must stop, otherwise large jior- tions of the lotion may find their way into the abdomen. The use of strong- solutions of carbolic acid or mercuric bichloride on the prolapsed gut is not advisable and is unnecessary. As soon as the gut is replaced, the sac should be wiped clean with a disinfected sponge, and another small sponge, fastened to a thread of catgut, should be pushed into the inguinal canal to serve as a barrier to the influx of blood into the peritoneal cavity. If the patient is seen to bear anaesthesia well, inguinal herniotomy can be supiDlemented by the addition of Czerny's suture of the inguinal ring, as described under the head- Fio. 106.— Purse-strinir siit- ing of " Radical Operation of Hernia." lire, employed for occliKlinjr ,,, it, n i . • • the neck of the hernial sito. ^^houJd, howcvcr, coiiapsc DC present or immi- SPECIAL APPLICATION OF THE ASEPTIC METHOD. 127 uent, and prolongation of ana?s- thesia inadvisable, a thread of strong catgut is passed through the neck of the sac (see cut) as high up as possible, assistants holding well apart the arter}' for- ceps by which the edges of the cut through the sac are secured. This suture resembles a purse- string in its working (Fig. 106). It is tightened and knotted, and will securely occlude the perito- neal caYity. Then the external wound is well irrigated with cor- rosive-sublimate lotion, a drain- age-tube is placed well up to the purse-string suture, and the edge: gut stitches 107. Suture of external wound. of the skin are brought together with cat- The dry dressings are applied so as to cover up the scrotum and both inguinal regions, a slit being left in the middle for the jDenis, which should protrude from the bandages. The use of a " hip- rest " Avill facilitate the application of the otherwise difficult dressing. In ptrivate practice, a common hassock or footstool, wrapped in a clean towel or slijjped into a clean pillow-case, will make a caj)- ital hip-rest. In female patients the com- The dressings should fit snugly, Fig. 108. — Volkmann's " hip-rest.' presses are held down by a spica bandage especially about the edges, and should not be too scanty. Six or seven days after the op- eration the dressings should be changed, to permit withdrawal of the drainage-tube. Five or six days more will complete the es- sential part of the cure. The patient's bowels should be moved forty-eight hours after the operation by a large enema of soap-water. Should fever set in from peritoneal irritation, a saline purge may be administered with good effect. As long as the patient is in Fig. 109. -Manner of applying dressing for wounds of scroto-ino-uinal region. 128 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. bed, initrition should be simple aud moderate. No patient should be per- mitted to go about his business before a truss can be worn with comfort. But there is no objection to his being up and about the room with a well-fitting pad and spica. Fig. 110.— Herniotomy. I'atient on " hip-rest," with completed dressing. Lateral view. Synopsis of successful cases hither Case XIII.— Mrs. C. Reinhardt, of three days' duration. Operation, Fig. 111. — Completed dressing of scroto-ignuinal region Anterior view. to not accounted for : aged fifty-four, left inguinal incarcerated hernia November 15, 1882. Cured, December 11th. Case XIV. — Chas. Roensch, four months old, congenital in- carcerated hernia. Operation in German Dispensary, Janu- ary 26, 1883. Cured, Febru- ary 22d. Case XV.— G. John. See history, page 24. Case XVI. — Fred. Hipp, me- chanic, aged sixty, right exter- nal inguinal hernia. Operation at German Hospital, April 6, 1884. Cured, May 1st. Case XVII.— Mrs. Emma T., aged forty-seven, left femoral hernia. Operation, March 25, 1887. Cured, April 10th. Case XVIII. — Anna Brown, aged fifty, left femoral hernia. Operation at Mount Sinai Hos- pital in September, 1880. Dis- charged cured, end of October. Case XIX.— Martin Thor- Operation, February 12, 1880. warth, cooper, aged sixty, right inguinal hernia. Cured, Marcii 5th. b. Radical Operation for Hernia. — In performing herniotomy for stran- gulation on a patient whose general condition is good, the additional steps for radical cure may be at once carried out to great advantage. In other cases of non-strangulated hernia, where retention by truss of a very large scrotal hernia is impracticable on account of wide distention of SPECIAL APPLICATION OF THE ASEPTIC METHOD. 129 the inguinal eantil, or where adhesions of the })ro]apsed gut or omentum to the sac render reduction impossible and make attempts at wearing a truss a torture to the patient, radical operation is proper and justified. Due ob- servance of the rules of asepsis makes this operation very safe as far as the production of purulent peritonitis is concerned. Still, some danger of septic infection can never be excluded with positive certainty. Therefore, bloody radical operation should be discouraged for a hernia that can be retained by a properly constructed truss. The author has, in the main, followed Czerny's directions in performing radical operation of hernia, the several steps of which are as follows : After due preparation by a laxative, preferably castor-oil, the patient's pubic region and scrotum, especially on the side of the rupture, are shaved and cleansed the day before the operation, with brush, soap, and hot water, and are wrapped up in a clean towel dipped in a three-per-cent solution of carbolic acid. This wet compress is again covered with a suitable piece of oiled silk or rubber tissue, and fastened on with a T-bandage. On the day of the operation the patient is placed on the table and anaes- thetized, a full and good anaesthesia being especially desirable. After re- peated disinfection, the hernial sac is exposed by a sufficiently long incision, in which all bleeding vessels are to be secured by ligature. The upper angle of the wound should be located well above the upj)er margin of the inguinal ring so as to permit easy manipulation. The sac is incised, and its edges are taken up by a number of artery forceps, which being held apart, an excellent view of the contents of the hernia can be had. Adhesions of the omentum to the sac will be found the most common cause of the irreducibility, the gut being rarely adherent. The author has observed only one case of old hernia in which adhesions of the gut were present (case Mau). The favorite place of omental adhesions is the anterior portion of the neck of the sac. As soon as the sac is open, the use of the irrigator has to be discon- tinued, to prevent entrance of large quantities of irrigating fluid into the peritoneal cavity. The lotions used for rinsing hands, sponges, and instru- ments ought to be very mild to prevent even superficial corrosion of the peritonaeum. The author has generally used Thiersch's boro-salicylic solution. A suitable sponge, fastened to a stout piece of silk or catgut, is pushed well up into the inguinal canal to prevent the entrance of blood into the abdomen. Care must be taken not to select a too brittle sponge, as it may happen that, on removing it, some portion of it may become detached and remain in the belly. The sac must be split open to within a quarter of an inch of the external inguinal ring, and the adherent omentum must be detached from the sac by preparation. As soon as the distal attachments of the omentum are severed, it is withdrawn a little farther from the inguinal canal, and, being deligated in small portions with reliable catgut, it is cut away by the knife, or, preferably, the thermo-cautery. After this the sac is wiped out cleaUj, 130 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. and, the sponge being withdrawn from the inguinal canal, the stump of the omentum is rej)laced in tlie abdominal cavity. In dissecting up adherent gut, great caution must be observed not to in- jure it. Where the adhesions are very close and extensive, it would be better to excise the attached portion of the sac with the gut, and replace them together in the peritongeum. Case I. — Henry Mau, slioeinaker, aged sixty-two. Very large scrotal hernia, con- taining adherent gut. The inguinal ring was so dilated that the tips of three fingers could easily be slipped within the abdominal cavity. February 23, 1886. — Radical op- eration at tlie German Hospital. Ether antesthesia produced violent retching and coughing, so that the irresistible escape of gut from the wound rendered operation impossible. Chloroform being administered, quiet anesthesia was achieved. The ad- herent thick gut was dissected away, together with the adhering portions of the sac, and was returned to the abdominal cavity. The remnant of the sac was separated, closed at its neck with a purse-string suture, and was cut away. The wide gap of the inguinal ring was closed with eight sutures of stout catgut, and the external wound was drained and sewed up. Uninterrupted recovery. March 25th. — The patient was discharged cured with instructions to wear a light truss. In November, 1886, he pre- sented himself with a relapse. His truss had been broken, and he neglected to have it repaired. In a fit of violent coughing the rupture reappeared. The contents of the sac being disposed of, excision of the sac is the next thing to be done. In most cases this can be readily accomplished by stripping up the sac from the surrounding tissues with the fingers, the scissors being only occa- sionally needed to sever resisting bands, which generally contain vessels requiring ligature. In some instances, however, especially in cases of con- genital hernia, the separation of the sac is not easy. The sac proper is not well defined, and in some localities consists of nothing but the bare peri- tonaeum. Hence it is difficult to get it out uninjured and in one piece. Another difficulty is jDresented by the close relations of the cord and its vessels to the sac. The greatest care must be taken to properly recognize them, as otherwise they may be accidentally damaged. Case II. — William Litzebauer, baker, aged twenty-seven. Left inguinal irreducible hernia. February 5, 1886. — Radical operation at the German Hospital. Liberation of adherent omentum, which was deligated and cut away. In dissecting up the sac, the vas deferens was cut across. A short piece of stout catgut was introduced into the patent ends of its lumen, and the duct was united by four fine catgut sutures passed through its involucrum. The sac being removed, the external ring was closed by six stout catgut sutures. The external wound was drained and sewed, February 7th. — Purulent urethral discharge was noted; no fever. February i5i/i.— Change of dressings. Wound healed by adhesion, left testicle somewhat swollen and pahi- ful. Tube was removed. February 27th. — Urethral discharge disappeared, testicle notably decreased in size. March 10th. — Discharged cured, with slightly enlarged testis. Congenital irreducible liernia is comparatively frequent. Four of the twelve cases operated on by the author belonged to this class. One was com- plicated with undescended testicle. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 131 In two of these cases castration had to be performed along with tlie radi- cal operation. Case III. — August B., painter, aged twenty-fDur. August 23, 1883. — Radical ooeratlon at the German Hospital. The omentum was found adherent to the left testi- cle, and contained near its adhesion to this organ a hard, pigmented tumor of the size of a walnut. The sac and the tunica propria of the testis were dotted with a large number of pigmented spots. Tlierefore the omentum, sac, and testicle were all re- moved. Closure of inguinal ring by catgut sutures. Treatment of external wound as usual. Septeniber 20th. — Discharged cured. Case IV. — George AV., cattle-raiser, aged thirty-six. Direct inguinal hernia of left side, containing the undescended testicle. August 24, 1885. — Radical operation at Mount Sinai Hospital. The attached omentum was freed and removed. The atrophic testicle was also taken away. Suture as usual. SejAemher Jftli. — Patient strained at stool, whereupon the external wound reopened, but subsequently healed by granu- lation. October 2d. — Patient was discharged cured. In a third case of congenital hernia, in an infant, eclamptic attacks caused repeated protrusion of the intestine, that could not be reduced with- out the employment of anaesthetics. Case Y. — Carl Schlichter, eight months old. April 18, 1886. — Prolapse of the gut during a convulsive seizure. Dr. Meltzer, tiie family attendant, administered chloro- form, whereupon the author reduced the gut with some difficulty. The accident had occurred the fourth time in spite of a truss. Radical operation was at once performed. May 5th. — Patient discharged cured. Case VI. — Franz Faulhaber, laborer, aged twenty-two. Left congenital omental hernia. July 28, 1885. — Radical operation at the German Hospital. Omentum adher- ing to sac treated as usual. Sac was cut away below from its reflexion upon the testi- cle, and above close beneath the purse-string suture. Treatment of inguinal ring and external wound as usual. Uninterrupted cure. September 1st. — Patient was discharged cured. The closure of the sac is to be done by the purse-string suture, depicted by Fig. 106. Rather stout catgut must be used for this, to withstand the powerful tension required for closing the circular suture. The sac is cut away below the knot, and any bleeding vessels must be separately de- ligated. The stump is pushed well up within the internal abdominal ring. In applying Czerny^s sutiire of the inguinal ring, the left index-finger is intruded as far as possible, its volar aspect being directed downward and inward to protect the cord, which should be kept near the inferior and inner angle of the slit of the inguinal aperture. A strongly curved needle, armed with stout catgut, is passed first through one, then through the other pillar of the ring, and the ends of the thread are secured in a pair of artery for- ceps, and reflected upon the abdomen, where they are received by an assist- ant. This first suture should be placed as high wp the inguinal ring as possible. In intervals of a third of an inch from four to seven stitches are applied in the manner indicated ; then they are tied firmly by surgeons' knots in the reverse order. A small -sized drainage-tube is placed in the wound, and the integument is united by finer catgut sutures, the tube being 132 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. brought out through the lower angle of the incision. An antiseptic dressing is next applied in the manner shown by Figs. 108, 109, 110, and 111. The first change of dressings should be made on the tenth day, when the tube is also removed. As soon as the wound is completely closed, the patient is permitted to get up with a spica bandage or truss. The patients should be directed to continue the use of a light truss, as this is the only reliable security against recurrence. In one case a fibromatous node in the adherent omentum was the chief source of pain complained of by the patient. Case VII. — Jacob ChristmanD, laborer, aged thirty-nine. August 15, 1885. — Eadi- cal operation at the German Hospital. A hard, irregular node was occupying the mid- dle of the prolapsed and adherent omentum. It was removed with the same. Dis- charged cured, September 19th. The node was tibromatous in character. In another case a subserous fibro-lipoma was located outside of, and was closely connected with, the neck of the sac. Case VIII. — Carl Dille, laborer, aged thirty. Subserous fibro-lipoma and left adherent omental hernia. March if, 1887. — Eadical operation at the German Hos- pital. Removal of omentum and sac, together with neoplasm. Sutures as usual. April 9th. — Discharged cured. The remaining four cases presented nothing unusual, and all recoyered without mishap : Case IX. — Charles Niemann, locksmith, aged tliirty. Adherent left omental hernia. February 19, 1887. — Radical operation at the German Hospital. March 12th. — Dis- cliarged cured. Case X. — Martin Hussmann, baker, aged twenty-five. Adherent right omental hernia. March 3, 1887. — Eadical operation at the German Hospital. April 7th. — Discharged cured. Case XI. — Henry Mehle, barber, aged twenty-five. Adherent right omental hernia. January 8, 1886. — Eadical operation at the German Hospital. February 12th. — Dis- charged cured. Case XII. — Mr. M. D., merchant, aged thirty-nine. Very massive, growing, adher- ent omental hernia of the right side. May 26, 1887. — Eadical operation at Mount Sinai Hospital. June 16th. — Patient discharged cured. It has been urged, notably by Weir and Abbe, of New York, that, after radical operation, healing of the external wound by granulation is preferable to primary union, on account of the larger mass of cicatricial matter result- ing from the granulating process. To the author this advantage seems of doubtful, certainly of only passing, value, as the massive cicatrix, first hard and resisting, must in the course of time become atrophied, soft, and yield- ing, and will 7iot be able to withstand for a long time the constant impact of the intra-abdominal pressure. The analogy of this fact with the experi- ences gathered about the wounds resulting from laparotomy can not be gain- saifl. These regularly terminate in ventral hernia when the healing of the abdominal incision was not by primary union, and tlie cicatrix produced by a long process of granulation is very wide and massive. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 133 3. Laparotomy. a. Exploratory Incision. — Although the aseptic method has very mate- rially reduced the dangers of exploratory laparotomy, its wanton and un- necessary practice must be deprecated on several grounds. Firnt of all, no surgeon is absolutely secure in his practice against accidental and un- expected, often unexplained, wound infection. Secondly, the dangers of anaesthesia, and of conditions indirectly caused by it, as nephritis, pneu- monia, thrombosis, and embolism, are ever present, and usually surprise the surgeon when least expected. Exploratory incision is only justified where, in the presence of a disorder threatening life, all known means for establishing a diagnosis have been exhausted without positive result, or where the extent and exact relations of a mechanical disturbance can not be estimated without ocular inspection and digital examination. Due observance of the rules against infection will exclude suppurative peritonitis with great certainty. The detail of the procedure is treated in the chapter on abdominal tumors. Case T.— Fred. Kahn, aged eleven. Intestinal obstruction of seven days' duration. Fecal vomiting, very great tympanites, and threatening exhaustion. No fever. June 27, 1882. — Lapal-otomy under ether. In the right iliac fossa an immovable convolu- tion of small gut could be felt. The incision was sufficiently extended to enable the author to inspect the locality. It was found that the tip of the vermiform appendix was attached to the parietal peritonaeum. A large loop of the ileum had slipped through tlie hiatus thus formed, and was there incarcerated. The vermiform appendix was cut between tw^o ligatures, and the loop of intestine became free. Reduction of the enor- mously distended intestines was impossible. At the suggestion of Dr. A. Seibert, an enema was administered, and it brought away a large quantity of gas, whereupon the somewhat collapsed gut could be replaced, and the abdominal incision closed. The operation lasted thirty minutes. Deep collapse followed, in which the patient died twelve hours after the operation. Very likely an early operation would have been followed by a better result. Case II. — Philippine Pahler, aged thirty-five. Pyloric cancer of stomach. Febru- ary 18, 1886. — Probatory abdominal incision at the German Hospital, with a view to possible resection of the pylorus. The extension of the disease to the retro-peritoneal glands, the pancreas, and omentum put the contemplated step out of question, where- fore the incision was closed. March 11th. — Patient discharged with firmly healed wound. Case III. — Albert Schroeder, painter, aged thirty. Large retro-peritoneal tumor located behind hepatic flexure of colon, causing intestinal stenosis. August 5, 188S. — Probatory incision at the German Hospital established the fact of the inoperability of the swelling — a sarcoma of the mesocolic glands. Closure of wound. August 9th. — Patient died in collapse. h. Abdominal Tumors : (a) GrEzsTEKAL Remakks. — Avoidance of infection from without by scru- pulous cleansing and disinfection of hands, instruments, sponges, and other 19 13J: RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. 112. — Ascites and ovarian tumor. Patient ready for operation in the lateral posture. Case of Dr. W. L. Estes, of Bethlehem, Pa. iiteusils should render nuuecessary the application to the peritoneal cavity of disinfectant lotions, which, by their corrosive properties, may produce mischief. The usual measures adopted for protecting the body of the j)atient against wetting and undue cooling off, as the wrapping up of the extremities in flannels, and the spreading of rubber cloths over the trunk and lower limbs, leaving exposed noth- ing but the abdomen, demand special care and attention. Excessive loss of dody heat is a great factor in determining collapse, and should he guarded against most sedulously. The principle of non- exposure applies equally to the contents of the abdominal cavity. The greater the incision, the more attention must be paid to the non-exposure of the intestines. Hot, flat sponges or towels should hide from view everything except the very spot subjected to surgical ma- nipulation. The use of the spray apparatus during abdominal operations is harmless, but unnecessary. Certainly it forms a very objectionable feature of the original Listerian method, and has been abandoned --N / in general as well as ab- dominal surgery by most operators. The author has not used the spray appa- ratus since 1881. The control of haemor- rhage is of the utmost importance to the success of abdominal operations. This and the former re- quirements can be best fulfilled by an intelligent observance of the rules laid down in the paragraphs on the technique of surgical dissection and the removal of tumors. The principles there explained remain unchanged, their application to abdominal tumors only being somewhat modified by the peculiarities of the locality. Fig. 113. — Protection of the intestines by flat sponges arranged about the tumor. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 135 An ample incision is the first condition of the safe removal of an abdomi- nal tumor. Wlieu ti unilocular, nou-adherent cyst is to be exsected, a small incision will be ample, because the cyst, however large, can be emptied by tapping, and is thus reduced to the elongated proportions of a flat band, which can be extracted through the small incision without much force until the pedicle comes in view. Multilocular cysts that can not be emptied readily, or solid tumors, or growths with many adhesions, must be freely exposed, to enable the sur- Fia. 114. — Protection of the intestines in ovariotomy by hot towels. geon to see what is to be done. Accidental laceration of the gut, bladder, or large veins will not easily occur while the adhesions binding the tumor to these organs are exposed to view. Disregard of this plain and rational rule is the cause of many an accident and mishap that might be easily avoided otherwise. Note. — However important the incision and final suture of the abdominal walls may be, it must not be forgotten that they do not represent the critical part of most abdominal operations. The abdominal incision, being a preliminary measure, should not occupy too much time. Of course, it must be done lege artis, but with expedition. Bleeding vessels need not be tied here, as the pressure of the hemostatic forceps, exerted for ten or fifteen luiuutes, will effectually arrest hfemorrhage. Here, as elsewhere, cutting between two forceps will be more expeditious and safer, than the use of the grooved director. The skillful and unstinted use of mass ligatures by means of Thiersch's spindle apparatus will render the dissection even of extensively adherent abdominal tumors remarkably bloodless and safe. Strong catgut is prefer- able to silk, as the latter is known to have been the cause of suppuration in a good many cases, although the silk was prepared in a seemingly proper fashion. Extensive masses of tissue, especially if their shape approaches that of a membrane, should not be included in a single ligature, as they are very ajjt to slip at the edges. It is safer to divide them into a number of smaller portions which should be separately tied. This rule apjDlies to the omentum especially. 130 EULES OF ASEPTIC AND ANTISEPTIC SURGEEY. Adhesions or pedicles of ti more cylindrical shape can be safely tied in one mass without risking the slipping of the ligature. Every mass should be included in two ligatures, between wiiich it can be severed with the knife or, better, the thermo-cautery. Transfixion of pedicles with a sharp Peaslee's needle is not advisable, as large veins passing into the mass may thus be cut open and cause trouble- some ha?morrhage from a point not included in the ligature. It is better to use a blunt instrument, such as Thiersch's spindle, or a dressing or artery for- ceps, which will pass through any pedicle easily without injuring the vessels. Where the adhesion or pedicle is too short, and the tumor too large, to admit of easy manipulation under the guidance of the eye, the use of a temporary elastic ligature, with or without preliminary transfixion to pre- A^ent slipping, will be found a welcome expedient. To this, a rather stout, solid band of {not rotten) pure gum-elastic, and one or more round probe- 23ointed steel needles are necessary. The pedicle is first transfixed singly or crucially, then the rubber band is thrown around the needles beyond the place of transfixion. The ends of the tightened rubber are crossed and secured at the crossing by a stout pedicle-clamp. After this the tiimor can be cut away, and the pedicle, becoming more accessible, can be divided and tied off with catgut in several portions. As soon as this is done the clamp is loosened, the rubber is removed, and the tied-off masses are trimmed and seared with the actual cautery. Close adJiesions of the gut require special care. Recent adhesions are easily separated by blunt preparation, but cause a good deal of oozing. Much wiping and sponging of the oozing points is apt to prolong haemor- rhage, for reasons explained elsewhere. It is better to cover these points with a flat sponge, and to let them alone till haemorrhage ceases spontane- ously. The blood that found its way into the abdomen must be sponged out at the final toilet. Old adhesions of the intestine are very dense, and efforts at their blunt separation may easily lead to injury of the gut. Dis- section by the scal23el, the line of section being well away from the intes- tine, will be found the most expeditious mode of proceeding. Spurting vessels must be tied, and as soon as the adhesion becomes less close and the formation of masses by blunt separation possible, mass ligatures should be applied. Forcible blunt preparation in the vicinity of large veins, more, especially of the large plexus regularly encountered in the bottom of the small pelvis near the uterus and its adnexa, is hazardous, on account of the haemorrhage often caused by laceration of the delicate walls of these vessels. Careful isolation and double deligation, with subsequent cutting between the liga- tures, are the best safeguard against dangerous haemorrhage. Blunt dissection, preferably by the tips of the fingers, is, however, emi- nently proper where the peritonaeum is to be stripped up from underlying tissues. It is, in fact, the only safe way of separating tumors that are located between the folds of the broad ligament, in the mesentery, or in any ])ortion of the retro-peritoneal space. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 1?,7 Exploratory puncture and aspiration of exposed abdominal cysts of un- known contents with a fine, hollow needle is very advisable, as the exact knowledge of the nature of the cystic contents may materially modify sub- sequent steps of the operation. If the cystic fluid be bland, its escape into the peritoneal cavity does not signify much, i)rovided that careful cleansing be employed before the clos- ure of the wound. But when the cyst contains purulent or fetid serum, accidental soiling of the peritonaeum by it may efEectually destroy all chances of recovery. Whenever puncture of an exposed tumor is determined on, whether by a small or large-sized instrument, good care must be taken to prevent, dur- ing and after the act, the escape of cystic fluid through the puncture-hole into the abdominal cavity. To do this it is necessary to surround the needle or trocar with a number of flat sponges laid on the tumor. As soon as the piston is withdrawn the nature of the fluids appearing in the barrel of the syringe will become manifest. If it be clear and limpid, no further precaution need be taken. Should the fluid appear to be turbid, or mani- festly purulent, the barrel should be emptied and refilled and emptied again, until the tension of the sac becomes so far reduced, that its transfixed portion may be raised in a fold and secured by a large clamp. The sponges used for this step of the operation should be at once discarded. To prevent laceration of the sac or capsule, the utmost gentleness and care should be practiced in handling the tumor. The use of sharp re- tractors and vulsellum forceps, or forcible traction with or without blunt force of any kind, are extremely ill-advised. Not only may the sac be torn, but large veins spread out over the surface of the tumor may be in- jured, and give rise to uncontrollable haemorrhage. The aperture of a torn vein can not be easily occluded by any kinds of artery-clamp, first, because of its irregular shape and extension, and principally because the tension of the capsule of a solid tumor precludes the formation of a fold that could be conveniently grasped. Note. — The author recalls an instance witnessed by him where, during the removal of a large uterine growth through an inadequate incision, sharp retractors were used in forcibly developing the mass from the abdominal cavity. Several large veins being torn, profuse hiem- orrhage set in. The incision was somewhat, but still insufficiently, enlarged, and, more force being applied, the tumor was iinally brought out of the abdomen. But very soon it became evi- dent that, in consequence of the forcible manipulation, the transverse colon, which was closely adherent to the posterior aspect of the tumor, had been extensively torn. Enterorrhaphy did not save the patient's life, which was forfeited by the injudicious management induced by super- stitious fear of a " large " abdominal incision. The tenet of making small incisions for the removal of abdominal tumors had its origin in the justified disinclination to expose a large peritoneal sur- face to the contaminating and refrigerating effect of the atmospheric air. And unnecessarily long incisions are certainly to be avoided. But the sur- geon's discretion must decide the question of the size of the incision, the principle of safe dissection under the guidance of the eye being herein of the first importance. 138 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Undue cooling off of the peritonaeum is a very undesirable thing, on account of the collapse it may induce ; therefore, all portions of the abdomi- nal organs that are not actually under dissection should be carefully covered up by large flat sponges or clean towels wrung out of hot Thiersch's solution. Note. — To always have a sufficient supply of warm sponges and towels, the following arrangement will be found convenient : A tin pan or basin, containing the sponges or towels immersed in Thiersch's solution, is rested on the tops of two clean bricks stood on edge. A blazing alcohol-lamp is placed between the bricks and underneath the vessel, which, being cov- ered with another pan, will preserve unchanged the temperature of its contents. For larger operations, three or four similarly prepared pans can be conveniently arranged on a separate table. "Whenever a stout adhesion or a pedicle is deligated and cut through, it should be dropped back into its natural position, where it should be inspected for a short while to see whether haemorrhage is thoroughly con- trolled by the ligature. Oozing points should be touched with the thermo- cautery, but care must be taken not to go too near the ligature, for fear of burning it. Oozing points located on the gut should never be touched with the thermo-cautery. It is best not to tap at all dermoid cysts or tumors containing clearly septic fluid, as the integrity of the cyst-wall is the only guarantee of pre- venting contamination of the abdominal cavity by cystic fluids. Eather increase the external incision, and remove the tumor intact. The relations of the bladder to the tumor should be carefully considered. Greig Smith advises not to emijty the Madder hefore oiieration, and it is undeniable that a full bladder can not be well overlooked or injured. In- jury to an empty and collapsed bladder, on the other hand, has repeatedly occurred in the presence of abnormal adhesions of the organ to the tumor. To further ascertain the extent of adhesions of the bladder, the introduc- tion and manipulation of a solid male urethral sound will be found very useful. XoTE. — Catheterism should be done, if possible, by a person not employed about the wound, or, if this be not feasible, careful cleansing and disinfection of the hands should follow it. After the removal of the tumor, the toilet or cleansing of the abdominal cavity has to be attended to. Sponges attached to long handles are very convenient for this purpose. With them first the lumbar, then the vesico- uterine recesses, finally the utero-rectal or Douglas's pouch, are to be thor- oughly cleansed and dried. In the presence of large denuded surfaces lacking peritoneal investment, a glass or hard-rubber drainage-tube is to be inserted into the bottom of the small pelvis. It can be brought out through a counter-opening made into the vagina from Douglas's pouch, or through the lower angle of the abdominal incision. In the former case, the external end of the tube projecting into the vagina or in the vulva must be wrapped in a packing of iodoformized gauze, which ought to be changed whenever it gets saturated. When the SPECIAL APPLICATION OF THE ASEPTIC METHOD. 139 tube is brought out through the abdominal incision, its outer end must be so dressed as to bo easily accessible. Every hour the serum collecting in its bottom should be exhausted with a pad of absorbent berated cotton fixed to a handle, or with a long-nozzled syringe. In the intervals the tube should be covered with a moist pad of sublimated gauze. As the serum diminishes, this process is gone through with at longer intervals. As soon as the tube remains dry for several hours, generally about the third day, it can be with- drawn. XotE. — Miculicz has successfully substituted for the drainage-tube a loose packing and fillet of iodoformized gauze, brought out through an angle of the wound. The exsiccation of the secre- tions by this arrangement is certainly very effective, as seen in several cases reported by Dr. F. Lange. The fillet should be removed on the third or fourth day. The closure of the abdominal wound should le done as rapidly as thor- oughness will permit, simplicity and solidity of the suture being the main desiderata. A Peaslee's needle is thrust on one side through the entire thickness of the abdominal wall, including the peritonaeum, and is brought out in a similar manner on the other. The points of entrance and emergence should be at least two inches from the edges of the wound. A piece of well-disin- fected silver wire or stout silk-worm gut, armed with a quill, or a leaden button and shot, is threaded through the eye of the needle. This is then withdrawn, brinaing out the end of the thread from one side of the; Fig. 115. — Completed quilled suture of abdominal incision. wound to the other, where it is temporarily secured by an artery forceps. Three, four, or more retentive sutures of this kind are passed at intervals of about an inch, until the entire length of the wound is covered by them. Note. — "While the stitches are being passed, a flat sponge should be kept spread over the intestines to receive the blood escaping from the stitch-holes. If the patient's condition be good, the peritonseum may be separately united by a row of catgut sutures placed between the silver or silk-worm gut stitches. But this is not essential. 140 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fi(3. 116. — Completed plate and shot suture of abdominal wounds. After the withdrawal of the flat sponge, and a final cleansing of the peri- tonaeum by sponges fixed to long handles, a quill is applied to the unarmed end of the thread, and is tightened until the edges of the incision are raised in the shape of a low ridge. Or, if lead buttons are to be used, one of these is slipped on the thread with a perforated shot, the thread is tight- ened, and the shot is pinched. After this, a sufficient number of exact " sutures of co- aptation," made of fine catgut, secure the edges of the incision. (Figs. 115 and 116). The dressings con- sist of a few strips of iodoform-gauze, and an ample compress of sublimated gauze over it, all snugly fastened by several strips of adhesive plaster and a broad flannel or gauze bandage. On from the eighth to the tenth day the dressings are changed, and the retentive sutures are removed ; but the bandage must be worn for some time to serve as a support to the fresh cicatrix. {b) Special Obseevations : a. Ovarian Tumors. — Probatory puncture of an abdominal tumor through the walls of the belly is not an indifferent matter. If the tumor be cystic, and its wall very tense, escape of a limited quantity of cystic contents is unavoidable. Bland and very thin contents may escape in large quantities without causing irritation. A large number of cases are on record in which probatory puncture of cysts of the broad ligament was followed by cure. Case. — Mrs. Francisca N., liquor-dealer's wife, aged thirty-four, was tapped, August 31, 1877, for a large abdominal cyst. About a gallon of fluid, characteristic of a cyst of the broad ligament, was removed, but a considerable quantity was left behind. In a short time the flabby, fluctuating swelling disappeared entirely, and the woman remained free from any further trouble. Escape of minute portions of purulent cyst-fluid is apt to cause circum- scribed peritonitis, resulting in more or less extensive adhesions. Larger quantities of septic matter, tliat find their way into the peritoneal cavity, may produce fatal purulent peritonitis. The preparations, with a view to the aseptic performance of exploratory or evacuating puncture, must be very thorough, as the use of an unclean SPECIAL APPLICATION OF THE ASEPTIC METHOD. 141 needle or trocar may be tlie source of peritonitis or suppuration of the sac. The hollow needle or trocar to be used must be sterilized either by boiling for an hour in a five-per-cent solution of carbolic acid, or by incandescence in the alcohol-flame. When an exposed cyst is to be tapped or emptied by incision, the patient should be turned over on her side. An assistant should prevent the escape of gut ; another one should surround the place of tapping with a circle of sponges to receive fluid that may escape alongside of the instrument. Tait's trocar is, on account of its simplicity, the best one of all instruments devised for evacuating cysts. As soon as the cyst begins to collapse, its folds should be taken up with large clamps. The empty cyst is then withdrawn to the pedicle, which is tied in one or more portions and cut off. Case I. — Mrs. Dorothy Grunewald, aged sixty-one, multipara. Unilocular cyst of the left ovary. December 19, 1882. — Ovariotomy. External incision four inches long. Cyst presenting, patient was brought in lateral position. Tapping, evacuation, and extraction. Eather stout pedicle transfixed with thumb- forceps, and tied in four por- tions, then cut off and dropped back into the abdomen. Uninterrupted recovery. January 4, 1883. — Discharged cured. Multilocular cysts can be best emptied by making a free incision through their presenting part, through which the hand can be carried within the tumor to break up intervening septa. All this should be done extra-abdom- inally if possible. When a cyst is found extensively adherent, its contents should be care- fully mopped out with a sponge, and the interior of the sac should be dis- infected while the patient is in the lateral posture. After this a large sponge is thrust into and left within the cavity until the cyst is dissected out. Case II.— Miss Lucretia Bernard, aged seventy-two, virgin. Very large multilocu- lar ovarian cyst of the right side, causing intense dyspnoea. August 8, 1881. — Punct- ure and partial evacuation at Mount Sinai Hospital, resulting in marked relief of the dyspnoea. August 10th. — Fever set in, with some abdominal tenderness, and suppura- tion of the cyst was apprehended. August 13th. — Ovariotomy. Incision twelve inches long. Broad, recent adhesion of the sac to the anterior abdominal wall severed by blunt preparation. Patient being brought into the side position, the cyst was first tapped, then incised, and its volume was much reduced by breaking down septa by the hand. Some hemorrhage occurring, a large sponge was thrust into the sac, and the patient was returned to the supine position. A number of adhesions to the right side of the parietal peritonaeum and ascending colon were divided between several double mass ligatures of silk. Short pedicle was similarly secured. Toilet of peritoneum ; closure of incision. Moderate elevations of the temperature. Uninterrupted healing of wound. Noxernber 15th. — Abscess of right groin was incised. Three silk ligatures were discharged. August 11, 1882. — Patient died of an intercurrent disease not con- nected with ovariotomy. Case III. — Mrs. Lena Dochtermann, aged thirty-nine, multipara. Very large multilocular cyst of right ovary. General condition very poor; chronic bronchial catarrh and chronic enteritis, with diarrhoea, ascites, and anasarca. April 19, 1886. — Ovariotomy. Extensive adhesions of cyst to anterior and lateral parietes ; to transverse 20 142 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. colon, omentum, and the bladder. A large number of mass ligatures were made, riffimorrhage insignificant. Duration of operation two hours and a half. Patient died in collapse seven hoars after the completion of the operation, temperature remaining subnormal to the last. Cysts of the broad ligament generally present great difficulties on account of their situation between the peritoneal folds of the ligament. If they extend low down into the small pelvis, their dissection is occasionally im- practicable, and always very difficult. The utmost circumspection and care must be exercised not to provoke haemorrhage by injuring large veins in the bottom of the wound, and all adhesions, not yielding to gentle blunt dissec- tion with the fingers, must be fashioned into suitable masses, doubly tied with Thiersch's spindles, and then divided. In cases baffling the skill or enterprise of the surgeon, the sac should be properly trimmed and stitched to the skin, so as to convert it, if possible, into an extra-peritoneal recess. Drainage of the sac is indispensable. Case IV. — ]yrs. Ethel D., aged twenty-one, nullipara. Eather immovable cyst of the right broad ligament of the size of a child's head. Apy'il 6, 1887. — Ovariotomy. Incision five inches long. The cyst had dissected its way out from between the folds of the broad ligament, and had pushed away the parietal peritonaeum of the anterior abdominal wall on the right side to such an extent as to remain entirely extra-peritoneal. The sac was tapped and emptied, then it was easily separated from its attachments by bluni preparation. About one fourth of a square foot of peritonaeum was detached. Finally, the pedicle was reached, secured in three ligatures carried through by means of Thiersch's spindles, tied, and cut off. The cavity was mopped out with corrosive- sublimate lotion, drained by two ordinary rub- ber tubes, and the external wound united and dressed in the nsual manner. April 7th. — Nothing alarming had occurred, the tempera- ture ranging about 99° Fahr. Ai^ril 8tli. — Temperature 101*5° Fahr., with a good deal of tympanites and dyspnoea. Pulse of varying in- tensity and rhythm, about 125 beats per minute, and rather weak. The outer bandage had to be loosened, and energetic stimulation by hourly enemata, consisting of one ounce of brandy and two ounces of warm vrater, were administered, till the pulse became decidedly fuller and more regular. April 10th. — Some flatus passed spon- taneously, the meteorism diminished markedly, and the temperature fell to the normal standard. April 11th. — Patient consumed a few oysters and a little champagne, her nourishment hav- ing consisted until then of milk and lime-water. On the same date slight uterine and vesical hfemon-hage was noted. The former may have been dependent upon subinvolution remaining behind after a recent miscarriage ; the vesical hseinorrliage seems to have been due to detachment of the superior and lateral vesical wall during dissection. April 13th. — A saline laxative was administered, caus- ing some nausea and vomiting with a good deal of griping, but resulting in three copi- FiG. 117. — Dia^am of cyst of the broad ligament. (Case IV.) SPECIAL APPLICATION OF THE ASEPTIC METHOD. 143 ous stools. The same day the drainage-tubes were shortened. The wound was found healed by adhesion except where the tubes lay. Three of the plate and shot sutures were also removed, and two were left behind. The catgut sutures had been all ab- sorbed. April ISth.— The tubes were entirely withdrawn and remaining sutures removed. April 20th. — The patient left tlie bed the first time. April S5th.—The wound was entirely healed. (Fig. 117). It seems that the extensive detachment of the peritonaBum from its nutrient vessels led to a grave disturbance of its circulation, and perhaps to partial {asejoUc) necrosis. An adhesive peritonitis of the intestinal invest- ment apposed to the denuded parietal peritoneum was set up, causing paralysis of the muscular layer of the gut with meteorism. As soon as the devitalized parts of the peritonseum were enveloped by fresh exudations, the irritation ceased. p. Supra-vagmal hysterectomy for large myo-fibroma of the uterus may be indicated either by profuse loss of blood at the menstrual epoch, or by other causes rendering the patient's life unendurable. An operation should be determined on only, after a faithful trial of less incisive remedies known to induce involution of uterine fibromata, has plainly failed to give relief. The jDreparations for the operation are to be made with all possible care, directed to the avoidance of septic infection. Haemorrhage is to be pre- vented by the •application of single or double mass ligatures to the uterine adnexa on both sides of the uterus, and a stout elastic cord to the cervix. Un- der favorable condi- tions (that is, when the cervix forms a slender pedicle to the otherwise movable womb), the applica- tion of double liga- tures can be obviated by cutting off the blood-supply of the organ from all sides by two continuous lines of mass ligatures converging from the free margin of the adnexa toward the cervix. A suitable-sized mass is first formed at the margin of the broad ligament by means of Thiersch's spindle, and is tied off with strong catgut or silk. A second mass adjoining the first one is now isolated, and the thread being carried around it and back through the aperture made for the applica- tion of the first ligature, is firmly knotted. A third mass is isolated by Thiersch's spindle, and the thread is carried back through the hole made for the isolation of the adjacent mass, and the application of the preceding hgature. Thus the cervix will be soon reached. While an assistant raises the tumor well above the pelvis, an elastic ligature is thrown around the elongated cervix ; being tightened, it is secured by a stout pedicle-clamp. Fig. 118. — Diagram showing the arrangement of mass ligatures in supra- vaginal hysterectomj'. 144 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. Tliis step will have completed the isolation of the uterus, which can be now exsected without loss of blood, the line of section being carried just outside of the chain of ligatures. (Fig. 118.) The uterine stump must not be cut oif too short, as it is desirable to retain sufficient material for covering up its raw surface with peritonaeum. The cervical canal is to be burned out thoroughly with the thermo-cautery, to destroy any septic material contained in it. After this, the cut surface of the uterine stump is hollowed out with the scalpel in the shape of a cup, its center being located in the cervical canal. This is done until the edges of the cut can be folded upon each other, when they are united with a sufficient number of deep, intermediate, and superficial catgut sutures. The deep sutures are to be applied with a large curved needle, that should dip down to the level of the elastic ligature. The intermediate sutures should reach to about one half of the depth of the stump ; the superficial stitches are to hold together the peritoneum. Thus exact coaptation of the entire cut surface of the uterine stump is brought about, and it serves two good purposes : First, the elas- tic ligature can be removed without fear of pro- FiG. 119.— Suture of uterine fuse haemorrhage. Any oozing between the stitches ?yTe'rectmy.Tcwl3 ^an be controlled by 'sponge pressure till a clot is formed within the wound. The second advantage is the exclusion of all communication between the vagina and cervix on one side, and the peritoneal cavity on the other. (Fig. 119). Where the pedicle is short and very stout, slij)ping of the elastic liga- ture must be prevented by crucial transfixion of the cervix with a pair of large and well-disinfected shawl-pins. These can be removed, together with the rubber cord, after the completion of the suture of the stump. In the j)resence of adhesions, or a broad imjalantation of the myoma into the decider parts of the pelvis, the same rules of dissection are to be heeded that have been elucidated in a former paragraph relating to abdominal tumors. The author's only case of supra-vaginal hysterectomy ended fatally by septicaemia. The sources of infection were presumably the sponges, man- aged by two raw members of the training-school for nurses at Mount Sinai Hospital. Case. — Mrs. S. Levy, aged thirty-three, multipara. Very large fibro-myoma of the corpus uteri. Severe metrorrliagia at each menstruation, with increasing anaamia and great helplessness from the size of the tumor. June 7, 1883. — Hysterectomy at Mount Sinai Hospital. Incision six inches long. Easy deligation of adnexa in two rows of mass ligatures ; elastic ligature of cervix ; ablation of the tumor and adnexa. Searing of tlie surface of the small stump by thermo-cautery. The smallness of the stump induced the author to treat it like an ovarian pedicle, and it was replaced in the abdomi- nal cavity after securing of the elastic ligature by a knot of strong silk. Hardly any blood was lost, and a smooth course of healing was expected. But all hopes were shattered by the development of septic symptoms in the night following the operation. June 8th. — High fever, retching, and sharp abdominal pain were present, but no signs SPECIAL APPLICATION OF THE ASEPTIC METHOD. 145 of peritonitis could be made out. Twenty-nine hours after tlie operation the patient died in coma. Post-mortem examination revealed an abscess of the abdominal wall in the line of suture, and a grayish discoloration of the peritonaeum near the elastic liga- ture. A few drachms of turbid, bloody serum were found in Douglas's pouch. No sign of peritonitis. Investigation showed that during the operation tlie management of the sponges by the nurses had been a careless one ; that a too large number of persons were intrusted with the care of the sponges. The practical out- come of this experience was the order, that the sponges should be attended to by one person only, and that this person should always be the most experienced and responsible one of the available number. The preceding case shows that fatal septicemia may be induced by infec- tion of the peritonaeum, and yet purulent peritonitis may be absent. Per- haps there was not enough time for the development of peritonitis. Many rcqndly fatal cases, classed hy various surgeons under the heading of '^ shocTc,^' or " exhaustion,^^ ivould, on closer iyiquiry, turn out to he cases of acute septiccBmia. y. Nephrectomy hy abdominal section is clearly Justified in cases of de- generated movable kidney when the urine gives sufficient evidence of chronic pyonephrosis .with or without stone. Case. — Mrs. S. Weissenstein, aged forty-six. Noticed fourteen years ago a mova- ble painless lump in her right hypocliondrium. Since about nine months very acute symptoms of cystic trouble set in, and the lump became larger and painful. Constant desire to urinate, continuous fever, with occasional rigors, and large quantities of pus in the urine brought her to a very low state. A smooth, hard, kidney-shaped movable tumor of the size of a large man's fist could be felt in the right hypochondriac region. January 11, 1887. — Examination under chloroform. The left hidney could not he made out distinctly. The urine was scanty and acid, amounting to about twenty ounces per day, of the consistency of cream, and contained very large quantities of pus. Janu- ary 15th. — Abdominal nephrectomy at the German Hospital. The tumor being ex- posed, the hand was slipped into the left lumbar part of the peritoneal cavity, when the left hidney could he distinctly felt. After this the peritonaeum and its capsule were split along the whole anterior aspect of the enlarged kidney, and the organ was easily peeled out. A pedicle was formed of the ureter and vessels, and was tied off in two masses. After the removal of the tumor, the large retro-peritoneal cavity was carefully mopped out and loosely packed with strips of iodoformed gauze. These were brought out near the upper angle of the abdominal wound. The edges of the incision through the posterior lamella of the peritonaeum and the renal capsule were stitched to the peritoneal lining of the anterior abdominal wall. The outer wound was united in the usual way. The patient lost very little blood, but dui-ing the operation threatening heart- weakness necessitated the subcutaneous exhibition of camphor and whisky. She rallied pretty well, and passed some perfectly clear urine shortly after the operation. January 16th. — Temperature, 100° Fahr. Patient cheerful, and suffering very little pain. Urine continues clear and very concentrated. In the night several fainting- spells. The night nurse did not pay sufficient attention to tlie patient, who died in a fit of syncope early in the morning of January 17th. Post-mortem examination failed to show any morbid change aside from the abdominal wound, which was found dry, and just as fresh as at the time of the operation. With more untiring stimulation, the 146 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. patient might have survived. The enlarged right kidney had lost its textural charac- ter, and was converted into an irregular sinuous hag, containing six uratic stones of various sizes, surrounded by a quantity of pus. ('. Gastrostomy. — ImjmssaUe cicatricial stenosis of the oesophagus is a very strong indication for the establishment of a gastric fistula. Threat- ening starvation will be thus averted, and an opportunity will at the same time be created for attempting retrograde catheterism of the oesophagus, which may succeed. Case. — Hedwig Meyer, aged twenty-four. Cicatricial impassable stricture of the oesophagus twelve inches from incisors, caused by swallowing pure carbolic acid. Liquids only could be swallowed, with frequent regurgitations. Extreme emaciation. April 17, 1886. — Gastrostomy at the German Hospital. Immediately below and par- allel with the left costal arch, an incision of two and a half inches exposed the perito- naeum. After stanching the slight haemorrhage, the peritonaeum was incised, and tlie edges of the pei-itoneal incision were taken up by four artery forceps. The left lobe of the liver was found presenting. This being pushed aside, the anterior wall of the empty stomach came in view, and was withdrawn from the wound with a pair of thumb-forceps. The cardiac portion of the organ was drawn well into the wound, and was transfixed with a Peaslee's needle to prevent its slipping back. The peritoneal covering of the stomach was stitched to the everted edges of the parietal peritonteum by two tiers of interrupted silk sutures. The artery forceps were of very great service in securing the apposition of broad peritoneal surfaces. The external wound was packed with iodoformized gauze, and dressed antiseptically. No reaction following, the packing was removed on April 20th, and the Peaslee's needle was withdrawn. After this an incision one half inch long was made into the stomach, and a short piece of stout drainage-tube snugly fitting into the aperture was placed in the stomach, and was secured from slipping in by a large safety-pin. Its opening was closed by a cork stopper. Previous to this the lips of the mucous membrane were stitched to the outer skin. From this date on daily attempts were made to pass the stricture with a sound, introduced into the oesophagus from below, through the gastric wound. May 13th. — Dr. Bachmann, the house-surgeon, succeeded in passing from below an elastic catheter armed with a mandrel through the stricture. Milk injected into the catheter made its appearance in the fauces. May IJ^tTi. — A small-sized sound was passed from above. Alimentation was carried on both artificially through the drainage-tube placed in the stomach, and by the mouth. Gradually, as the ability to swallow sohds returned, more and more food was taken by the mouth, and the drainage-tube was withdrawn from the stomach. The gastric fistula closed spontaneously by the end of June. August 26th. — Patient was discharged, with directions to continue the use of the oesophageal bougie. In cases of cancer of the (esophagus, gastrostomy does not yield favorable results. Of six cases, mostly men past middle age, and all presenting the picture of more or less extreme emaciation, five died in a few (all within twelve) hours after the operation. The slight depression of the heart's action by anaesthesia was sufficient to induce fatal collapse. The sixth case sur- vived the operation for thirty-two days, but was losing ground steadily m spite of artificial feeding by the tube placed in the stomach. A great deal of difficulty was experienced in this case on account of the considerable leakage that was taking place alongside of the tube. Apparently the incision had SPECIAL APPLICATION OF THE ASEPTIC METHOD. 