O IIWARUS 3 
 
 HEALTH 
 SCIKHCF5 
 LIBnAitY 
 

PREPARATORY 
 
 AND AFTER TREATMENT 
 
 IN OPERATIVE CASES 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/preparatoryafterOOhaub 
 
PREPARATORY 
 
 AND AFTER TREATMENT 
 
 IN OPERATIVE CASES 
 
 BY 
 HERMAN A. HAUBOLD, M.D. 
 
 CLINICAL PROFESSOR IN SURGERY AND DEMONSTRATOR OF OPERATIVE 
 
 SURGERY, NEW YORK UNIVERSITY AND BELLEVUE HOSPITAL 
 
 MEDICAL COLLEGE, NEW YORK ; VISITING SURGEON 
 
 HARLEM AND NEW YORK RED CROSS 
 
 HOSPITALS, NEW YORK, ETC. 
 
 WITH FOUR HUNDRED AND TWENTY-NINE ILLUSTRATIONS 
 
 NEW YORK AND LONDON 
 
 D. APPLETON AND COMPANY 
 
 1910 
 
Copyright, 1910, by 
 D. APPLETON AND COMPANY 
 
 PRINTED AT THE APPLETON PRESS 
 NEW YORK, U. S. A. 
 
TO 
 PROFESSOR JOSEPH D. BRYANT, M.D., LL.D. 
 
 IN RECOGNITION OF THE DETERMINING 
 
 GUIDANCE EXTENDED, IN THE FIELD 
 
 OF WHICH THIS BOOK SPEAKS, TO 
 
 THE AUTHOR 
 
INTRODUCTION 
 
 The relationship between the physician — i.e., the general prac- 
 titioner- — and the surgeon has undergone a radical change within 
 the recollection of the writer. It is not so very long ago -that the 
 practitioner was permitted to stand meekly aside as the eminent 
 surgeon walked out of the patient's house, after pouring forth 
 great wisdom to the gaping family, and later act the part of a 
 human phonograph reiterating again and again the oracular state- 
 ments of the surgeon. 
 
 Since then the practitioner's early educational opportunities 
 have been much increased. He is better educated, better equipped 
 and occupies a position toward his patient and the surgeon which is 
 no longer as objectionable as obtained previously. However, there 
 is still room for improvement in this regard, and the writer feels 
 that the education given the practitioner as the outcome of methods 
 of teaching surgical technic is not such as to place him in the 
 precise position which is his due. 
 
 The writer canvassed the position as to just what the fallacy 
 in the relationship of the practitioner to the surgeon is, in the fol- 
 lowing way. A number of surgeons of ages ranging between thirty- 
 five and forty-five were asked, " How do you feel when a practi- 
 tioner calls you on the wire to do at once a celiotomy? Do you 
 feel that you can safely go with only instruments and suture mate- 
 rial and expect to find everything in proper shape for operation 
 even though the practitioner tells you everything will be ready ? " 
 
 The answer was invariably in the negative, except in those in- 
 stances where the surgeon had repeatedly done work for a given 
 practitioner. 
 
 Further discussion brought out that the surgeon felt that the 
 feeling of apprehension was qualified by these considerations ; that 
 if the practitioner had recently finished a term as interne on the 
 
viii INTRODUCTION 
 
 surgical service of a hospital, things were apt to be in reliable 
 shape ; if he had had a medical service they were not. If he had 
 been in practice for five years and had not had ample opportunity 
 to take part in surgical procedures he would also probably make 
 defective preparation. If he had been in general practice for ten 
 or more years it was believed that minute instructions were neces- 
 sary. As to the reliability of the after treatment in the hands of 
 the general practitioner, the belief seemed to be universal that, 
 while the physician was apt to be able to take good care of the gen- 
 eral indications as the outcome of his experience, the care of the 
 wound itself would call for more exact instructions. 
 
 As a rule, a practitioner is not in a position to control cases 
 of the kind which require major operations, during the first five 
 years of practice, for obvious reasons, and by the time his position 
 becomes such that he can, as the outcome of hard work in a general 
 practice, he has neglected to maintain familiarity with the tech- 
 nic of operative work. 
 
 It is the intention of the writer to furnish a work from which 
 the practitioner can draw information with regard to the handling 
 of a case to be operated upon from the time the decision to operate 
 is reached up to the making of the incision, and then take up the 
 case again from the time the operative technic is ended until 
 recovery is complete. 
 
 It is to be regretted that human nature leans toward unusual 
 and peculiar indulgences. If the science of healing has established 
 anything, it is proven that infection of operative wounds is due 
 to contamination. This is prevented by sterilization of the field 
 of operation and all that comes in contact with it, and by measures 
 which are firmly established and which universally achieve the 
 object. Yet one need only go into the operating rooms of a num- 
 ber of surgeons to see a frightened assistant being scolded by the 
 operator for not having taken the peculiar precaution which he 
 happens to favor in the technic of anti- or asepsis. This pecul- 
 iarity, the writer is free to say, is not infrequently the outcome 
 of a desire to pose beyond the measure of most men, and one which 
 it would be well to have the surgeon control. The fact is, that 
 
INTRODUCTION i x 
 
 the object is attained in many ways, each of which has its special 
 field of usefulness, and in this connection it is the vriter's desire 
 to be of aid to the surgeon in bringing out the applicability of cer- 
 tain methods under certain circumstances. For instance, towels, 
 etc., are certainly rendered absolutely sterile by heat, yet the same 
 object is obtained by immersing them in a solution of mercuric 
 bichlorid for a long time. It need not call forth a dissertation 
 on heat sterilization from the surgeon if he be called to operate 
 on a case where the conditions made heat sterilization less certain 
 than the use of wet bichlorid towels. Especially is this true if the 
 surgeon is called upon to operate under conditions where the neces- 
 sary apparatus is not available. The ingenuity of the practitioner 
 is here called into play, and this work is intended to aid him in 
 making efficient preparation, and show the surgeon how he can 
 obtain the desired result under the circumstances. 
 
 Again, while asepsis has replaced very largely antisepsis, the 
 writer believes that there are certain conditions which make more 
 desirable the use of antiseptic measures, an opinion in which he 
 does not stand alone. 
 
 In some instances the ultimate result of an operative effort 
 is marred by avoidable sequels. It is intended to include here 
 advice by which this may be avoided. 
 
 During the transitional stage following the more complete edu- 
 cation of the candidate for the practice of the healing art, a spirit 
 of commercialism crept into the profession. The practitioner felt 
 that he was acting the part of a feeder to the surgeon. The family 
 paid him a small fee for each visit during the time the diagnosis 
 was being made, and when informed that operation was necessary, 
 hoarded together their money to meet the cost of the operation. 
 In many instances the physician not only lost his case but was 
 ultimately permitted to carry out the end treatment at a nominal 
 pay, which in many instances was not forthcoming because the 
 funds of the patient had been exhausted in paying the surgeon. 
 The practitioner then took his patient to the surgeon, arranged 
 for the fee to be charged, but exacted that he bo given a certain 
 proportion of the fee in compensation for bringing the case. How 
 
X INTRODUCTION 
 
 far this percentage business has gone it is of course difficult to 
 say. However, the concealment of an infirmity never contributes 
 to its cure, and there can be no doubt that this sort of thing has 
 been and is constantly done. 
 