147 been made too large, and gastric juice was escaping in varying quantities into the dressings. Tiie gradual emaciation and Unal dissolution were in a great measure due to this constant loss of albuminoid substances. The outer dressings of a gastrostomy wound are arranged in the follow- ing manner : A split compress of iodoformized gauze, similar to that used in tracheotomy dressings, is slipj)ed in under the safety-pin holding the drainage-tube, and is arranged around the same. A piece of rubber tissue, or sheet rubber, somewhat larger than the gauze compress, is provided with a not too large slit in its middle, which then is also slipped on the end of the tube by being jiassed first over one, then over the other end of the pin. The rubber should fit snugly to the tube. Over this is laid a succession of two or more sublimate-gauze compresses of increasing size, each pro- vided with a slit for the passage of the corked-uji end of the rubber tube. The safety-pin, which Avas underpadded by the iodoformed gauze and rub- ber sheet, is covered up by the subsequent comj)resses, which are snugly bandaged to the trunk. Over the outer bandage another apron of rubber tissue is pinned, the rubber tube projecting from a slit in its middle. ■ The object of this is to j^rotect the bandage from soiling by regurgitant food. Feeding is to be done at first in short intervals ; later on, larger quan- tities of food can be introduced m four daily doses. d. Colotomy. — Eectal obstruction, most commonly by syphilis or cancer, is an accepted indication for the establishment of an artificial anus, either in the groin or in the loin. Lumbar and inguinal colotomy each has special advantages and drawbacks, the consideration of which must determine the choice of the method preferable in a given case. While lumbar section is extra-peritoneal, nevertheless injury to the peritonaeum is very apt to occur; finding of the colon is not easy ; sometimes it is imjoossible without opening the peritoneum, notably when there is a well-developed mesocolon. The shape of the artificial anus after the lumbar operation is mostly excellent on account of the ample mass of tissues traversed by the fistula ; but the situa- tion of the aperture is unhandy, the patients generally requiring the aid of a second person for cleaning and dressing the artificial anus. Inguinal colotomy is a short and easy operation, and provides for an openmg located accessibly for the manipulations of the patient in cleaning and dressing the aperture. Its drawbacks are the necessity of incising the peritonaeum — a circumstance which has lost most of its terrors since the in- troduction of the aseptic method — and the tendency to troublesome prolapse of the intestinal mucous membrane. The latter difficulty can be overcome by a discreet proportioning of the external and intestinal openings. {a) Lumhar colotomy. — Finding of the posterior aspect of the colon is very much facilitated by insufflation of the thick gut. This can be done either by a bellows attached to a soft catheter passed in beyond the stricture, or by the similar employment of a siphon bottle filled with mineral water charged with carbonic acid. The mouth of the siphon is connected with the catheter by a piece of rubber tubing, then the siiDhon is inverted and the valve is opened. The carbonic-acid gas, collecting about the end of the 148 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. glass tube reaching to the bottom of the bottle, escapes into the gut, and pro- duces a visible bulging of the colon. When the stricture is impassable and inflation not practicable, recogni- tion of the colon may offer great difficulty. The landmarks are the kidney above, and the reflexion of the peritonaeum externally, but occasionally they are of little practical use. Case I. — Mrs. C. O., aged fifty-six. Very extensive far-gone cancer of the rectum with involvement of the uterus. The sti-icture was very long and impassable. June 25^ 1882. — Lumbar colotoray was attempted. Though the kidney and the reflexion of the peritonaeum were clearly discerned, the incision opened the peritonaeum, and the pro- truding gut turned out to be small intestine. The poor condition of the patient made further prolongation of anaesthesia undesirable, therefore the gut was attached to the skin and incised. The wound healed promptly, giviug much relief, but the patient died four weeks after the operation from emaciation, due in part to insufficient nutri- tion caused by the high position of the intestinal aperture. Post-mortem examination showed that the intestinal fistula was midway between the stomach and csecum. Case II. — Mrs. Mary Brunner, aged forty-three. August 23, 1885. — Lumbar coloto- my at Mount Sinai Hospital under ether. August 2Jf.th, 25th. — Acute lobar pneumonia of the entire right lung, to which the patient succumbed. The colotomy wound had closed by primary adhesion. Presumably the pneumonia was caused by the entrance of foul oral secretions into the right bronchus during tlie operation. [h) Inguinal colotomy. — A vertical incision is preferable to one parallel with Poupart's ligament. With the former, the fibers of the oblique muscles will be cut across their course and will retract, giving ample space for a clear insight and free manipulation. Asepticisni has to be maintained as in all abdominal operations mainly by scrupulous cleanliness. The peritongeum is sufficiently incised to grasp the presenting colon with the fingers for withdrawal, and its edges are secured with four artery -forceps. The gut will be known by its taeniae and the epiploic appendices. A loop about two inches in length is withdrawn, and its mesial and distal halves are stitched to each other in front and in the rear so as to cause the formation of a spur (a b, Fig. 120). The sutures are made with an ordinary straight sewing-needle, the suturing material being catgut No. 3. The stitches should include only the peritoneal covering of the intestine. The loop is then dropped back into the peritoneal incision, and its apex is stitched to the parietal peritonaeum all round with two tiers of catgut sutures. In doing this the parietal peritonaeum can be well everted / ^ \ \ by the artery-forceps attached to it, and a broad surface Fio. 120. — Fonna- of contact between it and the gut can be thus secured. ^^^xvl^'^^lxomy' J^inally, the gut is incised and the intestinal mucous mem- brane is sewed to the outer skin. To prevent prolapse of the mucous membrane, or leakage, the incision should not be made too large. The formation of the spur as suggested by Verneuil has this advan- tage, that fecal matter will not find its way into the lowest part of the rectum situated below the artificial anus, and thus painful and otherwise disagreeable regurgitation of faeces will be avoided. At the same time, secre- SPECIAL APPLICATION OF THE ASEPTIC METHOD. 149 tions forming in the distal section of the rectum will not be retained, but can escape through the fistula. The proposition of completely dividing the loop of extracted colon, sew- ing the upper end into the wound, and closing by suture and dropping back the distal end, is feasible, but is met by a serious objection. The stricture may lead to complete occlusion, and the secretions of an ulcerated cancer may so distend the closed gut as to lead to rupture of the sutured part and to fatal peritonitis. Case I. — Mary Steiger, aged fifty-nine. Extensive rectal cancer with a number of periproctitic abscesses causing profuse purulent discharge through the anus. Emaciat- ing hectic fever and distressing fecal retention. August 13, 1885. — Inguinal colotomy at the German Hospital. The thick gut was witlidrawn, and was closed with two ligatures of stout silk carried through the mesocolon by the point of a thumb-forceps. The peritoneal incision was covered with two flat sponges and the gut was cut through between the ligatures. A little fecal matter escaped and was caught by the sponges, whereupon they were changed. The open lumen of the gut was mopped out cleanly, and well irrigated with Thiersch's solution. After this the distal end of the gut was closed by two tiers of Lembert sutures made with catgut, and was returned to" the abdominal cavity. The peritoneal layer of the mesial end was stitched to the parietal peritonteum and the mucous membrane to the outer skin. The patient rallied well from the operation, but the high fever and profuse discharge from the anus continued. August 18th. — Tte patient died under septic symptoms. On autopsy, the wound was found healed by the first intention, likewise the sutured distal end of the gut. The ])eriton8eum was normal, but a very large retro-peritonael abscess, communicating with the rectal pouch above tlie cancer, extended high up along the front of the sacrum, and contained a large quantity of extremely fetid pus. Case II. — John Barnett, clerk, aged fifty. Inoperable cancer of lower end of rectum. November 15, 1886. — Inguinal colotomy with formation of spur at Mount Sinai Hospital. November 22d. — Stitches that were not absorbed, removed. Funnel-shaped artificial anus, no prolapse of gut. August 10, 1887. — Wears, with comfort, a r.mall hollow rubber ball over the fistula. Case III. — Stephen Y., government official, aged sixty-one. Far-gone rectal cancer, with involvement of the prostate and old strictures of the pendulous part of the urethra. Noteinber 15, 1886. — Inguinal colotomy with formation of spur at Mount Sinai Hospital under ether. November 16th. — Lobular pneumonia, probably caused by aspiration of mucus during the anaesthesia. By November 25th, the acute febrile symptoms had subsided, but profuse purulent sputa were continually expectorated. The bladder also caused much trouble, although the tight strictures had been well dilated. The urine contained much pus, later on blood, coming from the ulcerated portion of the cancer occupying the neck of the bladder. The colotomy wound healed kindly, and a satisfactory artificial anus had been secured. The chronic bronchial catarrh, fetid cystitis, and later pyelo-nephritis, however, hastened the death t)f the patient, which occurred on December 23d. Xn. HYDROCELE, VARICOCELE, AND CASTRATION. 1. Hydrops of the tunica vaginalis of the testis is either an essential disorder per se, or is symptomatic of some acute or chronic affection of the testicle. If it be produced by acute epididymitis and orchitis, it is transient ; 21 150 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. but if its cause is tuberculosis, or cancer, or syphilis of the testicle, it assumes the character of a chronic complaint. For the sake of a correct prognosis the recognition of secondary hydrocele is important, as it is im- probable that, brought on by these affections of the testicle, hydrocele can be cured by either tapping and injection or the radical operation. If the hydrocele is very tense, preliminary tapping is advisable, in order to afford an opportunity for estimating the condition of the testicle. Should this be found rugged, swollen, and hard, it is very doubtful that measures directed to the cure of the effusion will be successful, unless the condition of the testicle be improved by appropriate treatment. Gummy swellings will usually disappear under antisyphilitic medication, and with them the hydrocele. Tuberculosis and cancer, on the other hand, will require castration. The cure of simple hydrocele by tapping and suhsequent injection \f\i]i tincture of iodine or pure carbolic acid is safe, and is generally followed by cure. The only caution to be taken is a proper disinfection of the trocar or cannula to be used, by either boiling in carbolized lotion (five per cent), or by heating the instrument in an alcohol-flame. Care must also be exercised not to leave behind in the sac too large a quantity of the tincture of iodine, as there is on record a case of acute iodine-poisoning brought on by that circumstance. Volkmann^s radical operation is also safe, and offers the best chances of a permanent cure ; but it necessitates longer confinenent of the patient than the preceding method. The author has performed this operation suc- cessfully thirty-two times on thirty-one patients, and no serious disturbance was ever observed during the course of healing. In each case cure was complete in from two to three weeks, and was permanent. Lately the operation was done with the aid of local anaesthesia by cocaine. The procedure is as follows : The penis and scrotum are shaved, scrubbed off, and disinfected. A rubber band or drainage-tube is tied about the root of the penis and scrotum, and about twenty minims of a five-per-cent solution of cocaine are injected along the prospective line of incision. The skin and dartos are incised for about two inches, and the exposed tunica is opened. A ^Tiiustra'tkig'^oiT grooved director is slipped into the sac, which is then mann's operation gij^ open, this incision being somewhat shorter than the for hydrocele. ^ ^, . -, ,_ •l^ cutaneous one. The sac is mopped out with a sponge dipped in a five-per-cent solution of carbolic acid. After this the tunica is stitched to the skin by a continuous suture of fine catgut. A small drain- age-tube is inserted and secured from slipping in by transfixion with a safety-pin. The constricting rubber band is removed, and the scrotum is held compressed between two sponges for a few minutes to stanch any pos- sible hgemorrhage. A small strip of disinfected rubber tissue is laid on the wound, which is enveloped, together with the entire scrotum, in a dry dress- SPECIAL APPLICATION OF THE ASEPTIC METHOD. 151 ing, held, down by a roller baudage applied in the manner described in the paragraph on herniotomy. (Fig. 121.) The dressings are changed on the tenth day after the operation. On the second day the movement of the bowels is attended to by enema or laxa- tive. On changing the dressings the patient can be permitted to get up and to exercise moderately. The wound is dressed with a stri^D of iodoformed gauze until it is healed. 2. Varicocele of a moderate degree is best treated according to Keyes's plan, which consists of subcutaneous ligature of the distended veins with catgut. The scrotum being cocainized, the cord is separated from the vari- cose veins, and is held in the grasp of the thumb and index of the left hand, the patient standing during the procedure. A straight Peaslee's needle, armed with a loop of silk, is thrust through the scrotum from in front until its eye appears behind the scrotum. The left hand releasing its grasp is used for placing the ends of a medium-sized thread of catgut into the loop of silk, which is then pulled through forward and out of the anterior punct- ure-hole, and the catgut is released from the silken loop. Now the left hand grasps again the scrotum, and the needle is reinserted exactly into the anterior puncture-hole, and carried around the varices externally to them, and close to the scrotal integument backward, until it emerges exactly from the posterior puncture. The other end of the catgut thread is then taken up by the loop of silk, and is brought out through the anterior aperture by withdrawing the needle. Both ends of the ligature are now seen emerging from the anterior puncture-hole. They are tightly knotted, cut off short, and disappear in the scrotum as soon as released. A slight amount of hard swelling will appear around the jolace of ligature the next day, but will not cause sufficient discomfort to prevent the j)atient from attending to his avo- cation. The author has employed this method with the best success in four cases. Extensive varicocele can be cured only by free exposure, double ligature, and excision of the dilated veins. Under aseptic precautions this measure is free from danger. Case. — Emil Luhning, baker, aged twenty-one. Large varicocele of the left side, extending down to the middle of the inner aspect of tlie thigh. April 25^ 1882. — At the German Hospital the scrotal varices were exposed by incision, and a large plexus was separated and tied above and below. The intervening veins were exsected. Another incision of eight inches in length exposed the varicose veins extending down the thigh, and they were also exsected after being secured by double ligature. A rather wide strip of attenuated skin had to be removed along with the veins, prevent- ing entire closure of the femoral wound by suture. Uninterrupted cure of the scrotal wound by primary union of the femoral one by granulation. June 22d. — Patient was discharged cured. Four more somewhat less extensive cases were treated in a similar man- ner, and all healed by the first intention. Care must be taken not to remove all the veins of the pampiniform 152 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. plexus. In the authors sixth case necrosis of the testicle was caused by too extensive excision of the dilated veins. Case. — -Joseph Stern, baker, aged twenty-two. Extensive varicocele of the left side. March 17, 1886. — Excision of varices at the German Hospital. March 27th. — Necrosis of testicle was noted. A few of the stitches had given way, and the yellow- ish, discolored testis was distinctly visible. Ajml 8th.. — The testicle came away with very moderate sero-purulent secretion. April 26th. — Patient was discharged cured. 3. Castration is indicated by neoplasms, tuberculosis, or syphilis of the testicle, in the latter case, however, only when the disease is not amenable to systemic treatment, and is a source of much suffering. The author^ s procedure for ca&tration is as follows : The patient's geni- tal region is shaved, scrubbed with soap and hot water, and disinfected with corrosive-sublimate lotion, or, if any open ulcer or fistula be present, these are finally syringed or touched up with an eight-per-cent solution of chloride of zinc. First, the seminal cord is exposed well above the diseased testicle, and, being separated, is taken up by the index of the left hand. The ves- sels composing it are successively grasped by separate artery-forceps, while the vas deferens remains intact. As soon as all the vessels are thus secured, they are nipped off one after the other with the scissors in front of the artery-forceps, and are at once tied. The vas deferens is cut through. Before being released, the mesial end of the severed cord is somewhat relaxed and carefully inspected, to see whether all bleeding be stanched or not. By making the division of the cord the first step of the operation, the subsequent parts of the procedure are made decidedly less bloody. Dissec- tion of the testicle proper is much easier and more rapid than if the reverse order is observed, and the stump of the cord serving as a convenient handle, contact of the surgeon's fingers with ulcerating surfaces or fistulas can altogether be avoided. A few more ligatures will be generally needed along the bottom of the scrotum. A drainage-tube is inserted, extending from the inguinal ring down to the lower angle of the cutaneous incision, and then the wound is united by interrupted catgut sutures, the edges of the cut being held pinched up by the fingers in passing the stitches. A dressing similar to that used after herniotomy is applied and left on generally for eight or ten days. The tube is removed with the first dressing. Tying of the cord in mass saves a little time in operating, but the stump generally necroses, and cure is very much delayed by the slow process of its detachment. Castration was performed by the author twenty times ; in fifteen cases for tuberculosis. One of these cases died of croupous pneumonia, probably induced by ether ansesthesia. Case. — Moses II., merchant, aged sixty. Jamiary 24, 1887. — Castration for tuber- culosis of right testicle at Mount Sinai Hospital under ether. The operation did not pre- sent anything unusual, and the patient did well after it until two o'clock on the after- noon of January 26tli, when suddenly high fever with dyspnoea appeared, and developed into coma within a few hours. Al v. m. the thermometer indicated 106-7° Fahr. in SPECIAL APPLICATION OF THE ASEPTIC METHOD. 153 the rectum ; at 9'55 p. m. the patient died. Dullness at the base of the right lung, made out a few hours before death, corresponded to an area of fresh lobar pneumonia found at the autopsy. The wound, peritoneal cavity, and kidneys were normal. Fourteen eases castrated for tuberculosis all recovered. In one case castration was done for syphilitic gumma of the left testicle of five years' standing, which had remained uninfluenced by various kinds of constitutional treatment. Case. — John W. G., brewer, aged thirty-eiglit. Large hydrocele caused by chronic specific disease of the testicle. March J^^ 1887. — The hydrocele was incised, and the testicle was found very much enlarged ; the rugged and hard epididymis was occupied by a solid fibrous mass extending weU into the glandular tissue of the testicle. Cas- tration was at once done. March 15th. — Patient discharged nearly cured, the place of exit for the drainage-tube presenting a small spot of granulations. In two cases ablation of the testicle had to be done for malignant neo- plasm. They recovered. Case I. — Jacob Praeger, tailor, aged seventy-two. Very large giant-cell sarcoma of right testis. Deceniber 4, 1879. — Castration. Preparation of the bowels by laxatives was insuflicient, and on the third day after the operation violent colic developed, which could not be controlled by opiates. In the night a large stool escaped into tlie bed, the dressings and the wound were soiled, and in a few hours fever set in. The wound was injected wifh an eight-per-cent solution of chloride of zinc, which checked the fever. Much sloughing tissue came away, but patient recovered, and was discharged cured about five weeks after the operation. The author's experience in this case taught him the valuable lesson of never trusting the patients' statement regarding the action of their howels, and never leaving the manner of preparation of the intestine to their judg- ment. In this case the patient assured the author that citrate of magnesia acted on him like a charm. Citrate of magnesia was taken, with the result reported above. Had a good dose of oil or calomel raked out the flaccid and coprostatic gut of the old man before the operation, his life would not have been endangered by subsequent fecal infection of the wound. Case II. — Siegmund Hertz, clerk, aged thirty-two. August 24, i555.— Castration of right testicle for myxosarcoma at Mount Sinai Hospital. Primary union. Septem- ber 15th. — Patient discharged cured. Tioice castration teas done for spontaneous gangrene of the testicle. Both cases recovered. The record of one was lost ; that of the other is as follows : Case. — George Otto, butcher, aged thirty-nine, admitted, February 2, 1880, to German Hospital with an enormous emphysematous swelling of the left testicle. The organ had nearly the size of a man's head, was dusky red and hot, showed crepitus, and gave tympanitic percussion-sound. The patient, a powerfully built man, showed symptoms of most acute septic intoxication. He stated, on being shaken out of his stupor, that the swelling had come on three days ago suddenly with much pain after a probatory puncture. Immediate ablation of the organ was done. The skin was pre- served, and the very large wound cavity was filled with a packing of carbolized gauze. An almost immediate improvement of the patient's general condition followed. The 151 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. wound healed rather rapidly hy granulation. February 26tTi. — Patient was discharged oured. Examination of the specimen showed bloody infarction of the testis and epi- didymis, with far-gone disintegration and softening of the tissues. The tunica and subcutaneous connective tissue were in a state of emphysematous gangrene. Xin. ASEPTIC OPERATIONS ON THE RECTUM. 1. General Observations. — The aseptic performance of rectal operations done for hemorrhoidal or other tumors requires a careful preparation of the gut. It consists, first, of the administration of a cathartic like castor-oil or calomel several days, in elderly subjects a week before the op- eration, followed up by the daily exhibi- tion of a saline laxa- tive, to be given on an empty stomach. Four hours before the time of the operation a large enema of soap-water is administered, and, as soon as it has acted. Fig. 122. — Lateral view of patient in Bozeman's position. a full dose of opium is given by mouth, or is introduced into the rectum in the shape of a suppository. When the anaesthetized patient is laid on the operating-table, a good- sized sponge attached to a stout silken thread is thrust well up the rectum, and, the sphincter bting thoroughly stretched by manual force, the anus and rectal pouch are flushed with a stream of corrosive-sublimate lotion (1 : 1,000) thrown from an irrigator. £* "-. ^*'^'^B| During the progress of the operation irrigation stantly at short inter- vals. When the perito- na3um is approached, or has to be invaded by the surgeon, Thiersch's solution is substituted for the mercuric lotion as an irrigating fluid.. 2. Haemorrhoids.— A varicose condition of the hgemorrhoidal veins of recent origin, caused by some dis- FiG. 123. — Posterior view of [latient in Bozeman's position. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 155 turbance of the i)ortiil circulation, in often amenable to general treatment by fulfilling the causal indication. Eemoving a fecal retention, or regu- lating the portal circulation with a dose of calomel, followed up by a course of Carlsbad salts, will often do away with the hgemorrhoids caused by these conditions. Or regulation of the heart's action by digitalis in valvular lesions will be followed by marked improvement. When the haemorrhoidal nodes are in a state of acute phlebitis, marked by painful hot swelling and fever, topical applications of cold in the shape of enemata of ice-water or iced compresses will give much relief. Aggravated cases, however, especially when there is a state of prolaj^se of the mucous membrane of the anus, can be cured only by operative meas- ures. Of all operations for the cure of haemorrhoids, that by ligature com- mends itself as the simplest and safest. This statement is based on an experience gathered from several hundred cases operated by the author according to various methods. The manner of procedure is as follows : The ansesthetized patient is brought either in the lithotomy position, with a hard cushion under his buttocks, or he is arranged in Bozeman's manner for the operation of vesico- vaginal fistula (Figs. 122 and 123). This latter position is especially use- ful where the* assistance needed for holding the patient in the lithotomy position can not be procured. In both cases the feet and legs of the patient should be protected from exposure by a wrapping of rubber sheets. These should be covered over with clean towels wrung out of mercuric lotion for the protection of the assistants' hands from contamination. Selecting the lithotomy position, the patient's palms should be brought in contact with his soles, and this relation should be secured by tight band- aging. The operator, well protected by a rubber apron, takes a seat in front of the patient, and proceeds to vigorously stretch the sphincter ani muscle with his thumbs inserted in the anus. As soon as the sphincter is paralyzed by stretching, the hgemorrhoidal nodes, external and internal, will spontane- ously protrude. A sponge secured with a thread of silk is thrust into the rectum, and the field of operation is cleansed by irrigation. The lowest node is grasped with an artery forceps, and, being well drawn out, is cir- cumscribed by a shallow incision made with a pair of curved scissors. A curved needle is taken, armed with a double thread of stout disinfected silk, and with it the base of the tumor is transfixed from without inward. The silk is cut near the needle, and, the threads being separated, the base of the node is tied in two portions. The node is cut off below the ligatures, and then the remaining nodes are attended to in a similar manner. When the operation is finished, some iodoform powder is rubbed into the nodal stumps, and, after a final irrigation, the sponge is withdrawn from the rectum, which is mopped out dry with another sponge attached to a long stick or sponge-holder. (Fig. 124, a and c.) A hollow tampon is next prepared by wrapping a few layers of iodoform- ized gauze around a piece of stout rubber tubing three inches long. This 156 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. is introduced into the rectum well beyond the sphincter, and its protruding end is transfixed with a large-sized safety-pin. (Fig. 125.) The object of this tampon is twofold. Its main object is to facilitate the escape of flatus, a circumstance highly appreciated by elderly flatulent individuals. Another purpose is the prevention of oozing from the stitch-holes. The anal region is thickly anointed with vaseline, and, the safety-pin being un- der-padded with a few strips of iodo- formized gauze, a large pad of corros- ive-sublimate gauze is held down to the anus by a T-band- age. (Fig. 136.) Forty-eight hours after the operation four ounces of sweet oil are injected into the rectum through the rubber tube, which can be withdrawn a short while after with very little pain to the patient. A large ene- ma of soap- water is at once administered, and generally is followed by an evacuation of the bowels. After the stool another small enema is given to cleanse the hsemorrhoidal stumps of adherent faeces. The anus is dressed with a strip of iodoformized gauze and a pad as before. The next morning a dose of salts is given, and, stool following, the rec- tum is again washed out afterward. This practice may have to be repeated once or twice within the next few days. The patient may be permitted to get up about ten days after the operation, but must remain at home till after the detachment of the ligatures. Cauterization with fuming nitric acid was formerly also much employed by the author ; but in one case almost fatal hgemorrhage occurred from a small artery just within the sphincter on the detachment of the eschar. Since then the author has abandoned this practice. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 157 Fig. 125. — Tampon-tube. Case. — Mr. M. P., gilder, nged thirty-one. Febru- ary 24, i55^.— Cauterization of external and internal liaBraorrboids with nitric acid. March 10th. — At 2 a. m. the author was hastily summoned to the bed-side of the patient, and found him in a collapsed condition. He reported that shortly after supper he felt a desire to stool, and had a copious evacuation. Evacuations followed since then about every hour, but, the closet being dark, he could not say whether the stools were bloody. At 1 a. m., on coming back to bed from the water-closet, the patient fainted. Being brought to bed, another stool followed, consisting of a large clot and some liquid blood. The patient was at once anaes- thetized, and, a speculum being inserted, a rather large- sized artery was seen spurting from where an eschar had been detached just inside of the sphincter. The vessel was seized and tied, and the patient made a good recovery. Langeiiheclc's clamp and actual cautery meth- od is very good and safe, its only drawback be- ing the necessity for a cautery apparatus. Care must be taken not to grasp with the clamp the nodes too near their base, as the resulting eschar is apt to be very large, and anal stricture may follow. The hollow tampon is very useful in this method also, and its use can be warmly recommended (Fig. 124, b). 3. Rectal Tu- mors. — Since the publication of Volk- mann's remarkable results achieved by extirpation of the rectum for cancer, the operation, for- merly condemned, has met with fre- quent imitation. The author's mel- ancholy record of six deaths out of eight operations has nothing to inspire great confidence. It must be said, however, that most of these operations were performed under very unfavorable conditions. All the patients presented instances of very extensive involvement of the gut, requiring in each case the removal of more than three inches — in one case, 22 Fig. 126. — T-bandaffe in ,iiti/. 158 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. nine inches — of intestine. Almost all of them were performed during the first years of the author's independent surgical activity, when his mastery of the difficult technique, both of the aseptics and hemostasis of the region in question, was imperfect. Much unnecessary haemorrhage was incurred, and several of the most important cautelae against infection remained unem- ployed. Accordingly, two patients died shortly after the operation of col- lapse, due to acute anaemia; two died of purulent peritonitis, caused by infection of the incised peritonaeum ; one died of septicaemia, induced by the presence of a large retroperitoneal abscess, extending far up in front of the vertebral column. One patient, a very fat, flabby woman, died of lobar pneumonia at a time when the wound was nearly healed. Two cases of very extensive removal of the rectum made a remarkably short and easy recovery. Case I. — Ed. Turner, mechanic, aged twenty -nine. Extensive soft adenoid cancer of the rectum, of rapid growth. The involved part of the gut was freely movable, although its upper limit could not be reached by the tip of tlie index-finger. Novem- 'ber ir*?, ISSJf. — Extirpation of the rectum at Mount Sinai Hospital. As the growth did not extend downward to within an inch of the sphincter, this muscle was pre- served. The coccyx was exposed by a posterior median incision, and was exsected. The mucous membrane of the lower end of the gut was dissected up in the shape of a cylinder, and was closed by a ligature to prevent the escape of rectal contents during tlie operation. Every vessel was immediately secured and tied, either at being cut or before division, if it could be previously recognized. The levator ani muscle was detached by dissection from the intestine. All resisting bands of tissue, mostly con- taining vessels, were secured by double mass ligatures before being divided. Most diffi- culty was met with in freeing the gut from its attachments to the deep pelvic fascia, but by dint of mass ligatures this was also overcome. As soon as the pelvic fascia was passed, the intestine readily yielded to traction, and was witlidi'awn until the upper limit of the tumor was distinctly felt through the walls of the gut. The peritoneeum was detached anteriorly by blunt separation, but it had to be incised on the posterior aspect of the rectum to permit complete removal of the growth. The gut was grasped with a large clamp-forceps about an inch above the tumor, and was severed. The patent orifice of the rectum was carefully cleansed and disinfected, and, the clamp being removed, a number of vessels of the rectal wall were secured and tied. During the whole operation the wound was almost constantly irrigated with corrosive-subli- mate lotion (1 : 2,500). The peritoneal incision being closed by catgut suture, the wound was loosely packed with iodoformized gauze after the insertion of two drain- age-tubes into its bottom, and the gut was attached to the skin by two silk sutures. The ends of the drainage-tubes were left projecting from the dressings, and the wound was flushed through them at regular intervals of an hour. The temperature remained normal except on the sixth day, when it rose to 103° Fahr. The patient complained of colicky pains, and a saline purge was administered. A stool following, the fever disappeared. The wound was carefully cleansed by irrigation after each stool, and liealed in spite of its great extent in six weeks. The removed portion of the gut meas- ured, when laid upon the table, just five inches. The resulting incontinence of the widely patent gut was remedied by a procto- plasty performed February 28, 1885, at the German Hospital. The divided ends of the preserved sphincter muscle were dissected (jut, and were united by a row of catgut stitches placed in the median line. In Ajjril, 1887, the patient was free from relapse. SPECIAL APPLICATION OF THE ASEPTIC METHOD. 159 Case II. — Eugene Ilaffner, waiter, aged twenty-four. Relapsing cancer of rectum after extiri)ation done by Dr. F. Lange. February 2J^^ 1887. — Extirpation of addi- tional two inches of the gut at the German Hospital. Peritona3um was found descended to within half an inch from the skin. It liad to be freely incised, and was subsequently closed by five catgut sutures. Uninterrupted recovery. April 2d. — Patient was dis- charged cured. Tlie niaiu source of infection is the interior of the gnt. To exclude this danger, the lower end of tlie rectum must be closed by a circular ligature. When the gut is divided above, care must be taken to prevent soiling of the wound by escaping intestinal contents. XIV. ASEPTICS OF THE BLADDER. 1. Catheterism, — Infectious processes rarely originate in the bladder itself. Their most common way of entrance is by the urethra from with- out ; next to this come the modes of infection from within — that is, by descent from the kidneys or by extension of contiguous septic processes from the organs located in the vicinity of the bladder, as for instance from peritoneal or retro-peritoneal suppurations. As before indicated, the most common source of infection of the bladder is an unclean catheter. The ordinary metliods of cleansing metallic catheters by flushing with hot or cold water, and subsequent rubbing off ivith a clean towel, are altogether inadequate. In order to secure their absolute cleanli- ness, the same processes of sterilization must be employed that were recom- mended for cleansing other hollow tubes — notably, aspirating needles and trocars. Boiling for an hour in water, or passing the instrument through an alcohol flame until all organic matter contained in its lumen is volatilized by burning, is meant thereby. Only after smoke and steam have ceased to escape from the catheter can it be declared to be surgically clean. Before use, the cleansed catheter should be placed in a tray or flat pan filled with tepid salt water (6 : 1,000, or one heaped teaspoonful to a quart of boiled water) ; the surgeon's hands should be previously well washed with soap and hot water, and the instrument should be anointed with iodoform- ized vaseline of the strength of 1 : 50 (fifteen grains to two ounces). Note. — The ordinary solutions of corrosive sublimate or cai-bolic acid corrode the mucous membrane of the urethra and bladder, often causing intense pain and reflex symptoms. The resulting denudations of the epithelial layer all may serve as portals of subsequent infection, manifesting itself in the form of urethral fever, urethritis, cystitis, and, in extreme cases, metastatic processes. None of these very active germicides should be introduced into the healthy urethra or bladder : first, because they are unnecessary ; and, secondly, because they may do harm. Simple immersion of a filthy catheter into these germicidal lotions will not dis. infect it sufficiently, and, if some of the strong solution be carried into the urinary passages along with a filthy catheter, the chances of infection will only be increased by the combination. Catheters that were immersed in strong disinfectant solutions should be freed from them before being used. In passing the instrument into the bladder for exploration or evacuation, the utmost gentleness should be exercised, not only for the sake of the 100 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. patient's comfort, but also because it is of importance not to injure the urethral mucous membrane. Certain parts of the normal male urethra will often raise obstacles to the passage of the instruments which should never be overcome by force, but only by patient and gentle manipulation. The first obstacle is usually met at the susi^ensory or triangular ligament. Holding the shank of the catheter parallel with the abdominal wall while gently extending the penis upward in the same direction, thus pulling the latter over the former like a glove-finger over a finger, will easily guide the beak of the catheter around the promontory formed by the inferior margin of the symphysis pubis. The second obstacle will be occasionally found in the sinus of the bulbous portion. This pitfall must be avoided by exerting digital pressure upon the perinaeum, and indirectly upon the beak of the catheter while gently depressing its handle. In sensitive urethrse, the compressor urethrge, or " cut-off " muscle, will offer by reflex contraction considerable resist- ance to the progress of the operation, especially if an instrument of small caliber be employed. It is injudicious to force this obstacle. A better plan is to abide the moment when the muscle will relax, the instrument being held against the resisting band by gentle pressure. As soon as relaxa- tion begins, the point of the catheter will be felt slipping through the contracted part of the urethra. The enlarged prostate is the last and most difficult, because deepest, impediment that may retard the operator. A long-beaked instrument will penetrate to the bladder easier than any other one. The handle of the catheter must be deeply depressed between the thighs of the patient, and, if this be insufficient, the tip of the left index introduced in the rectum must aid the entrance of the beak by gentle upward pressure. Properly performed catheterism of a healthy urethra and Madder should not he folloiued by hmmorrhage. Soft catheters made of gum elastic or webbing impregnated with resinous matter are never safe unless their history is known to the operator. They should be new, or, at least, such should never be employed that had been previously used on a septic case, or were not carefully cleansed, disin- fected, and preserved in a projoer manner after use. Soft gum-elastic or Nelaton catheters are very cheap, and need not be preserved after having been used in a septic case. Before employing a soft catheter, it must be soaked for ten minutes in hot soap-water and flushed out with it ; then it is disinfected with a strong germicide lotion, preferably corrosive sublimate, from which it must be freed again by another flushing with salt water before it is anointed with iodoformized vaseline for intro- duction. After use, the catheter should be again flushed out thoroughly with car- bolic or mercurial lotion, dried, and put away in a tight box or wide- mouthed bottle. If needed frequently, the catheter should be kept im- mersed in a two-per-cent carbolic lotion. Before use, however, the adherent carbolic lotion must be always removed by washing in salt water. The SPECIAL APPLICATION OF THE ASEPTIC METHOD. H',] author saw a considerable number of cases in which catheterism had to bo done for some time after rectal operations, and in which troublesome urethritis developed on account of the corrosion caused by frequent contact of the urethral mucous membrane with the carbolic acid adherent to the elastic catheter. Searching a non-dilated bladder for stone, tumors, or foreign bodies would lead to superficial injury of the mucous membrane ; therefore, dilata- tion, by injecting three or four ounces of salt water, should precede every exploration. After completion of the search, clots should be removed by irrigation with the saline solution. These remarks refer to bladders only that discharge normal urine. Whenever examination of the urine gives evidence of a catarrhal or septic condition, every intravesical manipulation must be preceded by disin- fection of the bladder by Thiersch's solution, or a lotion consisting of one part of permanganate of potash to five thousand parts of tepid water. The operation should be completed by another disinfecting irrigation of the organ. 2. Litholapaxy. — The rapid and complete evacuation of the bladder in one session, of all fragments produced by crushing concrements with a lithotrite, forms a most valuable improvement of the technique of lithotripsy. Bigelow's evacuator enables the surgeon to free the bladder at once of all sharp-edged fragments of stone. This circumstance justifies the prolonga- tion of the operation to an extent formerly considered unsafe, as subse- quent irritation caused by the presence of sharp fragments is thus done away with. Before introducing the lithotrite, strictures ought to be cut or divulsed, and the bladder ought to be thoroughly washed out with tepid permanganate- of-potash or boro-salicylic solution. After this the bladder is filled with from three to four ounces of tepid boro-salicylic lotion, and the lithotrite is introduced well anointed with iodoformized. vaseline. The penis is tightly deligated with a piece of rubber tubing, and the stone, being grasped, is crushed first into a number of larger, and subsequently into as many small fragments as possible. The crushing instrument is removed and is replaced by the evacuating catheter, which is connected with the evacuating bulb, that was previously filled with boro-salicylic lotion. All small fragments are next sucked out of the bladder by the apparatus. Should a peculiar click indicate the fact that one or more fragments, too large to pass the catheter, are still remaining, the lithotrite must be introduced anew to com- plete their reduction to a proper size, after which complete evacuation will meet no difficulty. The bladder is washed out again until the irrigating fluid returns free from blood, and the patient is brought to bed. Small stones, especially of the softer varieties, are eminently suited for this treatment, which has the great advantage of a short convalescence ; hut its disadvantage of a possible relapse from failure to remove all frag- ments can not be denied. 162 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Case I. — Moritz Witzkal, peddler, aged fifty. April 5, 188J^. — Litholapasy at the German Hospital. Uratic stone with phosphatic shell weighing four drachms fifty- five grains. Duration of operation, thirty-five minutes. Discharged April 28th. In June, patient was readmitted for stone, which was removed hy Dr. Adler by median lithotomy. Case II. — Mr. E. B., clerk, aged twenty-one, renal colic followed hy symptoms of stone in the bladder, which was diagnosticated by sounding. In March, 1887, lithot- rity and evacuation. The bladder symptoms continued until June, when Dr. Schede, of Hamburg, removed another small calculus. The author performed litholapaxy in four more cases. Case III. — Edward Mink, baker, aged twenty-one. January 26, 1881. — Eapid lithotrity for a phosphatic calculus weighing two hundred and fifty grains. March 5th. — Patient discharged cured. Case IV. — Henry Bowitz, agent, aged forty. ApTil 2]j., 1881^. — Litholapaxy for uratic calculus, weighing three drachms and ten grains, at Mount Sinai Hospital. May 10th. — Patient discharged cured. Case V. — Francis Johnson, druggist, aged forty-seven. Phosphatic calculus, ammoniacal urine. October 6, 1883. — Rapid lithotrity at Mount Sinai Hospital. "Weight of stone, forty seven grains. Duration, fifty -five minutes. Discharged cured, October 27th. Case VI. — Philip Prinz, shoemaker, aged fifty-nine. Rapid lithotrity for small uratic calculus, done January 25, 1887, at German Hospital. On the day following the operation all the symptoms of stone disappeared, but the patient sustained a burn of the legs requiring surgical treatment. This delayed his discharge until March 17th. Intense forms of cystitis caused by the presence of calculi require after lithotrity continued treatment of the bladder by irrigation. 3. Cystotomy. — In perineal as well as in suprapubic cystotomy, the con- dition of the urine should serve as a guide in determining whether aseptic or antiseptic measures have to be observed during the operation. When the normal condition of the urine indicates that the vesical mucous membrane is in a healthy state, strong disinfecting solutions should not be used within the bladder, and the surgeon's chief attention should be directed to the care- ful cleansing of his instruments, in order to avoid the introduction of filth into the bladder. For purposes of filling and cleansing, a saline or Thiersch's solution will be all sufficient. In cases characterized by pyuria, with or without ammoniacal odor, or with outright fetidity of the urine, disinfection of the bladder must precede and follow each operation. The rules of asepticism referring to the treatment of the external wound must also be scrupulously observed. During the after-treatment, drainage of the bladder may be required, especially in cases where a septic condition of the organ would render retention of fetid urine undesirable or risky. A rather stout rubber drainage-tube inserted in the bladder will answer every practical purpose. (rt) Perineal Section : Case I. — Fred. Kurtz, aged fifty-five. Phosphatic stone, ammoniacal urine. Feb- ruary 1, 1881. — Lateral lithotomy at the German Hospital, Weight of stone, three SPECIAL APPLICATION OF THE ASEPTIC METHOD. 163 drachms and forty grains. No reaction or fever. Continued washings of bladder with salicylic-acid solutions. April 10th. — Discharged cured. Case II. — Hugo Liedtke, aged three and a half. Small uratic stone. March 19, 1881. — Lateral lithotomy with the assistance of the family attendant, Dr. Hassloch. Weight of stone, eighteen grains. April 15th. — Discharged cured. Fjg. 127. — Arrangeiucnt oi' ptitiunt I'or iieriueal cystotomy, i'uet wni2")iiC'd up in disinfected towels. (b) SuPEAPUBic Section. — Tumors, a very large prostate, encysted or very large stones, oxalic concrements, or rebellious cystic haemorrhage from dilated veins of the neck of the bladder, indicate the selection of the high operation. Petersen and Garson's proposition to distend both bladder and rectum before cutting, marks a most valuable improvement of the method, as injury to the anterior reflection of the peritonaeum can be thus avoided. A soft rubber bag, or "colpeurynter," similar to Barnes's dilator, is intro- duced into the rectum, and is filled with from fifteen to eighteen ounces of water. Escape of the water is prevented by attaching an artery forceps to the end of the tube. Seven or eight ounces of tepid salt water or boro-salicylic lotion are injected into the bladder, and the penis is tied with a piece of rubber tub- ing. The patient's shaved suprapubic region is carefully disinfected, and a median incision is made, commencing about three inches above, and ex- tending to the symphysis. The recti muscles are separated, and the pre- vesical fat is incised. Care must he taken not to injure the reflexion of the peritonceum, which may he looked for in the upper angle of the wound. In many cases the peritonaeum will not come in view at all. Should distention of the rectum and bladder not suffice to push up and out of the way the peritoneal fold, this must be separated from the bladder by blunt dissection, to be done preferably by the tips of the fingers. Vessels crossing the pre- vesical space should be divided between double ligatures. The bladder is transfixed on each side of the median line with curved needles, carrying fillets of silk. The vesical incision is made between these 164 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. hold-fasts with a sharp-pointed bistoury. In cases of doubt, the presen ting- organ may be first punctured with a hypodermic needle. While the silken threads keep the vesical wound patulous, the surgeon's finger explores the interior of the bladder. Stones are then extracted with forceps, or the scoop, or even with the fingers, tumors are inspected and excised under the guidance of the eye, and bleeding varices of the neck of the bladder are grasped and tied off or touched with the thermo-cautery. After thorough irrigation, a T-shaped drainage-tube (Fig. 138) is inserted in the bladder, and the external wound is loosely packed with iodoformized gauze. A split compress of the same material is ar- ranged about the projecting end of the tube, and is covered with a number of compresses consisting of corrosive-sublimate gauze. The skin all around the wound is profusely anointed with iodoformized vase- line, and the dressings are held down by a few turns of a roller-bandage. The patient is brought to bed, and is laid on his side upon a circular air-cushion, his back being supported by a number of cushions held up by the backs of several chairs, or by boards stuck into the side of the bed. As the lateral posi- tion has to be maintained for three days at least, sides should be changed every two or three hours. The drainage-tube projecting from the dressings is connected with a longer tube, that is led into a urinal placed alongside the patient in or out of bed. As soon as the urine ceases to be bloody, and its reaction becomes acid, the patient may be allowed to assume the supine posture. The drainage-tube can be re- moved on the fifth day, when the wound will be usu- ally found in a state of healthy granulation. The packing of iodoformized gauze has to be continued as long as urine escapes through the wound. As soon as urination per vias naturales is re-established, the wound should be dressed as any other superficial wound. Case I. — Martin Gyr, laborer, aged fifty. Large oxalic calculi of ten years' stand- ing, with undilatable bladder. Wretched general condition. April W, iS56.