 Much of this is due to the fact that neither the practitioner 
 nor the patient have been properly educated in the matter. The 
 practitioner has not devoted much energy to keeping in touch with 
 modern methods of preparing patients for operation, and the 
 patient has not been taught to understand that the work connected 
 with or the services necessary in this regard is special work and 
 demands a special fee. More so is this true of the after treatment 
 of operative cases. The surgeon does his operation, takes the fee, 
 and the practitioner is compelled to carry out the after treatment 
 of the case at the usual rate of charge for a visit. Manifestly this 
 is not an equable arrangement, and it certainly stands in a causa- 
 tive relationshijD to the methods of handling the financial end of 
 the surgical proposition in a manner from which most men shrink, 
 even though it would appear that this was the only way of treating 
 the practitioner fairly. 
 
 In cases which do not need immediate operation the surgeon 
 not infrequently sends to the patient a nurse who is familiar with 
 the work necessary for the preparation of the patient, the operat- 
 ing room, and the apparatus necessary. In some instances the 
 surgeon sends an assistant who makes the necessary preparations. 
 Again the general practitioner is placed in an undesirable posi- 
 tion, and one which need not be. The general practitioner should 
 be in the position to attend to these matters himself, and thus 
 occupy the position toward the patient and the surgeon that he 
 should. 
 
 As far as the preparation is concerned of the patient, who suf- 
 fers from some complication requiring special preparation, the 
 work to be submitted here is intended to act as a guide, taking 
 up nephritis, diabetes, obesity, tuberculosis, etc., in connection with 
 contemplated operations. 
 
 If the patient and the family are made to understand that the 
 surgeon will operate, that his advice with regard to the preliminary 
 
INTRODUCTION XI 
 
 and after treatment is at the patient's disposition if required, but 
 that the real carrying out of the measures indicated are in the 
 hands of the practitioner, who is thus an integral part of the pro- 
 cedure, and that this work is entitled to special financial remunera- 
 tion, the problem of what part of the entire fee available shall go 
 to the surgeon is solved, and there need be no ignominy entailed 
 upon anyone. 
 
 If this work achieves nothing beyond placing the relationship 
 of the practitioner and the surgeon to each other and of both to- 
 ward the patient, on a more equable and proper basis, the writer 
 will feel that .a worthy object has been attained. 
 
 The writer acknowledges most gratefully the assistance given 
 him by Dr. John F. Connors, who has been concerned in much of 
 the work necessary to make this book. 
 
 The house staff of the Harlem Hospital of K^ew York, together 
 with the nurses engaged there, have been of signal service in pro- 
 curing the material depicted in many of the illustrations given. 
 Their kindly offices are herewith gratefully acknowledged. Mr. 
 I. Steinberg of this city gave valuable aid to the writer with 
 respect to the art of photography, which has been considerably 
 employed in the illustrations. This assistance is herewith 
 acknowledged. The writer also wishes to commend the publish- 
 ers for kindly assistance given, and thanks them for the skillful 
 execution of their portion of this work. 
 
CONTENTS 
 
 CHAPTER I 
 
 PAGES 
 
 General Considerations 1-37 
 
 Cases in which operations are not urgent, 1 ; Recording the his- 
 tory, 2; Office arrangement, 6; Bronchitis, 10; Pulmonary tubercu- 
 losis, 11; Tuberculosis of glands, bones and other parts, 12; 
 Nephritis, 13; Cardiac and arterial diseases, 15; Rheumatism and 
 gout, 18; Syphilis, 20; Hemophilia, 21; Alcohol, 23; Tobacco, 28; 
 Morphin, cocain, etc., 30; Obesity, 31; Diabetes, 33; Training of 
 tolerance for manipulation of cavities, 36. 
 
 CHAPTER II 
 
 Preparation of the Patient 38-55 
 
 The sick room, 38; The bed, 39; Catharsis, 41; General prepara- 
 tion of patient: Kocher's method, 42; Moynihan's method, 43; 
 Diet, 44; Preparation of the operative field in clean cases, 46; 
 Preparation of the operative field in infected cases, 51; Attire of 
 patient about to be removed to operating room, 53. 
 
 CHAPTER III 
 
 Sterilization and Preparation op Instruments and Dressings . 56-84 
 
 Sterilization of instruments, 56; General sterilization, 60; Steam 
 dressing sterilizers, 62; Requisites for a major operation, 66; 
 Gowns, 68; Caps, 68; Rubber gloves, 60; Soap. 69; Nail brushes, 
 69; Calcium chlorid, 70; Gauze pads, 70; Wipes, 72; Sterilized 
 cotton, 75; Gauze for dressings, 75; Iodoform gauze, 76; Balsam 
 of Peru gauze, 76; Combined dressing, 77; Many-tailed binder, 
 80; T-binder, 80; Cigarette drains, 80; Rubber tube drains, 80 
 Sterilized salt, 81; Sterile towels, 81; Self -retaining catheters, 81 
 Lubricating agents, 82; Bath thermometer. 82; Rectal tube, 82 
 Douche bags, 83; Celiotomy sheet, 84; Rubber sheets, 84; Vulvar 
 pads, 84. 
 
xiv CONTENTS 
 
 CHAPTER IV 
 
 PAGES 
 
 Suture and Ligature Material ....;... 85-103 
 
 Absorbable and non-absorbable ligature material, 85; Absorbable 
 ligature material: Catgut, 86; Plain catgut, 88; Heating of cat- 
 gut in fatty liquid, 89; Chroniieized catgut, 90; Iodin catgut, 95; 
 Kangaroo tendon, 96; Non-absorbable suture material; Silk-worm 
 gut, 97; Silk, 98; Pagenstecher thread, 100; Horsehair, 102; Silver 
 and gold wire, 102. 
 
 CHAPTER V 
 
 Water and Cleansing Solutions . ....... 104-123 
 
 Water: Sterilization of Avater, 104; Apparatus for sterilization 
 of water, 105; Outfit for sterilization, 110; Handling of water 
 during operations, 114; Antiseptic solutions — Carbolic acid, 117; 
 Mercury, 119; Zinc chlorid, etc., 120; Thiersch's fluid, 120; Peroxid 
 of hydrogen, 121; Plain sterile water, 121; Saline solution, 122. 
 
 CHAPTER VI 
 
 The Preparation of Operator and the Assistants .... 124-138 
 
 The operating suits, 125; Cleansing the hands, 126; Canton flannel 
 gloves, 132; Gowns, 132; Gloves during operations, 133; Caps and 
 masks, 136. 
 
 CHAPTER VII 
 
 The Operating Room 139-185 
 
 The hospital operating room, 139; Artificial illumination, 141 
 Operating table, 142; Dressing table, 146; Instrument table, 148 
 Narcotist's table, 148; Adjustable tray for instruments, 148 
 Surgeon's lavatory, 149; Utensil sterilizer, 151; Irrigation, 151 
 Arrangement of tables, etc., in operating room, 152; Dressing of 
 tables in operating room, 153; The operating table, 153; The 
 instrument table, 154; The anesthetist's table, 154; The adjust- 
 able instrument tray, 156; Dressing table, 158; Final prepara- 
 tion of patient. 160; Disposition of operator, assistants and 
 nurses during the operation, 169; The operating room in private 
 practice, 169; The operating table, 173; Portable operating table, 
 175; The extemporized operating table, 177; Sterile water, 180; 
 Suture and ligature material, 185. 
 