— Supra- pubic lithotomy at the German Hospital under chloroform, which was preferred to ether on account of the presence of casts in the urine. Two immovable stones were found occupying the contracted bladder. They were grasped, freed by rotation, and extracted one after the other. They showed on extraction two freshly broken sur- faces, corresponding to as many pedicle-like projections, branching into two diverti- cles, each containing a separate calculus. One of these calculi was extracted, the othei- and smaller one was left behind, as the patient's poor condition verging on collapse did not justify continuation of the operation. The patient did not rally from the col- lapse, and died three hours after the completion of the lithotomy. The suprapubic incision gave free access to the bladder, and enabled the author to conduct the search and extraction of the calculi under the guid- FiG. 128.— T-shaped drain- age-tube for suprapubic cystotomy. ( Trende- lenburg. ) SPECIAL APPLICATION OF THE ASEPTIC METHOD. 165 ance of the eye. Removal or even the finding of the encysted calculi would have been utterly impossible from a perineal wound. Weight of calculi, one ounce, five drachms, and twenty grains. Case II. — Mr. Adolph "W., plumber, aged fiftj-six. Vesical trouble of three years' standing. Urine slightly acid, turbid, containing much pus, but no casts. March 30^ 1887. — Exploration of the very irritable bladder with the stone-searcher yielded no positive result. April 18, 1887. — On exploration in ether anassthesia, stone was found. A Thompson lithotrite being introduced, a large stone was grasped, and on rotation was felt to grind against another calculus. Suprapubic lithotomy. Extraction of three stones, each weighing about forty-three grammes, their aggregate weight being four ounces and three gi-ains Troy weight. Ajjril 20th. — Temperature, 100"5° Fahr. ; urine clear, acid, containing no blood ; its daily quantity eighty ounces. April 23(L. — Patient was allowed to occupy the supine position. April 25th. — The drainage-tube was with- drawn and the packing removed. A soft catheter was introduced by the urethra, and the bladder was irrigated through it. The catheter was left in the bladder; the ex- ternal wound was repacked. Temperature, 98'5° Fahr. May 1st. — Thrombosis of right femoral vein, apparently due to defective circulation caused by confinement. Tlie right lower extremity enormously increased in size. Treatment : Elevated post- ure; later on, moist packing, and elastic compression by Martin's bandage. May 25th. — Lithotomy wound nearly closed ; passed some water through urethra. June Jfth. — Lithotomy wound closed; urination normal. Patient up and about most of the time; oedema of thigh fast diminishing. June 20th. — Swelling of thigh almost gone ; patient dischai'ged cured. July 25th. — General condition excellent. Patient entirely recov- ered. Case III. — Mr. Meyer B., liveryman, aged thirty-nine. Symptoms of very acute cystic catarrh of four months' duration, causing the loss of fifty pounds of flesh. Almost constant desire of and very painful micturition, the acid urine containing blood, pus, some mucus, uric acid, and osalate-of-lime crystals. The prostate was very painful on touch, but not appreciably enlarged. The patient had become morphi- ophagous, and was thoroughly demoralized. Stone was searched for unsuccessfully by a surgeon. June 17, 1886. — Suprapubic cystotomy at Mount Sinai Hospital. No stone was found, but the mucous membrane of the bladder presented a most marked state of hypersemia and thickening, profusely bleeding at the slightest touch. The inflammation was most pronounced about the trigonum and the neck of the bladder, where the reddening and tendency to htemorrhage were most intense. Trendelen- burg's T-shaped drainage-tube was inserted, and the case was treated in the lateral position. The cystic irritation ceased at once, the blood and pus in the urine dimin- islied, and morphine was discontinued. July 17th. — The patient was removed to his home, where he made a rapid and perfect recovery. In March, 1887, a slight degree of catarrh of the neck of the bladder was cured by irrigation with permanganate-of- potash lotion. The patient remained well ever since then. 23 PART II. ANTISEPSIS. CHAPTER VI. NATURAL HISTORY OF IDIOPATHIC SUPPURATION. SUPPURATION. TREATMENT OF I. THE CAUSE OF SUPPURATION OR PHLEGMON. It would far transcend the limits of these essays to enter into a detailed presentation of all vegetable organisms known to lead a parasitic existence in the living human body. But a few glimpses into this new world of beings, more or less hostile to human health and life, may be welcome to the busy practitioner, who lacks time or opportunity for independent research. Rosenbach's classical investigations have revealed the fact that the most common source of suppuration is the implantation and thriving in the living human tissues of a minute globular fungus or micrococcus, called from the Fig. 129. — Microscopical as- pect of staphylococcus au- reus aad aibus. (Under the microscope their ap- pearance is identical.) (From Rosenbach.) Fig. 130. — Streptococcus pyogene (From Kosenbach.) ^♦8»ogfl»"* t Fig. 131. — Chain - coccus of erysipelas (Fehleisen). (From Eosenbach.) Fig. 132.— trescence bach.) Bacillus of pu- (From Eosen- 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, "Staphylococcus pyogenes aureus,'' or the golden grape-coccus. It is called grape-coccus {staphyle, grape) on account of the agminated or bunched arrangement of the single cocci that compose a colony. (Fig. 129.) 170 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 fungus 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 apj)earing 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 microscoj)e, 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 — Kosenbach's " Streptococcus pyogenes,^' ot: 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 peculiarity is to rapidly extend along the lymph-spaces and lymi^hatic 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 mori^hological 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 differ very distinctly in several important points (see Plate II, Figs. 4 and 5), but microscopically they can not be distinguished. 135. — Bacilli of putrefaction and divei'se 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 pyaemia by reflected light. (Prom Rosenbach.) NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 171 Xone of the pus-geneniting cocci cause what is commonly called putres- cence. Decomposition of tissties, accompanied by 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 septicaemia. (Figs. 132 and 133.) The accompanying 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- Fiq, ise.— Bacteria of blue pus (TOO diameters). (Koch.) cellence and truthfulness, a 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 P5^^ . :■ -■ ^-:'?-:"^': ^..-'n^T^'-^Li'- ..'l-V\.>»^.'| 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 sequels 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 kidney in pyelo-nephritis. In the center, urinary canal filled with cocci (700 diameters). (Koch.) 172 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. haemorrhage is very apt to dislodge and carry ofE particles of filth deposited in the wonnd 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 imi3ortance is, that wounds that bleed profusely generally come under the care of a jjliysician. 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 in contact with foul organic substances, and the injuring force will at the same time inoculate filth. No haemorrhage following, and the pain being insignificant, the matter is lightly passed over, and work proceeds without interruption. The cleansing effected by haemorrhage 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. Not all of these small injuries are infected from the beginning. They may and, as their frequent spontaneous healing proves, are often enough aseptic. As 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 reinjured, and infection by contact with foul matter follows, the consequence is sup- puration. Note. — Inflammatory 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. Slight injuries to the lips, tongue, buccal and faucial mucous membrane are very common. In most cases a profuse flow of saliva is instantly jiroduced by a painful injury, and, if haemorrhage 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., aged eiphteon, admitted to Mount Sinai Ilospita), 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 uiicfpial ])nrt.s. (Junshot perfora- Fig. 4. — Culture of chain-coccus from a ease of acute progressive gangrene. light. Fig. 5. — Chain-coccus of erysipelas (Fehleisen). Transmitted light. Fig. 6. — Chain-coccus of erysipelas by reflected light. (From Rosenbach.) Transmitted NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 173 tion of tlie ])illars of the fauces of the left side ; gunshot wound of the posterior pharyn- geal wall, tbe point of entrance situated Just bacl< of the faucial ])iilars of the left side, about an inch and a quarter from the median line, all of tliese 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 hasmorrhage from the tongue, and also a stream of arterial blood fi-om the pharyngeal wound. The latter being in close vicinity to the left internal carotid artery, the left common carotid was tied at once as a preventive measure, mainly with a view to the possibility of subsequent suppuration and second- ary hjBinorrhage. The perfect condition of the teetli and oral mucous membrane was noted. The lingual wound was lightly rubbed over with a small sponge dipped in iodoform-powder ; the pharyngeal wound teas 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 slight, and both the operation wound and the gunshot wound on the forehead, being redressed on December 15th, 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 foul from putrid processes accompany- ing an acute 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 hfemorrhage. A probing of similar wounds without a clear and necessary object in view is cdways a dangerous and invariably useless step, and should be refrained from under almost all circumstances. We 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 entrance of possibly fetid oral mucus into the narrow wound. Next 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. III. ENTRANCE, PROGRESS, AND LOCALIZATION OF THE INFECTION. As long as the integrity of the epidermis is preserved, 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 24 174 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. epidermis. This may be explained by the fact that slight injuries of the mucous lining are i)roduced 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 ha?morrhage, 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 punctured wounds the infective agents are very often deeply inoculated with the jDoint of the injuring article — that is, they are at once deposited in close vicinity to deejJ-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 v^ill undoubtedly empty the adjacent lymphatics centerward, their action being aptly comparable to that of a force-pump. What was formerly denoted as external mechanical irritation is nothing but this forcing 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 periosteum, 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 by which it traveled. Fig. 138. -Bacilli of antlirax and streptococcus (700 diameters). (Koch.) Plato III. Fia. 7.— Mixed culture of golden and lemon colored and of white grape-coccus from a case of empyaemia. Reflected light. Fig. 8.— Common organism of putrescence. Bacillus saprogenes. Reflected light. Fig. 9.— Bacillus saprogenes from a focus of septic compound fracture. Septicfemia. Reflected light. (From Rosenbach.) NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 175 The varying intensity of the infection, dependent on hitherto nnknown and varying fermentative qualities of different cultures of micro-organisms, will also greatly influence the rapidity and virulence of the inflammatory process. So much is well established that the intensity of the infection depends, ^r^'^, on the virulence of the invading culture of bacteria ; secondly, on the quantity of fungi absorbed ; and, thirdly, on the i)ower of resist- ance — that is, the state of health of the invaded organism. Mechanical Irritation. — Mechanical irritation ly 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 suppuratio7i unless infectious substances — 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 muscle, 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 287.) 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 astonisliment 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 under the skin. Why did it not cause suppuration ? Apparently the blade must have been newly ground, 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 structure was gradually invaded by granulation tissue — disintegration and final absorption follow- ing after a while, proportionate to the density of the implanted bodies. In 176 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. cases where the ordinary asei^tic measures liad been omitted, septic purulent peritonitis followed as a rule. Note. — The most remarkable of Dr. H. Tillmaim's experiments (Yirchow's " Archiv," Bd. Ixxviii, IS'TQ) is that concerning a rabbit, in the abdomen of which an entire rabbit's kidney was deposited without causing any harm whatever. The animal being killed forty-seven days after the operation, the implanted kidney was 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. Tliis 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 sufficient 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 cautelse 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 folloio- 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. f " Archiv fiir klin. Chirurgie," vol. xxxii, p. 500. \ Prize es.say, Berlin University, "Zeitschr. fiir klin. ]\lcd.," 1885, vol. x, p. 158. NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 177 tcr, and from the eschar and exudations in severer forms, no suppuration will follow. The modern use of the thermo-cautery in the peritoneal cavity, in joints, and, as 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 employed. 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 decomposing action of the presence of micro- organisms is excluded by proper measures. The behavior of superficial lurns of the skin is fully in accord with the facts Just presented. If a bleb be raised, and is left unbroken and dry, its contents will be absorbed, and the epidermis will settle back into its normal relation to the cutis. It will turn into a dry scale, and will peel off within ten to twelve days, exposing the tender new epidermis. 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 ! If the surgeon do not emj^loy timely disinfection and the application of a protective dressing, suppuration of the exposed cutis, witli all its accompaniment of pain, long-continued granulation, and a very tardy healing, will follow. IV. DEVELOPMENT OF PHLEGMON. From the moment that a sufficient quantity of active fungi have estab- lished themselves within the living tissues, remarkable local and general phenomena develop, known under the name of inflammatioji and septic fever. Our object is not research into, but rather a lucid explanation of, the essence of inflammation, as understood and accepted by contemporary au- thorities. Hence a brief sketch of the leading features of the process is deemed sufficient. Micrococci find a most favorable pabulum in dead or devitalized organic substances. The living tissues offer a decided resistance to the ravages of the micro-organism. The spontaneous 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 undecomposed albuminoid substances. As soon as the supply of dead animal tissue is exhausted, 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 fresh cadavers or animal substances in the recent stages of putrescence are much more infectious than those that are in a progressed state of decomposition. The varying intensity of different cases of infection seems to dej)end in a great measure upon the varying degrees 178 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. of vitality of ditferent 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 '^umps 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 by 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 ptomaines, 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 hypercemia, "rubor.'''' S €. #J^ Fig. 13'.». — Bacilli of anthrax (Iw diameters). (Koch.) Fig. 140. — Formation of spores in anthrax bacilli (700 diameters). (Koch.) The Ijlood 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 impermeability, and a number of white and often red -blood-corpuscles emigrate into the surrounding tissues, densely infiltrating their interstices, thus producing the characteristic sivelling, "turgor.'^ As a consequence of the increased blood-supply, possibly also of the active chemical i)roccss, 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. 1Y9 never absent, we have completed the classical cycle of the four cardinal sym])touis of inflammation — ''rubor, calor, 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 V)y 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 raj^idly 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 with lymph- serum, myriads of dead white blood -corpuscles (jius-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 exteiit 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, ^rs^, 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 parts 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 (fasciae, 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. ISO RULES OF ASEPTIC AND ANTISEPTIC SURGERY. As long as new areas of tissue become infected through 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 intervening substance being- discolored, i^ale, or more or less broken down and softened, or sloughed. In direct proportion with the spread of the infection and the multiplica- tion of suppurating foci, is the magnitude of necrosing areas, occasionally involving an entire limb. Organs of scanty vascularity, as, for instance, fascia?, 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 permeates all the adjacent parts, among others the lymphatics and thrombosed veins, forming a more or less effective harrier to the extension of the septic process and to the absorption of deleterious soluble substances into the general circulation. This self-limitation of the 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 matured abscess is generally followed by 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 I'ipen — 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 234. 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, 1885, with a very painful, hard, and massive swelling of the axillary contents, the skin being cedematous 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. ISl maines provoke constant or exploitive 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 piopagation. 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 granulations — 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 jjrocess. Note. — The notion that the law of gravity alone regulates the spread of abscesses is an erro- neous one, as it is *ell 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 difPerent 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 rapid death by explosive septicaemia. In these cases the microscope 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 182 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-develoj)ed pycemia, 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 he 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 pycemia 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 pyemia ; general furunculosis of trunk. '■^August 16, 1880. — Consultation with Dr. Gerster, who advised tonic treatment and daily full hatJis in vieak bichloride-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 Septembei", 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. H. 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 hath 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, first, 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 pressure 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 heai-t 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 HISTORY OF IDIOPATHIC SUPPURATION. 1S3 of lymi)liatics 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 dilference 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 sTceJeton 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. XoTE 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 t/ieir 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 it- 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 catarrhal 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. Reamputations, many joint exsections, almost all necrotomies, rarely give any 184 RULES 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 granulating 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 haemorrhage. 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. Granulations should ahvays be 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 phrase '^healing iy 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 iy it, hut in spite of it. The expression "laudable pus," as api)lied 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 Principles. 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 openings establish themselves, the damage to deep-seated DIAGNOSIS AND TREATMENT OF PHLEGMON. 185 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 propei'ly made incisions, folloioed 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 proper 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. {a) 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 clipping away their undermined edges with curved scissors. This can he done witliout 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. Streaks 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. (h) 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. 186 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 where the rapid spread of the affection and grave general symp- toms make prompt relief urgent, dilatory measures and cowardly tempor- izing are imjDroper. The cataplasm is resorted to not only to allay the patienfs pain 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, ansesthesia is always advisable, — in many cases indispensable. After the usual preparations for an anti- septic operation, a free incision should be made through the middle of the inflamed area, penetrating through the skin to tlie fascia. One or more small foci filled with pus will be thus opened. If their number be great, two or tliree more parallel incisions should be added. The engorgement or hard infiltration of the adjacent skin will be admirably re- moved by VolJcmami'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 <<( liiinl \\,r multiple puncture. (WilkMiaiiii.) DIAGNOSIS AND TREATMENT OF PHLEGMON. 187 dressinr/, held in place by loose turns of bandage, will comj)lete the work. An immediate fall of the tem})eratnre, 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, topical applications are in order. Cold, in the shaj)e 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 rheumatism. Drt/ 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 itiiti- 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 be 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 wafer, 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 special treatment of carbuncle, see page 210. Sulcutaneous 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 by 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 caviiy, 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 188 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 within. All 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 j^ressure causes the escape of new masses of pus, this is a sign that one or more recesses, communicating by small openings with the main cavity, remain U7idrained, 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. Fig. i42.-Hmon-E^er^s method of incising a rj^j^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. The squeezing out of abscess- es through an insufficient sjDon- taneous or artificial ojoening con- stitutes what may be called sur- gical barbarism. If the opening is too small or improperly placed, the abscess can never be drained 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 escajie til rough 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 ])roperly located artificial or spon- taneous opening supply the defect of drainage. Pio. 143.— Completed dressinfi of cervical abscess. DIAGNOSIS AND TKEx^TMENT OF PHLEGMON. 189 Fig. 144. -Underpadding of safety-pins thrust tliroutcli drainage- tubes after incision of ceiVtcal abscess. The best proof of the adequate treatment of an abscess is the fact that at change of dressings the cavity is found emjjty, 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 oedema 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. N^o 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 rapidly increasing dense infiltration characteristic of this condition. Relief from excessive tension is the first and most urgent indication, and this can be done 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. 2r. 190 RCTLES OF ASEPTIC AND ANTISEPTIC SURGERY. HiUon-Roser's method offers a safe and easy manner of evacuating these foci. Anfestliesia 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 possible. 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, which, 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. 191 Fig. 145. -Bacilli of malignant a?dema or acute progressive phlegmon (700 diameters). (Koch.) Gcmfircnoux phlcfimon (Pirogoff's ticute purulent oedema) represents one of the liigliost degrees of microbial ])oisoning, where the multiplication of the micro-organisms is so rapid and pervad- ing that the establish- ment of innumerable foci throughout all of the tissues composing a Avhole 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 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.) Em/phyfiematous Ga n- 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-coccuf< 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. Fig, 141). — -Bacilli of malisfnant oedema in the kidney (TOO diameters). (Koch.) 192 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. a dry tongue, foul bretith, 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 epiphysis, 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 erroneous 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 dispel 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 profound intoxication, mani- fested by very grave general symptoms. Cortical osteomyelitis, or what is known in text-books as suippurative 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, producing 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 anaemic 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 jjatella. Every bleeding DIAGNOSIS AND TREATMENT OF PHLEGMON. 193 vessel was carefully tied at once, and thus clear insight and much bloodsaving were effected. A large ulcerative defect of the periosteum was found corresponding to a well-circumscribed greenish-yellow spot of tlie tibia. This defect extended to the caj)- 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 lisemorrhage from entering branches was checked by packing with narrow strips of iodoformed gauze. A very tardy improvement followed these extensive measures. January 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, althougli the febrile disturbance had muchi 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 bursse, 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- 194 RULES OF ASEPTIC AND ANTISEPTIC SURGEEY. lary space in one or more places. So much is certain 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 tlie 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 angestbetized. 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 ilium of a very muscular man. Very intense sciatica and high 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 tbe affection, which until then bad 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 thie 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 epi])hysis of the femur ossify much later than the other epiphyses of tliese bones. Tlic active growtli and DIAGNOSIS AND TREATMENT OF PHLEGMON. 195 Fig. 147.- -Necrotomy of tibia. Leg placed on a hard cushion. Irrigator playing Irbm the right. abundant blood-,>^upi)ly near the knee-joint seem to favor the importation and deposition there of active micrococci circulating with the blood. Next in frequency of be- ing attacked is the lower jaw near the angle, and the upper end of the shaft of the hu- ^OTE. — Very likely the different gement of the nuti'ient vessels bones of the upper and lower eniities has a certain influence up- on the frequency of the location of osteomyelitis near the knee and shoul- der joints. The nutrient vessels of the femur and tibia diverge from, the knee -joint ; those of the humertis and the hones of the forearm converge toward 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 fistulae, 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 Anatomie," ISYO, p. 209. 196 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. 148. — Diagram of a transverse section, showing: relations of sequestrum, involu- erum, fistula, and skin. If the affection is extensive and no spontaneous or artificial relief is vonchsafed for a long period, a deep deterioration of the general health will follow, characterized by emaciation, Fi ace to heal by granulation, c, View of necrotomy wound treated according to Sehede'.s method. DIAGNOSIS AND TREATMENT OF PHLEGMON. 203 chisel. Previous to this tlie capsule of the knee-joint was carefully exposed to avoid entering the joint. The granular lining of the cavity vv^as 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- anguhir 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. Schede's 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 by skin commend it to the attention of the surgeon. The author found ISTeuber'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 9tJi. — 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. ■ 1 1 rj^B 1 k Fig. 160. — Anterior view of Frank IS'agengast's leg after com]ileted cui's. 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 t\\Q 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-haem- orrhage rather serious. It is, therefore, advisable not to deplete the limb by Fig. 161. — Lateral view Nagengast's leg :)f Frank 204 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. an elastic bandage of ail its blood before applying Esmarch's constriction. Each cut vessel will then pour out a small quantity of blood, and can be readily seen and deligated. The safest approach to the hone is from the external aspect, preferably above, or below the ham-strings. On the inner side, Hunter''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 the 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- oer of the entrance of blood into the respiratory tract, and facilitates complete and clean work. Fig. 102. — Illustratini; successive steps of Scliede's dressing, a, Necnitnuiy wound, b, Protect- ive, c, lodoforiiK'd jziiuze. i>, Sublimute frauze. e, ('om]ilete dressiii AI^TISEPTIO TEEATMEISTT 35 CHAPTER VIII. NATURAL HISTORY AND TREATMENT OF TUBERCULOSIS. I. ETIOLOGY OF TUBERCULOSIS. Koch's discovery of the specific bacillus of tuberculosis has brought about a recoustruction of pathological classification and nomenclature that commends itself by clearness and simplicity. Miliary tuberculosis of the lungs and other internal organs, scrofulous affections of the lymphatic glands, the various forms of surgical tuberculosis, as, for instance, white swelling and caries, finally the several forms of lupus, are manifestations of one and the sflme mor- bid process — namely, of cellular decay caused by the deleterious influence of a vegetable parasite, Koch's tubercle bacillus. The identity of this bacillus can be indubi- tably established by cer- tain modes of staining. 1^0 other known micro- organism will be affect- ed b}^ Koch's or Ehr- lich's mode of staining like the tubercle bacil- lus. It appears under the microscope as a blue, elongated body of the length of half a red blood-corpuscle, and is found occupying alone or in company with other individuals a giant cell generally located in the center of a fresh tubercle. {Figs. 191, 192, and 193.) The distribution of the tubercle bacillus is very unequal. It is found in large numbers where the invasion of the disease is recent, or where it is rapidly extending. It is very scanty in chronic affections like glandular scrofulosis or lupus. '►^^-£^ Fig. 191. — Miliary tubercles of lunsf, with central caseation (50 diameters). (Koch.) 264 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. ^^- « *t * ,;;?.. -X- %e 1^ ® f ^-^^._ m^ -f f>'"^~ •-S"i . •»;-* ~'^ -»-, stf ■ 3? ■ ^-.-- "<' •' m '-— "^ '" ' -- _ A- •. - m ^ .--- Fig. 192. — Part of one tubercle from foiegoing illustration. Bacilli interspersed between nu- clei (700 diameters). (Koch.) The peculiarity^ of the tubercle bacillus is to incorporate itself with a white blood-corpnscle, and to influence it in such a manner as to convert it into a lymphoid cell of somewhat large proportions. This cell becomes sessile in some part of the body. Alter a while new lymphoid cells appear in the vicinity of the first cell, which by this time will have grown to the proportions of a mul- tinnclear giant cell, containing a number of bacilli (Fig. 195). As the infection spreads along the pe- riphery, peculiar changes are seen to occur in the center of the nodule composed of lymphoid cells. The nuclei of the lymphoid and giant cells lose their staining capacity and coagulate into a granular mass. The bacilli contained within them dis- aj^pear, leaving behind, however, a crop of invisible spores that, trans- ferred to a suitable soil, will readily produce a new growth of bacilli. With the formation of this co- agulated mass of decayed cell-elements the process of caseation is estab- lished. The presence of this mass of necrosed tissue acts as an irritant upon the capillaries of the vicinity, and a wall of new-formed granulation tissue is thrown up around the focus. Should the infection of the neighbor- ing tissues occur before the protecting wall of new-formed granulation tissue is completed, exten- sive caseous infil- tration will be the result. The barrier of new-formed granu- lations is also liable, here and there, to invasion by bacilli, and therefore casea- tion will generally extend in a rather irregular manner. An increased ex- udation of blood- serum and white blood-corpuscles will finally bring about emulsification of the cheesy focus, which then represents the beginning of a cold abscess. Fl... llKj. -I'art of miliary tubercle from a case of basilar menin- gitis (Till/ diameters). (Koch.) ETIOLOGY OF TUBEECULOSIS. 2f;5 Fig. 194. — Giant cell containing bacilli taken from miliary tubercle (700 diameters). (Koch.) There is no organ of the human body that is exempt from the possibility of tuberculosis. The predisposition to infection by the ubiquitous spores of the bacillus of tuberculosis is manifestly increased by any kind of deterioration of local or general bodily vigor. Mal- nutrition, whether due to an at- tack of measles or the whooping- cough, or to a chronic catarrh of the infantile gut caused b}" improper nursing, or to long- continued suj^puration from an osteom3^elitic sequestrum, is, as a matter of actual observation, very often followed by local and general tuberculosis. The most common way of m- fection is undoubtedly that by the lungs. Catarrhal affections of the bronchial mucous mem- brane, regularly accompanied by superficial denudations of the epithelium, serve as portals for the entrance and implantation of the spores of the bacil- lus. And, as the deterioration of the general state of health after measles is combined with a catarrhal condition of the bronchi, infantile tuberculosis is most commonly acquired after this eruptive disease. For unknown reasons the pulmonary tissues of children do rarely become involved in serious tubercular trouble ; but the virus is promptly transmitted to the bronchial lymphatic glands (Fig. 195), which undergo casea- tion, and, on account of their close vicinity to the thoracic duct and. various vessels, serve as a depot for further distribution. We owe to Ponfick proof of the fact that perforation of a caseous focus into the thoracic duct may cause a more or less general dissemination of tuberculosis. Koch himself has demonstrated another manner of distribution in the involvement and caseation of arterial walls. But the most common way of systemic tubercu- lar infection was found by Weigert in the decay of the walls and perforation into the lumen of veins, which generally hold very intimate anatomical rela- tions to caseous glandular tumors. Entrance of small quantities of tubercular virus into the general circu- lation by the ways above indicated will lead to local tubercular affections of Fici. 195.— Giant cell, "n-itli radial arrangement of bacilli, from a caseous bronchial" gland (700 diameters). (Koch.) 266 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. various organs, as, for instance, the bones, testicle, or joints. Massive in- vasion, on the other hand, will cause fatal general miliary tuberculosis. Tulercular matter carried, along ly the circulating Mood is most apt to be arrested and to hecome sessile in the vicinity of the terininal arteries. The views expressed in the chapter on the localization of acute infectious osteomyelitis seem to be applicable also to the localization of the tubercular process. (Page 195.) Another rarer manner of tubercular infection is that by lesions of the skin. A Jewish circumciser suffering from pulmonary and faucial tuber- culosis, communi- cated the disease to twelve infants by sucking their preputial wounds. This used to be the accepted man- ner of stanching haemorrhage after ritual circumcision in former times. Note.— In 1879 the author was the victim of local tuberculosis of the pulp of the thumb, con- tracted by the infection of a small cut received during the amputation of a thigh for tuberculosis of the knee-joint, com- plicated with large tubercular abscesses of the thigh and of the medulla of the femur. A case- ating elevated ulcer of the thumb developed and persisted for six weeks. The complaint healed after the final detachment and expulsion of two caseous plugs. The dissemination of tubercular matter during surgical operations, done for the cure of the complaint, was first pointed out by Koenig, It is well known that death by general tuberculosis is seen to follow exsection of the hip-joint with especial frequency. Upon this circum- stance is based the statistically proved fact that the expectant or rather non-operative treatment of this complaint yields better results than an active operative therapy. Note. — These facts find a ready explanation in the circumstances under which most early exsections of the hip-joint are carried out. The depth of the diseased joint ; the diflSculty of liberating the head of the femur, still held down firmly by undestroyed ligaments ; the desire of operating subperiosteally, that is, with the employment of a good deal of blunt force ; the forci- ble manipulations in distending the edges of the deep wound by retractors — all serve to propel any freed caseous matter into the cut orifices of veins and lymphatics. The result is that, by the time the local tuberculosis combated by the surgeon is healed, the patient succumbs to meningeal or pulmonary tuberculosis, probably chargeable to operative interference. Fig. 196. — Giant cell containing one bacillus from Y'lg. 191 (700 diameters). (Koch.) TREATMENT OF TUBERCULOSIS. 267 II. COMPLICATION OF TUBERCULOSIS WITH PYOGENIC OR SUPPURATIVE INFECTION. Tubercular decay of tissues by caseation is a generally slow process, as long as the aifection remains subcutaneous — that is, occluded from access of air with its pyogenic organisms. But let a tubercular focus of the lung perforate into a bronchus, or let a group of caseous glands, or a cold abscess communicating with a distant focus of the spine or some joint, be opened without aseptic precautions, and the affection will have at once entered upon a new and more destructive phase. The formerly thin, flocculent dis- charge will assume a more purulent character, the production of pus will become prodigious, more or less fever will set in, and the symptoms of a rapidly progressive local destruction of tissue accompanied by hectic, will become more and more pronounced. A new infection was thus implanted upon a soil already impoverished by ill-nutrition and preyed upon by a destructive parasite. To the slow decay of tuberculosis, the rapidly disorganizing forces of purulent infection were added. The seriousness of this contingency was justly comprehended by old-time surgeons, who abhorred meddling with a cold abscess or any covert strumous affection. Incision of a cold abscess then meant purulent infection of the cavity, extending to the often inaccessible primary focus of the dis- ease, hectic fever, and rapid emaciation and decay of the patient. Just appreciation of these remarks will at once impress upon the mind the great necessity of aseptic measures in our operative dealings with tubercular affections. in. TREATMENT OF TUBERCULOSIS. General Principles. Considering the fact that about seventy per cent of all deaths are directly or indirectly caused by tuberculosis of various organs, principally consump- tion, and that the management of the infectious sputa of consumj)tives is careless in the extreme, it must be admitted that efforts at prevention offer no great hope of success. The sputa containing active bacilli or their spores are ejected on the ground or floor, dry there, and are converted into dust, which will penetrate everywhere and will cover everything with its deadly burden. The tent of the Indian and the palace of the millionaire are pene- trated alike by dust containing dried and pulverized sputa of consumptives, and millions of spores of pyogenic cocci, derived from suppurating wounds, the discharges of which are carelessly thrown every day upon the ground, to be whirled up from there by draughts of air. A more promising line of prevention can be cultivated in the proper nourishment and regime of the individual. The better the general con- dition of health, the fuller and more abundant the blood supply of this or that organ, the less the chance of its becoming the seat of tuberculosis. Or, 268 RULES OF ASEPTIC AND ANTISEPTIC SURaERY. if passing conditions of anaemia caused by illness or loss of blood have led to the establishment of a tubercular focus, raising of the general health by proper diet and exercise in the pure air of the sea or of high mountains, will check and often wholly eliminate the ravages of the disease. A generous diet, with plenty of exercise in the open air, is the l)est preventive and sys- temic curative of tuberculosis. To the observance of scrupulous cleanliness in the household and in our per social habits must also be acceded a great protective, and in sotne measure a curative influence. Local Treatment of Tuberculosis. Knowledge of the true nature of the various forms of surgical tubercu- losis has led to a clear understanding of the principles governing its suc- cessful treatment. Since we do not possess any therapeutic agent capable of destroying the bacillus of tuberculosis in situ, without interfering with the tissues that harbor it, chemical and mechanical influences must be brought to bear upon the tuberculous focus, with the object of destroying and removing all cell elements infested with the specific virus. In short, the modern treatment of local tuberculosis is identical with that accejjted for the cure of malignant new growths ; it consists in a more or less com- plete reinoval of the affected tissues or organs by caustics, the hnife, or the gouge, under aseptic precautions. 1. Cutaneous Tuberculosis. Lupus (Fig. 197). — Various chemical caus- tics, the actual cautery, and excision are known to effect a cure of cuta- neous tuberculosis. In- ternal medication has no effect upon it. The most destructive forms of lupus are those representing a complication of tubercu- losis with pyogenic infec- tion — as, for instance, lu- pus exedens. The miliary nodes nearest the surface caseate, break down, and perforate, and the way is open for the entrance of pus-generating cocci. Lupus of the face should be treated by caustics and scooping. The more radical treatment by ex- cision is not to be commended in facial lupus on account of the disfigure- ment it is apt to cause. Eelapses are frequent, and should be attacked over and over again as soon as they appear. Lupus of non-exposed jiarts of the skin should be cxsected. The following case demonstrates the identity of lupus and tuberculosis : /r ^ .^. m- jSk. _fe "'.rJ.^ fe' ii( 11j7. — Section of lupous i fistula in ana. Simple slitting up of these fistulous tracks, lined with caseous granulations, and often dotted with miliary tubercle, will not accomplish their cure. Every nook and recess of the fistula must be carefully ex]Dlored, and all caseous or granular matter must be removed by vigorous scooping and, if need be, excision. A thorough-going operation will always be followed by improvement, and in not too extensive cases by local cure. Tuberculosis of the urethra and bladder is a most distressing complaint, and is hardly amenable to any form of treatment. Sedatives and, in cases where the affection of the neck of the bladder renders life intolerable on account of the unceasing painful strangury, median perineal cystotomy, fol- lowed by drainage, are indicated. A common sequel of urethral tuberculosis is caseous epididymitis and orchitis. Testicular tuberculosis caused by urethral disease is generally bilateral. Single tuberculosis of the testicle, on the other hand, is gener- ally of embolic origin. Its sovereign remedy is castration. 3. Tuberculosis of Lymphatic Glands, or Scrofula (Fig. 198). — Caseous chronic lymphadenitis is one of the most common affections of childhood and adolescence. Its foundations are generally laid by chronic affections of the oral, nasal, and aural mucous membranes, by tubercular affections of the cervical Tertebrse, and by lupus and eczema of the face and scalp. The incipient stages 36 270 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. of the trouble can sometimes be controlled by timely attention to the causal disorders, an appropriate general treatment, and the local application of one or another pre^Daration containing iodine in the shape of an ointment. As soon as caseation has been well established, general and topical treat- ment of the milder sort will be of no avail. The modern therapy of scrofulous lymphatic glands is dominated by the idea that they are not only the cause of present discomfort and suf- fering to the patient, but especially that within them is contained the seed for renewed infection, which by its dissemination through the circulation may cause other local affections or a fatal general malady. The close ana- tomical relation of most lymphatic glands to important venous trunks or their immediate affluents renders their early attachment by inflammatory deposit very easy. Cheesy degeneration will ultimately reach the wall of the vein itself, and dissemina- tion of the tubercular virus through the circulation is the result. The surgical therapy of cheesy lymphadenitis will have to be varied according to the stage of the dis- ease, the chief object being always thorough removal or destruction of all infected tissues. Where there is central caseation only, and no fistula, nor an appre- ciable abscess, hodily excision of the glandular masses is most appro- priate. The neck being the most common seat of the trouble, a few words may be said regarding the detail of the operative treatment of scrofulous cervical glands. The incision should be ample, and, if the tumors be very exten- sive, the formation of a flap is advisable. The capsule of the uppermost gland being split, the glandular body is shelled out of its nest. This is much facilitated by an assistant's holding aside the detached capsule with a small, sharp retractor while the surgeon suitably changes the position of the mass by turning it one way, then another, until all the looser attach- ments are divided. Great care must be exercised herein not to lacerate or crush the brittle substance of the gland. Each gland has its afferent and efferent vessels, and these form a sort of pedicle, which must be tied off before it is cut. In cases of very extensive involvement of the cervical glands situated both in the vascular and intermuscular interspaces (see page 208), it is very advisable to cut the sterno-mastoid muscle across and in two. The spinal accessory nerve will be found near its posterior margin, and should be saved. Fig. 198. — Giaut cell coritaiuiuii' one bacillus from a scrofulous gland of the neck (700 diametersj. (Koch.) TREATMENT OF TUBERCULOSIS. 271 The stumps of the divided sterno-mastoid muscle are raised from their mesial attacliments, and one is turned up, the other is turned down. The otherwise difficult and even dangerous dissection of the glands from the vicinity of the large vessels is made much easier by the free exposure afforded by cutting the sterno-mastoid, which should be reunited by a number of catgut stitches after the completion of the exsection. The manner of placing the drainage-tubes, the suture, and dressings, do not differ from the usual arrangement. Before closing the wound, a thorough mojiping out with a strong solution (1 : 500) of corrosive subli- mate is necessary, to make sure of destroying all spores of tubercle bacilli that may have escaped with cheesy matter from accidentally injured glands. When dealing with progressed central cheesy abscesses of the cervical glands, a different course must be pursued. Incision of each abscess, fol- lowed by a thorough scooping away of all granulations and broken-down glandular tissue, is the proper treatment. The sharf spoon can and should be used rather vigorously, and no fear need be felt of injuring large vessels lying close by the walls of the abscesses, as there is a tough and thick wall of organized connective tissue interposed to protect them. A drainage-tube is to be inserted into each cavity. Caseous abscesses that have perforated spontaneously , or have been opened inadequately, generally lead to tubercular infection of the subcuta- neous tissue in the vicinity of the aperture. More or less extensive under- mining and bluish discoloration of the sTcin are the consequence. The un- dermined, irregular edges show very little tendency to heal ; they become inverted, and if healed, present an ill-shapen, uneven scar. To aid and hasten the inadequate efforts of Nature, it is necessary to extirpate or gonge out the glandular bodies, to trim away all the under- mined portions of skin with the curved scissors, payi7ig no regard to the ex- tent of the resulting ivound. However large the denudation, it will heal rapidly and kindly under Schede's dressing, and, on account of the mo- bility and abundance of the cervical integument, the resulting cicatrix will be nearly linear in shape. Note. — Glandular, cheesy abscesses on the necks of grown girls can be healed, without leaving a conspicuous scar, by repeated punctures with a stout aspirating-needle. The contents of the abscess being removed by aspiration, corrosive-sublimate lotion is injected through the cannula, and is again withdra\\"n. This is repeated until the lotion returns clear and limpid, when the cannula is taken out. The puncture-hole is protected by a drop of iodoformed collo- dion. The process is repeated whenever the abscess refills, until the cavity becomes closed. The author has cured two cases in this manner. 4. Tuberculosis of Tendinous Sheaths. — Weeping sinew or acute syno- vitis of the tendinous sheaths sometimes degenerates into a chronic affection of their synovial lining known under the name of proliferating hygroma. This rebellious affection is characterized by an elongated, fluctuating, irregular swelling of the carpal region. It is painless, but impedes the free use of the fingers. The swelling is due to a gelatinous thickening of the sheaths of the sinews. The tendons finally become adherent to the degen- 970, RULES OF ASEPTIC AND ANTISEPTIC SURGERY. erated mass, thus losing their free mobility. The sacs frequently contain some more or less discolored synovia; and sometimes a large number of rice- kernel-shaped concretions of fibrin. Fig. 199. — Group illustrating an exsection of tubercular tendinous sheaths of the palm. Topical applications make no impression upon this disorder, which can be cured only by free incision and methodical removal of the fibrinous bodies and the gelatinous sheaths by careful dissection in artificial anaemia. If the new growth extend underneath the transverse carpal ligament, and can not be got at otherwise, the ligament must be divided to permit thorough removal. The carpal ligament, fascia, and skin are united by several tiers of catgut sutures, a slit is left open at each, end of the incision, and a compressive Schede's dressing is applied to the arm and hand, which should be placed on a volar splint ex- tending to the line of the metacarpo-phalan- geal joints. The patient is directed to active- ly move Ids fingers from the second day on, and thus to fashion grooves in the blood-clot filling the interior of the wound, which are to become new tendinous sheaths after the substitution of the clot by new-formed con- nective tissue. (Figs. 199 and 200.) Case I. — Samuel H., medical student, aged twenty-five. Tubercular gelatinous synovitis of all extensors of right liand and of flexors of left hand. DecemherSO^ 1886. — Extirpation of diseased sheaths Yu.. iioM.- 1,11,, ~ .,1 iticisioii (in pal- of extensor tendons of riglit hand under Esmarch at mar and i)ed off easily with an elevator or Sayre's "oyster-knife," except at the site of the insertion of muscles, where the aid of the scalpel or a sharp rasi)atory must be accepted. The re-formation of the normal contour and function of the prospective joint depends in a great measure upon the preservation of the periosteum. With drainage by rubber tubes, an exact suture of the external wound, and Schede's modification of the aseptic dry dressing, the operation is com- pleted. Where Esmarch's constricting band was left m situ until the com- pletion of the dressings, these must be made rather ample, and a good deal of elastic pressure by snug bandaging must be brought to bear upon the wound to control oozing and soiling of the dressings. The dressed limb must be suspended or otherwise elevated in a vertical position until the hyperemia due to vascular paresis disappears. Care must be taken to ascer- tain, by the look of the tips of the toes or fingers, that circulation is not wholly cut off by strangulating compression of the bandage. Should the oozings penetrate the dressing in the course of a few hours, the soiled surface of the bandage must be thickly dusted with iodoform pow- der to favor exsiccation. A few compresses of sublimated gauze are placed over the bloody spots, and are secured by a few turns of a roller bandage. In case of continued oozing, further loss of blood can be checked by the temporary application of a Martin's elastic bandage over the dressings. If the soiling is too extensive to admit the use of such partial measures as those just indicated, the external compresses composing the dressing must be removed and replaced by clean ones. The deepest part of the dressing, hoioever, should not he disturhed. ~b. Aftee-Treatment. — Where, as for instance, in the elbow, mobility of the joint is aimed at, absolute fixation by splint should continue only so long as the drainage-tubes are withdrawn and the incisions are firmly healed. Passive, but especially early passive motions, so warmly recom- mended by older authors, are harmful, and not to be compared as regards their value with active exercises. The disadvantages of early passive motions can be summed up in this : Before the re-establishment of the normal condition of the tissues pertain- ing to an exsected joint — that is, before the disappearance of the swelling and rigidity of the soft parts — all motions, active and passive, will be pain- ful. Active motions will be limited to a harmless compass by the pain for- bidding extensive movements ; but passive motions, done without regard to the pain and struggles of the resisting patient, will be, and as a matter of fact often are, carried far beyond the limit of harmlessness. The forcible stretching and crushing together of the newly united parts and of the young connective tissue are inevitably followed by minute ruptures and lacerations. Eenewed exudation and a diffuse state of adhesive inflammation are set up, which will cause the persistence or even an increase of the painful swelling and induration primarily found about the exsected joint. The greater the surgeon's energy the worse the result, and in many cases anchylosis is brought on by the very measures intended to 2:)revent it. 37 278 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. If tli9 surgeon, on the other hand, patiently awaits the time of spontane- ous detumescence, which, with antiseptic measures and proper fixation, will occur at ahout the fourth or fifth week after the operation, gentle motions will cause no pain, and will encourage the patient to active exercise of the joint. The pain felt on excessive movement will serve as a wholesome check against undue zeal ; the improvement of nutrition due to active exer- cise will hasten the definitive involution of the inflammatory products. Thus, day by day will the strength and amplitude of the active movements be increased, and by dint of painless attrition new articular surfaces will be ground and polished into shape. The psychological and moral part of the after-treatment is of the greatest imjjortance here. The conviction that active movemefits of the exsected joint are possible without pain will inspire the patient with courage. Unceasing active exertion will work wonders, based upon the patient's confident expectation of a good final result. The acute pain produced by frequent and merciless passive motion, and the subsequent tenderness engendered by it, will convert the after-treatment to a source of constant terror and moral depression to the patient. His courage will be shattered, and no amount of persuasion or coercion will in- duce him to inflict pain upon himself by active movements. And it will be a lucky circumstance if the physician's illy conceived attempts at estab- lishing a normal function are frustrated at an early date by the patient's resistance. Subsequently, rest and the disappearance of local j)ain will naturally elicit first timid, later bolder, attempts at active movement, and after all, an unexpectedly good function may thus result. The aid afforded to Nature should be very discreet indeed, here as well as in other branches of surgery. Aside from active movements, massage and faradism are powerful aids in re-establishing normal circulation and lost mus- cular power. Special Part. a. Shoulder - JoiKT. — The application of arti- ficial angemia in exsection of the shoulder- joint is al- ways difficult and some- times entirely impracti- cable. After due cleans- ing and disinfection of the field of operation, the hand and forearm of the affected limb are envel- oped in a clean towel wrung out of mercuric lotion (Fig. 202), and, the rest of the body being well protected by rubber sheets and clean towels, an ample anterior incision is carried from midway between the acromion and l^'iG. 202. — Exsection of slioulder-johit. Head of humerus turned out of glenoid cavity. TREATMENT OF TUBERCULOSIS. 279 Fig. 203. -Exsection of shoulder-joint. Location of drainage on the posterior as23ect of the shoulder. the coracoid process down to the limit of the upper third of the humerus. The tendon of the long head of the biceps is held aside by a blunt hook. The capsular ligament and periosteum are raised from the bone by means of an elevator, or, where the insertions of the muscles offer greater resistance, by a sharp raspatory. This step will be very much facilitated by gradual inward and later by outward rotation of the humerus, to be done by an assistant holding the hand and bent elbow. After decapita- tion of tlie humerus, the capsule is to he exsected iy forceps and blunt scissors. This, the most diffi- cult part of the o])- eration, will be very easy if the primary incision is ample. If found diseased, the glenoid fossa is-thor- oughly scra^jed, and, a counter-incision being made at the posterior aspect of the joint, a drain- age-tube is inserted there. (Fig. 203.) The first incision is closed by several tiers of catgut sutures, and, the wound being dressed, the limb is bandaged to the thorax in a flexed position. Later on, an arm-sling will serve as an adequate support. (Figs. 204 and 205. ) The dressings are changed on the tenth day, when the drainage-tube can also be removed. In grown subjects the operation will generally result in a somewhat loose joint, lacking especially the power of active abduction. Case L— Anna Haupt, aged sixty. Large subdeltoid cold abscess; no fistula. May S5, 1879. — Exsection of right shoulder-joint at the German Hospital. Head of humerus bare of cartilage and carious ; caries of glenoid cavity. August 3d. — Discharged cured. Case II. — Willie Kunz, aged four. January S5, 1882. — Exsection of left shoulder-joint for cheesy osteitis of the head of humerus at the German Dis- pensary. March 10th. — Discharged cured. Cask III.— August Arnold, aged three and a half years. April 17, 1883.— 'Exsection of left shoulder- joint for caseous foci in the head of the humerus at the German Hos- pital. May 30th. — Discharged cured. Case IV. — Harry Gross, aged two. September 30, 1884- — Exsection of right shoulder-joint for caseous osteitis at Mount Sinai Hospital. Several relapses required •204. — First dressing after exsection of shoulder-joint. 280 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. 205 renewed scraping of the fungous granulations. January 15, 18S5. — Patient died of meningeal and peritoneal tuberculosis with ascites. Case V. — Carl Buchowsky, type-setter, aged twenty-eight. Synovial tubercu- losis of right shoulder-joint of six yeai's' standing; three tistulse. April £6, 1887. j — Exsection of the shoulder-joint at the "^ German Hospital. In May patient was discharged not cured, with two fistulse, but with a very fair prospect of an ulti- mate cure, the cause of his discharge be- ing a disciplinary breach of the rules of the hospital. l. Elbow. — The patient's shoul- der, hand, and part of his forearm are wrapped in clean towels soaked in corrosive-sublimate lotion. (Fig. 206.) The arm is vertically elevated for a few minutes, and elastic con- striction is applied to the humerus below the shoulder. Langenbeck's posterior longitudinal incision will give most space. (Fig. 207.) In denud- ing the internal epicondyle, injury of the ulnar nerve should be guarded against by closely hugging the bone with the instrument. The diseased portions of the bones being removed, the entire capsular ligament is ex- sected, care being taken not to overlook any cheesy foci. One or more drainage-tubes are inserted, preferably through pre-existing sinuses, and the incision is closed by catgut sutures. The region of the elbow is envel- oped in an ample Schede's dressing, held down by rather tight bandaging. The extended arm is fastened to a pair of lateral paste- board splints, and is kejjt in the vertical po- sition till the flushed appear- ance of the pro- jecting tips of the fingers due to vascular pa- ralysis has dis- Exscetion of cll)ow-joint. I'atient ready for operation. appeared. (Fig- 208.) Note. — The simplest way of makinf;; suitable pasteboard splints is by tearing them out of a sheet of pasteboard. (Fig. 209.) The advantage of tearing over cutting is in the circumstance that tlie edges of the torn splint are not abrupt and hard, hut become soft and thin on account of the gradual thinning of the torn edge. Snug adaptation and a good lit result therefrom. Care TREATMENT OF TUBERCULOSIS. 281 must be taken to ascertain first the trend of the fiber of the pasteboard, as the edge of the splint torn across the direction of the fiber will turn out uneven, and a splint thus made is apt to break. The dress- ings should be changed, and the drainage- tubes removed, a fortnight aft- er the exsection. The elbow is to be re-dressed and put up at the same angle. ' As soon as the drainage-holes are healed, passive, but especially active, exer- cises should commence, aided by massage and faradism applied to the muscles. After partial exsection of the joint, little lateral mobility will be observed. In these cases no special apparatus will be required. But where much lateral mobility, due to extensive removal of bones, is present, the use of an apini- ratus confining the movements of the joint to flexion and extension will be required. (Figs 212, 213. \ Fig. 207. — Posterior longitudinal nicision ot elbow-joint. Fig. 208. — Finished dressing and eleva- tion after exsection of elbow-joint. Ftg. 209.— Tearinif into of pasteboard splint. XoTE. — The apparatus can be Tuade by the surgeon without the aid of the instrument-maker in the following manner : Two strips of very light hoop-iron or sheet zinc, about one inch wide 2S2 KULES OF ASEPTIC AND ANTISEPTIC SURGERY. and from four to six inches long, are loosely riveted to each other at their ends, so as to form a hinge. Two pairs of such hinges are necessary. The patient's arm being protected by a few turns of a flannel bandage, a light silicate-of-soda wristlet and arm-band (Fig. 212) are applied. To these are fitted the hinges, one externally, the other internally, by giving their middle a suitable bend to allow for the expansion of the soft tissues on flexion of the joint (see front view). By Fig. 210. — Pattern for angular pasteboard splint. (Esmarch.) a few more turns of the silicate bandage, the hinges will become immured in the wristlet and arm-band. As soon as the splint is dry, it is split longitudinally on its anterior aspect, to per- mit its removal and further fitting. Shoe eyelets are put in along the edges of the longitudinal cuts for lacing. Two pairs of small-sized brass screw-eyes are let in on each side of the wristlet and arm-band, to serve for the attachment of solid rubber bands, which are to aid the efforts of the flexor muscles in bending the elbow. To prevent slipping down of the apparatus, a cap is made of a piece of sole-leather, softened in hot water, which is molded to the shoulder. It is left on till dry. A button is let into it to serve for suspending from it the apparatus by a short strap. Another strap slipped over this button is passed ai'ound the thorax of the patient, and is buckled in the opposite axilla. (Fig. 213.) Flexion and extension are to be done by the patient at regular intervals from six to eight times a day, by raising first an empty pail from the ground twenty or thirty times. The elbow flexed by the rubber bands is extended by the weight of the pail. As the strength Fig. 211. — Angular pasteboard splint in sitn. (Esmarch.) of the flexors improves, active flexion is to be tried, and the weight of the pail is to be gradu- ally increased by putting more and more sand or gravel into it. The apparatus is to be daily removed, for cleansing and the application of massage and faradism to the arm. The use of the apparatus can be abandoned with the disappearance of lateral mobility. The first of the nine cases of exsection of the elbow-joint performed by the author was done witliout aseptic precautions. Study of the history of this case and comparison with tlie other cases is earnestly recommended to the reader. TREATMENT OF TUBERCULOSIS. 283 Case I. — Jose[ili Keck, silk-weaver, aged tliirty-uine. Synoviiil tuberculosis of riglit elbow, with cold abscess situated beneath the supinators; no fistula. iJecemher 10, 1877. — Total exsection of the joint at the rooms of the patient without any aseptic precautions. Trochlea, ulna, and radius ca- ^\^ rious. Drainage, suture, and suspension in an interrupted wire s|)lint. Wound was dressed with a compress, to be kept moist by immersion in tepid water. The thermometer indicated 103° Fahr. on the evening of the same day, and never descended below this figure until December 24th. Frequently the temperature rose to 1(»5° Fahr, Decemher 13th. — Wound fetid, inflamed, suppurating; stitches were removed, whereupon the wound gaped open, and was seen to be covered with a thick, adherent coating. December 15th. — Great swelling and dusky appearance of cubital region. Incision of abscess near triceps tendon. Decemher 17th. — Rigor, elbow still more swollen. December 18th. — Rigor. December 19th. — Rigor and great debility. December 22d. — Rigor. December 2Ji.th. — Evacuation of another abscess from the upper angle of the wound, whereiipon the temperature fell to 99° Fahr., and the dusky swell- ing of the limb moderated. Apparently the fever was due to osteo- myelitis of the lower end of the humerus. December 25th. — Ery- sipelas set in, commencing from an abrasion caused by the splint. Temperature, 105° Fahr. December 29th. — Erysipelas extended to shoulder-joint, where it disappeared. March 10th. — Incised three abscesses of the forearm, wound granulating and contracting; re- moval of sequestrum of humerus. June Ufth. — Removal of six small sequestra from humerus. Active and passive movements com- menced. July 12th. — Flexion to 90°; extension normal. Sinuses were scraped in anesthesia. Lateral mobility diminishing. September 29th. — Api)lication of articulating apparatus. Oc- tober 30th. — Patient was dis- charged cured with normal flexion and extension, with limited pronation and supina- tion, and slight lateral mobil- ity. May., 1887. — Arm sound and quite useful, in spite of slight lateral mo- bility. Case II. — Hermann Prieg, laborer, aged thir- ty-eight. November 15, 1880. — Total exsection of elbow-joint at the German Hospital for syn- ovial fungous disease with fistula, under anti- septic precautions. Feverless course, primary union. February 27th. — The patient was dis- charged cured, with limited motion and no lat- eral mobility. Case III. — Lena Bois, aged twelve. March 14, 1882. — Partial exsection of elbow-joint for caseous ostitis of the olecranon, from which a sequestrum was removed at the German Hospital. April 30th. — Discharged cured with limited motion. Fig. 212.— Appara- tus for after-treat- ment of exsection of elbow-joint. Fig. 213. — Elbow-joint apparatus in position. 284 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Case IV. — Theodore Noirot, metal- woi'ker, aged twenty-eight. March 9^ 1882. — Total exsection of elbow-joint at the German Hospital for osseal tuberculosis of humerus, ulna, and radius. Primary union of the deep parts of the wound. May 9th. — Disciharged cured with almost perfect function of the new joint. C.vsE V. — Leonhard Path, aged seven. Cheesy tuberculosis of olecranon. October Slst. — Partial excision at Mount Sinai Hospital. Novemher 10th. — Discharged cured with limited motion, which improved somewhat in the course of the following six months. Case VI. — Luigi Martini. May S7, 1886. — Total exsection for osseal tuberculosis of humerus, ulna, and radius at the German Hospital. Primary union. June 6th.— Discharged cured with limited motion. Owing to neglect of the parents, who failed to present the boy for after-treatment, the joint became almost entirely stiff. Case VII. — Charles Dunninger, aged two and a half. A2}rU 2%, 1886. — Total ex- section for extensive osseal tuberculosis at the German Hospital. Primary union and ultimately excellent function. Discharged cured August 1st. The discharge was delayed by the inability of the parents to take care of the child. Case VIII. — Nathan Blumenbach, aged seven. Extensive osseal tuberculosis with several abscesses. February 9, 1886. — Incision and drainage of the abscesses, followed by severe chill and fever, very likely due to septic infection at the time of the incision. February 11th. — Total exsection at the Gennan Hospital, followed by prompt low- ering of the temperature from 105° Pahr. to 99° Pahr. Primary union. Marcli ll^th. — Discharged cured, with good function. Case IX. — Rudolph Boenke, aged twelve. Cheesy osteitis of olecranon vrith abscess. March 30th. — Partial excision. A shell of the olecranon adhering to the triceps tendon was preserved. Suture ; no drainage-tubes. April 12th. — Change of dressings; primary union. Elbow put up at a right angle. April IJ^th. — Passive motion ; fixation at an acute angle. Every few days passive motions were done., and the arm was put up at a different angle. This led to considerable irritation and dense oedema of the elbow, compelling cessation of the passive movements. The mistake made in the after-treatment was further emphasized by the detachment and expulsion of the necrosed remnant of the olecranon. Two fistulse discharging bloody serum remained open. May 30th. — The fistulse were scooped out with the sharp spoon. No improvement following, June 10th, the wound was reopened in ether anesthesia. Gelatinous infiltration of the soft parts surrounding the joint, tuberculosis of the radio- ulnar junction and caries of the resected bone-surfaces vv'ere found. Total exsection being performed, the arm was dressed and put up in a splint as usual, and remained undisturbed for five weelcs., after which active exercises were commenced. No passive movements were done at all. By August 1st., active flexion and extension were normal, and the arm had regained its power almost completely. c. Weist axd Hand. — Langeubeck's dorsal incision affords the most favorable approach to the radio-carpal as well as especially to the intercarpal and metacarpo-carpal joints. (Fig. 214.) With artificial angemia a very thorongh removal of the diseased bones and capsular ligaments can be done. The wound is drained and closed by catgut sutures, and, being inclosed in an aseptic Schede's dressing, the hand is fastened to a short volar splint of wood, loliicli nlumld not extend beyond the metacarpo-plialangeal joints. The patient is directed from the second day on to practice active motions of the fingers. This will achieve two good purposes. First, extreme atrophy of the muscles will be prevented ; and secondly, adhesions of the tendons TREATMENT OF TUBERCULOSIS. 285 Fig. 214.— Langenbeck's dorsal incision for exsection of wrist. and tendineal anchylosis will be avoided. The active movements, feeble and hardly perceptible at first, will become visibly stronger as the healing pro- gresses, and thus a very acceptable degree of usefulness of the hand may be regained. Case I. — Herman Ro- sengaiden, clerk, aged thirtj-four. June 7, 1882. — Total exsection of wrist at Mount Sinai Hospi- tal for synovial tubercu- losis with several fistulse. Primary union. August 7th. — Discharged cured. When leaving, he played on an accordion. Case II. — A woman, aged thirty-eight. Au- gust 25, 1885. — Total ex- section of left wrist at the German Hospital. Primary union. September 30th. — Discharged cured,"with moderate function. Case III. — Matthew Dempsey, laborer, aged twenty. June 22, 1885. — Total exsec- tion of wrist for osseal tuberculosis of carpal bones at Mount Sinai Hospital. Primary union and very fair function were secured. The discharge of the patient was delayed till the end of the year by several pulmonary hsemorrhages. Case IV. — Paul Klein, laborer, aged forty-one. February 25, 1886. — Total exsec- tion of wrist for osseal tuberculosis with several fistulse at the German Hospital. The patient was suffering from far-gone pulmonary phthisis. Primary union, but speedy relapse of tuberculosis in the interior of the wound and the cicatrix. April 11th. — Discharged not cured. Case V. — Max Friedmann, aged ten. April 4^^.— Partial excision of wrist-joint on account of csseous osteitis of styloid process of ulna, with involvement of the radio- ulnar and radio-carpal joints. Primary union. April 20th. — Discharged cured, with good function. Case VI. — Ferdinand Ohle, aged five and a half. March 22d. — Total exsection o± left wrist at the German Hospital for osseal tuberculosis. Wound healed by primary union. Patient remained in hospital for treatment of simultaneous tubercular disease of the knee-joint. d. Hip- JOINT. — The author's very limited experience in the op- erative treatment of hip-joint dis- ease, extending over three cases only, does not afford suflScient material to base any trustworthy conclu- sion upon. Moreover, Fig. 215.— Exsection of hip-.ioint. Position of patient. twO of the three CaSCS 38 286 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. 216.— Exsection of hiiJ-joint. Ar- rangement of pro- tective cloths. Fig. 217. — Completed dressing after hip-joint exsection. were, at the time of tlie operation, healed by anchylosis, as far as the affec- tion of the joint proper was concerned. They came under the author's care on account of tubercular processes located on the pelvic bones, requiring operative treatment. Case I. — Albert Gaiipp, aged thirteen. Anchylosed hip-joint; caseous ostitis of OS ilium with complicated sinuses and pelvic abscess. Avgust 12, 1882. — Incision and drainage of various sinus- es and of the pelvic abscess ; removal of a considerable portion of the ilinm and os pubis with mallet and chisel at the German Hospital, Jan. 21, 1555.— Discharged mucli improved. Case II. — Samuel Amster, aged ten. Tubercular coxitis, with sinus, of two years' duration. Decem- ber 3, 1885. — Exsection of hip-joint above the trochanters at Mount Si- nai Hospital. Removal of the ace- tabulum, wbich was found perfo- rated. After-treatment with weight extension. January 18 and 26, 1886. — Revisions of wound, on ac- count of the presence of exuberant granulations in the drainage-tracks. May 10th. — Discharged cured. In November the patient was readmit- ted on account of pelvic disease. A fistula had been established below the anterior-superior spine, leading to the inner aspect of the ilium. December 15th. — Three sequestra were removed by an incision made along the crest of the ilium. In June, 1887, the patient was dis- charged cured. Case HI. — John Renk, aged tliirty-nine. Anchylosis of right Fig. 218.— Exsection of hip- joint. Final result. Ante- rior view. (Di. F. Lange'.s case.) Fig. 219. — nip-joitit exsection. Lateral view. (Case of Dr. F. Lange.) TREATMENT OF TUBERCULOSIS. 287 hip-joint with shortening of limb, the result of hip disease contracted in childhood, which was treated orthopedically. No fistula. Tuberculous ostitis of ilium and adjoin- ing part of OS pubis. March 17, 1887. — At the German Hospital, exsection of great trochanter and remnant of neck of thigh as a means to gain access to the diseased focus. An abscess was opened in front of the joint, and, being followed up, led to a number of sequestra located at the juncture of ilium and os i)ubis, which were removed. The softened and broken-down walls of the cavity containing the sequestra were scraped and gouged. Drainage and suture of the wound. Uneventful course of healing. In August the patient was still under treatment. A sinus persisted at the site of the operation. The discharge was vei-y scanty and serous, however, promising early clos- ure. Anchylosis firm again. Patient walking without support. Cured October 1. e. Knee-joint. — White swelling of the knee-joint in adults of the laboring class can, for various external reasons, rarely be treated by ortho- pedic measures. In children, a rational mechanical and general treatment will often reward the patience and skill of the physician by excellent results. Exsection of the infantile knee-joint is to be avoided as long as possible, on account of the great shortening that is caused by the removal of the epi- physes adjoining the knee, on which depends the growth of the thigh and tibia. In adults exsection is the shortest and safest way of eliminating the tedious morbid process, and substituting firm anchylosis for a useless joint. ArtJiredomy, or exsection of the capsular ligament alone, as suggested by Volkmann, has not been attended with good success in the experience of the author. Two cases — one in an adult, the other in a child — resulted in relapse of the tubercular affection, although great care was taken in remov- ing the entire capsule. A third case was permanently cured. Case I. — S. Lindholm, metal-worker, aged twenty-seven. February 28, 1882. — ■ Arthrectomy and removal of the patella were done for fungous arthritis of the knee- joint. Primary union of wound followed. March 22d. — A relapse occurred in the cicatrix, which gradually involved the articular aspects of the femur and tibia. Amputation of the thigh was performed by Dr. I. Adler. Case II. — Fred. Ohle, aged five and a half. Tubercular arthritis of the knee-joint. January 26, 1887, — Arthrectomy was performed at the German Hospital.' March 22d. — Kevision and scraping of the entire cavity on account of tubercular relapse. In May the boy was still under treatment. Case III. — George Kuhn, butcher, aged twenty-six. July 6, 1882. — Arthrectomy and removal of carious patella was performed at the German Hospital. ISfoveiiiber 5th. — Discharged cured with slight mo- bility of joint. In children, exsection should be strictly limited to the re- moval of actually diseased parts of the bones. By Schede's plan of dressing the wound, the hollow space remaining be- Hahn's supra- tween the incongruent joint-surfaces will be filled up by an Fon^for^exsec- organiziug blood-clot, and firm union may be attained. tion of kuee- Case IV. — Eva Greenburg, aged eight. Osseal tuberculosis of the knee-joint with sequestrum in the external condyle ; granular ostitis of the internal condyle ; multiple cheesy deposits in the thickened capsule ; subluxation backward of 238 RULES OF ASEPTIC AND ANTISEPTIC SURaERY. the tibia with rectangular contraction, August IS, i5S(?.— Partial exsection of knee- joint at Mount Sinai Hospital. After the removal of the sequestrum, a deep recess was left behind in the intercondy- lar notch. Patella and entire cap- sule were removed ; the ham-string tendons were divided to prevent recontraction. The tibia was su- perficially pared, and the bones were held in apposition by a nail driven diagonally through femur and tibia. Plaster-of-Paris splint over a Schede's dressing. Several re- lapses in the popliteal space re- quired repeated scrapings. The pa- tient had one attack of erysipelas. By reason of these complications, cure was delayed. February S7, 1887. — Patient was discharged cured with firm anchylosis. Total exsection of the knee-joint is usually done by the author in the following manner : After careful shaving, scrubbing, and disinfec- tion of the region of the knee, the foot and leg and the thigh of the diseased clean Fig. 221. — Exsection of knee- joint. Exposure of articular planes. limb are wrapped in towels wrung out of corrosive- sublimate lotion. The limb is held elevated in the ver- tical position for five minutes to deplete its vessels, and the constricting elastic band is applied well up near the root of the thigh. The knee is flexed, and an incision, commencing at the middle of one condyle of the femur, and extending in a semicircular line above the patella to the middle of the other con- dyle, is carried into the joint. (Fig. 220. Note. — The transverse incision above the patella, proposed by Eugene Hahn, of Berlin, has many advantages over the incision made below the knee- pan. The chief one is the free access it affords to the bursa of the quadri- ceps, which must be carefully exsectcd along with the capsule. The crucial ligaments are cut close to their attachment to the femur, and the j)atella, semilunar cartilages, and entire capsule, together with tlie bursa of tlie quadriceps, are exsected with mouse-tooth forceps and curved scissors. Care must be taken not to overlook some small bursa? situated behind Fill. 2'J2. xsection _ ot knee - joint. A view of the sawed surfaces. • TREATMENT OF TUBERCULOSIS. 289 Fig. 223. — Steel iiui Fig. 224. — Exsection of knee-joint. view. Sutured wound. Anterior the head of the tibia, which regularly communicate with the interior of the joint. The condyles of the femur are sawed off, the plane of section correspond- ing to the transverse diameter of the epiphysis of the femur. (Fig. 222.) Note. — Disregard of tliis rule will lead to anchylosis in the bow-leg position. The articular as- pect of the tibia is sawed off at a right angle to the long- axis of this bone. All visible orifices of vessels are secured by ligature. They can be made visible by compress- ing the vicinity of the wound with both hands. If the transverse incision was not made long enough to permit of an easy arrangement of the drainage-tubes in the angles of the wound, it should be sufficiently lengthened. The inner ends of the tubes should reach into the popliteal space just behind the sawed surfaces, and the tubes must not be compressed and occluded by the tension of the soft parts surrounding them. The limb is placed upon a long cushion covered with a clean towel wrung out of corrosive-sublimate lotion, and, while the sawed surfaces are held in exact apposition, two or four long steel nails, previously well disinfected by heating in an alcohol flame, are driven diagonally through femur and tibia, so as to firmly lock the bones in the desired position. (See Fig. 79, page 84.) The cutaneous incision is united by a sufficient number of catgut stitches. The limb is raised by the foot from the cushion, which is then removed. Strips of disinfected rubber tissue are slipped under the safety-pins, securing the ends of the trimmed drainage-tubes, and an oblong compress of iodoformed gauze is laid over the entire line of union. A suit- 225. — Exsection of knee-joint. Sutured wound._ Lateral view. Heads of steel nails projecting from skin. 290 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. Fig. 226. — Immediate dressing of woimd after exsection of knee-joint. able number of sublimated gauze compresses are arranged around the knee- joint, and two short lateral splints of veneer or thin board are firmly band- aged on to serve as a deep support. (Figs. 226 and 227.) Over these comes an ample external dressing of corrosive- sublimate gauze, also firmly held down by a gauze bandage. The towels are removed, and the un- covered parts of the limb are enveloped in a layer of borated cotton to equalize the outline of the extremity. Two long, lateral, pasteboard splints, held down by a muslin or crino- line bandage, comj)lete the dress- ing for children or adolescents. (Fig. 228. ) The more voluminous limbs of adults are better secured by a solid circular plaster-of- Paris splint. The limb is vertically elevated, and the constricting rubber band is removed. Return of circulation is attested by the pink color of the toes. As soon as these turn pale, the extremity can be brought into the horizontal position. If asepticism was well maintained, little aseptic fever and no severe pain will follow the operation. The dressings should remain undisturbed for thirty days, to afford a good chance for bony union. After thirty days the splints and dressings can be removed, and the nails and drainage-tubes can be withdrawn. The remaining sinuses are to be dressed lightly, the limb is incased in a silicate-of-soda splint, and the patient is ordered to walk about on crutches, whether osseous union be present or not. Gradu- ally the use of crutches is dispensed with, and the patients generally learn to walk very well on __ an elevated sole, compensating the shortening. Of twelve cases of total ex- section done by the author for tuberculosis, eleven recovered. One died of meningeal tubercu- losis. Case I.— Fred. Fuchs, aged sev- en. Osseal relapsing tuberculosis after arthrectomy, done by Dr. F. Lange in June, 1885. March 4i 1884. — Total exsection, done at the German Hospital, reveals two periarticular abscesses and five cheesy foci in tibia and femur. Suppuration of wound. March 10th. — Incision of abscess on outer aspect of -Dec;p support of cxsc^e.tfd Ivnee-joint by .short lateral Ixiard s])lint.s. TREATMENT OF TUBERCULOSIS. 291 Fig. 228. — External long lateral pasteboard splints after exsec- tion of knee-joint, applied over complete dressing. knee. April ^.'?<^.— Separation of epiphysis of tibia. Separated epiphysis firmly united to femur. In April .symptoms of meningeal tuberculosis developed, to which patient succumbed May 31st. In one of the remaining eleven cases ampu- tation of the thigh became necessary on account of suppuration. Case II. — H. Desmond, professional athlete, aged tiiirty. Extensive destruction of right knee-joint by tuberculosis, complicated with pyogenic infection. The knee, leg, and thigh con- tain a large number of abscesses. Pro- fuse secretion from seven fistulse. The case was not suitable for exsection, and amputation was advised. But, at the patient's ur- gent request to make an attempt to save Ms limb, February 14, 1884, total exsection vras done at the German Hospital. As sup- puration was expected, the extremity was fixed to an interrupted dorsal suspension splint made of hoop-iron and plaster bandages. Profuse suppuration followed with evident prostration, and, April 19th, amputation of the thigh was performed. The wound healed by granulation, and in June patient was discharged cured. Ten cases were cured with preservation of the limb. In nine of these, firm bony anchylosis was secured. One case terminated in the formation of ligamentous union. Case I. — Niclas Gies, carpenter, aged fifty-four. Synovial tuberculosis with high temperatures and emaciation following a slight traumatism. Contraction of knee at an acute angle, with constant violent pain. February 19, 1886. — At the German Hos- pital, puncture yielded a small quantity of turbid bloody serum. In ansesthesia the limb was straightened, and the joint was incised, irrigated, and drained. The fever at once disappeared, but flocculent pus commenced to exude from the tubes, confirming the assumption of tuberculosis. In view of the patient's age, his wretched general condition, due partly to disease and to chronic alcoholism, amputation was thought to be advisable. The plan of operation was changed at the operating-table, and total exsection of the knee-joint was done. Hseraorrhagic synovitis and a large cheesy deposit in the bursa of the quadriceps were found. Five nails were employed, with an aseptic dressing and pasteboard splints. Temporary compression by Martin's elas- tic bandage was applied to control secondary oozing. Esmarch's constrictor was removed after the completion of the bandage. A feverless course of healing fol- lowed. Change of dressings was done on the twenty-second day. Four nails were found loose, and were withdrawn. May 8th. — Scraping of drainage-tracks and removal of fifth nail. Ligamentous union was found and a plaster splint applied. June 12th. — The sinuses were healed, and the patient was walking without the aid of stick or crutches in a light silicate-of-soda splint, though union of the bones was not perfect. 292 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. The other nine cases were in brief as follows : Case II. — Willie Bohn, aged three and a half. Osseal tuberculosis with fistute. February 2^ 1879. — Total exseetiou, April 2d. — Patient discharged cured. Case III. — Charles Harris, aged twelve. Osseal tuberculosis with tistuli© ; con- tracture and subluxation backward. June 13, 1884. — Total exsection at the German Hospital. Hahn's incision; two nails; plaster- of-Paris splint. Some fever and deep- seated oedema of the region ot the knee followed. Sawed surfaces and flesh-wound united by primary union. Tlie nails being withdrawn on the twelfth day, some pus exuded from their tracks, showing that the nails had apparently not been well disin- fected. Several revisions were required on account of unhealthy granulations in the drainage-holes. February ^, iSS^- — Patient discharged, with firm anchylosis and no fistula. Case IV. — Sussel Baerenknopf, aged nine. Osseal tuberculosis ; several fistulas ; subluxation. August 26, 1885. — Total exsection at Mount Sinai Hospital. Nails; plaster splint. September 25th, — Change of dressing. Drainage-tubes and nails were with- drawn; firm anchylosis. October 10th. — Patient discharged cured. Case V. — Leonard Peters, waiter, aged nineteen. Synovial tuberculosis; no fis- tula. August 27, 1885. — Total exsection at the German Hospital. September 27th. — Plaster splint, dressings, drainage-tubes, and nails removed. October 9th. — Sinuses healed. October 19th. — Discharged cured with firm anchylosis. Case VI. — Bertha Deutsch, aged twelve. Synovial tuberculosis of five weeks' standing. Continuous high fever with rapid emaciation. Probatory puncture yielded scanty bloody serum. January 21, 1886. — Total exsection at Mount Sinai Hospital. The capsule was found studded with innumerable miliary tubei'cles. The fever disap- peared immediately after the operation. February 20th. — Plaster splint removed ; wound healed by first intention. March 10th. — Patient discharged cured, with firm anchylosis. Case VII. — Lizzie Boettger, aged twenty. Osseal tuberculosis of eighteen years' standing; rectangular contraction with subluxation backward. No fistula. February 12, 1886. — Total exsection at German Hospital. March 10th. — Change of dressings ; primary union; three nails and drainage-tubes were removed. April Jfih. — Patient complained of a good deal of pain in walking. A hard body could be felt under the skin on the outer aspect of the tibia. An incision exposed the head of the fourth nail, which had not been found at the first change of dressings. It was withdrawn with some force, a little blood exuding from its track. May 9th. — Patient was discharged cured. Case VIII. — Anna Sauer, aged twenty-two. Synovial tuberculosis with osseal ulceration of articular surfaces of both femur and tibia. No fistula. May 10, 1886. — Total exsection at the German Hospital. June 12th. — First change of dressings ; primary union of soft parts ; delayed union of the bones. August 1st. — Discharged cured, with firm anchylosis. Case IX. — Katie Walter, aged eighteen. Synovial tuberculosis with caseous de- posits in several recesses of the capsule, notably around and beliind the crucial liga- ments. Caries of articular surfaces. No fistula. May 18, 1886. — Total exsection at the German Hospital. Slight fever following the operation, the dressings were re- moved May 2Gth. Marginal slough of the upper edge of the skin-woiind. June 17th. — Nails were removed ; firm anchylosis. July 26th. — Patient discharged cured. Case X. — Emma Friedmann, aged twenty-seven. Synovial tuberculosis with caries of articular surfaces. No fistula. April 18, 1887. — Total exsection. April 22d. — Considerable secondary oozing necessitated a change of external dressings and plaster splint. Feverless course. May 23d. — Change of dressings; primary union; firm TREATMENT OF TUBERCULOSIS. 293 anchylosis. Tubes and three nails were removed ; a fourth nail could not be found, but was removed by incision on June 2d. Patient was discharged cured, with firm anchylosis, July 1st. Note. — To prevent the disagreeable necessity of cutting down for searching out a nail buried in the tissues, Dr. F. Lange's suggestion of fastening a silk ligature to the head of each nail before driving it in, seems to be very appropriate. Fic 229. — Arrangement of patient for Mikulicz's operation. /. Ankle and Foot. — Tuberculous aifectious of the ankle-Joint, or of the Joints formed by the tarsal and metatar- sal bones, require, in case of the presence of one or more sinuses, exsection of the diseased parts. The long-continued dis- charges and lack of active exercise are ,jj very apt to reduce the general condition of the patient to serious anaemia and marasm, and, the disease extending to most of the com- plicated structures of the foot, may finally require am- putation. Early operations, especially in chil- dren, yield good functional results, as the extent of tlie removal can be lim- ■ ' 1 ' the parts actually involved. Exsections of the ankle or of other Joints of the foot are not followed by good results in grown sub- jects, on ac- count of the technical difficulty of a complete removal of the synovial membrane. Relapse of the tubercu- lar process often suiDcrvenes, making amputation a necessity. In tuberculosis of the calcaneum or the astragalo- calcaneal Joint, MihuUcz's osteoplastic exsection of the tarsus deserves employment. The lower ends of the tibia and fibula are sawed off as in Syme's amputation, and the articular surfaces of the cuboid and scaphoid bones are also sawed off, so as to fit the section of the tibia and fibula. (Fig. 230.) Nutrition of the ante- rior part of the foot is maintained by the dorsalis pedis artery, and the patient soon learns to walk on the balls of the toes, as in pes equinus. (Fig. 231.) 89 230. — Diagram illustrating the plan of Mikulicz's operation. (Esmarch.) Fig. 231.— Shape of foot after Mikulicz's oper- ation. (Esmarch.) 294 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Case. — Hermann Mehle, barber, aged thirty-four. Synovial tuberculosis of the astragalo- calcaneal joint, with several fistulse situated to the right and left of the tendo Achillis. August SO, 1885. — Osteoplastic exsection of tarsus at the German Hospital. Primary union of the deep parts of the wound and of the bones. Mar- ginal sloughing of limited extent of the upper edge of the wound delayed the cure somewhat. October 10th. — Patient was discharged cured. Note. — This operation was employed by the author successfully in two more cases. In one, an epithelioma of the calcaneal region ; in the other, extensive chronic ulceration, due to frost- bite of the heel, was the indication to its performance. The preparation of the foot to be operated on is of very great importance, and thorough removal of effete epidermis and dirt is a necessary condi- tion of asepticism (see page 61). In exsection of the ankle, the bilateral incision gives very good access to the ankle-joint, though excision of the capsule will he found, at best, difficult to accomplish. It being desirable to produce a movable joint, subperiosteal dissection is to be aimed at, as in exsection of the elbow. As soon as the sinuses are healed, active use of the foot on crutches, aided by a shoe and brace, or a silicate-of-soda splint, should be encouraged. The tendency to posterior or lateral deviation of the foot will be best met by the long-continued use of a supporting apparatus of one kind or another. Case T. — Oaecilia Raab, aged twenty-two. Synovial tuberculosis of ankle-joint with several sinuses. JSfovernber 9, 1882. — Exsection of ankle-joint at the German Hospital. Healing of the wound progressed favorably, when, November 30th, the patient contracted acute lobar pneumonia, in consequence of which she died Decem- ber 2, 1882. Case II. — George Eitt, aged six. Tuberculosis of ankle-joint caused by a cheesy focus in the astragalus. January 11, 1888. — Partial exsection of ankle-joint, part of the astragalus and the malleoli being removed. March, 13th. — Scraping of the sinuses on account of relapsing tuberculosis. Sinuses persisted until the summer of 1884, when Dr. F. Lange, then on duty at the German Hospital, performed total exsection, which resulted in a cure of the tuberculosis, but with pseudarthrosis. July SO, 1885. — The author exsected the ligamentous mass interposed between the lower aspect of the tibia and fibula and the calcaneum, and fixed the latter to the tibia by a steel nail driven through from the planta pedis. Primary adhesion followed, with the formation of a slightly movable union of the tibia and calcaneum. /September 5th. — The boy was dis- charged cured. In January, 1886, the brace worn until then was dispensed with. Case HI. — Henry Holzfaller, aged four. Osseal tuberculosis of ankle-joint. March 20, 1883. — Total exsection at the German Hospital. May 25th. — Patient discharged cured, with serviceable joint. Case IV. — Frida Schmoltz, aged three and a half. Osseal tuberculosis of ankle- joint with fistula. September 19, 1883. — Removal of external malleolus and part of astragalus, which contained a caseous deposit. October 15th. — Wound completely healed. Plaster-of-Paris splint applied. October 31st. — Silicate-of-soda splint applied, and patient directed to use the foot. August Jf,, 1885. — Normal position of foot; func- tion perfectly re-established. Case V. — I. S., aged eight. Osseal tuberculosis of ankle-joint with three sinuses. September 26, 1883. — Partial exsection of ankle-joint; astragalus and inner malleolus were removed. November 15th. — Patient discharged cured, with improving function and normal position of the foot. TREATMENT OF TUBERCULOSIS. 295 Case VI.— Jacob Deibel, farmer, aged twenty-three. Synovial tuberculosis of ankle and of astragalo-calcaneal joints. March 12, i5,*?6.— Removal of both malleoli and of entire astragalus at the German Hospital. April 20tJi.—? oWeni discharged cured, with fair function of the foot, walking with the aid of a stick. Case VII.— Abraham Moses Goldenberg, aged four. Osseal tuberculosis of ankle- joint with sinuses. November 8, 1S86.— Total exsection. Several relapses required repeated scraping with the sharp spoon. June 3, 1887.— The patient was discharged cured. PART IV. GONORRHCE A : ITS ANTISEPTIC TEEATMEI^T. CHAPTER IX. NATURAL HISTORY AND TREATMENT OF GONORRHCEA. I. ETIOLOGY OF GONORRHCEA. GONOCOCOUS. Fig. 232. Pure culture of gonocoocus (700 diameters). (From Bumm.) In examiniug the purulent secretion produced by a virulent case of ure- thral gonorrhoea, the observer will detect with the microscope a number of dark, round objects resembling grains of fine gunpowder, that are vividly oscillating, and can be clearly distinguished from the adja- cent pus-corpuscles. The use of a stronger lens will reveal i'.'S^,^ the fact that each individual coccus is divided in two un- ^'tTi'* equal halves. If staining is employed, the body of the coc- cus will appear colored, and the dividing-line will become very conspicuous in the shape of a light, colorless streak. (Fig. 233.) Frequently an indication of incipient secondary division of each half of the coccus can be seen. Thus four cocci will be united to a seemingly single body, which can be aptly compared with four coherent biscuits, divided into equal quarters by two cross -shaped grooves. The favorite location of the gono- cocci found in the urethral secretions is loitliin the pus- corpuscles. This peculiarity belongs exclusively to the coccus of gonorrhoea detected by Neis- ser in 1879, and represents its most important charac- teristic. (Fig. 234.) Oonococci are to he found in the secretion of every case of gonorrhoea, provided that no germicidal injec- tions were used. Infection of the urethra with pus containing gono- cocci ahv ays produces gonorrhoea, and secretions that do not contain gonococci are invariably non-infectious if brought upon the urethral mucous membrane. Gronococci have a peculiarly invasive faculty, by which they penetrate first the superficial layers of the epithelial membrane, and gradually by further proliferation the submucous layer. (Fig. 236). The route of their |rffi ^ (^ «MC W Fig. 233. Development and fission of gono- coccus. (From Bumm.) Fig cell studded with gonococci ; pus cell, its protoplasm filled with gonococci ; an- other pus cell gorged with gonococci ; a group of free cocci alongside of a nor- mal pus - cell (700 diameters). (From Bumm.) 300 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. ^^. - w\; yo]) Fig. 235. — Vertical section through mu- cous membrane, showing first coloni- zation of gonococci (700 diameters). (From Bumm.) inroads is along the intercellular substance. An intense hypergemia of the capillaries and other blood-vessels adjoining the seat of the primary infec- tion leads to a massive emigration of white blood-corpuscles into the affected epithelium. This and the growth of the gonococcal colonies lead to a rapid disintegration of the epithelium, which is washed away by the lymph-serum in the shape of single cells or in coherent epi- thelial flakes. Loss of the epithelial in- vestment is often followed by the exuda- tion of a croupous membrane, beneath which clumps of gonococci are to be seen in process of active proliferation. Gono- 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 leucocytes, the ex- tent of which serves as a gauge of the in- tensity of the infec- tious process. At the acme of the process, general- ly reached about the end of the second or third week, a regeneration of the lost epithelial layer commences. Comj^lete 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 « M!fl, *~ ^"^^^''' of instruments ; or portions _ ^'^ ' ' , _ which have recovered suc- -7i0?f''<^ 1 "^ ~^-' cumb anew to gonococcal de- struction. The regeneration of the epithelium is always accom- panied by hyperplasia, which somewhat resembles by its tubular formations epitheliomatous mucous membrane (Bumm). These foci of epithelial hyperplasia are often coincident with the seat of the most intense primary affection. They also coi*respond with those parts of the submucous layer at which the most intense inflammatory infiltration was present. Fig. 236.- -Invasion of epithelium by gonococci (700 diameters). (From Bumm.) ^"-^'^ ^1 s,®^#)« «» Fig. 237.- -Proliteration of gonococci in the epithelium (700 diameters). (From Bumm.) TREATMENT OF GONORRHCEA. 301 As regeneration progresses, the lijperplasia of the mucous membrane and the infiltration of the submucous connective tissue disappear by absorp- tion. In some cases, however, cicatricial transformation of the neiv-formed connective tissue of the suhmucous layer taTces place instead of absorption, and organic stricture develops. The transient hyperplastic conditions existing immediately after the termination of the gonorrhceal process, and which generally give rise to a scanty secretion called gleet, are mistahenly called strictures hy various authors. In contradistinction to stricture, which is a permanent condition, they must be declared to be transient stenoses of the urethral caliber, which in most cases do disappear without or with the methodical introduction of a full-sized bougie or sound. The salutary effect of dilatation upon these coarctations of the epithelial and submucous layers is explained by the hastening of the absorption of the cellular infiltration by pressure. It is true that, if neglected, some of these coarctations will not be ab- sorbed, but will become veritable cicatricial strictures. Nevertheless, it is an error to declare each and every narrowing of the urethral calHer observed shortly after a gonorrhceal attach a "stricture of ivide caliber." The term of ''incipient -stricture" is less objectionable, though often incorrect, as many of these "strictures" disappear spontaneously. Note. — The presence of various micro-organisms, aside from the gonococeus, in recent and chronic urethral discharges, seems to point to the fact that most cases of urethritis represent a mixed form of bacterial infection. There is no doubt that the mocula.tion oi pt/offenic mic7'obes into a gonorrhoeally affected mucous membrane foi'ms an important element determining the intensity and perniciousness of some very bad cases. This assumption is also more in accord- ance with the theory of the development of metastases, notably of gonorrhceal rheumatism. Bumm is very reserved in regard to the acceptance of Kammerer's investigations, who found gonococci in recent effusions produced during an attack of gonorrhceal rheumatism. On the other hand, we know that rheumatic attacks are occasionally provoked by an instrumental examination of the urethra of a patient afflicted with " simple " or "catarrhal " or "traumatic" urethritis, in which the absence of gonococci is indisputable. Finally, the frequent presence of simple pyogenic organisms in rheumatic effusions is generally accepted. It seems, then, that pus-generating organisms play an important part in cases of gonorrhceic and non gonorrhoeic urethritis, and that the metastatic processes complicating ui-ethral inflammations are mostly chargeable to their and not to the presence of gonococci. Hence the name " urethral rheuma- tism " would be preferable to " gonorrhceal rheumatism.'' II. TREATMENT OF GONORRHCEA. 1. Acute Gonorrhoea. Clap. — For practical reasons it will be found most convenient to divide the male urethra into two easily distinguished parts. The first part comprises the anterior poi^tionoi the urethra, extending from the meatus to the ''cut-off muscle," or compressor urethrce, which is situated in the membranous portion. All secretions originating in this anterior portion of the urethra will readily escape by the meatus into the linen of the patient. 40 302 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Tlte second or dee}} portion of the urethra consists of a fraction of the membranous part, together with the prostatic portion — in short, of all that is situated behind the "cut-off muscle." This posterior portion of the urethra is correctly called the nech of the bladder, as it forms one cavity with the bladder whenever this becomes distended with urine. The internal sphincter alone, unable to resist long, yields readily to the pressure of the urine. The voluntary contraction of the compressor urethrae becomes, then, the only barrier to the escape of the urine, and water is voided immediately after the relaxation of this muscle. Discharges secreted in the posterior part of the urethra can not escape outward past the compressor muscle, and do not appear at the meatus in the shape of an external discharge, as those of the anterior urethra. They accumulate in the neck of the bladder, and are voided only with the urine, which is rendered somewhat turbid by this admixture. A very useful practical test for determining the seat of urethral inflam- mation is that suggested by Ultzmann. The patient is made to pass his water consecutively into two tumblers, so that the amount voided should be about evenly distributed in the two vessels. Whenever the anterior urethra alone is the seat of inflammatio?i, only the first half of the urine will be turbid, or at least will be found con- taining flakes and threads ; the second portion will appear perfectly clear. In cases of deep-seated urethritis — that is, when the neck of the bladder is affected — the first tumbler luill receive flaky and turbid urine, and the water held by the second glass will appear also turbid, but somewhat less so than the first portion. A-W additional and most important symptom of the affection of the neck of the bladder \'& frequent micturition, in acute cases accompanied by severe spasm and the escape of a small quantity of blood at the end of the act. Simultaneously with the severe contraction of the vesical muscles, anal tenesmus is observed. In every case of recent gonorrhoea the infectious process is confined to the anterior urethra, and first to its foremost portion alone. It extends from the meatus backward to the compressor urethrae, where it generally stops. In exceptional cases only does it penetrate to the deep urethra, as the "cut-off muscle" seems to serve as an effective barrier to its extension backward. Note. — Forcible urethral injections made from a syringe containing too large a quantity of fluid, or the premature introduction of a sound, are frequent causes of the infection of the neck of the bladder. The seat of the most intense inflammation of the urethra is in its natu- rally widest parts — that is, in the fossa navicularis and the sinus bulbi. Here we find located the majority of all strictures. a. Anterior Gonorrhceal Urethritis. — The treatment of anterior gonorrhoeal urethritis should be very discreet in the first invasive stage of the disease. It should consist of rest and appropriate general sedative man- agement. Locally, cold applications will be found very grateful and effective. TREATMENT OF GONORRHOEA. 303 As soon as the turbulent first onset has abated, local treatment by dis- infectants should commence. Since the oedematous swelling of the parts is still prom.inent, introduction of any instrument for the purpose of irri- gation will have to be done with some force. It will cause abrasions of the tumid ei3ithelium, and thus will open new portals to gonococcal and pyo- genic invasion. Hence irrigation at this period is to be condemned. Urethral injections, on the other hand, done with a joroperly shaped syringe of moderate cajiacity, are very useful. Sigmund's syringe, hav- ing a blunt conical nozzle, is an appropriate instrument. It holds three eighths of an ounce of fluid, which quan- tity is sufficient. (Fig. 238.) The strength of Fig. 238.