CONTENTS XV 
 
 CHAPTER VIII 
 
 PAGES 
 
 Drainage of Operative Wounds ........ 186-200 
 
 Drainage in uninfected eases, 187; Drainage in infected cases, 
 188; Drainage agents: Tube drainage, 189; Silk-worm gut drain- 
 age, 193; Catgut drainage, 194; Rubber tissue drainage, 195; 
 Textile fabric drainage, 196. 
 
 CHAPTER IX 
 
 Suturing of Operative Wounds 201-216 
 
 Needles, 203; Needle holders, 207; Suturing of wounds: The con- 
 tinuous suture, 211; The interrupted suture, 215; Harelip pins, 
 216. 
 
 CHAPTER X 
 
 The Dressing of Operative Wounds 217-226 
 
 Antiseptic powders, 217; Iodoform and its modifications, 220; Ap- 
 plication of powder, 220; The protective dressing, 221; Gauze for 
 dressings, 223. 
 
 CHAPTER XI 
 
 Shock and Secondary Hemorrhage following Operations . . 227-271 
 
 Shock following operations, 227; -Shock bed, 229; Treatment of 
 shock, 233; Hypodermic injections, 235; Mechanical pressure, 
 236; Transfusion, 237; The direct transfusion of blood, 238; The 
 suture method of blood-vessel anastomosis, 238; The cannula 
 method of blood-vessel anastomosis, 242; General management 
 of a transfusion, 246; The donor, 250; The recipient, 253; Infu- 
 sion, 259; Needling of artery, 263; Hypodermoclysis, 263; En- 
 teroclysis, 265; Secondary hemorrhage following operations, 267; 
 The Mikulicz tampon, 268; Removal of Mikulicz tampon, 268. 
 
 CHAPTER XII 
 
 Vomiting and Acute Dilatation of Stomach and Gut . . . 272-282 
 
 Postoperative vomiting, 272; Character of vomited matter, 276; 
 Acute dilatation of stomach* and gut, 277; Treatment, 282. 
 
 CHAPTER XIII 
 
 Thirst and Pain 283-287 
 
 Thirst, 283; Treatment of thirst, 283; Pain, 285. 
 
xvi CONTENTS 
 
 CHAPTER XIV 
 
 PAGES 
 
 Feeding after Operations 28S-297 
 
 Feeding by mouth, 288; Rectal feeding, 291; Formulae for rectal 
 feeding, 293. 
 
 CHAPTER XV 
 
 Care of Wounds after Operations 298-310 
 
 Time of changing dressings, 299; Preparation for change of dress- 
 ing, 300; Exposing the wound, 302; Removal of stitches, 304; 
 Cleansing and drainage of infected wounds, 305. 
 
 CHAPTER XVI 
 
 Operations on the Scalp, Skull and Brain 311-357 
 
 Operations on the scalp: Preparation of narcotist, 311; Prepara- 
 tion of scalp, 312; Care of wounds, 314; Operations on the 
 cranium, 316; Kroenlein construction, 316; Care of wounds of 
 cranial bones, 326; Operations involving cranial contents, 328; 
 Bone necrosis, 332; Secondary hemorrhage, 333; Retention of 
 cerebrospinal fluid, 335; Edema and softening of the brain sub- 
 stance, 336; Discharge of cerebrospinal fluid, 341; Brain pro- 
 lapse, 343; The retaining bandage, 348; Mastoid operations: The 
 simple operation, 352; The radical ojteration, 355; Results of 
 after-treatment, 355; Intracranial neurectomy, 356. 
 
 CHAPTER XVII 
 Operations on the Face . 358-372 
 
 Rhinoplasty, 364; Osteoplastic rhinoplasty, 366; Harelip and 
 cleft palate, 367; Miscellaneous operations in the mouth, 369. 
 
 CHAPTER XVIII 
 Operations on the Neck . . 373-394 
 
 Torticollis, 373; Tuberculosis of cervical lymph glands, 375; 
 Operations on the larynx and trachea: Intubation of the larynx, 
 378; Tracheotomy, 380; Laryngectomy, 383; Thyroidectomy — 
 The rise of temperature, 388; Pneumonia, 388; Tetany and chronic 
 myxedema, 389; Acute myxedema, 389; Chronic postoperative 
 myxedema, 389; Treatment of tetany and cachexia, 389; Exo- 
 thyropexy, 391 ; Drainage and packing of cysts of the thyroid, 
 391; Esophagotomy, 392; The care of the wound, 393. 
 
CONTENTS xvii 
 
 CHAPTER XIX 
 
 PAGES 
 
 Operations on the Thorax 395-415 
 
 Excision of the breast, 395; Thoracotomy — Simple incision, 399; 
 Aspiration with drainage, 401; Thoracoplasty, 406; Decortication 
 of the lung, 408; Resection of large surfaces of the thoracic wall, 
 408; The deformity, 413. 
 
 CHAPTER XX 
 
 Operations on the Spinal Column 416-421 
 
 Laminectomy, 416; Tuberculous osteomyelitis of the spine, 420. 
 
 CHAPTER XXI 
 
 Operations on the Abdomen ■ . . . 422-450 
 
 Celiotomy, 422; Special preparation of the gastro- intestinal canal, 
 424; Sterile diet, 430; Drainage, 433; Closure of abdominal 
 wound, 435; Drainage of superficial wound, 436; The protective 
 dressing, 436; The after-treatment following celiotomy, 439; 
 Thirst, 442; If vomiting persists, 442; Nephritis, 442; Retention 
 of urine, 443; The administration of opiates, 443; Catharsis after 
 celiotomy, 444; Tympanitis, 445; The administration of solid food, 
 446; The time of leaving the bed, 447; Removal of sutures, 448. 
 
 CHAPTER XXII 
 
 Operations on the Abdomen: Peritonitis following Celiotomy . 451-460 
 
 Prevention of peritonitis, 451; Flushing of the peritoneum, 455; 
 Treatment of peritonitis, 456; The Murphy treatment, 457. 
 
 CHAPTER XXIII 
 
 Operations on the Abdomen: Complications following Celiotomy . 461-480 
 
 Lung complications, 461; Parotitis, 465; Hematemesis, 470; Phle- 
 bitis and thrombosis, 470; Adhesions following celiotomy, 473; 
 Abdominal belts and supporters, 475. 
 
 CHAPTER XXIV 
 
 Operations on the Abdomen: Operations on the Stomach . . 481-493 
 
 Gastrostomy, 481; Gastroenterostomy, 487; Hemorrhage, 488; 
 Regurgitant vomiting, 489; Intestinal obstruction, 490; Ulcer of 
 the jejunum, 491; Diarrhea, 491; Gastrectomy, 491. 
 2 
 
Xviii CONTENTS 
 
 CHAPTER XXV 
 
 PAGES 
 
 Operations on the Abdomen: Operations on the Intestines . . 494-507 
 
 Enterectomy. etc., 494; The diet, 495; Catharsis, 495; Fecal fis- 
 tula, 496; Appendectomy, 496; Appendicostomy, 498; Colostomy, 
 499; Colostomy pad, 502; Colectomy, 505. 
 
 CBAPTER XXVI 
 
 Operations on the Abdomen: Operations on Liver and Female 
 
 Pelvic Organs 508-520 
 
 Hydatid cyst, 508; Hepatic abscess, 509; Resection of liver, 511; 
 Operations on the gall-bladder and biliary passages, 512; chole- 
 cystotomy, 513; Cholecystectomy, 515; Hepaticostomy, chole- 
 docotomy, chole and cholecystenterostomy, 515; Biliary fistula, 
 517; Transperitoneal operations on the uterus and.adnexa; Sal- 
 pyngectomy, 518; Ovariotomy, hysterectomy, hysteromyomec- 
 tomy, 519. 
 