— Sigmund's urethral syringe. the solutions em- ployed should also be determined by the intensity of the local symptoms. Strong solutions will cause intense smarting, and on that account the injec- tions will not be made frequently enough by the patient. In very sensitive cases an entirely unirritant tepid solution of salt water (6:1,000, or a tea- spoonful to a quart) can be employed with much benefit. As the symptoms abate, sulphocarbolate of zinc (fifteen grains to six ounces), or permanganate of potash (one grain to six ounces), can be substituted for the saline solution. The main object of these first injections is the cleansing of the urethra ; hence the injections must he made frequently , at least six times in a day, or oftener. Each injection should be preceded by urination, and should be a double one — the first syringeful to wash out the pus ; the second syringe- ful to act upon the mucous membrane. This second injection should be retained in the urethra for two minutes. The strength of the injections should be increased ^an passu with the abatement in the acuity of the local symptoms, but the solutions should never be made corrosive. Every patient should receive practical instruction from the physician regarding the proper manner of injecting. Note. — The author saw a case of chronic gonorrhoea that had successively passed through the hands of three colleagues, none of whom convinced himself whether the patient was making the injections properly or not. Phimosis was present, and the patient was in the belief that the injections had to be made under the prepuce. No wonder his clap had remained uninflu- enced by this treatment. In the later stages of acute gonorrhoea irrigation of the anterior urethra will be found a very satisfactory and effective mode of treatment. It should be done by the physician himself at least once daily, or as often as possible, in the following manner : A pint bowl is filled with tepid water. To this is added enough con- centrated solution of permanganate of potash to color the water to the hue of light claret. A straight or slightly beaked female catheter of metal (Fig. 239), five inches in length (No. 8 English caliber), is lubricated with glyc- erin, and is introduced as far as the compressor-urethrse muscle. When- 304: RULES OF ASEPTIC AND ANTISEPTIC SURGERY. ever the beak of the instrument comes in contact with the muscle this will contract, and will resist further introduction. The patient stands in front of the sitting physician, and is made to hold a pus-basin or tin pan under his scrotum and penis. The physician fills with the solution a hand-syringe holding four or five ounces, and iniects the fluid Fig. 1^39. — Short metallic catheter for irrigation of ^ n ,^ , • , ,^ anterior urethra. through the catheter mto the urethra, whence it will readily escape by the meatus into the pus-basin. This is repeated until the solu- tion is exhausted. Irrigation should be preceded by micturition. With proper diet and regime, ordinary cases of gonorrhoea will be cured by this treatment in from three to six weeks. Note. — To prevent soiling of the patient's linen by profuse urethral discharges, the follow- ing simple arrangement will be found effective and convenient. A child's sock is fastened with a safety-pin to the interior of the skirt of the patient's undershirt. In the toe of the sock is thrust a small ball of cotton, which is then drawn over the penis, and is held there by the sock. Whenever occasion permits, the soiled cotton is replaced by clean material, and thus no tell- tale blotches will be made on shirt and drawers. b. Deep-seated Goistorehceal Urethritis. — Spontaneous extension of gonorrhoeal infection beyond the cut-off muscle to the posterior part of the urethra is a comparatively rare occurrence. More frequently infection is carried to the deep urethra by too large injections or the premature inser- tion of sounds. As long as in a case of anterior gonorrhoea the discharges are profuse and creamy, and the mouth of the urethra mdematous and red, no sound should ever he passed. Infection of the deep urethra invariably provokes an unmistakable com- plex of symptoms — namely, frequent urination, which is followed at its termination by a violent s^Dasmodic pain and the escape of some bloody urine or a few drops of pure blood. Ordinary injections, or even irrigations of the urethra as above described, are utterly unable to reach and to influence the course of deep-seated gon- orrhoea. To cleanse and disinfect the diseased part, an efficient germicidal solution must be brought exactly in contact with the morbid mucous mem- brane of the posterior urethra. If we inject a solution into the bladder, its chemical properties will be at once destroyed by the admixture of urine, hence means must be found by which we can make the unchanged solution come in contact with the seat of the disease. For this purpose Ultzmann's method of irrigating the necTc of the Madder will be found very effective. As soon as the most acute invasive stage of the affection shall have be- come mitigated by rest, sedatives, balsamics, and proper diet — that is, in about the third or fourth week — a quart of a mild, tepid solution of permanganate of potash (1 : 5,000) is prepared. A not too small-sized soft gum (Nelaton's) catheter (Fig. 240) is lubricated with glycerin, and is introduced as far as the compressor-urcthrae muscle. A hand-syringe holding about four ounces of fluid is filled with the solution, which is then injected into the catheter. TREATMENT OF GONORRHCEA. 305 and will be seen escaping from the meatus alongside of the instrument. After this preliminary washing of the anterior urethra, the patient is di- rected to assume the recumbent posture. The soft catheter is again lubri- cated, and is passed gently into the bladder. This process will be very much facilitated by the injection of a small quantity of glycerin through the catheter when it is about to pass the cut-off muscle. A small amount of pressure will overcome the tension of the compressor, and the arrival of the jDoint of the instrument in the desired locality can be tested by injecting an ounce or two of the prepared lotion. Should it escape from the urethra, this would be a sign that the eye of the catheter has not passed the com- FiG. 240. — N^latoii's soft gum catheter. pressor muscle. If, on removal of the syringe, the lotion is seen to escape at once from the bladder through the catheter, then it may be concluded that the eye of the catheter is in the cavity of the bladder, and that it has been introduced too far, and needs to be withdrawn an inch or a little more or less. Should, on renewed injection, the lotion all enter the Madder, but fail to escape through the catheter, this is a positive sign that the heaJc of the instrument is just beyond the cut-off muscle — that is, in the posterior part of the membranous portion. Fluids injected into this place will readily enter the bladder, as their pressure can easily overcome the internal sphinc- ter ; but recontraction of this muscle will prevent their escape until the beak of the instrument is pushed into the vesical cavity. According to the irritability of the patient, from one to four ounces of the lotion are slowly injected while the point of the catheter is located in the space between the cut-off and internal sphincter muscles. As soon as the patient complains of pressure, injection should cease, and the catheter should be gently pushed within the vesical cavity, whence it will at once conduct the injected fluid into a vessel placed between the thighs of the patient. It is better not to inject too large a quantity at the beginning, as this is liable to bring on vesical spasm, resulting in a violent and irresistible expulsion both of lotion and catheter. 306 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. The injections are to be repeated in this manner until the lotion is seen to return clear from the bladder. The final injection is voluntarily passed by the patient. This is to satisfy him that his bladder is empty, and that the sensation of the desire to urinate is not caused by retained fluid. The improvement following this procedure is very apparent, though not lasting, and daily repetition will be necessary until the frequency of mic- turition will have been very materially reduced. The author has never seen any untoward consequences following this gentle and very efficient mode of treating deep-seated urethral gonorrhoea. The danger of cystitis or inflammation of the testicle will be rather abated than increased by this treatment if it be carried out properly and without A'iolence. The possibility of performing the entire procedure without any abrasion, undue pressure, or injury of the inflamed jDarts, ranks it high above all measures in which unyielding sounds, catheters, or caustic holders are placed in the neck of the bladder for purposes of cauterization. Their use is often followed by epididymitis, and is deservedly held in bad repute. Where the affection extends over the whole urethra, treatment of the neck of the bladder and of the anterior urethra can and ought to be carried out simultaneously until the secretion escaping from the meatus be reduced to a minimum, and until the frequent urgency to urinate and the turbidity of the water give way to a marked extent. Gonorrhceal catarrh of the neck of the Madder should not be mistahen for acute cystitis. Pus will be found in the urine in ^e.T,iEJviAMjg-Ac.o:: Fig. 241. — Ultzmann's prostatic syringe. both cases, but in cystitis febrile disturbances accompanied by alteration of the general health will be observed, and pressure pain above the symphysis pubis will be noted aside from the periodical pain located in the perineal region, which follows urination, and which is the diagnostic sign of the affection of the deep urethra only. Should irriga- tion of the deep urethra not effect rapid or complete cessation of the ^■\^WV.NyMV^,V^ kWRt^tCQ. Fig. 242. — Keyes's modification of Ultzmann's deep urethral syringe. affection, instillation of a feto drops of a five-per-cent solution of nitrate of silver will be found very beneficial. This is done by Nelaton's catheter or Ultzmann's deep urethral syringe. (Figs. 241 and 242.) The point of the filled instrument is dipped in glycerin, and is gently introduced just within the compressor-urethraa muscle. When the barrel of the syringe is at an angle of forty-five degrees with the body of the recumbent patient, its beak is just within the neck of the bladder. Three, four, or five drops of the nitrate-of-silver solution are expelled from the syringe, and enter the deep TREATMENT OF GONORRHCEA. 307 urethra. Intense smarting and spasm of the neck of the bladder follow the injection, but soon disappear if the patient retain the reclining posture for a short while. These deep injections of nitrate of silver are a very effective though painful means of checking a gonorrhceal inflammation of the deep urethra, and deserve more frequent employment than they receive at present. The procedure does not entail any danger, and is rather a preventive than a cause of epididymitis or cystitis. 3. Chronic Gonorrlioea. Gleet : a. IXFLAMMATORT StENOSIS (INCIPIENT StRICTURE) AND Permanent or Cicatricial Stricture of the Urethra : (a) Anterior Urethra. — The termination of acute gonor- rhoea is never abrupt. It is always inaugurated by a period characterized by the escape of a scanty amount of purulent discharge. During this period subacute attacks or relapses of the affection may be precipitated by any cause inducing hyperaemia of the urethral mucous membrane. Sexual irrita- tion, alcoholic indulgence, severe bodily exercise, offer mainly occasions for this occurrence. When an acute gonorrhoea has reached this stage, the prog- ress of the recovery often seems to suffer a halt, due princi- pally to secondary hyperplastic changes of the mucous and submucous tissues. The daily introduction of a full-sized sound or bougie for a week or two is generally sufficient to produce rapid absorption of the interstitial exudation and a permanent cure. A contracted meatus is an effective impediment to the application of the sound, and requires an adequate division of the narrow urethral orifice. Meatotomy, however, should never he carried too far, its only object being the easy admis- sion of a full-sized steel sound. It is made with a blunt- pointed tenotomy knife, and the haemorrhage caused by it can be easily checked by the introduction of a small pledget of iodoformed gauze into the slit. Should the patient positively decline meatotomy, blunt dilatation of the part of the urethra, which is the seat of the inflammatory swelling and contraction, can be done by Otis' s urethrometer. (Fig. 243.) The closed instrument is intro- duced beyond the coarctation, then it is opened until the dial indicates that the bulb has been dilated to full caliber, and then it is drawn with some force through the narrowed portion of the urethra. The author has seen very good results follow this use of Otis's instrument, though the procedure does not deserve preference over mea- totomy and dilatation by the steel sound. The absorption and disappearance of these "incipient strictures" is very much hastened by the local application of a strong (five-per-cent) solution 308 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. of nitrate of silver. To enable an exact application of the caustic under the gtiidatice of the eye, the endoscope must he used. The endoscope is a cylindrical silver tube of from four to six inches in length, and of various calibers. (Fig. 244.) An obturator facilitates its painless introduction, and a flange or shield made of hard rubber, having a "dead finish," permits an easy handling of the instrument. Strong arti- ficial light or sunlight is needed for endoscopy. The patient reclines on a tall chair, or sits on the edge of a table, his back supported by a suitable rest, the examiner occupying the space between the patient's legs. To pro- tect the patient's clothing against soiling with blood or chemicals, a piece of rubber cloth (eighteen inches square), jDrovided with a small central slit just long enough to permit the slipping through of the penis, is spread on the pubic region. Thus the only object exposed to view will be the patient's Fig. 244. — Klotz's urethral endoscope. wBh penis. Over the rubber cloth a clean towel is laid for wiping off fingers, etc. A basin containing a number of slender match-sticks, their ends armed with tufts of absorbent cotton, is at hand, and a pus-basin is next to it, to receive the soiled sticks. On a little table adjoining the operating- chair are a small, wide-mouthed bottle of glycerin and a few glass salt- cellars or hour-glasses for the reception of such solutions as may be required. Of these the author uses two — a five-per-cent solution of nitrate of silver and a ten-per-cent solution of the same substance, both in dark bottles. An endoscopic tube of suitable size being selected, it is lubricated with a little glycerin, and is introduced well into the bulbous portion of the ure- thra. The obturator is withdrawn, and the surgeon by his head-mirror directs a ray of sun- or lamp-light into the bottom of the tube, where the mucous membrane of the urethra is visible in the shape of a tyjDical image, consisting of several concentric folds uniting to a central, funnel-shaped depression. In sunlight the normal mucous membrane is pale, of about the same hue as the normal buccal lining, and on it are visible a number of delicate trac- ings, produced by minute vessels. It is very smooth and glossy, and the folds of the image are flexible and rather delicate, and present 7io change of color on deej)er introduction or withdraival of the tube. Inflamed urethrm show an entirely diffei'ent aspect. The most delicate manner of introducing the instrument is apt to cause slight hgemorrhage, which sometimes is very troublesome, as the blood fills up the tube faster than it can be mopped aAvay, frustrating for the time being all further manipulation. When the mucous membrane, exposed in the bottom of the endoscope, is dried off with a pledget of cotton, it has a dull, dead gloss. TREATMENT OF GONOREHCEA. 309 or velvety appearance ; it shows a more or less intense, uniform shade of red, scarlet, or purple. The folds of the endoscopic image are few and coarse, and not so flexible as those of the normal nrethra. Gradually withdrawing the tube with short stops, the entire length of the urethra can be thus inspected. In chronic gonorrhceal urethritis the inflammation will be found limited to more or less well-circumscribed portions of the urethra. These parts, examined by urethrometer or bulbous bougie, quite frequently show a well- marked though moderate contraction, which can also be demonstrated to the eye through the endoscope. In withdrawing the tube, new parts of either normal or uniformly red, inflamed mucous membrane will j^resent themselves to the examiner's eye. Suddenly, however, the field of vision will become pale., perfectly ancemic, and ivory-colored. This change of color is due to depletion of blood and the ansemia of the constricted part of the urethra, caused by the distention produced by the dilating p^^_ 245.-Metaiiic buiboTb^ugie. instrument. As soon as the end of the tube is withdrawn from the stenosed part, the formerly bloodless tissues are seen to suddenly flush up and become of exactly the same color as the rest of the inflamed mucous membrane. Examination by the bulbous bougie (Fig. 245) will show that the seat of this phenomenon corresponds exactly with the locality of the narrowing of the urethral caliber. In cases where gleet has persisted for several months, these constricted places appear in the endoscope of a pearly color, which is due to the con- siderable thickening of the epithelial layer. The application of the nitrate-of-silver solution to these '' incipient strict- ures " will be found to materially hasten their absorption, if it be supple- mented by the introduction of a full-sized sound. The applications are made through the endoscope every other day with a cameFs-hair brash or a wad of absorbent cotton fastened to the end of a long match-stick. They cause a slight smarting, which does not persist very long. Occasionally they are followed by slight htemorrhage on the day subsequent to the ap^Dli- cation, which, however, is without any significance. Most of these '•' incipient strictures" get well iTuder the treatment just described, and do not require urethrotomy. But, when the embryonic connective tissue of these stenoses of inflam- matory character becomes definitely transformed into fibrillar connective tissue — that is, a fully developed cicatrix — it represents a permanent — that is, orgaiiic — stricture that can not be cured by simple dilatation and topical applications. True, it may be gradually dilated to the normal caliber, but the dilatation will be evanescent, and speedy recontraction will follow the cessation of the treatment. The appearance of a cicatricial or permanent stricture in the endoscopic field of vision differs in many ways from that of an inflammatory stenosis. This diagnostic distinction is all the more valuable, as an examination by 41 310 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. the bulbous bougie, although capable of demonstrating the presence of a narrowing of the urethral caliber, does not divulge anything regarding the nature of the stenosis. The most characteristic feature of permanent strictures is the unchang- ing anaemic, pale condition of the mucous membrane about the stricture in the endoscopic field of vision. The sudden flushing up on withdrawal of the endoscoj)ic tube, seen in the contractions of recent date, is absent. The second characteristic is the peculiar rigidity of the urethral ivall at the site of the stricture. On withdrawing the endoscope, the rigid walls of the urethra show a tendency to remain patulous, so that, instead of a small and rapidly changing image of soft, pliable mucous membrane, a comparatively long stretch of the urethra can be looked over at a glance, resembling somewhat the walls of a short tunnel. Absorption and disappearance of a cicatricial stricture are a very excep- tional occurrence, whether it be subjected to treatment or not. To suffi- ciently 2viden a strictured urethra, urethrotomy, followed hy methodical dilatation, is required. Such a cure as is not infrequently observed to come from treatment of an inflammatory stenosis — that is, a perfect restitution of the normal state of affairs — is never to he expected after the treatment of a cicatricial stricture, he this treatment dilatation alone, or cutting comhined loith suhsequent dila- tation. The cicatricial ring will become wider than before, but its rigidity and unnatural appearance will remain unchanged. The cases in which the cicatricial bands can be divided in their entirety yield the comparatively best results. But the worst strictures involve the entire thickness of the spongy part of the urethra, and to effect complete division in these cases the entire thickness of the urethra would have to be cut through, which is an impracticable and sometimes dangerous procedure. Case. — M. F., aged forty-two, had a series of old cicatricial strictures involving the entire anterior portion of the urethra. One seated in the fossa navicularis was very tight, another one at the bulbo-membranous junction was very massive, so that it could be felt through the peringeum. Blunt dilatation with steel sounds, up to No. 34 of the French scale, always produced cessation of the profuse discharge, but, recontrac- tion to the old condition always following within forty-eight hours, internal ure- throtomy was decided on. August 20, 1885. — The operation was performed with Otis's urethrotome. The urethra was dilated to No. 30, and then two parallel incisions were made along the entire length of the roof of the pendulous portion. Some hesitation of the bulbous bougie was noted at the bulbo-membranous junction, therefore Otis's instrument was reintroduced, dilated to No. 32, and the still narrow part of the urethra once more cut. Smart haemorrhage was observed, but not more than the length of the incision justified, and after some compression it ceased. On returning to the pa- tient after the lapse of two hours, the writer found him lying on bis blood-soaked mattress in a pool of blood, in a most deplorable state of prostration and anxiety. The scrotum and penis were swollen out of proportion, and had assumed a blue-black color, and blood was issuing from the meatus at varying intervals. A large English web- catheter was introduced and tied into the bladder, and only persistent digital pressure exerted over the bulbous portion for more than two hours succeeded in arresting the TREATMENT OF GONORRHCEA. 311 loss of blood, and cliecked further bloody infiltration of the penile and scrotal tissues. Fortunately, infection of the wound was avoided by careful asepsis, and thus, no fever and inflammation following, the entire enormous extravasation was readily absorbed. Introduction of large sounds was commenced on the twelfth day, and after a some- what prolonged convalescence the patient recovered. "With the regular use of the full- sized steel sound, and an occasional irrigation of the neck of the bladder, the patient suc- ceeds in maintaining a very comfortable state of health. In the case just related, complete di- vision of the posterior stricture, situated at the bulbo-membranous junction, led to the injury of the bulbar artery, imbedded in the cicatricial mass constituting the stricture. Had the wound been infected by the use of uncleanly instruments, sup- puration and decomposition of the large bloody infiltration might have brought the patient into very great danger. A serious objection to Otis's otherwise excellent urethrotome (Fig. 246) is the great difficulty of thoroughly cleansing the complicated instrument. The autlior recommends the folloioing simplified manner of performing inter- nal urethrotomy of the anterior urethra for strictures of wide caliber. A long and stout-shanked, rather narrow-bladed, blunt-pointed tenotomy-knife is first in- troduced well beyond the ascertained depth of the stricture. Alongside of this, Otis's urethrometer is inserted to the same depth. The bulb of the latter instrument, being well dilated, is drawn forward until it is arrested by the strict- ure. While the bulb of the urethrome- ter is held close to the mesial entrance of the stricture, the tenotomy-knife is grasped and its sharp edge is applied to the tense cicatricial bands. It is drawn forward until the blade is past the con- striction. Should the bulb of the ure- thrometer follow without a halt, the stricture can be considered as suffi- ciently divided ;. should the division be insufficient, the bulb of the ure- thrometer is closed, and the tenotomy-knife is slipped back past the stricture to repeat the process of cutting. Thus the surgeon is sure of dividing only 312 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. the stricture, and not cutting deeper than necessary to permit the passage of the dilated bulb. The method is both simple and exact, and seems well deserving of trial. For very tight strictures Maisonneuve's instrument is most proper. (Fig. 247.) Careful disinfection of the surgeon's hands and instruments, and irri- gation of the urethra with a watery tepid solution of permanganate of pot- ash (1 : 2,000), should precede every step or oper- fation that may lead to wounding of the urethral ^^^ mucous membrane. As a lubricant, iodoformized vaseline (1 : 30) should be used. The operation should terminate with a renewed irrigation of the urethra. Whenever strictures are cut that have their seat near the bulbo-membranous junction, a new, large- a^ sized, English elastic catheter should be tied into yi the bladder for twelve hours, and the patient should be kept in bed for a day or two. These precautions are rarely necessary in cutting strictures located in the pendulous portion, as it is not difficult to pre- vent haemorrhage by the application of a compres- sory bandage to the penis. A gutter of light paste- board is applied to the under side of the penis, which is first enveloped in a layer of cotton, and the splint is firmly secured by a few turns of a roller bandage. The penis and scrotum are held up to the belly by a snugly fitting T-bandage. This pre- ventive appliance can be abandoned on the second day after the operation. If ammoniacal urine be present, its condition should be influenced before operation by the in- ternal administration of boracic acid, benzoate of soda, lactic acid, or turjjentine, so as to become at least of neutral, or what is still better of acid, re- action. A full-sized steel sound is to be introduced twice weekly, the first application not to commence before the fifth or seventh day after the operation. Much pain to the patient will be avoided by first intro- ducing a copiously anointed smaller- sized sound, which will carry a good deal of the lubricant into the urethra, and will render the subsequent use of a full-sized instrument comparatively painless and easy. With the precautions above described, the author has not observed a case of urethral fever following either internal urethrotomy or the use of dilat- ing instruments in the urethra. His experience extends over twenty-one TREATMENT OF GONORRHCEA. 313 cases, in which strictures were cut successfully from within. No febrile or inflammatory complications were ever observed. {b) Deep Urethral Strictures. — Strictures of the deep urethra are located in the membranous portion. Their development is preceded by a stage of epithelial and submucous hyperplasia, identical with the process observed in the anterior urethra. This hyperjolastic condition is amenable to suc- cessful treatment by dilatation and caustics, but unheeded, will develop into permanent stricture. Internal urethrotomy of a deep-seated stricture is a much more grave undertaking than the cutting of a stricture of the anterior urethra. Both the danger of haemorrhage and the difficulty of controlling it, should it occur, render the operation serious. Haemorrhage from the posterior part of the urethra, lying behind the '^ cut-off" muscle, may long remain un- recognized on account of the absence of free bleeding from the meatus, as the escaping blood will flow back into the bladder, and can be expelled only with the urine. For these reasons treatment by gradual dilatation should be carried on whenever possible, and urethrotomy should be reserved for cases only that do not yield to dilatation after patient trial, or will not brook delay. When an operation is decided on as necessary, external ure- throtomy deserves the preference over the internal operation, especially in cases complicated by ammoniacal cystitis. Haemorrhage will be easy to control. The good drainage resulting from the external incision will pre- vent urine infiltration, and ready access to the bladder will facilitate anti- septic irrigations of the organ. External Urethrotomy. — The anaesthetized patient is brought in the lithotomy position, his hands being bandaged to the feet, which are then wrapped in clean towels, wrung out of corrosive-sublimate lotion. The perinseum and anal region being shaved and rubbed off with the same lotion, the operation begins. Irrigation of the wound by Thiersch's solu- tion is carried on during the entire operation. When a staff or even a fili- form bougie can be carried into the bladder to serve as a guide, the opera- tion will offer no difficulty whatever. As soon as the urethra is opened and the stricture exjDosed, its division can be accomplished by the use of a blunt- pointed tenotomy knife. External urethrotomy without a guide is not as easy, but its difficulties can be overcome by patience and circumspection. While an assistant exerts gentle pressure over the distended bladder, the bottom of the urethral wound being well exposed by small, sharp retractors or fillets of silk drawn through the lips of the urethral incision, one or two drops of urine will be seen exuding from one or another point of the strict- ure. A fine probe is inserted into the point in question, and will often penetrate the stricture. A narrow, grooved director is insinuated along the probe, and serves to guide a sharp-pointed tenotomy knife through the con- traction, which then can be divided without difficulty. Should this expedient fail, on account of inflammatory swelling of the tight part of the urethra, suprapubic aspiration of the bladder may serve to tide over the difficulty. Eelief of the distention of the bladder is often fol- 314 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. lowed by decrease of the swelling, and a few hours after the operation urine will be found escaping through the urethra, when the true channel can be searched out and dilated. Case. — N. S., laborer, aged 42, impermeable stricture of the membranous portion of the urethra. March 11, 1883. — External urethrotomy without guide. The stricture being exposed, most diligent search failed to ascertain the direction of the channel, which was obscured by the intumescence and great vascularity of the parts. The dis- tended bladder was finally emptied by snprabubic aspiration, and the patient was brought to bed. Six hours later the bladder had refilled, and urine was seen to trickle from the wound whenever the patient strained. Eenewed search was rewarded by the finding of the right track, which was divided on the grooved director without much trouble or pain to the patient. May 20th. — Patient was discharged cured. A modification of another expedient, proposed by the venerable Petit, was also successfully emi^loyed by the writer. Case. — John Smith, negro hostler, aged 31, suffered from impermeable stricture of the deep urethra with dangerous distension of the bladder. The usual expedients for entering the bladder having failed, external urethrotomy was determined upon, and was carried out December 2, 1876. The distal part of the stricture being exposed, no entrance could be effected. As there was no aspirating needle on hand, a slender trocar was inserted into the middle of the strictural mass, and was pushed forward in the direction of the urethra, toward the center of the prostate, under the guidance of the left index-finger placed in the rectum. The point of the instrument was several times caught in the mass of the prostatic gland, but finally entered the median canal and the bladder, this being attested by the escape of urine. A grooved director was pushed in along the cannula, which was withdrawn, and the stricture was divided with a tenotomy knife. A sharp attack of fever and cystitis followed, but the patient fully recovered and was discharged cured March 5, 187Y. Strictures located in the anterior urethra can be simultaneously divided by Otis's urethrotome or the tenotomy knife before the patient recovers from the anaesthetic. The bladder is then washed out with Thiersch's solution, and the wound is dressed with a pad of iodoformed and a compress of sublimated gauze, held in place by a T-bandage. In the presence of fetid urine, the use of a drainage-tube is advisable. Before applying the dressings the wound should be rubbed out with a small sponge dipped in iodoform jiowder. Anointing of the perinaeum and buttocks with vaseline is necessary to prevent eczema. The external dressings ought to be changed whenever soaked ; the iodoformed pads, however, should not be disturbed without necessity as long as they are adherent. Daily sitz-baths in a weak (1 : 10,000) corrosive-sublimate solution will tend to increase the comfort of the patient, and will aid the healing of the wound. The daily introduction of a full-sized steel sound need not be commenced before the seventh day, and should be continued at increasing intervals for at least a year after the operatio7i. Altogether, the author iierfonned external urethrotomy seventeen times. Fifteen patients recovered, two died. The fatal cases were as follows : Case I. — Mr. S. O., tailor, fifty-four years old, suffering from tight, deep-seated stricture of the urethra, complicated with purulent and fetid pyelo-nephritis. The TREATMENT OF GONOERHCEA. 315 urine remained ammoniucal, and the listula never closed. He died, August 5, 1886, of urfBmia, five months after the operation, done Mai'ch 25, 1886. Case II. — Abraham Goldfish, aged seventy-seven, suft'ering from deep-seated ure- thral stricture, fetid cystitis, and extensive urine infiltration of the perinaium, due to a false passage made by a physician. External urethrotomy was performed, November 1, 1886, at Mount Sinai Hospital, with much relief of the subjective symptoms, but the patient succumbed to septicaemia and septic nephritis on November 18, 1886. Of the remaining cases, one deserves special mention on account of its rarity : Case. — S. E., shopkeeper, aged sixty-three, sustained, in 1875, a compound fracture of the left liorizontal ramus of the os puMs, from vrhich he recovered after a long term of illness. In the spring of 1882 increasing difficulty of micturition became noticeable, and finally led to retention of urine. June £5, 1882. — The author saw the case in con- sultation with Dr. I. Schnetter. A metallic sound could be passed easily as far as the membranous portion, but was there arrested by a grating, hard body, thought to be a sequestrum or a stone. External urethrotomy was done June 27th, and an irregularly shaped sequestrum, one inch long and one sixth of an inch thick, was withdrawn with some difficulty. Patient recovered without fistula, and was cured in about six weeks. h. Vegetations of the Urethea. — Venereal vegetations, such as are frequently observed under the prepuce of men suffering from gleet, occa- sionally occur in the urethra, principally in the fossa navicularis and in the sinus bulbi. They maintain a rebellious urethral discharge that can be stopped only by their removal. Their diagnosis can be made by the aid of the endoscope, which also affords the best means of access for their treat- ment. The use of the curette, or a small wire snare, or of chromic acid in crystals, will readily destroy them, and will terminate the urethral discharge depending on their presence. c. Granular Urethritis. — One of the most tedious affections of the urethra is a chronic inflammation of the mucous membrane following an attack of acute gonorrhoea, characterized by an irregularly distributed hyper- semia and scanty discharge. The velvety mucous membrane bleeds at the slightest touch, and the condition resists every form of local treatment for a disproportionately long time. It seems that the intractability of this affection depends in a great measure upon constitutional disorders ; at least the author observed it most frequently in anaemic individuals of a scrofulous habit. Measures directed to the improvement of the general condition, and supplemented by the local application of a five-per-cent solution of nitrate of silver by the endoscope, seem to have been more efficient than anything else, though it must be admitted that a few cases resisted every kind of treatment, and had to be given up as entirely unmanageable. d. Chronic Catarrh of the Posterior Part of the Urethra, AND Chronic Cystitis. — Chronic catarrh of the membranous and prostatic part of the urethra is frequently observed following an acute attack of gon- orrhoea, in subjects formerly addicted to masturbation, or those indulging in general, and especially in sexual, excesses. In these cases no external urethral discharge is visible, but frequent micturition is present, and both 316 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. portions of the urine, passed into two tumblers, show turbidity, the first portion, however, being more turbid than the last. Treatment by gradual dilatation with full-sized sounds is perfectly use- less in this affection, and may even lead to epididymitis in some cases. Methodical irrigation of the neck of the Madder, on the other hand, by means of a soft gum catheter and hand syringe, as described in a preceding para- graph, will be very often found beneficial. Of all substances, a 1 : 2,000 tepid solution of permanganate of potash has been found most generally applicable. A quart china bowl is filled with warm water, and enough of a concentrated solution of the salt is added to tinge the water a light-claret color. This test, by observing the depth of the tinction, is very sensitive if applied to weak solutions, and commends itself by its simplicity. Next to permanganate of potash, one-]5er-cent solutions of sulpho-carbolate of zinc or of acetate of lead deserve mention. But nitrate of silver is the most efficient of all hnoion remedies in obstinate cases of chronic deep-seated urethritis or prostatic catarrh. A few drops of a five-per-cent solution are instilled, twice or three times a week, by Ultzmann's or Keyes's deep ure- thral syringe, as formerly described. Acute cystitis, whether gonorrhceal or pyogenic, is not amenable to in- strumental treatment, luhich should only commence after the cessation of the invasive stage. The object of medicinal irrigation is the disinfection and removal of fermenting urine and its decomposed contents, such as roj)y mucus, blood, and pus. If stone or a stricture be the causative agents, they must be removed ; if imperfect evacuation of the bladder, on account of paresis, or enlargement of the prostate, is at the bottom of the trouble, regulated evacuation of the organ by catheterism must be employed. Aside from fulfilling these causal indications, recovery can be materially hastened by methodical irrigation. Irrigation with a metallic '' double current" catheter, as recommended hy various authors, is unsatisfactory. Introduction of the rigid catheter is painful, and may be the source of various complications. The advantages of the double current are illusory, as much of the ropy mucus and other sediment found in the cul-de-sac of the bladder is not brought out by its use. A more gentle and much more efficient way of thoroughly emptying the deleterious contents of the inflamed bladder is as follows : The patient is made to stand before the seated physician. This position is more favorable than any other, as in it the sedimental matter contained in the urine is made to gravitate toward the neck of the bladder, where it is readily stirred up and evenly distributed in the urine by the injections. Thus it will pass the catheter much easier than when it forms a sticky mass. A soft rubber catheter is introduced into the bladder, and a hand-syringeful of a tepid, weak solution of cooking-salt (one teaspoonful to a quart, about 6 : 1,000) is thrown in gently, and is allowed to escape at once. This is repeated until the returning saline solution is clear and limpid. After this, two or four ounces of a tepid 1 : 5,000 solution of permanganate of potash are injected and retained for one or two minutes, and the process is repeated TREATMENT OF GONORRHCEA. 317 until the returning fluid ceases to be discolored. By and by, as the bladder becomes more tolerant, the injection should be made more forcible, as a thorough stirring up and dislodgment of the roi)y sediment by tlie jet of lotion is very essential to its complete evacuation. The strength of the medicinal lotion should also be gradually increased (to 1 : 1,000). In cases of paresis, or when a tendency to vesical haemorrhages be pres- ent, cold, instead of tepid, injections will be appropriate. In obstinate catarrh the strength of the permanganate-of-potash lotion can be increased to 3 : 1,000. Alum (from 1 : 100 to 5 : 100), sulphate of zinc (from 1 : 100 to 2 : 100), and nitrate of silver (from i : 100 to 2 : 100), will also be found very effective. Deodorization of fetid urine is readily effected by injections of a 3 : 100 solution of resorcine, which should be followed up by the employment of one or another of the medicinal solutions above mentioned (Ultzmann). If the capacity of the bladder be very much diminished by long-con- tinued spastic contraction accompanying gonorrhoeal or calculous cystitis, gentle and gradual distention of the organ by salt water or medicinal in- jections of increasing volume will be followed by increasing tolerance. Thus micturition will gradually become less frequent, and the normal con- dition of things may be re-established. Note. — Gradual distention of the shrunken bladder of elderly persons is dangerous, as it may lead to rupture of diverticula. 42 PAET V. SYPHILIS : ASEPTIC A^D ANTISEPTIC TEEATMEJSTT OF ITS EXTERI^AL LESIOE^S. CHAPTER X. ASEPTICS AND ANTISEPTICS APPLIED TO EXTERNAL SYPHILITIC LESIONS. 1. Aseptic Treatment of Primary Induration. — The nature of the specific virus of syphilis is not known. In most cases its local and general mani- festations ai*e amenable to appropriate systemic and topical remedies. It is not intended here to dwell uj)on the nature and treatment of syphilis as a general disease ; only inasmuch as some of its more common local phenomena require surgical treatment will their consideration be deemed within, the limits of this chapter. The anatomical structure of the primary induration, of tuberous syphi- lides, and of gummy swellings, resembles closely that of recent tuberculous deposits ; and their course of development and termination in central coagulation necrosis, fatty changes, or caseation, also bears much general resemblance to the affections caused by the bacillus of tuberculosis. But there is a third point of parallelism. As long as softened tuberculous or syphilitic foci remain subcutaneous, and are not exposed to the influence of the air and its pus-generating germs, their course is bland and slow, and their tendency is to fatty degeneration, encapsulation, and final absorption. But, as soon as such a softening deposit comes under the influence of the pyogenic elements contained in the at- mospheric air, its slow and bland character is changed to a most destructive one. Thus syphilitic nodes of the internal organs, being protected from contact with the outer air, rarely, if ever, terminate in ulcerative destruc- tion : they generally tend to fatty involution, absorption, and cicatrization. Specific deposits of the outer skin, the mucous membranes — as, for example, of the nasal and oral bones — on the other hand, are all noted for their pro- nounced tendency to rapid ulceration or gangrenous destruction. As an illustration of a parallel behavior of tuberculous foci, cold ab- scesses and articular tuberculosis may be mentioned. Before perforation, their course is mild and slow ; but after the establishment of one or more sinuses they become the source of profuse secretion, and their course is characterized by rapid local destruction with general emaciation. The explanation of this peculiar difference in the behavior of syjDhilitic indurations or tumors, essentially identical in morbid character, is to be found in the fact that the poor nutrition and low vitality of the cellular 322 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. elements composing a primary or secondary syphilitic node, exposed to pyogenic infection by contact with the outer air, offer very favorable con- ditions for the rapid development and destrnctive multiplication of germs, that are notoriously deleterious even to healthy tissues. Pus-generating cocci deposited on the excoriated surface of a syphilitic focus, as, for in- stance, a primary induration of the prepuce, or a gummy swelling of the nasal bones, will, by their multiplication, lead to massive invasion and raj)id ulcerative destruction of the densely infiltrated and poorly nourished node. Syphilitic ulcers of every Tcind present a comhination of syphilitic and of pyogenic infection. If we succeed by appropriate systemic treatment in preventing the ex- tension of the central softening of a syphilitic node to the surface, ulcerat- ive changes also will thus be prevented. For example, the timely admin- istration of large doses of iodide of potash may prevent necrosis of the nasal bones, which are the seat of a growing gummy swelling. Their dense infil- tration pertains to syphilis ; their necrosis, however, is caused by the invasion of pyogenic germs. But we possess another means for preventing ulcerative destruction of syphilitic deposits located in the outer skin. They are more exposed to pyogenic infection, but they are also more accessible to local remedies. The aseptic protection of the surface of the primary ii^duration offers an easy remedy for preventing the formation of the primary ulcer or chancre. True, that the prevention of the ulcerative destruction of a primary in- duration of the prepuce will not prevent the systemic development of syphilis ; but it will, nevertheless, constitute a valuable service rendered to the patient, who will be spared all the suffering, annoyance, and danger connected with the development of the primary ulcer. If a patient, exhibiting a recent primary induration of the penis, pre- sents himself for treatment before the appearance of the pustular excoria- tion, or before the epidermal film of the formed pustule is broken, and if the surgeon thoroughly cleanses and disinfects the affected parts, afterward carefully enveloping the penis in an -aseptic dry dressing, ulceration of the indurated node — that is, the development of a primary ulcer — can be efl'ectu- ally prevented. The node will lose its epidermidal covering, but the aseptic dressing will exclude pyogenic infection, and the course of development and involution of the syphilitic deposit will be as though it were subcutaneous. A small quantity of lymph will exude from the excoriated surface, will be imbibed by the aseptic dressing, and will exsiccate, thus forming a hermetic seal and protection to the diseased tissues. Fatty disintegration of the infiltrated tissues will be followed by the formation of new epidermis, and when, after three or four weeks, the dress- ings come off, a cicatrized though still somewhat indurated portion of skin will be exposed to view. Specific rash, and other manifestations of systemic infection, will appear in due course of time ; but the incalculable extension of the ulceration to ASEPTICS AND ANTISEPTICS IN SYPHILITIC LESIONS. 323 adjoining noii-infiltrated parts of the skin, and the formation of suppurat- ive bnboes and other complications, will be obviated. The following case may serve as an illustration : Case. — H. B., aged twenty-tive, presented liimself January 2, 1887, with a hard, elevated node, the size of a nickel, occupying the dorsum penis, and another smaller induration near the frenulum. Suspicious cohabitation had been indulged in for some time until within a few days of the visit. Bilateral indolent inguinal lymphadenitis was noted, and the presence of specific infection was assumed. The patient was kept under daily observation, and was directed not to meddle with any blister that might appear on the indurated spots. January 8th. — A yellowish discoloration was observed occupying the apex of the larger node, and was looked upon as an indication that a pustule was forming. The entire penis was carefully cleansed with green soap and warm water, and was disinfected with a 1 : 1,000 solution of corrosive sublimate, good care being taken not to break the transparent layer of epidermis covering the dis- colored spot. A thick layer of iodoform powder was sprinkled over both indurated nodes, and a small patch of iodoformized gauze was placed over them — this being held down by a narrow, oblong compress of corrosive-sublimate gauze, snugly bandaged on with a muslin roller. The meatus was left exposed for micturition, and the patient was directed not to interfere with the dressings and to report daily. The first dress- ing remained undisturbed until January 17th, when its external part, getting disar- ranged, was removed. The strip of iodoform gauze was found firmly attached to the underlying indurated nodes, and had the appearance of a hard, flat cake, that had been evidently soaked through by lymph or serum some time since its application. Evap- oration of its aqueous contents had converted it to the shape just described. It was left in situ, and a fresh outer dressing was applied. At the same date (January 17th) the girl with whom the patient had held com- merce, presented herself for examination at the author's request, and was found to be covered with a small, papulous, specific rash. The appearance of her throat, the uni- versal adenitis, and two freshly-cicatrized spots on the labia minora, left no doubt of her being subject to florid syphilis. She remained under prolonged specific treat- ment, and in July, 1887. still exhibited pharyngeal ulcerations. January 25th. — The dressings applied to the patient's penis became again disar- ranged, and had to be renewed. The immediate covering of the nodes, consisting of iodoform gauze, was still firmly adherent, and was left unchanged. February 12th. — A general maculous rash appeared on the patient's body, and sys- temic treatment by mercurial inunctions was commenced. February 20th. — The entire dressings came off — the strip of iodoform gauze in the shape of a perfectly dry scab, to the inner side of which was found attached a patch of shiny scales, consisting of effete epidermis. The nodes, which were formerly promi- nent, had receded to the level of the surrounding skin, and the induration, which still could be felt, was marked by a coat of fresh-looking young epidermis. The patient received fifty inunctions of blue ointment, which freed him fi-om all cutaneous symp- toms of the disease. In May, pharyngeal ulcerations appearing, the inunctions were resumed. Size and hardness of the initial sclerosis were visibly diminished by this time. It seems in the foregoing case that the ulcerative destruction of the pri- mary induration was forestalled by disinfection and subsequent aseptic management. Without them the imminent formation of an initial sore would have inevitably occurred. The treatment of the fully-developed chancre would certainly have been a much more disagreeable, painful, and filthy ex- 324 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. perience than the simple maiiipuhitiou of once cleansing and protecting the initial induration. The site of the morbid process thus protected against "ex- ternal irritation'' — that is, pyogenic infection — ran, as it were, a subcuta- neous and bland course of slow involution, the aggregate of discharge during forty-three days not exceeding the small quantity required to permeate a strip of four layers of iodoformized gauze, covering an area of about two thirds of a square inch. 2. Antiseptic Treatment of the Primary Syphilitic Ulcer. — The results obtained by the various time-honored and well-established forms of local treatment of the primary syphilitic ulcer all bear out the assumption that the specific alteration of the affected tissues only serves as a predisposing condition to the subsequent ulcerative destruction of the initial sclerosis. The ulceration is directly produced by the ingrafting of purulent infection on a soil, devitalized by the dense cellular infiltration, characteristic of initial sclerosis. The rapid destruction observed in chancre is always sig- nalized by the detachment of the epidermis raised in the shape of a pustule, under which we find a yellowish, brittle necrobiotic nucleus, which is the first to succumb to the onslaught of the pyogenic organisms, deposited on it by the manipulations of the patient or otherwise. Tlte various forms of local treatment successfully employed for the cure of cliancre are all antiseptic in character. Their aim is either the prompt removal of the infectious discharge by prolonged baths and frequent moist dressings, or disinfection by weak or concentrated caustics, or a combination of measures directed toward a rapid mechanical removal of the deleterious secretions, with chemical disinfection. As the most powerful and most effective arrester of the destructive course of phagedenic chancre, the actual cautery is to be mentioned — the sover- eign destroyer of all microbial parasites. a. Chemical Sterilization ked Sueface Drai^stage by Medicated Moist Dressings. — The energy to be applied to the local treatment of an ulcerating initial sclerosis should be proportionate to the virulence and de- structiveness of the morbid process. In most cases the resistance of the vital forces combating the morbid process will be sufficient to check the damage. This is attested by the numerous cases of neglected chancre that end ultimately in spontaneous cure. Hence, in most instances, a mild treatment by local antiseptic baths, combined with moist antiseptic dress- ings, will answer the purpose. Frequent removal of the soiled dressings forms the most essential part of this plan of therapy. The patient is directed to provide himself with a wide-mouthed, one-ounce vial, which is filled with suitably proportioned small, square pieces of lint or gauze, over which is poured a moderate quan- tity of a one-per-cent solution of carbolic acid, or a 1 : 5,000 solution of corrosive sublimate. The cork-stoppered vial can be easily carried by the patient, who is enjoined to dress the sore or sores at least once every hour, and oftener if the discharge be very profuse. In the morning and evening a prolonged local bath in the same solution is advisable. In many cases ASEPTICS AND ANTISEPTICS IN SYPHILITIC LESIONS. 