 CHAPTER XXVII 
 
 Gynecological Operations by the Perineal Route .... 521-540 
 
 - Position of the patient, 521; Isolation of the operative field. 524; 
 Irrigation, 525; Care during convalescence, 526; The care of the 
 wound, 527; Vaginal drainage of pelvic abscess, 529; Vaginal 
 hysterectomy, 532; Fecal or urinary fistulse, 537; Cystitis, 537. 
 
 CHAPTER XXVIII 
 
 Operations on the Rectum and Anus ... ... 541-555 
 
 Operations on the rectum by the sacral route, 542; Operations 
 on the anus and rectum by the perineal route, 548; Fistula in 
 ano, 550; Removal of hemorrhoids, 552; Prolapse of rectum, 
 perineal proctectomy and excision of tumors from rectum, 554. 
 
 CHAPTER XXIX 
 
 Operations on Kidney and Ureter 556-565 
 
 Operations on the kidney, 556; Nephropexy, 557; Nephrotomy — 
 Renal colic, 560; Urinary fistula, 561; Nephrectomy — Uremia, 562; 
 Peritonitis, 563; Operations on the ureter — The position of the 
 patient, 564; Urinary fistula, 564; Grafting of ureter into bladder, 
 564. 
 
CONTENTS xix 
 
 CHAPTER XXX 
 
 PAGES 
 
 Operations on the Bladder and Prostate Gland .... 566-578 
 
 Operations on the bladder: Suprapubic cystotomy, 566; Tem- 
 porary suprapubic drainage, 567; Permanent suprapubic drainage 
 following cystotomy, 571; Perineal pi-ostatectomy: The prepara- 
 tion of the patient, 573; The position of the patient, 574; Drain- 
 age, 575; Cleansing of bladder, 577. 
 
 CHAPTER XXXI 
 
 Operations on the Scrotum and Penis 579-5J 
 
 Hydrocele, 579; Castration, 580; Varicocele, 580; Circumcision, 
 582; Plastic operations on the penis, 583; Urethrotomy for 
 stricture, 584. 
 
 CHAPTER XXXII 
 
 Operations on the Extremities . . 589-611 
 
 Dupuytren's contraction, 589; Hallux valgus, 591; Flat-foot, 593; 
 Club-foot, 597; Osteotomy, 600; Resection and excision of joints, 
 601; Amputations, 606. 
 
 CHAPTER XXXIII 
 
 Artificial Limbs . 612-629 
 
 Instep amputations, 616; Retracted heels, 618; Ankle-joint ampu- 
 tations, 619; Leg amputations, 621; Knee-bearing stumps, 623; 
 Thigh stumps, 625; Hip- joint amputations, 628; Amputations of 
 upper extremities, 628. 
 
 CHAPTER XXXIV 
 
 Miscellaneous Operations 630-639 
 
 Fracture of patella, 630; Union of fractured bones, 633; Nailing 
 the neck of the femur, 634; Skin-grafting, 636. 
 
 INDEX ....... 641-650 
 
LIST OF ILLUSTRATIONS 
 
 practice 
 
 1. Front view of history card . 
 
 2. Reverse side of history card . 
 
 3. History card for urinary examinations 
 
 4. History card for pathological report 
 
 5. Office equipment .... 
 
 6. Office equipment .... 
 
 7. Office equipment .... 
 
 8. A simple form of consulting and reception room. (Kelly.) 
 
 9. Arrangement of examining room separate from the consulting 
 
 (Kelly.) 
 
 10. Bed suitable for abdominal cases . 
 
 11. Bed suitable for head cases 
 
 12. Arrangement of bed in sick room in private 
 
 13. Kelly pads 
 
 14. Rubber sponge for cleansing skin . 
 
 15. Patient attired for conveyance to operating 
 
 16. Instrument sterilizer 
 
 17. Portable instrument sterilizer . 
 
 18. Glass tube with knives for steam sterilization 
 
 19. Single knife in glass tube for sterilization 
 
 20. Rack for holding knives for sterilization 
 
 21. Steam pressure sterilizer .... 
 
 22. Sectional view of steam pressure sterilizer 
 
 23. Gauze pad and wipes of two sizes . 
 
 24. Gauze for making wipe .... 
 
 25. Gauze folded once 
 
 26. Gauze folded twice 
 
 27. Gauze folded one-third length . 
 
 28. Gauze strip folded two-thirds of length . 
 
 29. Manner of holding gauze preliminary to invi 
 
 30. Manner of inverting folded gauze strip . 
 
 31. Gauze wipe completed. (Front view.) . 
 
 32. Gauze wipe completed. (Back view.) 
 
 33. Gauze roll 
 
 34. Gauze for packing in glass container 
 
 35. Making combined dressing 
 
 36. Transverse section of combined dressing 
 
 37. Many-tailed abdominal binder . 
 
 38. T-binder 
 
 39. Sterile rubber drainage tube in hermetically sealed glass tube 
 
 40. Concentrated salt solution in hermetically sealed glass tube 
 
 ertintr ed 
 
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XX11 
 
 LIST OF ILLUSTRATIONS 
 
 figiti 
 
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 tube 
 
 Lubricant in collapsible metal tube . 
 
 Bath thermometer 
 
 Soft rubber rectal tube 
 
 Celiotomy sheet 
 
 Vulvar pad . . . . . . 
 
 Catgut looped and ready for sterilization 
 
 Catgut wound on bobbin, ready for use . 
 
 Catgut coils in biniodid of mercury 
 
 Convenient arrangement of jars of catgut . 
 
 Apparatus for eumolizing catgut 
 
 Sterile catgut in hermetically sealed glass tube 
 
 Emergency sutures with needle in hermetically sealed 
 
 Kangaroo tendon in hermetically sealed glass tube 
 
 Silk-worm gut in hank . ' . 
 
 Iron-dyed silk-worm gut in glass tube . 
 
 Surgeons silk wound on cardboard . 
 
 Silk on spools. (Bryant.) .... 
 
 "Wide-mouthed bottle for ligatures. (Bryant. 
 Braided white silk in hermetically sealed glass tube 
 Twisted iron-dyed silk in hermetically sealed glass tube 
 
 Pagenstecher thread 
 
 Silver wire in hermetically sealed tube . 
 Apparatus for sterile water .... 
 Water sterilizer for emergency service . 
 .Apparatus for sterilizing and cooling water . 
 
 Sectional view of Fig. 65 
 
 Complete sterilizing plant assembled 
 
 Plan of sterilizing plant for use in hospital . 
 
 Combined water, dressing and instrument sterilizer 
 
 Convenient arrangement of pitchers for lavage 
 
 Method of handling sterile water . 
 
 Drawing sterile water without risk of contamina 
 
 "Wrong way to hold basin .... 
 
 Proper way of holding basin .... 
 
 Linen suit worn by surgeon .... 
 
 Table with material for cleansing hands . 
 Wash stand used for cleansing hands . 
 Immersion bowls ...... 
 
 Canton flannel gloves. (Bryant.) . 
 
 Hand and wrist covered with rubber glove . 
 
 Hand covered with rubber glove, forearm bandaged with sterile 
 
 Forearm covered with sleeve of gown . 
 
 Ends of fingers covered with rubber finger cots 
 
 Crile mask 
 
 Surgeon attired for operation .... 
 Attire of " sterile " nurse .... 
 Operating table showing appliances for raising up 
 
 " kidney " position ..... 
 Operating table showing appliances for lithotomy 
 Operating table arranged for Hartley position 
 
 per 
 
 position 
 
 do men or for 
 
 office 
 
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LIST OF ILLUSTRATIONS xxiii 
 
 FIGURE PAGE 
 
 90. Operating table in Trendelenburg position 146 
 
 91. Table for dressings * . . .147 
 
 92. Table for instruments 147 
 
 93. Narcotist's table 148 
 
 94. Adjustable instrument tray 149 
 
 95. Surgeon's lavatory 149 
 
 96. Operating room utensil sterilizer 150 
 
 97. Operating room irrigating apparatus 151 
 
 98. Diagram of arrangement of apparatus and assistants during a celi- 
 
 otomy operation. (Bryant.) 152 
 
 99. Tables, etc.. used in operating room 153 
 
 100. Operating table covered with pads 153 
 
 101. Instrument table covered with sterile towel 154 
 
 102. Instruments spread on sterile towel 155 
 
 103. Instruments ready for use 155 
 
 104. Table arranged with material for narcotist 156 
 
 105. Adjustable instrument tray covered with sterile pillow case . . 157 
 
 106. Adjustable instrument tray with sterile towel and instruments in 
 
 immediate use 157 
 
 107. Dressing table arranged for extensive operation 158 
 
 108. Dressings, etc., protected by sterile sheets 159 
 
 109. Table arranged with instruments and dressings suitable for small 
 
 sanatoria ............ 160 
 
 110. Carriage for transportation of patient to operating room, covered 
 
 with pad 161 
 
 111. Carriage covered with blanket and small pillow 161 
 
 112. Carriage with folded sheet over blanket 162 
 
 113. Patient placed on carriage " 162 
 
 114. Restraining sheet placed about patient 163 
 
 115. Patient completely prepared for narcosis 163 
 
 116. Surrounding parts of operative field covered with woolen blankets . 164 
 
 117. Woolen blankets protected from moisture with rubber sheets . . 165 
 
 118. Convenient arrangement of articles for final cleansing of skin . 166 
 
 119. Rubber sheets covered with sterile towels 167 
 
 120. Operative field isolated by celiotomy sheet 168 
 
 121. Side view of arrangement of celiotomy sheet 168 
 
 122. Sterile towels arranged in manner to surround operative field . . 169 
 
 123. Sterile towels applied to surroundings contiguous to operative field . 170 
 
 124. Prepared for operation. (Bryant.) 171 
 
 125. Squier's portable operating table showing Trendelenburg posture 
 
 and crank . . . . . 174 
 
 126. Method of folding Squier's portable operating table . . . .174 
 
 127. Squier's portable operating table folded for transportation . . 175 
 
 128. Squier's portable operating table arranged for lithotomy position . 176 
 
 129. Extemporized operating table. Kitchen table covered with blanket . 177 
 
 130. Extemporized operating table covered with blanket and rubber sheet 177 
 
 131. Small pillow and sheet on extemporized operating table . . . 178 
 
 132. Drainage pad on extemporized operating table 178 
 
 133. Kelly pad arranged on extemporized operating table to drain into 
 
 pail ... 179 
 
XXIV LIST OF ILLUSTRATIONS 
 
 FIGURE PAGE 
 
 134. Clamps and uprights for lithotomy position 179 
 
 135. Clamp and stirrup for extemporized table . 180 
 
 136. Portable operating and instrument table 180 
 
 137. Portable operating and instrument table folded for transportation . 181 
 
 138. Flask filled with water 182 
 
 139. Flask of sterile water with rubber tube connection for irrigation . 182 
 
 140. Glass bulb connection in rubber tube to control flow of irrigating 
 
 fluid 183 
 
 141. Flask used as irrigator . 184 
 
 142. Glass jar containing rubber drainage tubes 190 
 
 143. Rubber drainage tube fenestrated and safety pin attached . . 191 
 
 144. Rubber drainage tube in situ 192 
 
 145. Triplex rubber drainage tube 193 
 
 140. Transverse section of triplex rubber drainage tube .... 193 
 
 147. Silk-worm gut looped for drainage purposes 194 
 
 148. Silk-worm gut drain in situ 195 
 
 149. Catgut arranged for drainage 196 
 
 150. Catgut drain in situ 197 
 
 151. Glass jar for storing sterile rubber tissue 198 
 
 152. Rubber tissue rolled on itself for drainage purposes .... 198 
 
 153. Rubber tissue drain in situ 199 
 
 154. Cigarette drain 199 
 
 155. Cigarette drain in situ 200 
 
 156. Suture properly tied 201 
 
 157.. Suture improperly tied 202 
 
 158. Straight surgical needle. (Bryant.) 203 
 
 159. Half-curved surgical needle. (Bryant.) 203 
 
 160. Full-curved surgical needle. (Bryant.) 203 
 
 161. Straight Hagedorn needle. (Bryant.) 204 
 
 162. Half-curved Hagedorn needle. (Bryant.) 204 
 
 163. Full-curved Hagedorn needle. (Bryant.) 204 
 
 164. Needle wounds 204 
 
 165. Round needle for approximating serous surfaces. (Kelly.) . . 205 
 
 166. Coe's needle with handle 205 
 
 167. Hagedorn needle with Gentile handle 205 
 
 168. De Garmo's femoral needle 206 
 
 169. Hartley-Markoe needle holder. (Bryant.) 207 
 
 170. Sand's needle holder. (Bryant.) 208 
 
 171. Luer's needle holder. (Bryant.) 208 
 
 172. Halsted-Leur needle holder. (Bryant.) 208 
 
 173. Ermold needle holder 208 
 
 174. Kelly needle holder. (Kelly.) 209 
 
 175. Needle holder showing method of grasping round needle. (Kelly.) . 209 
 
 176. Continuous suture ready to be tied 210 
 
 177. Continuous suture completed and tied 211 
 
 178. Interrupted suture properly introduced and tied 211 
 
 179. Relaxation sutures or tension sutures 212 
 
 180. Tension sutures threaded on buttons 212 
 
 181. Tension sutures looped over pledgets of gauze 213 
 
 182. Method of introducing harelip pins. 213 
 
LIST OF ILLUSTRATIONS 
 
 XXV 
 
 fter 
 
 the operation 
 
 FIGURE 
 
 183. Suture material looped over harelip pins 
 
 184. Ends of harelip pins cut off . 
 
 185. Antiseptic powder sprinkler. (Bryant.) 
 
 186. Powder sprinkler used in operating room 
 
 187. Flat gauze applied immediately to wound 
 
 188. Fluffed gauze placed over flat gauze 
 
 189. Roll gauze applied over fluffed gauze . 
 
 190. Combined dressing applied over roll gauze 
 
 191. Shock bed with slip sheet and blocks . 
 
 192. Shock bed with foot-end elevated . 
 
 193. Shock bed completely prepared for patient 
 
 194. Bedside table with appliances used immediately a 
 
 195. Hypodermic syringes 
 
 190. Usual method of making hypodermic injections 
 
 197. A useful method of making a hypodermic injection 
 
 198. Crile's inflated rubber suit for treatment of shock. (Bryant.) . 
 
 199. Instruments used in performing a transfusion by end-to-end anas- 
 
 tomosis by the cannula method. (Crile.) . . . . . 
 