325 this plan will be sufficient to check the extension of the ulcer, taid to bring about cleansing of its bottom. Another mild form of antiseptic treatment consists of the application of iodoform powder to the ulcerating surface. The objectionable odor of the drug can be excellently masked by the admixture of equal parts of freshly roasted and ground coffee. As soon as the appearance of a cicatricial border is apparent, these modes of treatment should be abandoned in favor of the application of strips of mecurial plaster, which should be renewed in pro- portion to the amount of discharge. Cicatrization will be very much has- tened by this change. h. Chemical Sterilization by Strong Caustics. — Cases of greater virulence which do not yield within a fortnight or so to the mild plan of treatment by scrupulous cleansing and disinfection, or in which rapid ex- tension of the ulcer does not justify temporizing, require the application of escharotics. The author has found a fifty -per-cent solution of chloride of zinc the most convenient and most effective of all chemicals recommended for the cauterization of chancre. Its application is to be done as follows : The ulcer and its vicinity are subjected to a careful cleansing by a mop of cotton dipped in a 1 : 1,000 solution of corrosive sublimate. Crusts and scabs overlapping the edge of the sore must be gently removed. A small piece of clean blotting-paper is applied to the ulcer and its vicinity with gentle pressure to remove all moisture. A moderate quantity of the caustic solution is applied to the sore with a glass rod or match-stick, care being taken not to corrode unnecessarily the surrounding healthy skin. Previous thorough drying of the integument with blotting-paper will best prevent overflowing of the caustic. All the nooks and indentations of the margin of the ulcer must be carefully covered by the solution. As soon as the base of the sore assumes the color of parchment, which will occur in from three to five minutes, cauterization is completed, whereupon the surplus of caustic should be removed by the application of another piece of blotting-paper. The eschar is dusted with a little iodoform and coffee-powder, and is pro- tected from injury by a strip of moist lint or gauze. If the cauterization was sufficient, further extension of the ulcerative process will be arrested thereby. In from two to six days, according to the depth of the eschar, a narrow line of demarkation will appear, and, the eschar being detached, a healthy granulating surface will become visible. This should be dressed with strips of mercurial plaster until cicatrization is completed. Insufficient chemical cauterization will not check the ulcerative decay of the tissues. In proportion to the incompleteness of the application, par- tial or total extension of the ulcer will be observed. In some cases only a tongue of renewed ulceration will be seen extending outward from the mar- gin of the eschar. In others, the ulceration will spread all around the cauterized patch, thus demonstrating the entire inadequacy of the applica- tion. The surgeon's error should be in favor of too much rather than too little of the caustic. 43 326 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. Wlien the process is found to be extending more or less in spite of a pre- vious cauterization, the deficiency should be corrected without delay by a renewed application. c. Sterilization by the Actual Cautery. — Phagedenic forms of chancre, occurring on the penis, lips, or fingers, and characterized by dusky swelling and a rapidly-spreading, more or less gangrenous decay of the tissues, can be rarely arrested by anything short of the energetic application of the actual cautery. In some cases renewed searing will be required to check the trouble brought under control in one portion of the ulcer, but extending further in another direction from a limited part of the lesion. It is espe- cially important to search out all recesses overlapped by the undermined margin of integument, as they are the chief nidus of active infection. The thermo-cautery, or red-hot iron, should be well inserted in all of these re- cesses and sinuses, otherwise the result will be incomplete or entirely un- satisfactory. The wound should be packed with very narrow strips of iodo- form gauze while the patient is still under the influence of the indispensable anaesthetic, and care should be taken to line all nooks and crevices of the irregular wound with the gauze. The object of this is to prevent retention, and to secure prompt disinfection of the discharges which needs must he absorbed by the dressings. The penis is enveloped in an ample compress, moistened with warm carbolic lotion (one per cent), over which is placed a piece of rubber tissue to prevent evaporation. On the penis, daily change of dressings is to be done after a hip-bath, which will very much facilitate their painless removal. The febrile disturbance regularly noted with these most virulent forms of specific ulcer, and the general debility and anfemia, which is its main predisposing cause, require appropriate roborant and anti-febrile general treatment. As soon as cicatrization shall have com- menced, the atfection is to be treated like a simple ulcer. The foregoing view of the relation of sup- puration to syphilitic lesions is based exclu- sively upon clinical data, and needs corrobo- ration at the hands of pathologists more ex- pert in systematic and exact research than the author. One object of these re- marks was to arrange the clinical facts pertaining to syphilitic ulcera- tions under a general principle, from which the therapeutic measures usu- ally employed for their cure could be easily and logically deduced. Viv.. 248. — Specific ulcer of inde.K lintjcr. INDEX Abdominal drainage, 138. operations, 115. suture, 139. toilet, 138. Abscess, anal, 254. of bone, 205. cervical, 220. cold, 264. formation of, 179, glandular, 189. iliac, 247. of liver, 251. lumbar, 251. mammary, 223. mastoid, 221. metastatic, 181. pelvic, 246. perinephritic, 251. perityphlitic, 246. prevesical, 247, 249. psoas, 246. retroperitoneal, 246. self-limitation of, 180. tonsillai', 215. temporal, 221. Accidental wounds, 29. Acetic acid, 11. Active movements after joint exsection, 278. Actual cautery for syphilitic ulcers, 326. Adhesions, abdominal, 136. yEther pneumonia, 148, 149, 152. nephritis, 118. Amputations, 59. dressings after, 72. Anal abscess, 254. Anal fistula, 256. excision of, 256. suture of, 257. tuberculous, 269. Anatomy of connective-tissue planes of neck, 208. planes of pelvis, 246. Anaesthetics in herniotomy, dangerous depress- ing efPect of, 125. Aneurism, 48. needle, 48. Anchylosis, bony, 84. Ankle-joint, exsection of, 293. Antisepsis, 27, 167. Antiseptics applied to primary syphilitic ul- cers, 324, Apnoea after tracheotomy, 101. Apparatus for the after-treatment of the ex- sected elbow-joint, 281. Aprons, 20. Arm, suppuration of, 230. Arteries, ^ligature of, 47. Artery forceps, 66. Arthrotomy, 75, 79. for elbow fracture, SO. for dislocation, 79. for habitual dislocation, 8. Artificial anaemia, 66. anus, 122. Aseptic cap, 89. Asepsis, 3. in peritoneal operations, 115. Aseptic wounds, 5. accidental wounds, 32. Aseptics of amputation, 59. of the orifices, 93. of rectum, 154. Axilla, evacuation of. 111. Axillary glands, 238. vein. 111. Bacteria of putrescence, 171. Bismuth, 11. Bladder, antiseptics of the, 159. treatment of, before ovariotomy, 138. Bloodclot, healing under the, 6. Bone abscess, 205. tuberculosis, 273. Boro-salicylic lotion, 10. 328 INDEX. Bose's methods of tracheotomy, 99. Bottle-shaped wounds, 40. Bow-leg, 83. Bozeman's position, 154. Breast amputation, lii9. Broad ligament, 14'2. Bursa, iliac, 230. olecranic, 238. prepatellary, 242. of quadriceps, 243. Cachexia strumipriva, 108, Cancer of tongue, 94. Caries. 273. Carbolic acid, 10. Carpal exsection, 284. Caseation, 264. Caseous infiltration, 264. Castration, 152. Cataplasms, 186. Catgut, 8. impure, 8. slipping of, 69 Catheters, cleansing of, 159. Catheterism, 159. Cervical abscess, 220. Change of dressings, 20. Chisels, 198. Chloride-of-zinc solution, 825. Clap, 301. Cleanliness, surgical, '7. Cleansing process of feet, 61. Club-foot, 85. Cold abscess, 264, 273. applications, 187. Colotomy, lumbar, 147. inguinal, 148. Compressor urethras, 301. Continuous suture, 45. Corrosive-sublimate lotion, 10. Coryza, scrofulous, 269. Cotton dressings, 15. "Cut-off" muscle, 160, 301. Cynanche, parotid, 219. sublingual, 217. Cyst of broad ligament, 142. Cystitis, 315. Cystotomy, perineal, 162. suprapubic, 163. Czerny's suture for hernia, 130. Deformities, 83. Diphtheria of fauces, 211. of intestine, 125. Dissection, technique of, 35. Dislocation, irreducible, 79. habitual, 79. Drainage, 59. abdominal, 138. Drainage-tubes, 9. T-shaped, for cystotomy, 164 Dressings, 11. for hand and forearm, 80. Dry dressings, 12. spores, 178. Dust, 5. Elastic ligatures, 9, 136. in anal fistula, 258. Elbow apparatus, 281. fracture, 80. joint, exsection of, 280. Embolism, septic, 181. Emergencies, 23. Emphysematous gangrene, 191. Empyema, 226. Endoscoj)e, urethral, 308. Epididymitis, tuberculous, 269. Erysipelas, 170, 259. phlegmonous, 260. Esmarch's bandage, 67. Estlander's operation, 228. Excii^ion of anal fistula, 256, Exsection of ankle-joint, 293. of elbow-joint, 280. of joints for tuberculosis, 275, of hip-joint, 285. of knee-joint, 287. of shoulder-joint, 278. of wrist, 284. External urethrotomy, 313. Extirpation of axillary glands, 289, of cervical glands, 51, 58. of inguinal glands, 55, 246. of tumors, 50. Eace, carbuncle of, 210. Fauces, diphtheria of, 211, Faucial suppuration, 211. Feet, cleansing process of, 61, Femur, necrotomy of, 203. Fibrinous arthritis, 74. Finger-joints, exsection of, 238. suppuration, 237. Fistula in ano, 254. in ano, tubercular, 269. thoracic, 228. Floating bodies, 77. INDEX. 329 Follicular tonsillitis, 212. Fresh cadavers, infectiousness of, 177. Funnel-shaped wounds, 40. Gastrostomy, 14(3. Gauze, 14. corrosive-sublimate, 15. iodoformized, 15. Giant cell, in tuberculosis, 2(34. Glandular tuberculosis, 269. Gleet, 3u7. Goitre, 107. Gonococcus, 299. Gonorrhoea, 299. acute, 301. anterior, 302. chronic, 307. deep-seated, 304. posterior, 304. Granular urethritis, 315. Granulations, infection of, 184. Gross dirt, 178. Gunshot wounds, 34. Habituation to septic influences, 183. Haemorrhoids, 154. Hcemostatic needle, 41. Hahn's incision for exsection of knee-joint, 288. Hand, phlegmon of, 230. Hernia, congenital, 130. radical operation for, 128. strangulated, 119. Hernial sac, ti'eatment of, 120. Herniotomy, 117. dressings after, 127. Hilton-Roser's method of incising abscesses, 188. Hip-rest, Volkmann's, 127. Hip-joint exsection, 285. Hot applications, 187. Hydrocele, 149. tapping of, 150. Hygroma, proliferating, 271. Hysterectomy, 143. Iliac abscess, 247. bursa, 250. Immersion, continuous, 235. Incontinentia alvi, 258. Infection, portals of, 171. Infectiousness of tonsillitis, 214. Inflammation, 178. Ingrown toe-nail, 239. Inguinal glands, 245. Inguinal glands, supi)uration of, 238, 245. Injections, urethral, 303. Instrument-pouch, 26. Intermuscular space, 209, 220. Internal urethrotomy, 311. Interrupted suture, 45. Intubation, 213. Iodoform, 11. dusting box, 15. Irrigation, 7. continuous, 235. of joints, 73. of the neck of the bladder, 304, of the urethra, 303. Irritation, caloric, 176. chemical, 176. mechanical, 175. Joints, after-treatment of, 277. Joint-exsection, 275. Joints, suppuration of, 73. tuberculosis of, 275. Kidney, surgical, 253. Klotz's endoscope, 308. Knee-joint exsection, technique of, 288. suppuration of, 242. tuberculosis of, 289. Knock-knee, S3. Lange's position for nephrotomy, 252. Laparotomy, exploratory, 133. Laryngeal operations, 97. Laryngofissure, 103. Larynx, extirpation of, 104. Laudable pus, 184. Lead-plate suture. Lister's, 45. Leg, ulcer of, 241. Leptothrix, 214. Ligatures, 8. Litliolapaxy, Bigelow's, 161. Little finger, suppuration of, 232. Liver abscess, 251. Lumbar abscess, 251. dressings, 254. Lupus, 268. Lymphadenitis, caseous, 269. Lymphangitis, 185. Maas's operation, 91. Mamma, amputation of, 109. Mammary abscess, 223. Mastitis, interstitial, 225. suppurative, 223. 330 INDEX. Mastoid abscess, 221. Measles and tuberculosis, 265. Meatotomy, 307. Mechanical irritation, 175. Mikulicz's operation, 293. Moist dressings, 13. Moss, 17. Mucous membranes, tuberculosis of, 260. Multiple puncturing, Volkmanu's, 186. Myxa?dema, loS. Nails, arrangement of, 84. extraction of, after exsection of knee-joint, 293. for knee-joint exsection, 289. Neck of the bladder, cauterization of, 306. irrigation of, 304. Neck, caseous lymphadenitis of, 270. connective-tissue planes of, 208. Necrosis of bone, 193. of gut, 123. 124. Necrotomy, 194. Needle-holder, 41. Nephrectomy, 145 Neuber's implantation, 200. (Esophagus, retrograde cathetcrism of, 146. cancer of, 146. Olecranic bursa, 238. Open treatment, 66. Operating bag, 25. Oral cavity, 93. Orchitis, tuberculous, 269. Osteomyelitis, acute infectious, 191. Otis's urethrometer, 307. Ovarian tumors, 140. Palmar bursa, 232. suppuration, 231. Passive movements, 75. after joint exsection, 277. Pasteboard splints, 281. Patella, suturing of fractured, 77. Pelvic abscesses, 246. Pelvis, connective-tissue planes of, 246. Perineoplasty, 91. Perinephritic abscess, 251. Peritoneal tuberculosis, 118. Peritonjcum, protection of, 138. Peritonitis after abdominal section, 117. Pcrityphlitic abscess, 246. Perivascular interspace, 209, 220. Pes valgus, 85. Phelps's operation, 85. Phlegmon, cause of, 169. Phlegmon, cutaneous, 185. retro-pharyngeal, 215. subcutaneous, 185. subfascial, 189. treatment of, 184. Phlegmonous erysipelas, 190. Plastic operations, 88. Pleurisy, purulent, 226. Pneumonia, from aether, 148, 149, 152. Predisposition to tuberculosis, 265. Prepatellary bursa, 242. Prevesical abscess, 247, 249. Previsceral interspace, 208. Primary induration, syphilitic, 321. ulcer, syphilitic, 322. Probing of wounds, 193. Proctoplasty, 258. Prostatic syringe, Ultzmann's, 306. Pseudo-erysipelas, 260. Psoas abscess, 246. Ptomaines, 4. Puncture of abdominal tumors, 137. Purse-string suture, 126. Putrescence, bacilli of, 171. Pyaemia, 182. Quadriceps, bursa of, 243. Quilled suture, 139. Quinsy sore throat, 215. Radical operation for hernia, 128. for hydrocele, 150. for varicocele, 151. Rectal tampon-tube, 155. Rectum, aseptics of, 154. Retractors, 39. Retrograde catheterism of oesophagus, 146. Retro-peritoneal abscess, 246. Retro-pharyngeal abscess, 215. Retro-visceral interspace, 208. Revision for tuberculosis, 274. Rose's position of head, 213. Rubber sheets, arrangement of, 75, 81). Rubber tissue, 12, 13. Sawdust, 16. Saws, disinfection of, 63. Schede's dressing, 12, 203. Schroeder's suture of uterine stump, 144. Scrofula, 269. Sepsin, 4. Sepsis, 3. Sej)tic fever, 179. INDEX. 331 Shock after laparotomy, 145. Shoulder-joint, exsection of, 278. Sigmund's urethral syringe, 303. Silk, 9. Silk-worm gut, 'J. Soiled accidental wounds, .31. Solutions for disinfection, lu. Spanish windlass, 30. Splints of pasteboard, 280. Sponges, 8. in laparotomy, 134. Spra}--apparatus, 134. Staphylococcus, 169. Slarcke's irrigation-tube, 236. Sterilization, chemical, 7. Strangulating hernial band, 120. Strangulated hernia, 119. Streptococcus, 169. Stricture, urethral, 301. incipient, 307. permanent or cicatricial, 309. Styptic solutions, abuse of, 230. Submaxillary capsule, 208, 218. Suction lead, 45. • Suppuration, cause of, 169. spread of, 179. superficial, 185. Suppurations on the face, 209. of the fauces, 211. Surgical kidney, 253. Suture, abdominal, 139. of anal fistula, 257. Sutures, 8, 43. Suturing fractured patella, 77. Syphilitic external lesions, 321. Syphilitic ulcer, caustic treatment of, 325. primary, 324. moist treatment of, 325. treatment by the actual cautery of, 326. T-bandage, 157. T-splint, Volkmann's, 74. Tampon cannula, Gerster's, 94. Tampon-tube, rectal, 157. Temporal abscess, 22 1 . Tendinous sheaths, tuberculosis of, 271. Testis, necrosis of, 152. removal of, 152. Thiersch's solution, 10. spindle-apparatus, 41. Thomas's operation for mammary tumors, 110. Thoracic fistula, 228. Thrombosis of pulmonary artery, 114, 227. Thrombosis, septic, 181. venous, 1 14. Through-drainage, 46. Thumb, suppuration of, 232. Toilet, abdominal, 138. Tongue, 94. Tonsils, cauterization of, 213. Tonsillar abscess, 215. Tonsillitis, 213. Tracheotomy, preliminary, 94, 97. superior, 99. inferior, 100. for goitre, 109. Trendelenburg's T-shaped drainage-tube, 164. Trocars, disinfection of, 73. Tuberculosis, 263. of ankle-joint, 293. of bone, 273. cutaneous, 268. dissemination of, 265. general treatment of, 269. of joints, 275. of knee-joint, 289. local treatment of, 268. of lymphatic glands, 269. of mucous membranes, 269. of peritonseum, 118. prevention of, 289. and pyogenic infection, combination of, 267. of tendinous sheaths, 271. of testicle, 269. Tuberculous infection, direct, 266. through the lungs, 265. Tumors, extirpation of, 50. Ulcer of leg, 241. Ultzmann's method of irrigating the neck of the bladder, 304. prostatic syringe, S06. test, 302. Uraemia from aether, 118. Urethral endoscope, 308. injections, 303. irrigation, 303. stricture, 301. syringe, Sigmund's, 303. tuberculosis, 269. vegetations, 315. Urethritis, chronic, 315. gi'anular, 315. Urethrometer, Otis's, 307. Urethroplasty, 90. Urethrotomy, external, 313. 332 Urethrotomy, internal, 311. Uterine stump, 144. Yaricocele, 151. Vein, axillary, 111. Veins, exsection of, 57. injury of femoral, 56. lateral closure of, 55. treatment of, 42. Venereal vegetations, urethral, 315. INDEX. Vermiform appendix, necrosis of, 124. Vertical suspension of limbs, 235. Vesical tuberculosis, 269. Volkmann's hip-rest, 127. multiple puncturing, 186. suspension splint, 235. T-splint, 74. White swelling, 275. THE END. *:jt* The Books advertised in this List are commonly for sale by booksellers in all parts of the country ; but any 7vork will be sent by D. Appleton & Co. to any address in the United States, postage prepaid, on receipt of the advertised price. CATALOGUE OF MEDICAL WO R KS. THE PUERPERAL DISEASES. Clinical Lectures deliv- ered at Eellevue Hospital. By Fordyce Barker, M. D., Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical College; late Obstetric Physician to Bellevue Hospital; Surgeon to the New York State Woman's Hospital, etc. Fourth edition, i vol., 8vo, 526 pp. Cloth, $5.00; sheep, $6.00. " For nearly twenty years it has been my duty, as well as my privilege, to give clinical lectures at Bellevue Hospital, on midwifery, the puerperal, and the other diseases of women. This volume is made up substantrally from phonographic reports of the lectures which I have given on the puerperal diseases. 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" These lectures were delivered in University College Hospital last year, at a time when I was doing duty for one of the senior physicians, and during the same year — after they had been repro- duced from very full notes taken by my friend Mr. John Tweedy — they appeared in the pages of ' The Lancet.' They are now republished at the request of many friends, though only after having undergone a very careful revision, during which a considerable quantity of new matter has been added. It would have been easy to have very much increased the size of the book by the intro duction of a larger number of illustrative cases, and by treatment of many of the subjects at greater length, but this the author has purposely abstained from doing under the belief that in its present form it is likely to prove more acceptable to students, and also perhaps more useful to busy prac- titioners." — Extract fro7n Preface. THE MANAGEMENT OF INFANCY, Physiological and Moral. 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" Few persons are better qualified than Dr. Cor- field to write intelligently upon the .subject of health, and it is not a matter for surprise, therefore, that he has given us a volume remarkable for accuracy and interest Commencing with general anatomy, the bones and muscles are given attention ; next, the circulation of the blood, then respiration, nutrition, the liver, and the execretoiy organs, the nervous system, organs of the senses, the health of the indi- vidual, air, foods and drinks, drinking-water, cli- mate, houses and towns, small-pox, and communi- cable diseases." — Philadelphia Item. D. APPLETON (&- CO:S MEDICAL WORKS. THE BRAIN AS AN ORGAN OF MIND. By H. Charlton Bastian, M. A., M. D., Fellow of the Royal College of Phy- sicians ; Professor of Pathological Anatomy in University College, London. With 184 Illustrations and an Index. I vol., i2mo, 708 pp. Cloth, $2.50. " This work is the best book of its kind. 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TREATISE ON MATERIA MEDICA AND THERA- PEUTICS. Revised and enlarged. Edition of 1883, with Complete Index and Table of Contents. By Roberts Bartholow, M. A., M. D., LL.D., Professor of Materia Medica and Therapeutics in the Jefferson Medical Col- lege ; formerly Professor of the Theory and Practice of Medicine, and of Clinical Medicine, and Professor of Materia Medica and Therapeutics in the Medical College of Ohio, etc. Sixth edition, revised and enlarged, i vol., 8vo. Cloth, $5.00; sheep, $6.00. "This edition of my treatise contains much new matter. The domain of Pharmacology is rapidly enlarging by the contributions of chemistry, and by new remedies brought forward by dealers with a view to profit. When a new remedy is announced, its physiological actions are immediately studied and defined. ... As in previous issues of this work, I have sought to give the facts, and to some extent current opinions of the time, on the new remedies ; but as far as possible demonstrable incongruities of opinion and of practice have been omitted. Only by actual inspection in all parts of the work, as it now appears, can the numerous additions to the individual remedies be seen. ... I now place the sixth edition before my readers and the medical profession in general, with the expression of my hope that it will deserve and maintain the place in their esteem which it has always held." — From Preface to Sixth Edition. "The very best evidence of the success of a work is the continuous and increasing demand for it. Bartholow's ' Materia Medica and Therapeu- tics ' has followed this course since the appearance of the first edition, in June, 1876, and has com- pelled the publishers to again place before the pro- fession the sixth edition. In this issue of the work the author has revised the former edition most carefully, and has included in its pages the latest and the most valuable remedies. About one hun- dred pages have thus been added to this valuable work, the new contributions having, as the author states, been assigned to places according to their physiological relations. The many additions, just referred to, can only be observed by a careful ex- amination of all parts of the book. . . . The work is not only, as in former editions, well arranged, but is the most progressive one of all those now before the profession, in the thorough consideration of all therapeutic measures of value in the treatment of disease." — Medical Register. "Since 1876 this work has passed through six editions, a degree of favor which is seldom ac- corded to medical works. . . . We have written in former issues of the Journal our appreciation of this volume, and we take this occasion to say that we consider it essential to every well-selected library." — North Carolina Medical yournal. " It is to be naturally assumed that the appear- ance of six editions of this work in a period of a little more than eleven years, is an indication of the measure of appreciation in which it is held by the profession. . . . The author's additions have been extensive and important, and give increased value to a work that is already recognized as oc- cupying a very conspicuous place in the medical literature of the day." — College and Clinical Record. " Since Bartholow's ' Materia Medica ' appeared eleven years ago, its several editions have occupied a place of which its author may well feel proud. In the present edition we find much new matter, which, taken as a whole, adds nearly one hundred pages. The 'Clinical Index,' which contributes greatly to the value of the book, has been retained. But few books become so popular as Bartholow's ' Materia Medica.' " — Practice. ' ' Bartholow's ' Materia Medica ' is a book too well known to the practitioners of medicine to need at this day any review. . . . Unquestionably the new edition is a great improvement on the old one ; and even if nothing were added but a sum- mary statement about new remedies in use since the last edition, the work would be desirable." — Gaillard''s Medical jfournal. D. APPLE TON C0:S MEDICAL WORKS. A TREATISE ON THE PRACTICE OF MEDICINE, for the Use of Students and Practitioners. By Roberts Bartholow, M. A., M. D., LL. D., Professor of Materia Medica and General Therapeu- tics in the Jefferson Medical College of Philadelphia ; recently Professor of the Practice of Medicine and of Clinical Medicine in the Medical College of Ohio, in Cincinnati, etc., etc. !?ixth edition, revised and enlarged, i vol., 8vo. Cloth, $5.00; sheep or half russia, $6.00. The same qualities and characteristics which have rendered the author's "Treatise on Materia Medica and Therapeutics " so acceptable are equally manifest in this. It is clear, condensed, and accurate. The whole work is brought up on a level with, and incorporates, the latest acquisitions of medical science, and may be depended on to contain the most recent information up to the date of publication. Specimen of Ilu'stration. i,t-i_ 1 i_ ? 1 1 "The large number of readers who are ^ ^ already familiar with this work will be glad '•y'-^ to learn that the present edition has been ' ' ' carefully revised by the author, considerably .^S> enlarged, and is intended to include all that has in the most recent period been added to practical medicine, especially in its clinical , horizon. The author felicitates himself on {'^_^ the large sales obtained for the previous edi- '.S tions, and there is no reason why the pres- ent one should not continue to gain in the opinion of many. What doubtless lends the volume one of its special attractions to these is the authoritative expressions which are frequent in its pages on subjects where the reader might be left in uncertainty else- where. This remark applies both to pa- thology and treatment. The fullness with which therapeutics are taught stands in noteworthy contrast to the majority of treat- ^ ises on practice. This, too, is undoubtedly J . "/ . >■. a feature which will be agreeable to numer- '^U'fi'l' j" ,,"" ;'f- ous purchasers. Some seeming excess of ^^ " ' i conciseness in certain portions is explained by the fact that this is but one volume of a series proposed by the author, which will whole domain of special pathology and therapeutics." — Medical and Surgical Reporter. cover the ' ' That six editions of such a work should be called for in six years is, perhaps, the most flattering testimonial that a book can receive, and must out- weigh every other comment, favorable or unfavor- able. In the preface to this edition is an announce- ment which will be welcomed by all of Dr. Bartho- low's numerous admirers, namely, that he has now in preparation another work on the ' Principles of Medicine' which, together with the one under review, and his 'Materia Medica and Therapeutics,' shall constitute a trio of volumes, each containing matter complementary to the others. Certainly three such volumes must constitute a monument which will ren- der the writer's fame almost undying." — Medical Press 0/ Western New York. " Professor Bartholow announces in the preface of this edition his intention of preparing a work in three volumes which shall cover the whole domain of special pathology and therapeutics. The volume on ' Materia -Medica ' appeared some time ago, but the third volume, which will treat of the ' Principles of .Medicine,' is now in course of careful preparation, and will, when published, complete a most valuable set. The present edition of Professor Bartholow's ' Practice ' is considerably larger than the last, several new subjects having been introduced, together with numerous new illustrations. It is deservedly popu- lar with practitioners and students, and likely ere long to become one of the standard works on prac- tice, if it has not already attained this position." — Pacific Medical and .Surgical yournal and Western Lancet, " The deserved popularity of this work is attested by the fact that the first edition was issued in 1880, that a second was demanded in three months, and that the others have followed them in rapid suc- cession and been met by appreciative students al- ways. The author says in his preface to this edition that he has sought to make it worthy of the appro- bation of his readers by increasing the practical re- sources of his work, devoting his attention chiefly to the clinical aspects of medicine, without overlooking the advances made in the scientific branch. This book, like the previous editions of the work, is the product of a master and an honored authority, and in its new form, with such of the latest ideas as the author can conscientiously indorse or present for consideration, continues to hold its place among the standard text-books on all matters included in it." — North Carolina Medical yournal. " This valuable work appears in its sixth edition considerably enlarged, and improved materially in many respects. The arrangement of the subjects appears to be pretty much the .same as in former editions, and the description of diseases is also little modified. Some new chapters have been added, however, and new subjects introduced, making the volume completely cover the entire domain of prac- tice, without anything superfluous. Considering the immense scope of subjects, the directness of statement, and the plain, terse manner of dealing with the phenomena of disease, this practical work has no counterpart." — Kansas City Medical Rec- ord. D. APPLE TON &- CO:S MEDICAL WORKS. ^ ON THE ANTAGONISM BETWEEN MEDICINES AND BETWEEN REMEDIES AND DISEASES. Being the Cart- wright Lectures for the Year 1880. By Roberts Bartholow, M. A., M. D., LL. D., Professor of Materia Medica and General Therapeutics in the Jefferson Medical College of Philadelphia, etc., etc. I vol., 8vo. Cloth, $1.25. "We are glad to possess, in a form convenient no doubt that this, his latest contribution to medi- for reference, this most recent summary of the physi- cal science, will add materially to his previously high ological action of important remedies, with the de- reputation. Much profit, no little pleasure, and ductions of a careful and accomplished observer, re- material assistance in the solution of many thera- garding the applications of this knowledge to dis- peutical problems are to be obtained from a perusal eased states." — College and Clinical Record. of these lectures. The author has done wisely and "There are few writers who have taken the conferred a boon by permitting their publication in trouble to compile the lucubrations of the multitude ^^^ present book-form, and we are satisfied it wUl of scribblers who find a specific in every drug they ^.e extensively asked for, and just as extensively read happen to prescribe for a self-limited, non-malig- ^^ appreciated. —Canada Medical and Surgical nant disease , and fewer who can detect the trashy /"''' '^"-l- chaff and gamer only the ripe, plump grains. This ' ' It will be observed that the scope of the work Bartholow has done, and no one is more ripe, nor is extensive, and, in justice to the author, not only better qualified for this herculean task ; and, the is the extent of this indicated, but the character of best of all is, condense it all in his antagonisms. it is also furnished. No one can read the synopsis No one can peruse its pregnant pages without no- given without being impressed with the impjortance ticing the painstaking research and large collection and diversity of the subjects considered. Indeed, of authorities from which he has drawn his conclu- most of the important forces in therapeutics and sions. The practitioner who purchases these antag- materia medica are herein stated and analyzed. " — onisms wiU find himself better qualified to cope with American Medical Bi- Weekly. the multifarious maladies after its careful perusal. " "Probably most of our readers wiU consider —Indiana Medical Reporter. that we have awarded this treatise high praise when ' ' The criticisms made upon these lectures have we say that it seems to us the most carefully writ- invariably been most favorable, the topic itself is ten, best thought-out, and least dogmatic work one of the most interesting in the entire range of which we have yet read from the pen of its author, medicine, and it is treated of by the accomplished It is indeed a very praiseworthy book ; not an origi- author in a most scholarly manner. Dr. Bartholow nal research, indeed, but, as a resume of the world's worthily ranks as one of the best writers, while at work upon the subject, the best that has hitherto the same time one of the most diligent workers, in been published in any language." — Philadelphia the medical field in all America, and there can be Medical Times. WINTER AND SPRING ON THE SHORES OF THE MEDITERRiVNEAN; or, the Genoese Rivieras, Italy, Spain, Corfu, Greece, the Archipelago, Constantinople, Corsica, Sicily, Sardinia, Malta, Algeria, Tunis, Smyrna, Asia Minor, with Biarritz and Arcachon, as Winter Climates. By James Henry Bennet, M. D., Member of the Royal College of Physicians, London, etc., etc. Fifth edition. With numerous Illustrations and Maps, i vol., i2mo, 655 pp. Cloth, $3.50. This work embodies the experience of fifteen winters and springs passed by Dr. Bennet on the shores of the Mediterranean, and contains much valuable information for physicians in relation to the health-restoring climate of the regions described. " We commend this book to our readers as a vol- once entertaining and instructive." — New York ume presenting two capital qualifications — it is at Medical Joui-nal. ON THE TREATMENT OF PULMONARY CON- SUMPTION, by Hygiene, Climate, and Medicine, in its Connection with Modern Doctrines. By James Henry Bennet, M- D., Member of the Royal College of Physicians, London ; Doctor of Medicine of the Uni- versity of Paris, etc., etc. I vol., thin 8vo, 190 pp. Cloth, $1.50. An interesting and instructive work, written in the strong, clear, and lucid manner which ap- pears in all the contributions of Dr. Bennet to medical or general literature. "We cordially commend this book to the at- temperate climates, pulmonary consumption." — Dc' tention of all, for its practical, common-sense views trait Review of Medicine. of the nature and treatment of the scouige of all D. APPLE TO jY &- CO:S MEDICAL WORKS. GENERAL SURGICAL PATHOLOGY AND THERA- PEUTICS, in Fifty-one Lectures. A Text-Book for Students and Phy- sicians. By Dr. Theodor Billroth, Professor of Surgery in Vienna. With Additions by Dr. Alexander von Winiwarter, Professor of Surgery in Liittich. Translated from the fourth German edition with the special per- mission of the author, and revised from the tenth edition, by Charles E. Hackley, A. M., M. D., Physician to the New York and Trinity Hospitals; Member of the New York County Medical Society, etc. I vol., 8vo, 835 pp. Cloth, $5.00; sheep, $6.00. Giant-celled Sarcoma with Cysts and Ossifying Foci from the Lower Jaw. — Magnified 350 diameters. " Since this translation was revised from the sixth German edition in 1874, two other editions have been published. The present revision is made to correspond to the eighth German edition. " Lister's method of antiseptic treatment is referred to in various places, and other new points that have come up within a few years are discussed. "A chapter has been written on amputation and resection. In all, there are seventy-four additional pages, with a number of woodcuts." — Extract from Translator'' s Preface to the Revised Edition. ture to say no book could more perfectly supply that want than the present volume." — The Lan- cet. " The want of a book in the English language, presenting in a concise form the views of the Ger- man pathologists, has long been felt, and we ven- THE PHYSIOLOGICAL AND THERAPEUTICAL ACTION OF ERGOT. Being the Joseph Mather Smith Prize Essay for 1881. By Etienne Evetzky, M. D. I vol., 8vo. Limp cloth, $1.00. "In undertaking the present work my object was to present in a condensed manner all the therapeutic possibilities of ergot. In a task of this nature, original research is out of the ques- tion. No man's evidence is sufficient to establish the merits of a drug considered in the manner indicated, and no one man's opportunities are sufficient to grasp the entire subject. Consequently it remained to gather from the volumes of past and current periodical literature the testimony of the multitude of physicians that had been led to use ergot in different morbid conditions. I have recorded everything that has come to my notice, I have grouped and classified the immense mate- rial in our possession. In all cases in which the action of ergot could be explained, I have at- tempted to do so, although this task is frequently difficult, if not impossible. . . . The reader will see that ergot has been used in a large number of diseases; some of these uses have little or no practical value, yet it is very important to know them, as they serve to illustrate the therapeutic properties of the drug. They have been brought to tlie notice of the reader without any com- ments, but those that are essential and of the greatest ]iractical importance have been dealt with more fully. Among the latter may be mentioned the use of ergot in inflammation, aneurism, car- diac diseases, the post-parturient state, uterine fibroid tumors, rheumatism, etc." — From Preface. D. APPLE TON &- CO:S MEDICAL WORKS. 7 OBSTETRIC CLINIC. A Practical Contribution to the Study of Obstetrics, and the Diseases of Women and Children. By George T. Elliot, M. D., late Professor of Obstetrics and Diseases of Women and Children in the Bellevue Hospital Medical College ; Physician to Bellevue Hospital and to the New York Lying-in Asylum, etc, I vol., 8vo, 458 pp. Cloth, $4.50. This work is, in a measure, a resume of separate papers previously prepared by the late Dr. Elliot; and contains, besides, a record of nearly two hundred important and difficult cases in mid- wifery, selected from his own practice. The cases thus collected represent faithfully the diffi- culties, anxieties, and disappointments inseparable from the practice of obstetrics, as well as some of the successes for which the profession are entitled to hope in these arduous and responsible tasks. It has met with a hearty reception, and has received the highest encomiums both in this country and in Europe. THE SOURCE OF MUSCULAR POWER. Arguments and Conclusions drawn from Observations upon the Human Subject under conditions of Rest and of Muscular Exercise. By Austin Flint, Jr., M. D., Professor of Physiology in the Bellevue Hospital Medical College, New York, etc., etc. I vol., 8vo, 103 pp. Cloth, $1.00. "There are few questions relating to Philosophy of greater interest and importance than the one which is the subject of this essay. I have attempted to present an accurate statement of my own observations and what seem to me to be the logical conclusions to be drawn from them, as well as from experiments made by others upon the human subject under conditions of rest and of muscular exercise." — From the Preface. ON THE PHYSIOLOGICAL EFFECTS OF SEVERE AND PROTRACTED MUSCULAR EXERCISE. With special ref- erence to its Influence upon the Excretion of Nitrogen. By Austin Flint, Jr., M. D., Professor of Physiology in the Bellevue Hospital Medical Col- lege, New York, etc., etc. I vol., 8vo, 91 pp. Cloth, $1.00. This monograph on the relations of Urea to Exercise is the result of a thorough anil careful investigation made in the case of Mr. Edward Payson Weston, the celebrated pedestrian. The chemical analyses were made under the direction of R. O. Doremus, M. D., Professor of Chem- istry and Toxicology in the Bellevue Hospital Medical College, by Mr. Oscar Loew, his assistant. The observations were made with the co-operation of J. C. Dalton, M. D., Professor of Physiol- ogy in the College of Physicians and Surgeons; Alexander B. Mott, M. D., Professor of Surgical Anatomy; W. H. Van Buren, M. D., Professor of Principles of Surgery; Austin Flint, M. D., Professor of the Principles and Practice of Medicine; W. A. Hammond, M. D., Professor of the Diseases of the Mind and Nervous System — all of the Bellevue Hospital Medical College. MANUAL OF CHEMICAL EXAMINATION OF THE URINE IN DISEASE. With Brief Directions for the Examination of the most Common Varieties of Urinary Calculi. By Austin Flint, Jr., M. D., Professor of Physiology and Microscopy in the Bellevue Hospital Medical College ; Fellow of the New York Academy of Medicine, etc. Fifth edition, revised and corrected, i vol., i2mo, 77 pp. Cloth, $1.00. The chief aim of this little work is to enable the busy practitioner to make for himself, rapidly and easily, all ordinary examinations of Urine; to give him the benefit of the author's experience in eliminating little difficulties in the manipulations, and in reducing processes of analysis to the utmost simplicity that is consistent with accuracy. " We do not know of any work in Eng;lish so reputation of the author is a sufficient guarantee of complete and handy as the Manual now offered to the accuracy of all the directions given."— Journai the Profession by Dr. Flint, and the high scientific of Applied C/teimstry. 8 D. APPLETON &- CO:S MEDICAL WORKS. TEXT-BOOK OF HUMAN PHYSIOLOGY, for the Use of Students and Practitioners of Medicine. By Austin Flint, Jr., M. D., Professor of Physiology and Physiological Anatomy in the Bellevue Hospital Medical College, New York ; Fellow of the New York Academy of Medi- cine, etc. Third edition. Revised and corrected. In one large 8vo volume of 978 pp., elegantly printed on fine paper, and profusely illustrated with three Lithographic Plates and 315 Engravings on Wood. Cloth, $6.00; sheep, $7.00. Stomnch, Pancreas, Large IntLSlme, etc " The author of this work takes rank among the very foremost physiolojpsts of the day, and the care which he has bestowed in bringing this third edition of his text-book up to the present position of his science is exhibited in every chapter. " — Medical and Surgical Jteporter {Philadelphia). "In the amount of matter that it contains, in the aptness and beauty of its illustrations, in the variety of experiments described, in the complete- ness with which it discusses the whole field of human physiology, this work surpasses any text-book in the English language." — Detroit Lancet. " The student and the practitioner, whose sound practice must be based on an intelligent appreciation of the principles of physiology, will herein find all sub- jects in which they are interested fully discussed and thoroughly elaborated." — College and Clin. Record. " We have not the slighte.st intention of criticis- ing the work before us. The medical profession and colleges have taken that prerogative out of the Longitudinal becLiun of the Human Larynx, showing the Vocal Cords. hands of the journalists by adopting it as one of their standard text-books. The work has very few equals and no superior in our language, and eveiy- body knows it." — Hahnemannian Monthly. " We need only say that in this third edition the work has been carefully and thoroughly revised. It is one of our standard text-books, and no physician's library should be without it. We treasure it highly, shall give it a choice, snug, and prominent position on our shelf, and deem ourselves fortunate to pos- sess this elegant, comprehensive, and authoritative work. " — American Specialist. " Professor Flint is one of the most practical teachers of physiology in this country, and his book is eminently like the man. It is very full and com- plete, containing practically all the established facts relating to the different subjects. This edition con- tains a number of important additions and changes, besides numerous corrections of slight typographical and other errors, "r- Ohio Medical Recorder. D. APPLETON &- CO:S MEDICAL WORKS. THE PHYSIOLOGY OF MAN. Designed to represent the Existing State of Physiological Science as applied to the Functions of the Human Body. By Austin Flint, Jr., M. D., Professor of Physiology and Physiological Anatomy in the Bellevue Hospital Medical College, New- York; Fellow of the New York Academy of Medicine, etc., etc. New and thoroughly revised edition. In 5 vols., 8vo. Per volume, doth, $4.50; sheep, $5.50. Volume I. The Blood ; Circulation ; Respiration. Volume II. Alimentation ; Digestion ; Absorption ; Lymph and Chyle. Volume III. Secretion; Excretion; Ductless Glands; Nutrition; Animal Heat ; Movements ; Voice and Speech. Volume IV. The Nervous System. Volume V. Special Senses ; Generation. " As a book of general information it will be found useful to the practitioner, and, as a book of reference, invaluable in the hands of the anatomist and physiologist." — Dublin Quarterly yourfial of Medical Scietice. " Dr. Flint's reputation is sufficient to give a character to the book among the profession, where it will chiefly circulate, and many of the facts given have been verified by the author in his laboratory and in public demonstration." — Chicago Courier. ' ' The author bestows judicious care and labor. Facts are selected with discrimination, theories crit- ically examined, and conclusions enunciated with commendable clearness and precision." — American Journal of the Medical Sciences. SYPHILIS AND MARRIAGE. Lectures delivered at the St. Louis Hospital, Paris. By Alfred Fournier, Professeur a la Faculte de Medecine de Paris ; Medecin de I'Hdpital Saint-Louis. Translated by P. Albert Morrow, M. D., Physician to the Skin and Venereal Departmenc_ New York Dispensary, etc., etc. I vol., 8vo. Cloth, $2.00; sheep, $3.00. "The book supplies a want long recognized in medical literature, and is based upon a very ex- tended experience in the special hospitals for syphilis of Paris, which have furnished the author with a rich and rare store of clinical cases, utilized by him with great discrimination, originality, and clinical judg- ment. It exhibits a profound knowledge of its sub- ject under all relations, united with marked skill and tact in treating the delicate social questions neces- sarily involved in such a line of investigation. The entire volume is full of information, mnemonically condensed into axiomatic ' points. ' It is a book to buy, to keep, to read, to profit by, and to lend to others." — Boston Medical and Stirgical fota-Jial. " This work of the able and distinguished French syphilographer. Professor Fournier, is without doubt one of the most remarkable and important produc- tions of the day. Possessing profound knowledge of syphilis in all its protean forms, an unexcelled experience, a dramatic force of expression, untinged, however, by even a suspicion of exaggeration, and a rare tact in dealing with the most delicate prob- lems, he has given to the world a series of lectures which, by their fascination of style, compels atten- tion, and by their profundity of wisdom carries con- viction." — St. Louis Courier of Medicine and Col- lateral Sciences. "Written with a perfect fairness, with a supe- rior ability, and in a style which, without aiming at effect, engages, interests, persuades, this work is one of those which ought to be immediately placed in the hands of every physician who desires not only to cure his patients, but to understand and fulfill his duty as an honest man." — Lyo7i Medicate. '■ No physician, who pretends to keep himself informed upon the grave social questions to which this disease imparts an absorbing interest, can afford to leave this valuable work unread." — St. Louis Clinical Record. ' ' The author handles this grave social problem without stint. A general perusal of this work would be of untold benefit to society." — Louisville Medical News. ' ' The subject is treated by Professor Fournier in a manner that is above criticism. Exhaustive clini- cal knowledge, discriminating judgment, and thor- ough honesty of opinion are united in the author, and he presents his subject in a crisp and almost dramatic style, so that it is a positive pleasure to read the book, apart from the absolute importance of the question of which it treats." — New York Medical Record. ' ' Every page is full of the most practical and plain advice, couched in vigorous, emphatic lan- guage." — Detroit La?tcet. ' ' The subject here presented is one of the most important that can engage the attention of the pro- fession. The volume should be generally read, as the subject-matter is of great importance to society." — Maryland Medical Journal. ' ' We can give only a very incomplete idea of this work of M. Fournier, which, by its precision, its clearness, by the forcible manner in which the facts are grouped and presented, defies all analysis. ' Syphilis and Marriage ' ought to be read by aU physicians, who will find in it, first of all, science, but who will also find in it, during the hours they devote to its perusal, a charming literary pleasure.'' — Annates de Dermatologie et de Syphiligraphie. lO D. APPLETON &- CO:S MEDICAL WORKS. CYCLOPAEDIA OF PRACTICAL RECEIPTS, and Col- lateral Information in the Arts, Manufactures, Professions, and Trades, including Medicine, Pharmacy, and Domestic Economy. Designed as a Comprehensive Supplement to the Pharmacopoeia, and General Book of Reference for the Manufacturer, Tradesman, Amateur, and Heads of Fam- ilies. Sixth edition, revised and partly rewritten by Richard V. Tuson, Professor of Chemistry and Toxicology in the Royal Veterinary College. Complete in 2 vols., 1,796 pp. With Illustrations. Cloth, $9.00. Cooley's " Cyclooajdia of Practical Receipts " has for many years enjoyed an extended reputa- tion for its accuracy and comprehensiveness. The sixth edition, now just completed, is larger than the last by some six hundred pages. Much greater space than hitherto is devoted to Hygiene (including sanitation, the composition and adulteration of foods), as well as to the Arts, Phar- macy, Manufacturing Chemistry, and other subjects of importance to those for whom the work is intended. The articles on what is commonly termed "Household Medicine" have been ampli- fied and numerically increased. • The design of this work is briefly but not completely expressed in its title-page. Independ- ently of a reliable and comprehensive collection of formula and processes in nearly all the indus- trial and useful arts, it contains a description of the leading properties and applications of the substances referred to, together with ample directions, hints, data, and allied information, cal- culated to facilitate the development of the practical value of the book in the shop, the laboratory, the factory, and the household. Notices of the substances embraced in the Materia Medica, in addition to the whole of their preparations, and numerous other animal and vegetable substances employed in medicine, as well as most of those used for food, clothing, and fuel, with their eco- nomic applications, have been included in the \uork. The synonyms and references are other addi- tions which will prove invaluable to the reader. Lastly, there have been appended to all the principal articles referred to brief but clear directions for determining their purity and commercial value, and for detecting their presence and proportions in compounds. The indiscriminate adop- tion of matter, without examination, has been uniformly avoided, and in no instance has any form- ula or process been admitted into this work, unless it rested on some well-known fact of science, had been sanctioned by usage, or come recommended by some respectable authority. THE COMPARATIVE ANATOMY OF THE DOMES- TICATED ANIMALS. By A. Chauveau, Professor at the Lyons Vet- erinary School. Second edition, revised and enlarged, with the co-operation of S. Arloing, late Principal of Anatomy at the Lyons Veterinary School: Professor at the Toulouse Veterinary School. Translated and edited by George Fleming, F. R. G. S., M. A. I., Veterinary Surgeon, Royal Engineers. I vol., 8vo, 957 pp. With 450 Illustrations. Cloth, $6.00. Specimen of Illustration. "Takinp: it altof,'etlier, the book is a ver}' wel- come addition to EnfjHsh literature, and fjreat credit is due to Mr. Fleming for the excellence of the trans- lation, and the many additional notes he has ap- pended to Chauveau's treatise." — Lancet [London). " The descriptions of the text are illustrated and assisted by no less than 450 excellent woodcuts. In a work which ranp;es over so vast a field of anatomi- cal detail and description, it is difficult to select any one portion for review, but our examination of it enables us to speak in high terms of its general ex- cellence. . . ." — Medical Times and Gazette {Lon- don). D. APPLE TON &- CO.'S MEDICAL WORKS. II THE HISTOLOGY AND HISTO-CHEMISTRY OF MAN. A Practical Treatise on the Elements of Composition and Struc- ture of the Human Body. By Heinrich Frey, Professor of Medicine in Zurich. Translated from the fourth German edition, by Arthur E. J. Bar- ker, Surgeon to the City of Dublin Hospital; Demonstrator of Anatomy, Royal College of Surgeons, Ireland ; and revised by the Author. With 680 Engravings. I vol., 8vo, 683 pp. Cloth, $5; sheep, $6. CONTENTS.— 'Yh^ Elements of Composition and of Structure of the Body : Elements of Com- position — Albuminous or Protein Compounds, Haemoglobulin, His- togenic Derivatives of the Albu- minous Substances or Albumi- noids, the Eatty Acids and Fats, the Carbo-hydrates, Non-Nitro- genous Acids, Nitrogenous Acids, Amides, Amido-Acids, and Or- ganic Bases, Animal Coloring Matters, Cyanogen Compounds, Mineral Constituents ; Elements \ of Structure — the Cell, the Origin of the Remaining Elements of Tissue; the Tissues of the Body — Tissues composed of Simple Cells, with Fluid Intermediate Substance, Tissues composed of Simple Cells, with a small amount of Solid Intermediate Substance, Tissues belonging to the Con- nective Substance Group, Tissues composed of Transformed and, as a rule. Cohering Cells, with Homogeneous, Scanty, and more or less Solid Intermediate Substance ; Composite Tissues : The Organs of the Body — Organs of the Vegetative Type, Organs of the Animal Group. -^ systematic and strictly accurate treatise on mamman tumors, and brought to his task all the light afforded by the most recent investigations into their pathol- ogy." — .5"^. Louis Clinical Reco7-d. " This book is a real contribution to our profes- sional literature ; and it comes from a source which commands our respect. The plan is very systematic and complete, and the student or practitioner alike will find exactly the information he seeks upon anj of the diseases which are incident to the mammar) gland." — Obstetrical Gazette. " Altogether, the work is one of more than ordi nary interest to the surgeon, gynecologist, and phy- sician." — Detroit Lancet, OUTLINES OF THE PATHOLOGY AND TREAT- MENT OF SYPHILIS AND ALLIED VENEREAL DISEASES. By Hermann von Zeissl, M. D., late Professor at the Imperial- Royal Univer- sity of Vienna. Second edition, revised by Maximilian von Zeissl, M. D., Privat-Docent for Diseases of the Skin and Syphilis at the Imperial-Royal University of Vienna. Authorized edition. Translated, with Notes, by H. Raphael, M. D., Attending Physician for Diseases of the Genito-Urinary Organs and Syphilis, Bellevue Hospital Out-patient Department, etc. 8vo, 402 pages. Cloth, $4.00; sheep, $5.00. " We regard the book as an excellent text-book for student or physician, and hope to hear of its adoption as sucli In therapeutic detail, the rec- ommendations are all good." — Virginia Medical Monthly. "It is scarcely necessary to refer to the talented author of the above-named work, since his life-long labor as a teacher and writer upon venereal diseases has made him known and quoted wherever these af- fections exist and are treated." — Polyclinic. " The book is a most excellent one in every re- spect, and the translator has done his work well." — Columbus Medical Journal. " It is a most thorough and practical manual, and translator and publisher both have done well in their respective capacities in thus issuing it." — Medical Press 0/ Western New York. " Medical science suffered a severe loss when, in September, 1SS4, Hermann von Zeissl died. Hap- pily for us, this master in his chosen specialty had embodied the results of his vast experience in a text- book on syphilis and venereal diseases and pubhshed it some years before his death. The booli now be- fore us is a second edition of the former book, re- vised and in large part rewritten by Maximilian von Zeissl, and issued in the original some seven months before the father's death. It is a masterly treatise and thoroughly practical. We can commend it to all who are interested in venereal subjects. . . . Dr. Raphael has made a smooth and readable transla- tion and has added much valuable matter to the book, adapting it to the use of American physicians. The chapter on galloping syphilis is entirely by him." — The New York Medical Journal. H D. APPLE TON &- CO:S MEDICAL WORKS. EMERGENCIES, AND HOW TO TREAT THEM. The Etiology, Pathology, and Treatment of Accidents, Diseases, and Cases of Poisoning, which demand Prompt Action. Designed for Students and Practitioners of Medicine. By Joseph W. Howe, M. D., Clinical Profess- or of Surgery in the Medical Department of the University of New York, etc., etc. Fourth edition, revised, i vol., 8vo, 265 pp. Cloth, $2.50. book we recommend it most heartily to the profes- sion." — Boston Medical and Surgical Journal. ' ' This work bears evidence of a thoroug-h prac- tical acquaintance with the different branches of the " To the general practitioner in towns, villages, and in the countrj-, where the aid and moral sup- port of a consultation can not be availed of, this volume will be recognized as a valuable help. We commend it to the profession." — Ci7icinnati Lancet arid Observer. " The author wastes no words, but devotes him- self to the description of each disease as if the pa- tient were under his hands. Because it is a good profession. The author seems to possess a peculiar aptitude for imparting instruction as well as for simplifying tedious details. A careful perusal will amply repay the student and practitioner." — New York Medical Joiirjial. Specimen of Illustration. A TREATISE ON THE DISEASES OF THE NERV- OUS SYSTEM. By William A. Hammond, M. D., Surgeon-General U. S. Army (retired list) ; Professor of Diseases of the Mind and Nervous System in the New York Post-Graduate Medical School and Hospital; Member of the American Neurological Association and of the New York Neurological Society ; of the New York County Medical Society, etc. With 112 Illustrations. Eighth edition, revised, corrected, and enlarged by the Addi- tion of a New Section on Certain Obscure Nervous Diseases. 