 200. Diagram of stages of end-to- end anastomosis of two blood vessels 
 
 by the suture method. (Crile.) 
 
 201. Diagram of stages of end-to-end anastomosis of two blood vessels 
 
 by the cannula method. (Crile.) ....... 
 
 202. Diagram of arrangement of operating room for transfusion. (Crile.) 
 
 203. A clinical transfusion in progress. (Crile.) 
 
 204. Opening the vein with scalpel. (Bryant.) 
 
 205. Instruments employed in the operation of infusion. (Bryant.) 
 
 206. Apparatus for infusion. (Bryant.) 
 
 207. Introducing the tube in infusion (Bryant.) 
 
 208. Hypodermoclysis 
 
 209. Administration of saline solution into rectum 
 
 210. Mikulicz tampon in situ 
 
 211. Mikulicz tampon . . . 
 
 212. Mikulicz tampon grasped with heavy hysterectomy forceps 
 
 213. Mikulicz tampon twisted, ready for removal 
 
 214. Postural treatment for acute dilatation of stomach and intestine . 
 
 215. Wales' soft rubber rectal bougie. (Tattle.) 
 
 216. Gaaze in contact with woand 
 
 217. Angular probe-pointed scissors 
 
 218. Removing sutures from wound ........ 
 
 219. Director introduced into wound in search of infective secretions 
 
 220. Method of cleansing an infected wound 
 
 221. Dressing forceps introduced through wound 
 
 222. Gauze drainage in situ . . . 
 
 223. Infected wound packed with gauze and sutures placed . 
 
 224. Method of isolating portion of scalp 
 
 225. Rubber tube, drainage of subaponeurotic space of scalp 
 
 226. Fissure of Sylvius and Rolando outlined with nitrate of silver. 
 
 (Krause.) 
 
 227. Kroenlein construction 
 
 228. Example of frontipetal type of brain. (Krause.) . 
 
 PAGE 
 
 214 
 215 
 220 
 221 
 222 
 223 
 225 
 225 
 230 
 230 
 231 
 232 
 235 
 235 
 236 
 236 
 
 239 
 
 241 
 
 244 
 247 
 249 
 259 
 260 
 261 
 262 
 265 
 266 
 269 
 269 
 270 
 270 
 281 
 294 
 302 
 304 
 304 
 305 
 306 
 307 
 308 
 309 
 313 
 315 
 
 317 
 318 
 
 320 
 
XXVI 
 
 LIST OF ILLUSTRATIONS 
 
 ebral 
 
 229. Example of occipitopetal type of brain. (Krause.) . 
 
 230. Location of the insula and lateral ventricles. (Krause.) 
 
 231. Area of cerebral softening. (Krause.) .... 
 
 232. Area of cerebral softening. (Krause.) 
 233 Cerebral prolapse 
 
 234. Same as Fig. 233 
 
 235. Adhesive plaster strips and gauze tapes for pressure on 
 
 prolapse ......... 
 
 236. Gauze pad applied to cerebral prolapse 
 
 237. Cerebral hernia. (Krause.) 
 
 238. Single roller bandage of the head. (Foote.) . 
 
 239. Single roller bandage of head completed. (Foote.) . 
 
 240. Double roller bandage of the head. (Foote.) 
 
 241. Double roller head bandage completed. (Foote.) . 
 
 242. Figure of eight bandage of the head. (Foote.) . 
 
 243. Skull cap for delirious patients 
 
 244. Applying aseptic cap, First step. (Gerster.) 
 
 245. Applying aseptic cap, Second step. (Gerster.) 
 
 246. Aseptic cap held in place with sterile gauze. (Gerster.) 
 
 247. Dressing for wounds of face. (Gerster.) 
 
 248. Bandaging upper portion of one side of face. (Foote.) 
 
 249. Syringe for cleansing nasopharynx .... 
 
 250. Dressing for face and neck operations. (Gerster.) 
 
 251. Janet-Frank syringe 
 
 252. Cleansing mouth after operation 
 
 253. Left torticollis, showing method of fixing head after 
 
 (Whitman.) 
 
 254. Manipulation of neck following operation for torticollis 
 
 Bergmann.) 
 
 255. Glisson's sling. (Von Bergmann.) 
 
 256. Dressing for extensive operations on neck . 
 
 257. Method of feeding infant after intubation . 
 
 258. Luer's double tracheotomy cannula. (Von Bergmann 
 
 259. Tracheotomy tube in place and position of patient after tr 
 
 otomy 
 
 260. Cannula used for convalescents after tracheotomy. (Von Bergmann 
 
 261. Porier cannula used after laryngectomy. (Von Bergmann.) 
 
 262. Gussenbauer's artificial larynx. (Bryant.) .... 
 
 263. Gluck's phonation apparatus in place. (Von Bergmann.) . 
 
 264. Record syringe 
 
 265. Appearance of wound after excision of breast. (Gerster.) . 
 
 266. Cuirass to hold dressing in place after removal of breast. 
 
 Bergmann.) 
 
 267. Method of drainage of pleural cavity after simple thoracotom 
 
 268. Wound with drainage tubes after thoracotomy. (Bryant.) 
 
 269. Bryant's aspiration apparatus. (Bryant.) . 
 
 270. Aspiration of pleural cavity. (Bryant.) 
 
 271. Aspiration of pleural cavity. (Bryant.) 
 
 272. Aspiration of pleural cavity. (Bryant.) 
 
 273. Aspiration of pleural cavity. (Bryant.) 
 
 oper 
 
 PAGE 
 
 321 
 
 325 
 
 338 
 
 , 339 
 
 , 343 
 
 tion. 
 
 (Von 
 
 ache- 
 
 Von 
 
 345 
 346 
 347 
 348 
 349 
 350 
 351 
 351 
 352 
 358 
 359 
 359 
 360 
 360 
 363 
 364 
 370 
 371 
 
 373 
 
 374 
 374 
 377 
 379 
 380 
 
 381 
 382 
 384 
 385 
 386 
 390 
 396 
 
 397 
 400 
 400 
 401 
 402 
 402 
 403 
 404 
 
LIST OF ILLUSTRATIONS xxvii 
 
 FIGURE PAGE 
 
 274. Appearance of chest following extensive resection of ribs. (Von 
 
 Bergmann.) 40D 
 
 275. Fell-O'Dwyer apparatus in action. (Bryant.) ..... 410 
 
 276. Forced respiration. Fell's improved apparatus. (Bryant.) . . 411 
 
 277. Tracheotomy tube and rings used in forced artificial respiration. 
 
 (Bryant.) 411 
 
 278. Deformity following extensive resection of ribs. (Von Bergmann.) 413 
 
 279. Retraction of flap following thoracoplasty. (Von Bergmann.) . . 414 
 
 280. Bulging of flap following thoracoplasty. (Von Bergmann.) . . 415 
 
 281. Gilbert and Domenici's diagram. (Moynihan.) 426 
 
 282. Harvey Cushing's diagram. (Moynihan.) 427 
 
 283. Vessel for sterile diet . . . 430 
 
 284. Arrangement for sterilizing food 431 
 
 285. Abdominal dressing held in place with adhesive strips and tapes . 437 
 
 286. Many-tailed abdominal binder in situ . . . . . . . . 438 
 
 287. Retaining bandage after celiotomy. (Bryant.) ..... 439 
 
 288. Acute dilatation of stomach. (Campbell Thomson.) .... 440 
 
 289. Method of restraining patient after operation 441 
 
 290. Granulating wound ready for secondary suturing 448 
 
 291. Granulating celiotomy wound approximated with adhesive plaster 
 
 strips 449 
 
 292. Patient in Fowler position being given the Murphy instillation into 
 
 rectum 459 
 
 293. Parotitis. (Rupert Bucknall.) . . 467 
 
 294. Parotitis. (Rupert Bucknall.) 468 
 
 295. Parotitis. (Rupert Bucknall.) 469 
 
 296. Method of strapping abdomen, Preliminary step. (Kemp.) . . 476 
 
 297. Method of strapping abdomen,- Second step. (Kemp.) .... 477 
 
 298. Method of strapping of abdomen, Final step. (Kemp.) . . . 478 
 
 299. Lines of measurement for abdominal belt 478 
 
 300. Abdominal supporter 479 
 
 301. Abdominal supporter in position 479 
 
 302. Abdominal supporter and corset combined 479 
 
 303. Adjusting lower segment of combined abdominal supporter and 
 
 corset 480 
 
 304. Adjusting upper segment of combined abdominal supporter and 
 
 corset 4S0 
 
 305. Tube leading into stomach following gastrostomy held in place . 482 
 
 306. Introduction of liquid nourishment through gastric fistula . . . 483 
 
 307. Soft rubber obturator for gastric fistula 484 
 
 308. Forcing macerated beef through gastric fistula 486 
 
 309. Moynihan's position after gastric operation 487 
 
 310. First step of colostomy. (Tuttle.) 500 
 
 311. Incision of protruding gut in colostomy. (Tuttle.) .... 501 
 
 312. Colostomy pad held in place ......... 502 
 
 313. Receptacle suitable for receiving feces from colostomy opening . 503 
 
 314. Emptying colon into receptacle 503 
 
 315. Cleansing colon through colostomy opening 504 
 
 316. Colostomy pad with abdominal belt 504 
 
 317. Colostomy pad and ring 505 
 
xxviil LIST OF ILLUSTRATIONS 
 
 FIGURE PAGE 
 
 318. Paul's tubes in situ. (Moynihan.) 506 
 
 319. Paul's tubes. (Moynihan.) 506 
 
 320. Sandbag in position for approach to biliary passages. (Moynihan.) 512 
 
 321. Drainage arrangement following cholecystotoniy 513 
 
 322. Angular soft rubber tube 514 
 
 323. Patient in Trendelenburg position 520 
 
 324. Position of patient for perineal operation 521 
 
 325. Clover's crutch. (Keyes.) 522 
 
 326. Adjustable leg-holders . . .522 
 
 327. Portable heel cups 523 
 
 328. Miller's sponge holder. (Kelly.) 523 
 
 329. Swedish hard rubber nozzle. (Kelly.) : 525 
 
 330. Curved volsella for holding cervix. (Kelly.) 529 
 
 331. Saw-toothed traction forceps. (Kelly.) 530 
 
 332. Bozeman's return flow irrigating tube 530 
 
 333. Uterine dressing forceps 531 
 
 334. Hysterectomy clamps rolled in gauze. (Kelly and Noble.) . . . 533 
 
 335. Vaginal vault after vaginal hysterectomy. (Kelly.) .... 536 
 
 336. Irrigation of bladder with two-way catheter. (Kelly.) . . . 538 
 
 337. Method of continuous irrigation of bladder. (Kelly.) . . . 539 
 
 338. Tuttle's pneumatic proctoscope. (Tuttle.) 541 
 
 339. Alligator forceps. (Tuttle.) 542 
 
 340. Appearance of wound after excision of rectum by sacral route. 
 
 (Tuttle.) 543 
 
 341. Appearance of artificial anus. (Tuttle.) 544 
 
 342. Kelly's set of instruments for treatment of wounds of rectum and 
 
 sigmoid. (Kelly.) 546 
 
 343. Knee-chest position. (Tuttle.) 548 
 
 344. T-bandage in situ. (Gerster.) 552 
 
 345. Kemp's tube 554 
 
 346. Cleansing rectum with Kemp tube 555 
 
 347. Patient postured for approach to kidney. (Von Bergmann.) . . 557 
 
 348. EdebohFs air cushion 557 
 
 349. Patient postured on air cushion for nephropexy. (Von Bergmann.) 558 
 
 350. Urinal for urinary fistula 562 
 
 351. Angular "double flow" soft catheter for suprapubic drainage of 
 
 bladder 567 
 
 352. Marion soft rubber apparatus for bladder drainage and cleansing . 568 
 
 353. Apparatus for drainage and cleansing bladder in situ .... 568 
 
 354. Mushroom retention catheter for drainage of bladder .... 569 
 
 355. Specially constructed stylet for introducing mushroom catheter . 569 
 
 356. Mushroom catheter drawn over stylet 570 
 
 357. Permanent suprapubic drainage tube. (Keyes.) 571 
 
 358. Front view of apparatus for permanent suprapubic drainage of blad- 
 
 der. (Keyes.) 572 
 
 359. Leg urinal used in conjunction with permanent suprapubic drainage 
 
 apparatus. (Keyes.) 572 
 
 360. Patient in exaggerated lithotomy position. (Bryant.) . . . 574 
 
 361. Chemise cannula. (Bryant.) 575 
 
 362. Chemise catheter. (Bryant.) 575 
 
LIST OF ILLUSTRATIONS xxix 
 
 363. Lateral drainage of bladder after crescentric approach to prostate 
 
 gland 576 
 
 364. Appearance of wound after incision for hydrocele. (Bryant.) . . 579 
 
 365. Infiltration of tunica, scrotum and penis following operation for 
 
 varicocele 581 
 
 366. Dressing after circumcision 582 
 
 367. Chetwood's two-way urethral nozzle. (Keyes.) 585 
 
 368. Chetwood's scissors shut off. (Keyes.) ....... 585 
 
 369. Chetwood's irrigator. (Keyes.) ........ 586 
 
 370. Chetwood's irrigator in use. (Keyes.) 586 
 
 371. Dupuytren's contraction. Splint for dressing. (Cheyne.) . . . 590 
 
 372. Lateral splint for holding toe after operation for hallux valgus. 
 
 (Foote.) 591 
 
 373. Hallux valgus. Diagram showing principle in making shoes. 
 
 (Cheyne.) 592 
 
 374. Piece of gauze arranged to obviate tendency to recurrence of hallux 
 
 valgus 593 
 
 375. Diagram to illustrate "toe-post." (Cheyne.) 593 
 
 376. Markedly rigid feet up in corrected position in circular gypsum 
 
 splints. (Foote.) 594 
 
 377. Whitman's spring for flat feet. (Cheyne.) 595 
 
 37S. Lateral and inferior view of Hoffa's foot plate for flat-foot. (Von 
 
 Bergmann.) 595 
 
 379. Boots for flat-foot. (Cheyne.) . 596 
 
 380. Manipulation to overcome recurrence of flat-foot after correction. 
 
 (Foote.) 597 
 
 381. Sayre's apparatus for use after tenotomy of tendo-Achillis. 
 
 (Cheyne.) . . 598 
 
 382. Boot for use after tenotomy of tendo-Achillis. (Cheyne.) . . 599 
 
 383. Apparatus for bow-legs. (Dennis.) 601 
 