8vo, 945 pages. Cloth, $5.00; sheep, $6.00. The work has received the honor of a French translation by Dr. Labadie-Lagrave, of Paris, and an Italian transla- tion by Professor Diodato Bor- relli, of the Royal University, has gone through the press at Naples. " In the Buddhist faith the eight gates of purity are de- scribed as : I. Correct ideas ; 2. Correct thoughts ; 3. Correct words ; 4. Correct works ; 5. Correct life ; 6. Correct endeav- ors ; 7. Correct judgment ; and 8. Correct tranquillity. If Dr. Hammond has not attained the medical nirvana, and passed those eight gates of purity, he has at least realized the Buddhist beatitude : ' Much insight and education, self-control and pleasant speech ; and whatever word be well spoken, this is the greatest blessing.' At least, the thoughts and utterances of Dr. Hammond have been so appreciated by the medical profession of America and England that the work has already passed through eight editions since its first appearance in 1871. As now revised by the author and published by the Appletons, it constitutes decidedly the best work in the English language upon dis- eases of the nervous system." — Kansas City Medical Index. ten anything but this one work, it would have been a monument of learning that would have lasted for ages." — Kansas City Medical Record. " This excellent work has now been fifteen years before the profession, its popularity being sufficient- ly evidenced by the fact that it has rapidly passed through eight editions.'' — College and Clinical Rec- ord. "This great work of the gifted author has now reached its eighth edition. A work of this charac- ter that has, within fifteen years, gone through eight revisions needs but little commendation from us, being fully able to speak for itself. It is, like its au- thor, without a peer in the special line of medicine it takes up. ... If Dr. Hammond had never writ- " The author of this work justly congratulates himself that the various previous editions which have been called for have received the approval of the profession beyond that ever given to any other work of like scope and objects published in any part of the world. In order to maintain the high char- acter thus attributed to it by the best judges, he has subjected this edition to a thorough revision, and has added a new section treating of certain obscure dis D. APPLETON &- CO:S MEDICAL WORKS. 15 eases ot the nervous system, as tetany, Thomsen's disease, miryachit, and kindred affections. In all respects we must place this treatise as the best in the langfuage on the specialty to which it is devoted." — .Medical and Surgical Reporter. "When a work has reached its eighth edition, the reviewer might as well keep quiet, as the book- buyer has already decided that a demand has been met." — A'eiu YorA Medical Tijiies. " This volume has been received by the profes- sion ' to an extent beyond that ever given to any other work of like scope and objects published in any part of the world.' The present edition contains a section on ' Certain Obscure Diseases of the Nervous System,' is thoroughly revised throughout, and sev- eral changes made, thereby increasing greatly its use- fulness." — Buffalo Medical a?id Surgical Jourtial. ' ' The eighth edition of this work speaks for itself in the fact of its existence. The talented author has carefully revised the previous editions, elaborat- ing many portions which subsequent experience and observation have made necessary. A section has also been added on certain obscure diseases of the nervous system, comprising tetany, Thomsen's dis- ease, miryachit, and kindred affections. These sub- jects are treated, like others in the work, with a master-hand and with the pen of a ready and enter- taining writer. The author made his reputation long ago, and that he is able to maintain it his last effort will abundantly prove." — Medical Record. Specimen of Illustration. %,!^'^'^^' CLINICAL LECTURES ON DISEASES OF THE NERVOUS SYSTEM. Delivered at the Bellevue Hospital Medical Col- lege. By William A. Hammond, M. D., Professor of Diseases of the Mind and Nervous System, etc. Edited, with Notes, by T. M. B. Cross, M. D., Assistant to the Chairs of Diseases of the Mind and Nervous System, etc. In one handsome vohime of 300 pages. $3.50. These lectures have been reported in full, and, together with the histories of the cases, which were prepared by the editor after careful study and prolonged observation, constitute a clinical volume which, while it does not claim to be exhaustive, will nevertheless be found to contain many of the more important affections of the kind that are commonly met with in practice. As these lectures were intended especially for the benefit of students, the author has confined himself to a full consideration of the symptoms, causes, and treatment of each affection, without attempting to enter into the pathology or morbid anatomy. THE ANATOMY OF VERTEBRATED ANIMALS. By Thomas Henry Huxley, LL. D., F. R. S. I vol., i2mo. Illustrated. 431 pp. Cloth, $2.50. " The present work is intended to provide students of comparative anatomy with a condensed statement of the most important facts relating to the structure of vertebrated animals which have hitherto been ascertained. The Vertebrata are distinguished from all other animals by the circum- stance that a transverse and vertical section of the body exhibits two cavities completely separated from one another by a partition. The dorsal cavity contains the cerebro-spinal nervous system ; the ventral, the alimentary canal, the heart, and usually a double chain of ganglia, which passes under the name of the ' sympathetic. ' It is probable that this sympathetic nervous system repre- sents, wholly or partially, the principal nervous system of the Animlosa and Mollusca. And, in any case, the central parts of the cerebro-spinal nervous system, viz., the brain and the spinal cord, would appear to be unrepresented among invertebrated animals." — The Author. " This long-expected work will be cordially wel- It is enough to say that it realizes, in a remarkable comed by all students and teachers of Comparative deg^ree, the anticipations which have been formed Anatomy as a compendious, reliable, and, notwith- of it ; and that it presents an extraordinary combi- standing its small dimensions, most comprehensive nation of wide, general views, with the clear, accu- guide on the subject of which it treats. To praise rate, and succinct statement of a prodigious number or to criticise the work of so accomplished a master of individual facts." — Nature. of his favorite science would be equally out of place. i6 D. APPLETON 6- CO.'S MEDICAL WORKS. Specimen of Illustration. A TREATISE ON ORAL DEFORMITIES, as a Branch of Mechanical Surgery. By Norman W. Kingsley, M. D. S., D. D. S., President of the Board of Censors of the State of New York, late Dean of the New York College of Dentistry and Professor of Dental Art and Mech- anism, etc., etc. With over 350 Illustrations. One vol., 8vo. Cloth, $5; sheep, $6. " I have read with great pleasure and much profit your valuable ' Treatise on Oral Deformi- ties.' The v^'ork contains much original matter of great practical value, and is full of useful in- formation, which will be of great benefit to the profession." — Lewis A. Sayre, M. D., LL. D., Professor of Orthopedic Siirgery and Clinica! Surge?'y, Bellevue flospital Medical College. "A casual glance at this work might impress the reader with the idea that its contents were of more practical value to the dentist than to the general practitioner or surgeon. But it is by no means a mere work on dentistry, although a prac- tical knowledge of the latter art seems to be es- sential to the carrying out of the author's views regarding the correction of the different varieties of oral deformities of which he treats. We would be doing injustice to the work did not we make particular reference to the masterly chapter on the treatment of fractures of the lower jaw. The whole subject is so thoroughly studied that noth- ing is left to be desired by any surgeon who wish- es to treat these fractures intelligently and success- fully. The work, as a whole, bears marks of originality in every section, and impresses the reader with the painstaking efforts of the author to get at the truth, and apply it in an ingenious and practical way to the wants of the general practitioner, the surgeon, and the dentist." — Medical Record. "The profession is to be congratulated on possessing so valuable an addition to its litera- ture and the author to be unstintedly praised for his successful issue to an arduous undertaking. The work bears in a word, every evidence of having been written leisurely and with care. . . ."—Dental Cosmos. "To the surgeon and general practitioner of medicine, as well as the dentist, its mstruction will be found invaluable. It is clear in style, practical in its application, comprehensive in its illustrations, and so exhaustive that it is not likely to meet in these respects a rival."-WiLLiAM H. Dwinelle, A. M., M. D. " I consider it to be the most valuable work that has ever appeared in this country in any department of the science of dental surgery. . , , . j j ^- *u- u i, "There is no doubt of its great value to every man who wishes to study and practice this branch of surgery, and I hope it may be adopted as a text-book in every dental college, that the students may have the benefit of the great experience of the author. " It places many things between the covers of one book which heretofore I have been obliged to look for in many directions, and often without success."— Frank Abkot, M. D., Dean of the New York College of Dentistry. ' ' The writer does not hesitate to express his belief that the chapters on the ' aesthetics of den- tistry ' will be found of more practical value to tlie prosthetic dentist than all the other essays on this subject existent in the English language. ... A perusal of its pages seems to compel the mind to advance in directions variously indi- cated ; so variously, indeed, that there is hardly a page of the book which does not contain some important truth, some pregnant hint, or some ^ valuable conclusion." — Dental Afiscellany. "I congratulate you on having written a book containing so much valuable and original matter. It will prove of value not only to den- tists, but also to surgeons and physicians." — Frank Hastings Ha.milton, M. D., LL. D., Ptofessor of the Practice of Surgery with Opera- tions, and of Clinical Surgery in Bellevue Hos- pital Medical College. Specimen of Illustration. D. APPLE TON &^ CO.'S MEDICAL WORKS. 17 THE BREATH, AND THE DISEASES WHICH GIVE IT A FETID ODOR. With Directions for Treatment. By Joseph VV. Howe, M. D., Clinical Professor of Surgery in the Medical Department of the University of New York, etc. Second edition, revised and corrected, i vol., i2mo, 108 pp. Cloth, $1. " This little volume well deserves the attention of physicians, to whom we commend it most high- ly." — Chicago Medical JoJirnal. " To any one suffering from the affection, either in his own person or in that of his intimate ac- quaintances, we can commend this volume as con- taining all that is known concerning the subject, set forth in a pleasant style." — Fhiladelphia Medical Times. " The author gives a succinct account of the dis- eased conditions in which a fetid breath is an im- portant symptom, with his method of treatment. We consider the work a real addiiion to medical lit- erature." — Cincinnati Medical Journal. ON THE BILE, JAUNDICE, AND BILIOUS DIS- EASES. By J. WiCKHAM Legg, M. D., F. R. C. S., Assistant Physician to St. Bartholomew's Hospital, and Lecturer on Pathological Anatomy in the Medical School. In one volume, 8vo, 719 pp. With Illustrations in Chromo-lithography. Cloth, $6 ; sheep, $7. "... And let us turn — which we gladly do — to the mine of wealth which the volume itself contains, for it is the outcome of a vast deal of labor ; so great indeed, that one unfamiliar with it would be surprised at the nuniber of facts and references which the book contains." — Medical Times and Ga- zefti', Londoji. " The book is an exceedingly good one, and, in some points, we doubt if it could be made better. . . . And we venture to say, after an attentive perusal of the whole, that any one who takes it in hand will derive from it both information and pleasure ; it gives such ample evidence of honest hard work, of wide reading, and an impartial at- tempt to state the case of jaundice, as it is known by observation up to the present date. The book will not only live, but be in the enjoyment of a vig- orous existence long after some of the more popular productions of the present age are buried, past all hope of resurrection." — London Medical Reco7-d. " This portly, tome contains the fullest account of the subjects of which it treats in the English. lan- guage. The historical, scientific, and practical de- tails are all equally well worked out, and together constitute a repertorium of knowledge which no practitioner can well dn without. The illustrative chromo-lithographs are beyond all praise." — Edi?i- burgli Medical 'Journal. ' ' Dr. Legg's treatise is a really great book, ex- hibiting immense industry and research, and full of valuable information." — American Journal of Med- ical Scietice. ' ' It seems to us an exhaustive epitome of all that is known on the subject." — Fhiladelphia Medi- cal Titnes. "This volume is one which will command pro- fessional respect and attention. It is, perhaps, the most comprehensive and exhaustive treatise upon the subject treated ever published in the English language." — Maj-yland Medical Jour7ial. " It is the work of one who has thoroughly stud- ied the subject, and who, when he finds the evi- dence conflicting on disputed points, has attempted to solve the problem by experiments and observa- tions of his own." — Practitioner, London. "It is a valuable work of reference and a wel- come addition to medical literature. — Dublin Jour- nal of Medical Science. "... The reader is at once struck with the im- mense amount of research exhibited, the author having left unimproved no accessible source of in- formation connected with his subject. It is, indeed, a valuable book, and the best storehouse of knowl- edge in its department that we know of." — Pacific Medical a7id Surgical Jourtial. FIRST LINES OF THERAPEUTICS as Based on the Modes and the Processes of Healing, as occurring spontaneously in Dis- eases ; and on the Modes and the Processes of Dying as resulting naturally from Disease. In a Series of Lectures. By Alexander Harvey, M. A., M. D., Emeritus Professor of Materia Medica in the University of Aber- deen, etc., etc. I vol., i2mo, 278 pp. Cloth, $1.50. " If only it can get a fair hearing before the pro- fession it will be the means of aiding in the devel- opment of a therapeutics more rational than we now dream of. To medical students and practi- tioners of all sorts it will open up lines of thought and investigation of the utmost moment." — Detroit Lancet. 2 "We may say that, as a contribution to the philosophy of medicine, this treatise, which may be profitably read during odd moments of leisure, has a happy method of statement and a refreshing free- dom from dogmatism." — JVew York Medical Rec- ord. i: D. APPLE TON &- CO:S MEDICAL WORKS. THE SCIENCE AND ART OF MIDWIFERY. By William Thompson Lusk, M. A., M. D., Professor of Obstetrics and Dis- eases of Women and Children in the Bellevue Hospital Medical College ; Obstetric Surgeon to the Maternity and Emergency Hospitals ; and Gynae- cologist to the Bellevue Hospital. New edition. Revised and enlarged. Complete in one volume, 8vo, with 246 Illustrations. Cloth, $5.00; sheep, $6.00. . j^ ^^^^^j^g ^^^ ^f ^^^ ^^^^ ^^^ . positions of the obstetric science and practice of the day with which we are acquainted. Throughout the work the author shows an intimate acquaintance with the hterature of obstetrics, and gives evidence of large practical experience, great discrimi- nation, and sound judgment. We heartily recommend the book as a full and clear exposition of obstetric science and safe guide to student and practitioner." — London Lancet. " Professor Lusk's book presents the art of midwifery with all that modern science or earlier learning has contributed to it." — Medical Reco7'd, New York. "This book bears evidence on every page of being the result of patient and laborious research and great personal experience, united and harmonized by the true critical or scientific spirit, and we are con- vinced that the book will raise the general standard of obstetric knowl- edge both in his own country and in this. Whether for the student obliged to learn the theoretical part of midwifery, or for the busy prac- titioner seeking aid in face of practical difficulties, it is, in our opinion, the best modern work on mid- wifery in the English language." — Dublm Journal of Medical Scie7ice. D'Outrepont's Method, modified by Scanzoni. Author's Modification of Tarnier's Forceps. " Dr. Lusk's style is clear, generally concise, and he has succeeded in putting in less than seven hun- dred pages the best exposition in the English lan- guage of obstetric science and art. The book will prove invaluable alike to the student and the prac- titioner." — Ame7-ican Practitioner'. " Dr. Lusk's work is so comprehensive in design and so elaborate in execution that it must be recog- nized as having a status peculiarly its own among the text-books of midwifery in the English lan- guage." — New York Mediccil Journal. "The work is, perhaps, better adapted to the wants of the student as a text-book, and to the practitioner as a work of reference, than any other one publication on the subject. It contains about all that is known of the ars ohstetrica, and must add greatly to both the fame and fortune of the distinguished author." — Medical Herald, Lotiis- villc. "Dr. Lusk's book is eminently viable. It can not fail to live and obtain the honor of a second, a third, and nobody can foretell how many editions. It is the mature product of great industiy and acute observation. It is by far the most learned and most complete exposition of the science and art of obstet- rics written in the English language. It is a book so rich in scientific ancl practical information, that nobody practicing obstetrics ought to deprive him- self of the advantage lie is sure to gain from a fre- quent recourse to its pages." — American Journal oj Obstetrics. "It is a pleasure to read such a book as that which Dr. Lusk has prepared ; everything pertain- ing to the important subject of obstetrics is dis- cussed in a masterly and captivating manner. We recommend the book as an excellent one, and feel confident that those who read it will be amply re- paid." — Obstetric Gazette, Cinciiinati. D. APPLETON &- CO.'S MEDICAL WORKS. I9 THE METHODS OF BACTERIOLOGICAL INVESTI- GATION. By Ferdinand Hueppe, Decent in Hygiene and Bacteriology in the Chemical Laboratory of R. Fresenius, at Wiesbaden. Written at the request of Dr. Robert Koch. Translated by Hermann M. Biggs, M. D., Instructor in the Carnegie Laboratory, and Assistant to the Chair of Patho- logical Anatomy in Bellevue Hospital Medical College. 8vo, 218 pp. With 31 Illustrations. Cloth, $2.50. ' ■ This is the best book so far available in Eng- of author, and is one which no student of pathol- lish, being better adapted to the general student who ogy can afford to be without. The translation undertakes the study from first principles." — North seems to have been most acceptably made." —Medi- Carolina Medical Joui-nal. cal Press of Western New York. " All students of bacteriology will at once place u Qf the many works that have recently appeared this volume on their tables as mdispensable for their ^^ ^^^ g^bject of bacterial technology, this one cer- most accurate and rapid study. —American Lancet, ^^j^iy ^^^^^ ^he requirements of a practical guide "The work is written by one who thoroughly and book of reference ; . . . the merits of the work understands his subject and puts it clearly before the are decided, and should secure for it the reputation stnd&ni."— Pacific Medical and Surgical Joiirnal it deserves:' —Atlanta Medical and Su7-gical and Western Lancet. Jom-nal. "He has sifted the whole of the scattered and "The book treats the subject in an exceedingly sometimes almost inaccessible literature of the sub- clear and comprehensive manner, and leaves httle to ject, and has furnished the independent investigator ^g desired by the beginner, and is a complete guide a most valuable book, useful alike to the practitioner to those wishing to work out any of the innumerable and to the student, as a trustworthy introduction problems connected with the' Hfe-history of the into this territory."— C(3//^^i Courier. "Particular attention is given to diseases from "The work is of great value as a practical g^uide worry and mental strain, from the passions, from to enable the reader to detect and avoid various alcohol, tobacco, narcotics, food, impure air, late sources of disease, and it contains, in addition, sev- hours, and broken sleep, idleness, intermarriage, eral introductor)- chapters on natural life and natu- etc., thus touching upon causes which do not enter ral death, the phenomena of disease, disease ante- into the consideration of sickness." — Bost07i Com- cedent to birth, and on the effects of the seasons, 7nonwealth. THE WATERING-PLACES AND MINERAL SPRINGS OF GERMANY, AUSTRIA, AND SWITZERLAND. With Notes on Climatic Resorts and Consumption, Sanitariums, Peat, Mud, and Sand Baths, Whey and Grape Cures, etc. By Edward Gutmann, M. D With Illustrations, Comparative Tables, and a Colored Map, explaining the Situation and Chemi- cal Composition of the Spas, i vol., i2mo. Cloth, $2.50. '' Dr. Gutmann has compiled an excellent medi- tions, with the therapeutical applications of the cal guide, which gives full information on the man- mineral waters, are very thoroughly presented in ners and customs of living at all the principal separate parts of the volume." — New York Tiines. watering-places in Europe. The chemical composi- A PRACTICAL MANUAL ON THE TREATMENT OF CLUB-FOOT. By Lewis A. Sayre, M. D., Professor of Orthopedic Surgery and Clinical Surgery in Bellevue Hospital Medical College; Con- sulting Surgeon to Bellevue Hospital, Charity Hospital, etc., etc. Fourth edition, enlarged and corrected, i vol., i2mo. Illustrated. Cloth, $1.25. "A more extensive experience in the treatment of club-foot has proved that the doctrines taught in my first edition were correct, viz., that in all cases of congenital club-foot the treatment should commence at birth, as at that time there is generally no difficulty that can not be overcome by the ordinary family physician ; and that, by following the simple rules laid down in this volume, the great majority of cases can be relieved, and many cured, without any operation or surgical inter- ference. If this early treatment has been neglected, and the deformity has been permitted to in- crease by use of the foot in its abnormal position, surgical aid may be requisite to overcome the difficulty ; and I have here endeavored to clearly lay down the rules that should govern the treat- ment of this class of cases." — Preface. "The book will very well satisfy the wants of use, as stated, it is intended.'' — New York Medical the majority of general practitioners, for whose yournal. COMPENDIUM OF CHILDREN'S DISEASES. A Hand-Book for Practitioners and Students. By Dr. Johann Steiner, Professor of the Diseases of Children in the University of Prague. Trans- lated from the second German edition by Lawson Tait, F. R. C. S., Sur- geon to the Birmingham Hospital for Wornen. I vol., 8vo. Cloth, $3.50; sheep, $4.50. "Dr. Steiner's book has met with such marked success in Germany that a second edition has already appeared, a circumstance which has delayed the appearance of its English form, in order that I might lie able to give his additions and corrections. " I have added as an Appendix the ' Rules for Management of Infants,' which have been issued by the staff of the Birmingham Sick Children's Hospital, because I think that they have set an ex- ample, bv freely distributing these rules among the poor, for which they can not be sufficiently commended, and which it would be wise for other sick children's hospitals to follow. " I have also added a few notes, chiefly, of course, relating to the surgical ailments of chil- dren." — Extract from Translator's Preface. D. APPLETON &- CO:S MEDICAL WORKS. 29 HEALTH : A Hand-Book for Households and Schools. By Edward Smith, M. D., F. R. S., Fellow of the Royal College of Physicians and Surgeons of England, etc. I vol., i2mo. Illustrated. 198 pp. Cloth, $1. It is intended to inform the mind on the subjects involved in the word Health, to show how health may be retained and ill-health avoided, and to add to the pleasure and usefulness of life. " The author of this manual has rendered a real service to families and teachers. It is not a mere treatise on health, such as would be written by a medical professor for medical students. Nor is it a treatise on the treatment of disease, but a plain, common-sense essay on the prevention of most of the ills that flesh is heir to. There is no doubt that much of the sickness with which humanity is af- flicted is the result of ignorance, and proceeds from the use of improper food, from defective drainage, overcrowded rooms, ill-ventilated workshops, im- pure water, and other like preventable causes. Legislation and municipal regulations may do something in the line of prevention, but the people themselves can do a great deal more — particularly if properly enlightened ; and this is the purpose of the book." — Albany Jourtial. LECTURES ON ORTHOPEDIC SURGERY AND DIS- EASES OF THE JOINTS. By Lewis A. Sayre, M. D., Professor of Orthopedic Surgery and Clinical Surgery in Bellevue Hospital Medical Col- lege ; Consulting Surgeon to Bellevue Hospital, Charity Hospital, etc., etc. Second edition, revised and greatly enlarged, with 324 Illustrations, i vol., 8vo, 569 pp. Cloth, $5; sheep, $6. This edition has been thoroughly revised and rearranged, and the subjects classified in the ana- tomical and pathological order of their development. Many of the chapters have been entirely rewritten, and several new ones added, and the whole work brought up to the present time, with all the new improvements that have been developed in this department of surgery. Many new engravings have been added, each illustrating some special point in practice. Specimen of Illustration. "The name of the author is a sufficient guar- antee of its excellence, as no man in America or elsewhere has devoted such unremitting attention for the past thirty years to this department of Sur- gery, or given to the profession so many new truths and laws as applying to the pathology and treat- ment of deformities." — Western Lancet. " The name of Lewis A. Sayre is so intimately connected and identified with orthopsedics in all its branches, that a book relating his experience can not but form an epoch in medical science, and prore a blessing to the profession and humanity. Dr. Sayre's views on many points differ from those entertained by other surgeons, but the great suc- cesses he has obtained fully warrant him in main- taining the 'courage of his opinions.' " — AjnericaJi yournal of Obstetrics. ' ' Dr. Sayre has stamped his individuality on every part of his book. Possessed of a taste for mechanics, he has admirably utilized it in so modi- fying the inventions of others as to make them of far greater practical value. The care, patience, and perseverance which he exhibits in fulfilling all the conditions necessary for success in the treatment of this troublesome class of cases are worthy of all praise and imitation." — Detroit Review of Medi- cine. ''Its teaching is sound, and the originality throughout very pleasing ; in a word, no man should attempt the treatment of deformities of joint affections without being familiar with the views contained in these lectures." — Catiada Medical and Surgical yournal. 30 D. APPLETON &- CO.'S MEDICAL WORKS. LECTURES UPON DISEASES OF THE RECTUM AND THE SURGERY OF THE LOWER BOWEL. Delivered at the Bellevue Hospital Medical College by W. H. Van Buren, M. D., late Professor of the Principles and Practice of Surgery in the Bellevue Hospi- tal Medical College, etc., etc. Second edition, revised and enlarged, i volume, 8vo, 412 pp., with 27 Illustrations and complete Cloth, $3; sheep, $4. ' ' The reviewer too often finds it a difficult Index. Specimen of Illustration. task to discover points to praise, in order that his criticisms may not seem one-sided and un- just. These lectures, however, place him upon the other horn of the dilemma, viz., to find somewhat to criticise severely enough to clear himself of the charge of indiscriminating lau- dation. Of course, the author upholds some views which conflict with other authorities, but he substantiates them by the most powerful of arguments, viz. , a large experience, the results of which are enunciated by one who elsewhere shows that he can appreciate, and accord the due value to, the work and experience of others. ' ' — Archives of Medicine. ' ' The present is a new volume rather than a new edition. Both its size and material are vastly beyond its predecessor. The same scholarly method, the same calm, convincing statement, the same wise, carefully matured counsel, pervade every paragraph. The dis- comfort and dangers of the diseases of the rectum call for greater consideration than they usually receive at the hands of the pro- fession." — Deti'oit Lancet. " These lectures are twelve in number, and may be taken as an excellent epitome of our present knowledge of the diseases of the parts in question. The work is full of practical matter, but it owes not a little of its value to the original thought, labor, and suggestions as to the treatment of disease, which always characterize the productions of the pen of Dr. Van Buren." — Philadelphia Medical Times. " The most attractive feature of the work is the plain, common-sense manner in which each subject is treated. The author has laid down instructions for the treatment, medicinal and opera- tive, of rectal diseases in so clear and lucid style as that any practitioner is enabled to follow it. The large and successful experience of the distinguished author in this class of diseases is sufficient of itself to warrant the high character of the book." — Nashville Jou7-nal of Medicine a?id Sta-gery. We have thus briefly tried to give the known to the profession as one of our most accom- reader an idea of the scope of this work : and the work is a good one — as good as either Allingham's or Curling's, with which it will inevitably be com- pared. Indeed, we should have been greatly sur- prised if any work from the pen of Dr. Van Buren had not been a good one ; and we have to thank him that for the first time we have an American text-book on this subject which equals those that have so long been the standards." — New York Med- ical yo2irnal. " Mere praise of a book like this would be super- fluous—almost impertinent. The author is well plished surgeons and ablest scientific men. Much is expected of him in a book like the one before us, and those who read it will not be disappointed. It will, indeed, be widely read, and, in a short time, take its place as the standard American authority." — .5'^. Louis Coui'ier of Medicine. " Taken as a whole, the book is one of the most complete and reliable ones extant. It is certainly the best of any similar work from an American au- thor. It is handsomely bound and illustrated, and should be in the hands of every practitioner and student of medicine. " — Louisville Medical Llerald. REPORTS. Bellevue and Charity Hospital Reports for 1870, containing valuable contributions from Isaac E. Taylor, M. D., Austin Flint, M. D., Lewis A. Sayre, M. D,, William A. Hammond, M. D., T. Gaillard Thomas, M. D., Frank H. Hamilton, M. D., and others. I vol., 8vo, 415 pp. Cloth, $4. '' These institutions are the most important, as connected with tht^m are acknowledged to be among regards accommf)dations for patients and variety of •ases treated, of any on this continent, and are sur- passed by but few in the world. The gentlemen the first in tlioir profession, and the volume is an important addition to the professional literature o< this country." — J'sychological yoiirnal. D APPLETON . in this volume an attempt is made to give a for his clear and accurate presentation of the ex- connected account of the general physiology of perimental data upon which must rest all future muscles and nerves, a subject which has never be- knowledgeof a very important branch of medical fore had so thorough an exposition in any text- and electrical science. The book consists of 317 book, although it is one which has many points of pages, with seventy-five woodcuts, many of which interest for evei7 cultivated man who seeks to be represent physiological apparatus devised by the ^ell informed on all branches of the science of life, author or by his friends, Professor Du Bois-Rey- This work sets before its readers all, even the most mond and Helmholtz. It must be regarded as m- intricate, phases of its subject with such clearness of dispensable to all future courses of medical study." expression that any educated person though not a Aew York Herald. specialist can comprehend it." — New Haven Palla- " Although this work is written for the instruc- dium, tion of students, it is by no means so technical and MEDICAL AND SURGICAL ASPECTS OF IN-KNEE (Genu-Valgum) : Its Relation to Rickets ; its Prevention ; and its Treat- ment, with or without Surgical Operation. By W. J. Little, M. D., F. R. C. P., late Senior Physician to and Lecturer on Medicine at the London Hospital; Visiting Physician to the Infant Orphan Asylum at Wanstead ; the Earlswood Asylum for Idiots ; Founder of the Royal Orthopsedic Hos- pital, etc. Assisted by E. Muirhead Little, M. R. C. S. One 8vo vol., containing 161 pages, with complete Index, and illustrated by upward of 50 Figures and Diagrams. Cloth, $2. A DICTIONARY OF MEDICINE, including General Pathology, General Therapeutics, Hygiene, and the Diseases peculiar to Woinen and Children.' By Various Writers. Edited by Richard Quain, M. D., F. R. S., Fellow of the Royal College of Physicians; Member of the Senate of the University of London ; Member of the General Council of Medical Education and Registration; Consulting Physician to the Hospital for Consumption and Diseases of the Chest at Brompton, etc. In one large 8vo volume of 1,834 pages, and 138 Illustrations. Half morocco, $8. Sold only by sul^scription. This work is primarily a Dictionary of Medicine, in which the several diseases are fully dis- cussed in alphabetical order. The description of each includes an account of its etiology and ana- tomical characters; its symptoms, course, duration, and termination; its diagnosis, progncsis. D. APPLETON &- CO.'S MEDICAL WORKS. 35 and, lastly, ils treatment. General Pathology comprehends articles on the origin, characters, and nature of disease. General Therapeutics includes articles on the several classes of remedies, their modes of ac- tion, and on the methods of their use. The articles devoted to the subject of Hygiene treat of the causes and prevention of disease, of the agencies and laws affecting public health, of the means of preserving the health of the individual, of the construction and management of hospitals, and of tiie nursing of the sick. Lastly, the diseases peculiar to women and children are discussed under their respective head- ings, both in aggregate and in detail. Among the leading contributors, whose names at once strike the reader as affording a guaran- tee of the value of their contributions, are the following : Allbutt, T. Clifford, M. A., M. D. Barnes, Robert, M. D. Bastian, H. Charlton, M. A., M. D. BiNZ, Carl, M. D. Bristowe, J. Syer, M. D. Brown-Sequard, C. E., M. D., LL. D. Brunton, T. Lauder, M. D., D. Sc. Fayrer, Sir Joseph, K. C. S. L, M. D., LL. D. Fox, Tilbury, M. D. Galton, Captain Douglas, R. E. (retired). Gowers, W. R., M. D. Greenfield, W. S., M. D. Jenner, Sir William, Bart Lego, J. Wickham, M. D. Nightingale, Florence. Paget, Sir James, Bart. Parkes, Edmund A., M. D. Pavy, F. W., M.D. Playfair, W. S., M. D. Simon, John, C. B., D. C. Thompson, Sir Henry. Waters, A. T. H., M. D. K. C. B., M.D. L. Wells, T. Spencer. " Not only is the work a Dictionary of Medicine in its fullest sense ; but it is so encyclopedic in its scope that it may be considered a condensed review of the entire field of practical medicine. Each sub- ject is marked up to date and contains in a nutshell the accumulated e.x:perience of the leading medical men of the day. As a volume for ready reference and careful study, it-will be found of immense value to the general practitioner and student." — Medical Record. "The 'Medical Dictionary' of Dr. Quain is something more than its title would at first indicate. It might with equal propriety be called an encyclo- pjedia. The different diseases are fully discussed in alphabetical order. The description of each in- cludes an account of its various attributes, often covering several pages. Although we have pos- sessed the book only the short time since its publica- tion, its loss would leave a void we would not know how to fill." — Boston Medical atid Surg. Jourttal. "Although a volume of over i,8oo pages, it is truly a multunt in parvo, and will be found of much more practical utility than other works which might be named extending over many volumes. The profession of this country are under obligations to you for the republication of the work, and I de- sire to congratulate you on the excellence of the illustrations, together with the excellent typograph- ical execution in all respects." — Austin Flint, M. D. " It is with great pleasure, indeed, that we an- nounce the publication in this country, by the Ap- pletons, of this most superb work. Of all the medical works which have been, and which will be, published this year, the most conspicuous one as embodying learning and research — the compilation into one great volume, as it were, of the whole sci- ence and art of medicine — is the ' Dictionary of Medicine ' of Dr. Quain. Ziemen's ' Practice of Medicine ' and Reynolds's ' System of Medicine ' are distinguished works, forming compilations, in the single department of practice, of the labors of many very eminent physicians, each one in his con- tributions presenting the results of his own observa- tions and experiences, as well as those of the inves- tigations of others. But in the dictionaiy of Dr. Quain there are embraced not merely the principles and practice of medicine in the contributions by the various writers of eminence, but general pathology, general therapeutics, hygiene, diseases of women and children, etc." — Cincin?iati Medical News. " Criticism in detail we have not attempted, and this is in the main because there is not much room for it. Those who are most competent to pass an opinion will, we believe, admit that Dr. Quain has carried out a most arduous enterprise with great success. His ' Dictionaiy of Medicine ' embodies an enormous amount of information in a most ac- cessible form, and it deserves to take its place in the library of every medical man as a ready guide and safe counselor. Others, too, will find within its pages so much information of various kinds that it can not fail to establish itself as a standard work of reference." — St. Jameses Budget. ' ' Therefore we believe that as a whole the work will admirably fulfill its purpose of being a standard book of reference until, like other dictionaries of progressive science, it will require to be remodeled or supplemented to keep pace with advancing knowledge." — The Lancet {London). "I think ' Quain's Dictionary of Medicine 'an excellent work, and of great practical use for eveiy- day reference by the physician." — Alexander J. C. Skene, M. D., Professor of the Medical atid Surgi- cal Diseases of Women, Long Island College Hos- pital, Brooklytt, N. Y. " I regard ' Quain's Dictionary of Medicine ' the most important, because most useful, publication of its kind issued from the medical press for many a year. In fact, I know of no similar work that can fitly be compared with it. The extraordinary facili- ties Dr. Quain possesses, in the choice of distin- guished collaborators, have been applied to the con- struction of a volume whose contents are so clear and compact, yet so full, that the hungriest seeker after the latest results of strictly medical research can be satisfied at one sitting." — Alexander Hutchins, M. D. " In this important v/ork the editor has endeav- ored to combine two features or purposes : in the first place, to offer a dictionary of the technical words used in medicine and the collateral sciences, and also to present a treatise on systematic medi- cine, in which the separate articles on diseases should be short monographs by eminent specialists in the several branches of medical and surgical sci- ence. Especially for the latter purpose, he secured the aid of such well-known gentlemen as Charles Murchison, John Rose Cormack, Tilbury Fox, Thomas Ha)'den, William Aitken, Charlton Bas- tian, Brown-Sequard, Sir William Jenner, Eras- mus Wilson, and a host of others. By their aid he may fairly be said to have attained his object of ' bringing together the latest and most complete in- formation, in a form which would allow of ready and easy reference.' " — Med. and Surg. Reporter. 36 D. APPLETON 5- CO:S MEDICAL WORKS. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Third American from the eighth German edition. Revised and enlarged. Illustrated by Six Lithographic Plates. By Alfred VoGEL, M. D., Professor of Clinical Medicine in the University of Dorpat, Russia. Translated and edited by H. Raphael, M. D., late House Sur- geon to Bellevue Hospital ; Physician to the Eastern Dispensary for the Diseases of Children, etc., etc. I vol., 8vo, 640 pp. Cloth, $4.50 ; sheep, $5.50. "'Vogel's Treatise on Diseases of Children' derived from the possession of this work." — Btcffato has a world-wide reputation, having appeared in the Medical and Surgical Journal. Russian, German, Dutch, and EngUsh languages. This is a deserved success, for it is a book admira- " This is indeed a valuable addition to the litera- bly adapted to the wants both of the practitioner ture of Pediatrics. ... In this latest edition ('3d and student. The present edition is brought well American) much has been added to the chapters on up to the present state of pathological knowledge, Artificial Nutrition, a subject of deep interest to the it is complete without prohxity, and the book bears practitioner, on Difficulties of Dentition, and on upon its pages the evidence of the work of a skillful Nervous Diseases of Children. . . . This alone and experienced clinical practitioner. . . . We should be worth the price of the book, as the treat- would most heartily commend the book as one of ment of diseases of children is too much after the the most valuable upon the subject, and indeed few stereotyped fashion of the last century." — DaniePs physicians can afford to forego the advantages to be Texas Medical yournal. THE NEW YORK MEDICAL JOURNAL: A Weekly Review of Medicine. Edited by Frank P. Foster, M. D. The New York Medical Journal, now in the twenty-third year of its publication, is pub- lished every Saturday, each number containing twenty-eight large double-columned pages of reading matter. By reason of the condensed form in which the matter is arranged, it contains more reading matter than any other journal of its class in the United States. It is also more freely illustrated, and its illustrations are generally better executed, than is the case with other weekly journals. REASONS WHY PHYSICIANS SHOULD SUBSCRIBE FOR THE JOURNAL. BECAUSE: It is the LEADING JOURNAL of America, and contains more reading matter than any other journal of its class. BECAUSE: It is the exponent of the most advanced scientific medical thought. BECAUSE : Its contributors are among the most learned medical men of this country. BECAUSE: Its "Original Articles" are the results of scientific observation and research, and are of infinite practical value to the general practitioner. BECAUSE: The "Reports on the Progress of Medicine," which are published from time to time, contain the most recent discoveries in the various departments of medicine, and are written by practitioners especially qualified for the purpose. BECAUSE: The column devoted in each number to "Therapeutical Notes" contains a resume of the practical application of the most recent therapeutic novelties. BECAUSE: The Society Proceedings, of which each number contains one or more, are reports of the practical experience of prominent physicians who thus give to the profession the results of certain modes of treatment in given cases. BECAUSE: The Editorial Columns are controlled only by the desire to promote the welfare, honor, and advancement of the science of medicine, as viewed from a standpoint looking to the best interests of the profession. BECAUSE: Nothing is admitted to its columns that has not some bearing on medicine, or is not possessed of some practical value. BECAUSE: It is published solely in the interests of medicine, and for the upholding of the elevated position occupied by the profession of America. The volumes begin with January and July of each year. Subscriptions can be arranged to begin with the volume. Terms, Payable in Advance: One Year, $5.00; Six Months, $2.50; Single Copy, 10 cents. (No subscriptions received for less than six months. ) Bindhig Cases, Cloth, 50 cents. THE POPULAR SCIENCE MONTHLY and TMl': NEW YORK MEDICAL JOUR- NAL to the same address, $9.00 per annum (full price, $10.00), payable in advance. D. APPLETON S- CO:S MEDICAL WORKS. t^j PARALYSES: CEREBRAL, BULBAR, AND SPINAL. A Manual of Diagnosis for Students and Practitioners. By H. Charlton Bastian, M. a., M. D., F. R. S. ; Fellow of the Royal College of Physicians; Examiner in Medicine at the Royal College of Physicians ; Professor of Clinical Medicine and of Pathological Anatomy in University College, London, etc. With 136 Illustrations. Small 8vo, 671 pages. Cloth, $4.50. " The work is designed to facilitate diagnosis of " This is ' a manual of diagnosis for students the various forms of paralysis. . . . The book sup- and practitioners,' and as a special work on the di- plies a want long felt ; to come from this celebrated agnosis on localization of a paralyzmg lesion we do author makes it much more vaXnahXe."— Buffalo not know of its equal in any language."— Fir^zwzfl Medical and Surgical Jotirnal. Medical Monthly. " We deem the work to be one of immense value ,,^^ ^^^ strongly recommend Dr. Bastian's which must add greatly to its author's already large ^^^y. ^^ ^-^^ student and practitioner as a monument reputation, and we are heartily glad to see it repro- ^j learning exceedingly well put together."— Z,a«c^/. duced by an American publishing ho\is&."— Medical Press oj Western New York. , , p^^. diagnosis Bastian's work will take the high- " Throughout the work the author's mastery of est rank. It is remarkable for its philosophical tone the subject is constantly apparent, and it must take and for the author's critical comments on numerous rank as without a superior in its special department." obscure problems on n&xxoXo^ .''—American Jour- — Medical and Surgical Reporter. nal of the Medical Sciences. ELEMENTS OF PRACTICAL MEDICINE. By Alfred H. Carter, M. D., Member of the Royal College of Physicians, London ; Physician to the Queen's Hospital, Birmingham, etc. Third edition, revised and enlarged, i vol., i2mo, 427 pages. Cloth, $3.00. "Although this work does not profess to be a wisely, perhaps, since we know so little about it ; complete treatise on the practice of medicine, it is and of that other almost unknown quantity in too full to be called a compend ; it is rather an in- medicine, scrofula, the author has with equal pru- troduction to the more exhaustive study embodied dence abstained from saying much. He admits in the larger text-books. An idea of the degree to such a condition as scrofulosis, but thinks it has no which condensation has been carried in it can be necessary connection with tuberculosis. He is a gathered from the statement that but twenty-one believer in the germ-theory of disease, and speaks pages are occupied with the diseases of the circula- of Koch's investigations and discoveries as very im- tory system. If the reader gets the impression that portant, to him almost conclusive, the physical signs are given somewhat too meager- "Notwithstanding the condensed make-up of ly, it is to be said that, by way of compensation, the book, it is quite comprehensive, including even the symptomatology in general is considered with cutaneous and venereal diseases. It contains much admirable perspicuity and good judgment. valuable information, and we may add that it is " Leucocythffimia is dismissed with one page — very readable." — New York Medical yoiirnal. THE MINERAL SPRINGS OF THE UNITED STATES AND CANADA, with Analysis and Notes on the Prominent Spas of Europe and a List of Sea-side Resorts. An enlarged and revised edition By George E. Walton, M. D., Lecturer on Materia Medica in the Miami Medical College, Cincinnati. Second edition, revised and enlarged. I vol., i2mo, 414 pp. With Maps. $2. The author has given the analysis of all the springs in this country and those of the principal European spas, reduced to a uniform standard of one wine-pint, so that they may readily be com- pared. He has arranged the springs of America and Europe in seven distinct classes, and de- scribed the diseases to which mineral waters are adapted, with references to the class of waters applicable to the treatment ; and the peculiar characteristics of each spring as near as known are given — also the location, mode of access, and post-office address of every spring are mentioned. In addition, he has described the various kinds of baths and the appropriate use of them in the treatment of disease. " Precise and comprehensive, presenting not only use as intelligently and beneficially as they can other reliable analysis of the waters, but their therapeutic valuable alterative agents." — Sanitarian. value, so that physicians can hereafter advise their D. APPLE TON &- CO:S MEDICAL WORKS. DISEASES OF MEMORY : An Essay in the Positive Psy- chology. By Th. Ribot, Author of " Heredity," etc. Translated from the French by William Huntington Smith. i2mo. Cloth, $1.50. "Not merely to scientific, but to all thinking men, this volume will prove Intensely interesting." — New York Observer. " M. Ribot has bestowed the most painstaking attention upon his theme, and numerous examples of the conditions considered greatly increase the value and interest of the volume." — P/iiladelphia North American. "'Memorj',' says M. Ribot, 'is a general func- tion of the nervous system. It is based upon the faculty posses«!ed by the nervous elements of con- serving a received modification, and of forming as- sociations.' And again : ' Memory is a biological fact. A rich and extensive memory is not a collec- tion of impressions, but an accumulation of dynam- ical associations, very stable and very responsive to proper stimuli. . . . The brain is like a laboratory full of movement where thousands of operations are going on all at once. Unconscious cerebration, not being subject to restrictions of time, operating, so to speak, only in space, may act in several directions at the same moment. Consciousness is the narrow gate through which a very small part of all this work is able to reach us.' M. Ribot thus reduces diseases of memory to law, and his treatise is of ex- traordinary interest." — Philadelphia Press. " It is not too much to say that in no single work have so many curious cases been brought together and interpreted in a scientific manner." — Boston Eveni?ig Traveller. A TREATISE ON INSANITY, in its Medical Relations. By William A. Hammond, M. D., Surgeon-General U. S. Army (retired list) ; Professor of Diseases of the Mind and Nervous System, in the New York Post-Graduate Medical School ; President of the American Neuro- logical Association, etc. I vol., 8vo, 767 pp. Cloth, $5; sheep, $6. In this work the author has not only considered the subject of Insanity, but has prefixed that division of his work with a general view of the mind and the several categories of mental faculties, and a full account of the various causes that exercise an influence over mental derangement, such as habit, age, sex, hereditary tendency, constitution, temperament, instinct, sleep, dreams, and many other factors. Insanity, it is believed, is in this volume brought before the reader in an original manner, and with a degree of thoroughness which can not but lead to important results in the study of psycho- logical medicine. Those forms which have only been incidentally alluded to or entirely disregard- ed in the text-books hitherto published are here shown to be of the greatest interest to the general practitioner and student of mental science, both from a normal and abnormal stand-point. To a great extent the work relates to those species of mental derangement which are not seen within asylum walls, and which, therefore, are of special importance to the non-asylum physician. Moreover, it points out the symptoms of Insanity in its first stages, during which there is most hope of successful medical treatment, and before the idea of an asylum has occurred to the patient's friends. " We believe we may fairly say that the volume is a sound and practical treatise on the subject with which it deals ; contains a great deal of information carefully selected and put together in a pleasant and readable form ; and, emanating, as it does, from an author whose previous works have met with a most favorable reception, will, we have little doubt, obtain a wide circulation." — The Dublin Journal of Medi- cal Science. "... The times are ripe for a new work on in- sanity, and Dr. Hammond's great work will serve hereafter to mark an era in the history of American psychiatry. It should be in the hands of every physician who wishes to have an understanding of the present status of this advancing science. Who begins to read it will need no urging to continue ; he will ba carried along irresistibly. We unhesitat- ingly pronounce it one of the best works on insan- ity which has yet appeared in the English language." — American yournal 0/ the Medical Sciotces. " Dr. Hammond is a bold and strong writer, has given much study to his subject, and expresses him- self so as to be understood by the reader, even if the latter does not coincide with him. We like the book very much, and consider it a valuable addition to the literature of insanity. We have no hesitancy in commending the book to the medical profession, as it is to them it is specially addressed." — Therapeutic Gazette. " Dr. Hammond has added another great work to the long list of valuable publications which have placed him among the foremost neurologists and alienists of America ; and we predict for this volume the happy fortune of its predecessors — a rapid jour- ney through paying editions. We are sorry that our limits will not permit of an analysis of this work, the best text-book on insanity that has yet appeared." — 7'he Polyclitzic. ' ' We are ready to welcome the present volume as the most lucid, comprehensive, and practical ex- position on insanity that has been issued in this country by an American alienist, and furthermore, it is the most instructive and assimilable that can be placed at present in the hands of the student unini- tiated in psychiatry. The instruction contained within its pages is a food thoroughly prepared for mental digestion : rich in the condiments that stimu- late the appetite for learning, and substantial in the more solid elements that enlarge and strengthen the intellect." — New Orleans Medical and Surgical Journal. D. APPLETON <&- CO:S MEDICAL WORKS. oA THE POPULAR SCIENCE MONTHLY. Established by E. L- YouMANS. Edited by W. J. Youmans. The volumes begin in May and November of each year. Subscriptions may begin at any time. Terms, $5.00 per annum; single numbers, 50 cents. "The Popular Science Monthly" and "New York Medical Journal" to one address, $9.00 per annum (full price, $10.00), payable in advance. "The Popular Science Monthly" will contain articles by well-known writers on all subjects of practical interest. Its range of topics, which is widening with the advance of science, includes : Political Science and Government. Architecture and Art in connection with Domestic and Social Economy. Practical Life. Education. The Development of the Race. Religion as it is related to Science. Food-products and Agriculture. Ethics, based on Scientific Principles. Natural History; Scientific Exploration. Sanitary Conditions; Hygiene; the Pre- Discovery; Experimental Science, vention of Disease. The Practical Arts. The Science of Living. Contains Illustrated Articles ; Portraits ; Biographical Sketches. It records the advance made in every branch of science. It is not technical ; it is intended for non-scientific as well as scientific readers, for all persons of intelligence. No magazine in the world contains papers of a more instructive and at the same time of a more interesting character. " This is one of the very best periodicals of its to persons of literary tastes who have neither time kind published in the world. Its corps of contribu- nor opportunity to prosecute special scientific re- tors comprise many of the ablest minds known to searches, but who, nevertheless, wish to have a cor- science and literature." — Atnerican Medical you7'- rect understanding of what is being done by others nal (St. Louis). in the various departments of science." — Louisiana CO.'S MEDICAL WORKS. A TREATISE ON NERVOUS DISEASES: Their Symp- toms and Treatment. A Text-book for Students and Practitioners. By S. G. Webber, M. D., Clinical Instructor in Nervous Diseases, Harvard Med- ical School ; Visiting Physician for Diseases of the Nervous System at the Boston City Hospital, etc. I vol., 8vo, 415 pp. 15 Illustrations. Cloth, $3.00. " The book before us is especially adapted to the needs of the general practitioner who, though con- scious of his inability to discern and trace the nerv- ous element in the cases,under his care, realizes very fully that this inability is not consonant with the best interests of his patient. Dr. Webber has not written for the specialist, but for the student and general practitioner, who will find in his book what they most need for the diagnosis and treat- ment of the diseases as they present themselves in general practice. His style is very readable and lucid, and is well adapted to those who have not specially prepared themselves to understand the peculiar language of the more advanced neurologist. He covers very completely the field of nervous affec- tions, and his book will prove a very valuable acqui- sition to the library of the intelligent physician." — Medical Age. ' ' The beauty and usefulness of the book are much enhanced by the fact that it is not loaded down with references to other authors, but proceeds in an orig- inal manner to sum up all that is known to the present day upon the subjects treated. Taking the book as a wliole it is one of the best we have seen in many a day." — Texas Courier-Record. THE CURABILITY AND TREATMENT OF PUL- MONARY PHTHISIS. By S. Jaccoud, Professor of Medical Pathology to the Faculty of Paris ; Member of the Academy of Medicine ; Physician to the Lariboisiere Hospital, Paris, etc. Translated and edited by Montagu Lubbock, M. D. (London and Paris), M. R. C. P. (England), etc. 8vo, 407 pp. Cloth, $4.00. " This is the work of that most eminent French- man of the Ecole de Medecine of Paris, and the translation of Lubbock is strong and masterly inas- much as it evidences the possession of a large vocabulary knowledge of both the original and English. No man of the present day, with the single exception perhaps of Hughes Bennet, has devoted as much careful study to the climatic treat- ment of phthisis as Dr. Jaccoud, and his conclusions on this point so far as regards the Continent of Europe must be deemed final." — Cincinnati Lancet and Clinic. "M. Jaccoud, the author of the work, and the eminent professor of the Ecole de MMecine, Paris, is generally recognized on the Continent as one of the best authorities on pulmonary phthisis, so that an English edition of his work will certainly be very acceptable to those interested in the subject. . . . M. Jaccoud' s reputation is justly so great that his opinions with respect to the treatment will be read with general interest." — Texas Courier-Record of Medicine. THE USE OF THE MICROSCOPE IN CLINICAL AND PATHOLOGICAL EXAMINATIONS. By Dr. Carl Friedlaen- DER, Privat-Docent in Pathological Anatomy in Berlin. Translated from the enlarged and improved second edition, by Henry C. Coe, M. D., etc. With a Chromo-Lithograph. r2mo, 195 pp., with copious Index. Cloth, $1.00. " We are very much pleased to see Dr. Fried- laender's little book make its appearance in English dress. As we have a practical acquaintance of the German edition since its appearance, we can speak of it in terms of unqualified praise. . . . Every one doing pathological work sliould have this little book in his possession. . . . The translator has done his work well, and has certainly conferred a great favor on all microscopists by placing within the reach of every one the work of so accomplished a teacher as Dr. Carl F'riedlaender." — Canada Medical and Sur- gical Journal. " Much good has been done in placing this little work in the hands of the profession. The technique of preparing, cutting, and staining specimens is given at some length ; also rules for the examination of the various bodily fluids in both health and disease. The use of the microscope with high pow- ers, immersion lenses, and other accessories, is ex- plained very clearly. It is a very readable volume, even for those not engaged in actual laboratory work. A chromo-lithograph shows the various forms of disease-germs which have been definitely isolated." — Medical Reco7-d. MEDICAL ETHICS AND ETIQUETTE. Commentaries on the National Code of Ethics. By Austin Flint, M. D. i2mo, loi pp. 60 cents. D. APPLE TON &- CO.'S MEDICAL WORKS. 45 A MANUAL OF DERMATOLOGY. By A. R. Robinson, M. B., L. R. C. P. and S. (Edinburgh), Professor of Dermatology at the New York Polyclinic ; Professor of Histology and Pathological Anatomy at the Woman's Medical College of the New York Infirmary. Revised and corrected. 8vo, 647 pp. Cloth, $5.00. "It includes so much good, original work, and so well illustrates the best practical teachings of the subject by our most advanced men, that I regard it as commanding at once a place in the very front rank of all authorities. . . . " — James Nevins HVDE, M. D. " Dr. Robinson's experience has amply qualified him for the task which he assumed, and he has given us a book which commends itself to the considera- tion of the general practitioner." — Medical Age. " In general appearance it is similar to Duhring's excellent book, more valuable, however, in that it contains much later views, and also on account of the excellence of the anatomical description accom- panying the microscopical appearances of the diseases spoken of." — St. Louis Med. and Sn?'g. yournal. ' ' Altogether it is an excellent work, helpful to every one who consults its pages for aid in the study of skin-diseases. No physican who studies it will regret the placing of it in his library." — Detroit Lancet. AN ATLAS OF CLINICAL MICROSCOPY. By Alex- ander Peyer, M. D. Translated and edited by Alfred C. Girard, M. D., Assistant Surgeon United States Army. First American, from the manu- script of the second German edition, with Additions. 90 Plates, with 105 Illustrations, Chromo-Lithographs. Square 8vo. Cloth, $6.00. "AU who are interested in clinical microscopy will be pleased with the design and execution of this work, and will feel under obligation to the author, translator, and publishers for placing so valuable a work in their hands. The plates in which are figured the various urinary inorganic deposits are especially fine, and the various forms of tube-casts, hyaline, waxy, epithelial, and mucous, are depicted with great fidelity and accuracy." — Pliiladelphia Med. Times. ' ' To those students and practitioners of medicine who are interested in microscopical work and who are familiar with the use of this valuable aid to hu- man vision in the study of nature, the present work will prove of incalculable value, since it represents the original work of an accomplished microscopist and artist. Accompanying the plates is a text of explanatory notes showing the various methods of working with the microscope and the significance of what is obsarved. The plates have been most handsomely printed. We have seen nothing in this special line of study that will compare in point of accuracy of detail and artistic effect with the work under consideration." — Maryland Med. Joia-nal. ELEMENTS OF MODERN MEDICINE, including Princi- ples of Pathology and Therapeutics, with many Useful Memoranda and Valuable Tables of Reference. Accompanied by Pocket Fever Charts. Designed for the Use of Students and Practitioners of Medicine. By R. French Stone, M. D., Professor of Materia Medica and Therapeutics and Clinical Medicine in the Central College of Physicians and Surgeons, Indianapolis ; Physician to the Indiana Institute for the Blind ; Consulting Physician to the Indianapolis City Hospital, etc., etc. In wallet-book form, wjth pockets on each cover for Memoranda, Temperature Charts, etc., $2.50. " This is an abridged work in pocket-book form, presenting the more advanced views of leading authorities, with reference to general patholog>' and therapeutics. Under general pathology are included articles on the origin, nature, and duration of dis- ease, chief symptoms, diagnosis, prognosis, and treatment. In the second part will be found what is regarded by the author as an improved classiScation of drugs, followed b}' articles on their physiological action, indications, and methods of use. The work contains a fund of useful information culled from the best authorities in the Old and New World." — Canada Lancet. " This is a neatly printed pocket manual of medi- cal practice. It is a well-condensed compilation of the kind, containing a short sketch of nearlj' every- thing that is met with in practice. The fever charts are well arranged, and there is a convenient thera- peutic table which will be found valuable. It will probably be more suitable for young practitioners, on account of its containing many practical points that are not to be found elsewhere in such a con- densed manner. It will be found a valuable aid to those just commencing practice." — Medical Herald. 46 D. APPLETON &- CO.'S MEDICAL WORKS. A TEXT-BOOK OF OPHTHALMOSCOPY. By Edward G. LoRiNG, M. D. Part I. — The Normal Eye, Determination of Refrac- tion, and Diseases of the Media. Specimen of Illustration. 8vo. 267 pp., with 131 Illustrations, and Four Chromo -Lithograph Plates, containing 14 Figures. Cloth, $5.00. "The ' Text-book of Oph- thalmoscopy,' by Edward G. Loring, M. D., is a splendid work. ... I am well pleased with it, and am satisfied that it will be of service both to the teacher and pupil. . . . In this book Dr. Loring has given us a substantial exposi- tion of Nature's deeds and misdeeds as they are found written in the eye, and the key by means of which they can be comprehended." — W. R. Amick, a. M., M. D., Pro- fessor of Ophthalmology and Otology^ Cincinnati College of Medicine and Surgery. THE DISEASES OF SEDENTARY AND ADVANCED LIFE. A Work for Medical and Lay Readers. By J. Milner Foth- ERGiLL, M. D., M. R. C. P., Physician to the City of London Hospital for Diseases of the Chest (Victoria Park) ; late Assistant Physician to the West London Hospital; Hon. M. D., Rush Medical College, Chicago; Foreign Associate Fellow of the Royal College of Physicians of Philadelphia. Small 8vo, 296 pp. Cloth, $2.00. "This work is written to fill a gap in medical forgotten. . . . The writer ventures to think that in literature. The diseases of sedentary and advanced this work an aspect of disease is presented which is life lie a little outside and beyond the ordinary text- not always kept sufficiently in view ; and which will books of practice of physic. As such a work is cer- make the work acceptable even to some well-read tain to be read by lay-readers, the fact has not been members of the profession." — From the Preface. THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE EAR. By Oren D. Pomeroy, M. D., Surgeon to the Manhat- tan Eye and Ear Hospital, etc. With One Hundred Illustrations. New edition, revised and enlarged. Cloth, $3.00. 8vo. "The several forms of aural disease are dealt with in a manner exceedingly satisfactory. The work is quite exhaustive in its scope, and will repre- sent an authority on this subject which we believe will be duly appreciated by the profession." — Medi- cal Record. ''The author uses good language, telling in a clear and interesting manner what he has to say. The book is a valuable one for both students and practitioners." — Lancet and Clinic. "The author's opportunity to know of what he writes has been abundant, and the work itself shows that hs has made good use of his information. We have not the slightest reason for not commending it not only to the otologist but also to the general student. " — Therapeutic Gazette. " Well arranged and well written, and not too scientific.'' — Boston Medical and Surgical Jour- nal. D. APPLE TON &- CO.'S MEDICAL WORKS. 47 LOCAL ANAESTHESIA IN GENERAL MEDICINE AND SURGERY. Being the Practical Application of the Author's Re- cent Discoveries in Local Anaesthesia. By J. Leonard Corning, M. D., author of " Brain Exhaustion," " Carotid Compression," "Brain Rest," etc. ; Fellow ot the New York Academy of Medicine, Member of the Medical Society of the County of New York, of the New York Neurological Society, etc. Small 8vo, 103 pp. With 14 Illustrations. Cloth, $1.25. " The work has in it much that is instructive and attractive, and is quite an addition to a field of lit- erature which may be considered novel. . . ." — College and Clinical Record. " The book should find its way everywhere on its merits, and will be welcomed by a host of interested readers." — Medical Press 0/ Westerti New York. "This is a valuable little work on cocaine, giving the author's method of increasing and prolonging the cocaine anesthesia. . . . Some very formidable operations, even amputation of the thigh, have been performed by this method and with but very little pain. It is a valuable contribution to surgical prac- tice." — Peoria Medical Monthly. "The book merits careful consideration, as being an interesting and practical original contribution to surgery." — Medical Bulletin. ' ' The work is worthy the careful study of every practical surgeon and physician. It is clearly writ- ten, with little useless padding. The author stops when he has said what he wishes." — American Lancet. "To Dr. Corning belongs the honor of discov- ering that cocaine anaesthesia may be almost indefi- nitely prolonged by checking the circulation in the part anaesthetized by means of an Esmarch's band- age, and any one desiring full details should send to the Appletons for this neat little work." — Kansas City Medical Itidex. "It is of interest to note the author's -statement that the ' discovery in question was in no respect the result of a chance, but was, on the contrary, the di- rect outgrowth of a chain of deductive reasoning.' The importance of this discovery needs no insisting on ; and no surgeon can afford to be in ignorance of its details, or can fail to be scientifically the richer for the possession of the present work." — New Eng- land Medical Gazette. A TEXT-BOOK OF NURSING. For the Use of Training- Schools, Families, and Private Students. Compiled by Clara S. WeekS) Graduate of the New York Hospital Training- School ; Superintendent of Training-School for Nurses, Paterson, New Jersey. I2mo, 396 pp., with 13 Illustrations, Questions for Review and Examination, and Vocabulary of Medical Terms. $1.75. ' ' This book, in twenty-three chapters, communi- cates a large quantity of useful information in a form intelligible to the public. It is well written, remarkablv correct, sufficiently illustrated, and hand- somelv printed. The amount of technical skill and knowledge required of nurses at the present day makes the use of some text-book indispensable. To those who need such a work we can speak ap- provingly of its design, scope, and execution." — Philadelphia Medical Tiines. " This is an admirably written book, and is full of those important practical details necessary for the medical and surgical nurse. In fact, it could be read with profit by every medical student and young practitioner." — Medical Record. MEDICINE OF THE FUTURE. An Address prepared for the Annual Meeting of the British Medical Association in 1886. By Aus- tin Flint (Senior), M. D., LL. D. With Steel Engraving of the author. l2mo, 37 pages. Cloth, $1.00. " The above, the last of the thoughts of Austin Flint, should be in the hands of every admirer of the great and good physician, and who that knows anything of American medicine did not admire him ? iFlint never wrote anything that was not good, and the nice little hooK—soiivenir—h^'i.oxfi us bears that characteristic. The manuscript was found among his papers after his death, and was printed just as it was written. It contains a good likeness of the author— an elegant steel engraving— and nothing has been left undone by the well-known publishers to make it sXtxasXiv^:'— Mississippi Val- ley Medical Monthly. " The late Dr. Austin Flint was appointed to read the address on Medicine before the British Medical Association at its meeting in 1SS6. The manuscript was found among his papers, and the address is printed precisely as it was written. The proof was reverently read by his son, who dedicates this, his father's last literary work, to the profession he so loved and admired. The book contains an excellent portrait of the late Dr. Flint. It is a most fitting memor'al volume. The address itself is a most scholarly work, and should be added to the library of every -pxzzXSXion^r."''— Buffalo Medical and Surgical yournal. 48 D. APPLE TON &- CO.'S MEDICAL WORKS. A TEXT-BOOK OF MEDICINE. For Students and Prac- titioners. By Adolph Strumpell, formerly Professor and Director of the Medical Polyclinic at the University of Leipsic. Translated, by permission, from the second and third German editions by Herman F. Vickery, A. B., M. D., Assistant in Clinical Medicine, Harvard Medical School, etc., and Philip Coombs Knapp, Physician to Out-patients with Diseases of the Nervous System, Boston City Hospital, etc. With Editorial Notes by Frederick C. Shattuck, A. M., M. D., Instructor in the Theory and Prac- tice of Physic, Harvard Medical School, etc. With III Illustrations. 8vo, 981 pages. Cloth, $6.00; sheep, $7.00. " The above work, which is new to most of our readers, has achieved great success in Germany, hav- ing reached the third edition in a verj' short time. It has been introduced as the text-book on medicine in the Har\'ard Medical School. The work is espe- cially commendable in its treatment of nervous dis- eases, which are dealt with fully, concisely, and clearly. The patholog)' of disease, as might be ex- pected from so eminent a teacher, has received due and careful attention, and this is another strong feature of the work. The author gives in this work the results of the experience and observation of more than six years' active work in the medical clinic in Leipsic. We heartily commend the work to the at- tention of our readers." — Canada La?icet. " In spite of the fact that within the last year or two so many excellent works on general medicine have appeared, we think there will be found a place for the volume before us. The best part of the book is the section devoted to nervous diseases. The va- rious affections of the ner\'Ous system are discussed in a very concise way, together with the most recent discoveries in neuro-pathology. The translators have done their work well, and the editor has made a number of important additions. Altogether the book is a very valuable contribution and compilation, and will be useful both to teacher and practitioner. " — Maryland Medical Journal. '• The work before us is one that is peculiarly at- tractive to the student of medicine, not only on ac- count of the well delineated German plans of treat- ment, but especially for the clear and accurate pa- Dr. Shattuck states that he is acquainted with no work°wli!ch treats of the diseases of the nervous system, in which our knowledge has advanced so rapidly of late years, so fully, concisely, and clearly. The style is clear for a German work, which as a rule do not make models in this particular. The translators have overcome the difficulties of the original so suc- cessfully that they have made it a decidedly agreeable text-book. The book is extremely popular in Ger- many, having reached the third edition in a comparativelv short time, and we do not doubt but that its popularity in Amsrica will soon be assured."— J/ww^^/^ Valley Medical Monthly. its covers will be found a very complete and sys- Fig. 78. — Spasm of the right Splenius Capitis. (From Duchen.ne.) thology given by the author in almost all diseases. " I like it so well that I have commended it to my class and have called special attention to its three hundred pages devoted to the nervous system, bringing to date all the knowledge which the last ten years, more than many centuries past, have brought to the use of the profession." — H. D. Didama, tematic description of aU the diseases which are classed under the head of internal medicine. Un- like most of the larger works on practice, we do not find the preliminary discourse on general pathologi- cal subjects, an omission which is very much to be M. D., Professor 0/ the Principles and Practice 0/ commended, because there are at ths present day so Medicine and Clinical Medicine, College 0/ Medi- cine, Syracuse University. " I consider it the best text-book of medicine with which I am acquainted. The part on nervous diseases is so excellent that I shall recommend the whole book to my class as a text-book on diseases of the nervous system." — Henry Hu.\, M. D., LL. D., Dean 0/ the Faculty and fimeritus Professor of the Institutes of Medicine, Albany Medical College. "Of the German text-books of practice that have been translated into Knglish, Professor Strum- pell's will probably take the highest rank. Between many special treatises upon pathological subjects that there is no longer a necessity for such a section in a work of this kind. While it is impossible to refer to all these particularly, we may call attention to the chapter on Typhoid Fever as being especially valuable, not only on account of the advanced views in regard to the pathology of that disease, but also becau.se of the careful description of its clinical his- tory and of its treatment. Taken altogether, it is one of the most valuable works on practice that we have, and one which every studious practitioner should have upon his shelves." — New York Medical Journal. D. APPLETON &- CO:S MEDICAL WORKS. 49 Fig. 390. — Making Plantar Flap. A MANUAL OF OPERATIVE SURGERY. By Joseph D. Bryant, M. D., Professor of Anatomy and Clinical Surgery, and Asso- ciate Professor of Orthopoedic Surgery in Bellevue Hospital Medical Col- lege ; Visiting Surgeon to Bellevue Hospital, and Consulting Surgeon to the New York Lunatic Asylum and the Out-Door Department of Bellevue Hospital. New edition, revised and enlarged. With 793 Illustrations. 8vo, 530 pages. Cloth, $5.00; sheep, $6.00. "The apolog;)' given by the author, if any apology be needed for the appearance of so excellent a work, is the fre- quent request on the part of those whom it has been his pleas- ure to instruct in operative surgery during ihe past few years, to make a book based somewhat on the plan he has employed in teaching this subject. We have perused this work with great pleasure and profit, and can bear testimony to the care and attention which the author has bestowed to make the book, a benefit to his co-workers in the same field. The cuts are numerous and well executed, and the text clear and well printed. The various operative procedures are clearly and concisely described, and the results of the various operations briefly stated. The chapter on the treatment of operation wounds is worthy of special mention. The work is fully abreast of the most recent advances in operative surgerj', and we have much pleasure in recommending it to our readers." — Canada Lancet. " The author of this work seems to know how in the brief- est space to give the student of surgery the aid necessary ' to acquire established facts,' and this is an important point in a book of this kind. The text is most fully illustrated, and brings the subject to date, and it will be found useful in the sphere to which it belongs " — A'eio y'ork Medical Times. " The work of Professor Brj'ant, while it does not pretend to be a rival of the larger works or systems of surgery, is of its kind a most excellent book. Theories and doubtful methods of operating find no place in the volume. It is rather to known facts and established procedures that the author has limited his labor, and the judgment which he evinces in selecting from the various methods of operating in sur- gical cases is generally of a most reliable nature ; indeed, it is this selecting from many proposed proced- ures, which are usually met with in the larger surgical works, that much of the value of Professor Bry- ant's book depends, and in this respect the book becomes a very able aid to the inexperienced surgeon. The scope of the work includes most of the surgical diseases, and the operative meth- ods for their relief or cure. The operations peculiar to the female sex, and the surgery of the eye and ear, are not considered in the book. ... In conclud- ing our notice of Pro- fessor Bryant's book, it remains for us to con- gratulate him upon the successful result of his labor. He has written a very able and reliable surgical work, one that may be consulted both by surgeon and stu- dent, and one that con- tains all the more im- portant advances of modem surgery. The publishers' part of the work has been well done, and the numer- ous illustrations add much to the value of the volume." — Thera- peutic Gazette. 459. — Compressing Femoral Vessels. D. APPLE TON (S- CO:S MEDICAL WORKS. PRACTICAL SUGGESTIONS RESPECTING THE VARIETIES OF ELECTRIC CURRENTS AND THE USES OF ELECTRICITY IN MEDICINE, with Hints relating to the Selection and Care of Electrical Apparatus. By Ambrose L. Ranney, M. D., Pro- fessor of Nervous Diseases in the Medical Department of the University of Vermont ; Professor of the Anatomy and Physiology of the Nervous System in the New York Post-Graduate Medical School and Hospital, etc. l6mo, 147 pp., with 44 Illustrations and 14 Plates, as an aid in treating morbid states of the motor or sensory apparatus. $1.00. " It is clearly written, quite practical in tone, and " It presents in a condensed form the latest views offers an excellent epitome of the subject."— i/^'f^z- on this important subject. Numerous illustrations cal and Siir°-ical Reporter. increase the clearness with which the author presents "^ . his subject. In this form it is more conveniently "This is a useful httle work, presentmg m a reached; . . . it is also more conveniently arranged brief way the subject of electro-technique and elec- than it is likely to be in a large work on the diag- tro-therapeutics."— yl/J - ■ ^^ ^^^^^^ ^^if^^r^A on the ap- Carolina Medical Journal. pHcation of electricity to disease. It is full of prac- ' ' For the practitioner who wants brief directions tical hints and many valuable cuts, illustrating the where to put the positive pole and where the nega- author's methods." — Denver Medical Times. tive, this is the book." — Medical Press of Westej-n New York. "The title of this work sufficiently indicates its sphere, and all we need say of it is that it is emi- " The author is well known as an accomplished nently practical and worthy of a place as a text-book writer and teacher on nervous diseases, and his con- in this important and rapidly developing department sciousness that much depends, in neurology, upon a of medical practice. "—iVew York Medical Times. knowledge of electricity and electrical appliances, induced him to prepare this very useful and timely ' ' The hints contained in it embrace the later work, for the benefit of those desiring to use this ideas upon the best electrical apparatus, and the mode agent scientificcdly and successfully in their general of its application in different diseased conditions." — practice." — College and Clinical Record. Hahnemannian. GYNECOLOGICAL TRANSACTIONS, VOLS. I TO VII, will be supplied at $5.00 a volume. GYNECOLOGICAL TRANSACTIONS, VOL. VIII. Be- ing the Proceedings of the Eighth Annual Meeting of the American Gynae- cological Society, held in Philadelphia, September 18, 19, and 20, 1883. 8vo. 276 pp. Cloth, $5.00. GYNECOLOGICAL TRANSACTIONS, VOL. IX. Be- ing the Proceedings of the Ninth Annual Meeting of the American Gynaeco- logical Society, held in Chicago, September 30, and October i and 2, 1884. 8vo. 408 pp. Cloth, $5.00. GYNECOLOGICAL TRANSACTIONS, VOL. X. Being the Proceedings of the Tenth Annual Meeting of the American Gynseco- logical Society, held in Washington, D. C, September 22, 23, and 24, 1885. 8vo. 357 pp. Cloth, $5.00. D. APPLE TON &- CO.'S MEDICAL WORKS. 5 1 GYNECOLOGICAL TRANSACTIONS, VOL. XI. Be- ing the Proceedings of the Eleventh Annual Meeting of the American Gynae- cological Society, held in Baltimore, September 21, 22, and 23, 1886. 8vo. 516 pp. Cloth, $5.00. GYNECOLOGICAL TRANSACTIONS, VOL. XII. Be- ing the Proceedings of the Twelfth Annual Meeting of the American Gynae- cological Society, held in New York City, September 13, 14, and 15, 1887. 8vo. 512 pp. Cloth, $5.00. A TEXT-BOOK ON SURGERY: General, Operative, AND Mechanical. By John A. Wyeth, M. D., Professor of General and Genito-Urinary Surgery in the New York Polyclinic ; Visiting Sur- geon to Mount Sinai Hospital, etc. Sold by Subscription. " The above work we have read, and will judge it from its title, viz., 'A Text-Book on" Surgery,' or, in other words, a book to teach from ; but may we not also look at it from the opposite side, and consider it a book to learn from ? In answer to the first of these definitions we do not hesitate to say that Professor Wyeth has given us a most excel- lent book, one in which will be found all the advances of modern surgery and all that is good of older sur- gery. . . . The more important question to answer is in regard to the value of the book as a means of obtaining surgical knowledge, and, indeed, it is in this sense that the title of the work must be mainly considered. Again do we answer in the affirmative, and believe of the many text-books which are in use by the medical colleges, none are better, few are equal, and many are inferior ; therefore we hope to see this work of Professor Wyeth's recommended to those beginning the study of surgery, since we think a good foundation to build up a knowledge of the science and art of surgery may be found in it. Pro- fessor Wyeth is certainly to be con- gratulated for the manner in which his publishers have done their part. The illustrations, the paper, the typography, and in fact the entire work may be regarded as a beautiful specimen of the art of book-mak- ing." — Therapeutic Gazette. " . . . In order to produce such a work, and make it satisfactory to those who desire a guide thoroughly up to the times in this department of medicine, it has evidently been the author's aim to discard all that has become ob- solete and that is not essential, and to present the whole science and art of surgery as it is taught and practiced at the present day by the ablest Specimen of Illustration. authorities at home and abroad, in a very compact and yet thoroughly intelligible form. That he has succeeded in this design the pages of this beautiful volume seem clearly to indicate. The work 52 D. APPLETON &- CO.'S MEDICAL WORKS. Specimen of Illustration. throughout is stamped with his own individuality, and if at times he seems a little dogmatic in his manner, it is because he is speaking of matters with which he is thoroughly conversant, and ad- vocating methods the efficacy of which he has thoroughly tested in a practical way. That there are honest differences of opinion on many of the points of pathology and practice upon which he treats, of course, goes without saying, but through- out the work the teaching is unquestionably sound and conscientious, and if in any given condition only one plan of treatment may be advised, it is because the author honestly believes it to be the best. Three years of unremitting toil have been given to the preparation of the book, to say nothing of the many additional years of study, teaching, and practical work of which it is the fruit." — Gaillard's Medical Journal. "... The writing of a surgery that shall be new in its matter is simply impo-ssible. But the author has evidently grasped and digested the facts of surgery as known to-day, and, after finding those which best suited his practical work, pre- sented them to his professional fellow-workers. Others would write a different work from the same data, because no two minds run in the same direc- tion. But in this sense this work is original. In this sense it will be found interesting and instruc- tive to all students and professional men. The chapter on the ligation of arteries is worth the price of the entire work. The illustrations are superb, showing in color the parts to be met with in the reaching of arteries in every portion of the body. Quite as important and as beautifully illus- trated is the chapter on amputations. He who, possessing proper anatomical knowledge, could not by the directions here given perform these amputations, should be convinced that he had missed his calling." — American Lancet. "A modern text-book on surgery, provided it professes to give within a moderate compass a satisfactory account of the general range of sur- gery, is valuable to the general practitioner in proportion as it makes details plain and clearly presents their underlying principles. Gauging it on this basis, we are convinced that Dr. Wyeth's work will speedily take a prominent place in the esteem of the profession. ... In particular, we would commend the care that has been bestowed on the important matters of surgical dressings, bandaging, and the like. These details lie at the very foundation of success in surgical practice, and too much attention can scarcely be given to them in a text-book. The appearance of the book is in the highest degree creditable to the publishers ; the print is clear, the paper is excellent, and the illustrations, which are numerous and nearly all original, are among the best of their class that we have seen. They include quite a number printed in colors." — New York Medical Journal. "As a specimen of typographical and book- makers' work it is unexceptionable. It is one of the handsomest works ever published, is profusely and beautifully illustrated, having 771 engravings, of which about fifty are colored, and is printed in large type on heavy paper. Nor, when we have praised the mechanical work of the book, have we given all of its merits. It is undoubtedly a useful and convenient manual of surgery. The author has kept himself thoroughly posted in the present literature of his profession, and has incorporated in his book nearly all of the latest achievements and notions in surgery. We believe the book to be the production of a good and conscientious surgeon, and can safely recommend it to the pro- fession." — Medical Herald. ' ' The perusal of this book by any one interested in surgery can not fail to afford both pleasure and instruction. . . . The illustrations constitute a special feature, for they are used unsparingly throughout the entire work, and are of a very superior order of merit. . . . The book is well written, fully up with the present status of sur- gery, is a credit alike to author and publishers, and would be very cheap at double the price charged for it. It affords us pleasure to look over a book which we can thus praise without stint, knowing that we can say nothing in excess of its merits. ' ' — Southern Clin ic. ". . . Its readers will have nothing derived from its study to unlearn. Its teachings are the accepted ones of to-day, while within its nearly 800 pages we have found but very few superfluous sentences. ... In conclusion, we may say that the book is characterized throughout by good, practical common-sense, wide research, and excellent judg- ment as to what should be left out of, as well as what should enter into, a work of this scope." — Canada Lancet. ' ' Dr. Wyeth has prepared a very excellent trea- tise on general, mechanical, and operative surgery. . . . The work ... is distinctly what it claims to be, ' A Text- Book on General, Operative, and Mechanical Surgery,' carefully prepared and fully up to all the modern improvements in surgery." — New York Medical Times. "... The eminent surgeon. Dr. Wyeth, has here presented a most valuable production. Though styled a text-book, it is admirably adapted as a work of reference for the surgeon and practitioner, giv- ing, as it does, the recent and advanced views upon all surgical procedures. ... In short, the entire book evinces the work of a master-mind and a supe- rior operator in surgery." — Southern Med. Record. D. APPLETON (Sr- CO:S MEDICAL WORKS. 53 OPERATIVE SURGERY ON THE CADAVER. By Jasper Jewett Garmany, A. M., M. D., F. R. C. S,, Attending Surgeon to Out-door Poor Dispensary of Bellevue Hospital; Visiting Surgeon to Ninety-ninth Street Reception Hospital; Member of the British Medical Association, etc. Small 8vo. 150 pp. With Two Colored Diagrams showing the Collateral Circulation after Ligatures of Arteries of Arm, Abdomen, and Lower Extremity. Cloth, $2.00. "To the more advanced student who has the opportunity of operating on the cadaver, this work will be of great value, since it reduces to a system the procedure of ordinary surgical operations. To the practitioner it will be valuable as a work of easy reference as to the best methods of operation. In fact, it should have been named a manual of surgical operations. The instructions given are full, yet very plain and concise, and we predict for it a wide circulation." — Peoria Medical Monthly. ". . . In its necessarily limited scope it is above criticism. . . . Indeed, there is nothing superfluous in the book, and the busy practitioner, who must do more or less surgery, would find it a very useful manuaJ for frequent reference." — Med- ical Press of Western New York. "... For the student in the dead-room, or the busy operating surgeon, this book is one of the most reliable and handy works we have ever seen." — Southern Clinic. " Post-mortem surgery must always precede in- telligent and successful surgery. No more accept- able or useful g^ide to this form of experimental teaching could be desired than the admirable little work before us. Not a superfluous phrase and net an obscure phrase mars its pages. . . ." — New England Medical Gazette. "... No space is wasted, either bywords or by illustrations, a fact which we believe greatly en- hances its value for the earnest student." — Pacific Medical and Surgical Journal and Western Lan- cet. "... All the ordinary operations practiced in surgery are described in a concise and clear man- ner, many of the later procedures finding a place which are not incorporated in larger works on sur- gery already before the pubUc. The book will prove to be a great convenience to the practitioner in active work, as well as to the student in the dis- secting-room." — Weekly Medical Review. " This book contains a simple and clear state- ment of the way in which a large number of opera- tions are to be performed on the cadaver, and can be recommended to the use of teachers and students in this important part of a surgical education. ..." — Medical and Surgical Reporter. FUNCTIONAL NERVOUS DISEASES: Their Causes AND THEIR TREATMENT. Memoir for the Concourse of 1881-1883, Academic Royale de Medecine de Belgique. With a Supplement, on the Anomalies of Refraction and Accommodation of the Eye, and of the Oc- ular Muscles. By George T. Stevens, M. D., Ph. D., Member of the American Medical Association, of the American Ophthalmological Society, etc. ; formerly Professor of Ophthalmology and Physiology in the Albany Medical College. Small 8vo. 217 pp. With Six Photographic Plates and Twelve Illustrations. Cloth, $2.50. ' ' A careful study of this work will undoubtedly clear up many hitherto illy understood cases of nervous troubles, and will lead to a more success- ful treatment of such. . . . " — Peoria Medical Monthly. "... We heartily commend his book to all thoughtful students of nervous diseases, feeling sure that they can not fail of finding in it most valuable suggestions." — Medical and Surgical Re- porter. ". . . It is fortunate for the profession that Dr. Stevens has done his views full justice in a work to which all can have access, for they cer- tainly deserve careful attention." — Medical Press of Western New York. "... The work is eminently suggestive and practical upon numerous points, and must prove interesting and very useful to the student and practitioner." — Southern Medical Record. ". . . To Dr. Stevens the profession is un- questionably indebted for the discovery of a new and important class of causative influences ; and no physician, after a thoughtful reading of this ad- mirable treatise, will fail to the diagnosis of an ex- perienced oculist an invaluable aid to his own in any obstinate case of nervous disease under his care.'' — New England Medical Gazette. "Dr. Stevens has written a suggestive little book, and the mere fact that it has excited criticism is pretty fair proof that there is good in it. For our own part, we confess that we have derived much pleasure from its perusal. . . . Finally, the book is written in a style which is decidedly fas- cinating. Dr. Stevens knows much about English prose, and he has a well-developed rhythm both in ideas and words, and hence he renders the assimila- tion of knowledge easy. His monograph should be read by those who are interested in the prob- lems of neuro-pathology." — The New York Medi- cal Joui-nal. 54 D. APPLE TON <&- CO:S MEDICAL WORKS. THE RULES OF ASEPTIC AND ANTISEPTIC SUR- GERY. A Practical Treatise for the Use of Students and the General Practitioner. By Arpad G. Gerster, M. D., Professor of Surgery at the New York Polyclinic ; Visiting Surgeon to the German Hospital and to Mount Sinai Hospital, New York. 8vo. Illustrated with Two Hundred and Forty-eight Fine Engravings. Cloth, $5.00; sheep, $6.00. The following are the points of excel- lence in this work : It deals only with matters of practical interest to, and questions that are likely to arise daily in the work of the practicing physician. Its scope is a terse yet clear exposition of the principles governing modern operative surgery. It enters into the practical details of all the varying con- ditions of the application of the antiseptic method as brought about by emergencies. Every important prin- ciple is clearly illus- trated by citations from actual cases occurring in the author's prac- tice. It is not intended to take the place of any text-book on surgery, but rather to supply a need which exists in every work on the sub- ject in the English lan- guage, by furnishing information on the sub- ject of Asepsis and Antisepsis, with which It is, in short, a supple- Fig. 147. — Necrotomy of tibia. Leg placed on a hard cushion, from the right. Irric no book on surgery deals to an extent demanded by modern methods ment to all surgical text-books. The illustrations are typo-gra- vures, made from photographic negatives taken from life, and are marvels of beauty, artistic elegance, and fidelity, each illustration being a faithful representation, by the camera, of the details of the appli- cation of . all important antiseptic dressings and apparatus, approach- ing nearer to an actual demonstra- tion than has ever before been at- tempted to be done in any medical work. With the exception of a few bacteriological illustrations taken from Koch, Rosenbach, and Bumm, the illustrations are from negatives made in the operating-room, and are of a character now for the first time em- ployed in a medical work. The work has been adopted by the Medical Department of the United States Army. "This work of three hundred and twenty-five pages occupies a field which, though hinted at in other treatises on surgery, has never as satisfac- torily been presented, and as such will be welcomed by the entire medical fraternity. . . . Typograph- ically, the volume is perfect, and no physician, whether he has made surgery a matter of special investigation or not, will ever regret having pur- chased this work, which is the matured thought of --^y. Fig. 172. — Dressing for mammary abscess, or empyema. a careful and scholarly medical scientist." — Ameri- can Medical Digest. "... Just such books as this are needed to ex- pound the principles of asepsis, while demonstrat- ing the methods by which it may be attained. . . . It is a difficult matter to find anything in this magnificent book that may be adversely criticised." Pittsburg Medical Review. D. APPLE TON &- CO.'S MEDICAL WORKS. 55 " Dr. Gerster has written a valuable and inter- esting book ; valuable in that it gives the details of anti-parasitic surgery in the hands of an adept and an enthusiastic behever in it, and interesting be- cause it is largely a record of personal experience. The profuseness of the illustrations, and their beauty, add much to the value of the work." — Philadelphia Medical Times. "... The book may be termed a treatise on operative surgical physiology and pathology, if there be no contradiction in this combination of words. Or, it may be said that the book is a series of illustrative sermons on the text. The surgeoti's act determines the fate of a fresh wound, and its infection and suppuration are due to his technical faults of omission and com7nission. . . ." — jour- nal of the America7i Medical Association. " If ever there was a timely book written this is it. . . . We need say nothing more of this volume than we have already said to assure our readers that it is one of remarkable value. If it has its equal anywhere we are not aware of it. If anything is needed to make the author's reputation this book will do it, as it will most surely find its way into every town, village, and hamlet in our broad land. . . ." — North Carolitia Medical Journal. "This is as beautiful a specimen of the book- maker's art as we have seen. . . . The beauty and abundance of the illustrations — which are photo- graphs taken during operation — add greatly to the practical value of the work. In a word, it is a book which every physician who does any surgical work ought to have." — Buffalo Medical atid Surgi- cal fournal. A TEXT-BOOK OF DISEASES OF THE SKIN. By John V. Shoemaker, A. M., M. D., Professor of Dermatology in the Medico-Chirurgical College of Philadelphia. 8vo. With Six Chromo-Lithographs and numerous Engravings. Cloth, $5.00; sheep, $6.00. " . . . It is a treatise on the skin which we can recommend to every physician as a work of refer- ence, and in which "he will find the latest views on pathology and treatment. At the end of the work are a number of formulae, which will prove very valuable as a reference. It is certainly a very com- plete book." — Canada Lancet. " This is an entirely new work upon diseases of the skin, by one who evidently has had very large observation and experience in those affections. . . . Students and physicians will find it well adapted to their wants. A proper study of it will give them a very satisfactory knowledge of skin affections." — Cincinnati Medical News. "... Dr. Shoemaker's excellent work will be especially acceptable to the profession as being free from cumbrous technicality, and as having been prepared to interest and instruct the practitioner, and not to embarrass him with burdensome details that might make the study and the subject a tax rather than a pleasure." — College and Clinical Record. ELEMENTS OF THERAPEUTICS AND PRACTICE ACCORDING TO THE DOSIMETRIC SYSTEM. By Dr. D'Oliveira Castro. 8vo, 488 pp. Cloth, $4.00. THE NEW YORK MEDICAL JOURNAL VISITING- LIST AND COMPLETE POCKET ACCOUNT-BOOK. Prepared by Charles H. Shears, A. M., M. D. Price, $1.25. This List is based upon an entirely new plan, the result of an effort to do away v/ith the defective method of keeping accounts found in all visiting-lists hitherto published. Each page is arranged for the accounts of three patients, to the number of thirty-one visits each, which may have been made during a current month or may extend over a number of months, according to the frequency of the visits. With the simple system here inaugurated, the practitioner can at a glance, and without the trouble of tracing the narrow columns found in the ordinary lists, ascertain the condition of the account of any patient ; when, and how many visits have been made ; what has been paid, and how much is still due. It is provided with an Index, and is, without doubt, the most perfect Visiting-List e^jer offered to the profession, as it possesses all the advantages without the obiectionable features found in all others. Its USE can be BEGUN AT ANY TIME, INDEX PiGK Air, Essays on the Floating Matter of the 25 Anaesthesia, Local, in General Medicine and Surgery. 47 Anatomy, of the Nervous System 26 i'hysiology and Hygiene, I'he Essentials of 42 The Comparative, of the Domesticated Animals. 10 i'he, of Invertebrated Animals 20 The, of Vertebrated Animals 15 Aorta, Diseases of the Heart and Thoracic 42 Bacteriological Investigation, The Methods of 19 Barker. On Sea-Sickness i The Puerperal Diseases i Bartholow. A i' realise on the Practice of Medicine. . 4 On the .Antagonism between Medicines 5 I realise on Materia Medica and Therapeutics . . 3 Bastian. Paralyses: Cerebral, Bulbar, and Spinal... 37 Paralysis from Brain Disease i The Brain as an Organ of Mind 3 Bennet. On th? i'reatment of Pulmonary Consump- tion... 5 Winter and Spring on the Shores of the Medi- terranean 5 Bile, Jaundice, and Bilious Diseases, On the 17 Billings. The Relation of Animal Diseases to the Public Health 43 Billroth. General Surgical Pathology and Therapeu- tics 6 Body and Mind 22 B mes, A Treatise on Diseases of the 24 Brain Disease, Paralysis from i Exhaustion, A Treatise on 41 The, and its Functions 34 The, as an Organ of Mind 3 Bramwell. Diseases of the Heart and Thoracic Aorta 42 Breath, The, and the Diseases which give it a Fetid Odor 17 Bryant. A Manual of Operative Surgery 49 Buck. Contributions to Reparative Surgery 12 Carpenter. Principles of Mental Physiology 2 Carter. Elements of Practical iNIedicine 37 Castro. Elements of Therapeutics and Practice ac- cording to the Dosimetric System 55 Chauveau. The Comparative Anatomy of the Do- mesticated Animals 10 Chemical Technology, A Hand-book of 31 Che.Tiistry, Inorganic 33 Organic 33 Short Text-book of Organic 2 The, of Common Life 12 Children, A Pr.^ctical Treatise on Disea.ses of 36 Children's Diseases, Compendium of. 28 Club-Foot, A Practical Manual on the Treatment of. . 28 Combe. I he Management of Infancy i Consumption, On the Treatment of Pulmonary 5 Corfield. On Health 2 Corning. A Treatise on Brain-Exhaustion 41 Local Anaesthesia in General Medicine and Sur- gery 47 Davis. Conservative Surgery 11 Deformities, A Treatise on Oral 16 Dermatology, A Manual of 45 Diseases, The. of Sedentary and Advanced Life 46 Down. Health Primers 19 Ear, The Diagnosis and Treatment of Diseases of the. 46 Education, Physical 23 Electricity in Medicine, The Uses of 50 Elliot. Obstetric Clinic 7 Emergencies, and How to Treat them 14 EvetsJcy. The Physiological and Therapeutical Ac- tion of Ergot 6 Eye, A Hand-book of the Diseases of the 42 Flint. Manual of Chemical Examination of the Urine in Disease 7 Medical Ethics and Etiquette 44 Medicine of the F'utiirc 47 On the Physiological Effects of Severe and Pro- tracted Muscular Exercise 7 Text-book of Human Physiology 8 The Physiology of Man 9 Flint. The Source of Muscular Power 7 Foods 31 Fothergill. The Diseases of Sedentary and Advanced Life 46 Fournier. Syphilis and Marriage 9 Erey. The Histology and Histo-Chemistry of Man. . 11 Friedlaender. The Use of the Microscope 44 Gamgee. Yellow Fever, a Nautical Disease 11 Garmany. Operative Surgery on the Cadaver 53 Genito-Urinary Organs, Surgical Diseases of the .... 31 Gerster. Rules of Aseptic and Antiseptic Surgery. . . 54 Gross. A Practical Treatise on Tumors of the Alam- mary Gland 13 Gutmann. Watering-Places and Mineral Springs of Germany, Austria, and Switzerland 28 Gynaecological Transactions. Vols. VIII, IX, X, and XI 50 Hamilton. Clinical Electro-Therapeutics 20 Hammoiid. A Treatise 011 Insanity 38 A Treatise on the Diseases of the Nervous Sys- tem 14 Clinical Lectures on Diseases of the Nervous System 15 Harvey. First Lines of Therapeutics 17 Health 2, 29 A Ministry of, etc 27 And How to Promote it 22 Primers 19 Heart and Thoracic Aorta, Diseases of the 42 Histology and Histo-Chemistry, The, of Man 11 Hoffman and Ultzmann. Analysis of the Urine. . . . 20 Hospital Reports. Bellevue and Charity 30 Hospitals 33 Howe. Emergencies, and How to Treat them. ...... 14 The Breath, and the Diseases which give it a Fetid Odor , 17 Hueppe. The Methods of Bacteriological Investiga- tion 19 Huxley. The Anatomy of Invertebrated Animals. . . 20 The Anatomy of Vertebrated Animals 15 Hygiene, Physiologj-, and Anatomy, The Essentials of 42 Infancy, The Management of i In-Knee, Medical and Surgical Aspects of 34 Insanity, A Treatise on 38 Jaccoud. The Curability and Treatment of Pulmo- nary Phthisis 44 Johnson. The Chemistry of Common Life 12 Joints, Lectures on Orthopedic Surgery and Diseases of the 29 Jones. Practical Manual of Diseases of Women and Uterine Therapeutics 41 Journal, The New York Medical 36 Keyes. A Practical Treatise on the Surgical Dis- eases of the Genito-Urinary Organs 32 ■ The Tonic Treatment of Syphilis 12 Kingsley. A Treatise on Oral Deformities 16 Iiegg. On the Bile, Jaundice, and Biliotis Diseases . 17 Letterman. Medical Recollections of the Army of the Potomac 22 Life, Diseases of Modern 28 The Diseases of Sedentary and Advanced 46 Little. Mediciil and Surcic.nl Aspects of In-Knee. .. . 34 Loring. A Text-bonk of Ophthalmoscopy 46 f.usk. The .Science and Art of Midwifery 18 Luys. The Brain and its Functions 34 Mammary Gland, Tumors of the 13 Markoe. A J'reatise on Diseases of the Bones 24 Materia Medica and Therapeutics, Elements of 24 Treatise on 3 Matter, the Floating, of the Air, Essays on 25 Maudsley. Body and Mind 22 Responsibility in Mental Diseases 22 The Pathology of Mind 21 The Physiology of the Mind 23 McSherry. Health, and How to Promote it 22