 384. Suspended bracketed plaster-of-Paris splint. (Bryant.) . . . 604 
 
 385. Bracketed suspended plaster-of-Paris splint for excision of ankle 
 
 joint. (Bryant.) 604 
 
 3S6. Bracketed suspended plaster- of- Paris splint for excision of wrist 
 
 joint. (Bryant.) . 605 
 
 387. Open method of treating amputation wound 607 
 
 388. Amputation wound with interrupted sutures and tube drainage intro- 
 
 duced 609 
 
 389. Amputation wound dressed, stump on splint 609 
 
 390. Profile view of rubber foot 614 
 
 391. Spring mattress for rubber foot. 615 
 
 392. Position of rubber foot when walking 615 
 
 393. Position of rubber foot on inclined plane 616 
 
 394. Appliance for instep amputations 616 
 
 395. Appliance for instep amputations in place . . . . . .617 
 
 396. Appliance for instep amputations in use 617 
 
 397. Appliance for retracted heels following tarsal amputations . . 61S 
 
 398. Appliance for retracted heel following tarsal amputations in place . 618 
 
 399. Appliance with annular top for retracted heel following tarsal ampu- 
 
 tations 619 
 
XXX 
 
 LIST OF ILLUSTRATIONS 
 
 FIGURE « 
 
 400. Appliance with knee joint and thigh for tarsal amputations 
 
 401. Appliance for ankle-joint amputations . 
 
 402. Appliance for ankle-joint amputations in place . 
 
 403. Appliance for end-bearing stumps at ankle joint . 
 
 404. Appliance for tapering tibial stump 
 
 405. Appliance for tapering tibial stumps . 
 
 406. Appliance for short tibial stumps .... 
 
 407. Appliance for short tibial stump in place . 
 
 408. Mechanism of knee joint for short tibial stumps 
 
 409. Knee joint in place . 
 
 410. Mechanism of appliance in knee-bearing stumps . 
 
 411. Appliance for knee-bearing stumps . . • . 
 
 412. Appliance for knee -bearing stump, showing degree 
 
 tainable 
 
 413. Appliance for thigh stump. (Lateral view.) 
 
 414. Appliance for thigh stump. (Posterior view.) 
 
 415. Mechanism of knee joint in appliance for thigh stum 
 
 416. Appliance for thigh stump. Knee in full extension 
 
 417. Appliance for thigh stump. Knee in partial flexion 
 
 418. Appliance for thigh stump. Knee in full flexion 
 
 419. Appliance for hip amputation. (Anterior view.) 
 
 420. Appliance for hip amputation. (Posterior view 
 
 421. Appliance for hip amputation. (Lateral view. 
 
 422. Appliance for hip amputation. (Patient sitting 
 
 423. Appliance for amputation of hand 
 424.. Appliance for amputation of arm . 
 
 425. Lateral manipulation of patella 
 
 426. ParkhilPs screws in situ. (Bryant.) 
 
 427. Method of preparing rubber tissue for dressing wounds 
 
 428. Rubber tissue prepared for application to wound 
 
 429. Fenestrated rubber tissue applied to wound . 
 
 of flexion ob- 
 
 PAGE 
 
 619 
 620 
 620 
 621 
 621 
 621 
 622 
 622 
 623 
 623 
 623 
 624 
 
 624 
 625 
 625 
 626 
 626 
 627 
 627 
 627 
 627 
 627 
 628 
 628 
 629 
 632 
 633 
 637 
 638 
 638 
 
PREPARATORY AND AFTER TREATMENT 
 IN OPERATIVE CASES 
 
 CHAPTEE I 
 GENERAL CONSIDERATIONS 
 
 Cases in which operations are not urgent — Recording the history — Office ar- 
 rangement — Bronchitis — Pulmonary tuberculosis — Tuberculosis of glands, 
 bones, and other parts — Nephritis — Cardiac and arterial disease — Rheuma- 
 tism and gout — Syphilis — Hemophilia — Alcohol — Tobacco — Morphin, Co- 
 cain, etc. — Obesity — Diabetes — Training of Tolerance for Manipulation of 
 Cavities. 
 
 CASES IN WHICH OPERATIONS ARE NOT URGENT 
 
 The practitioner frequently sees cases presenting afflictions 
 which require operative procedure for relief, but in which the con- 
 dition will allow of previous systematic preparation. !STot infre- 
 quently a careful taking of the history and a detailed general 
 examination will discover complications which in no wise are 
 consequential to the condition from which relief is sought, and 
 which do not in any sense stand in a causative relationship to it. 
 
 If the operative measures are postponed until the coexisting 
 pathological condition is remedied, or at least modified, so as to 
 take from the surgical problem factors which may have a deter- 
 mining influence on the outcome of operative efforts at relief, the 
 mortality rate of major operations will be reduced, and the period 
 of postoperative disability much shortened. Also, patients may 
 escape postoperative complications which might not have obtained 
 had due consideration been shown the co-existing disease. 
 
 The conditions which are perhaps the most important factors 
 worthy of consideration in this connection are taken up under a 
 general head, as indicated in the .title of this chapter. 
 
 Surgical operations have become so common a procedure and 
 are now so universally employed for relief of affliction, that it is 
 not improbable that the viewpoint of the profession has produced 
 
 1 
 
2 GENERAL CONSIDERATIONS 
 
 a dilution of conservatism which is to be deprecated. It is cer- 
 tain that the measures submitted here are wise and useful, and 
 have been of signal service to those employing them. 
 
 RECORDING THE HISTORY 
 
 In well equipped institutions devoted to the care of the sick 
 and injured, a systematic history of each patient is taken and a 
 careful examination of the blood, urine, feces, etc., is made. 
 The results of these examinations, together with the history, 
 are recorded by the house staff, and as a rule form a valuable ad- 
 junct to the means at the disposition of the surgeon of arriving at 
 a conclusion as to the diagnosis, and aid much in determining 
 upon a method of surgical procedure indicated in a given case. 
 
 However, a patient admitted to an institution for the purpose 
 of seeking relief by operation is not infrequently in a mental 
 state which renders an accurate recital of the history a doubtful 
 matter, yet the patient would be very apt to recite the facts 
 more accurately to his physician, with whom he is likely to have 
 been on terms of more or less intimacy. 
 
 Patients who are to be subjected to operation in their homes, 
 or under conditions where the regime of a large hospital is not 
 available, are entirely in the hands of their medical advisers, and 
 the surgeon looks to them for full information as to the conditions 
 which may influence his own actions. 
 
 It is not a laborious undertaking to inscribe a history of the 
 case and file it in a convenient place for reference. The useful- 
 ness of such a measure will appear as the writer progresses with 
 this work, but it is perhaps proper to suggest here a simple method 
 by which the history of a case may be conveniently recorded and 
 be readily available when needed. 
 
 A convenient method of making records for office use and for 
 the purpose of guiding the surgeon is shown by the accompany- 
 ing illustrations. There are many cabinets for the filing of card 
 records in the market, purchasable at moderate cost. These cabi- 
 nets may be located in a convenient place and the cards filed alpha- 
 betically. The writer uses three cards, a white one (Figs. 1 and 
 2) upon which the general history is written, a yellow one for the 
 urine (Fig. 3), and a blue one (Fig. 4) for the pathological 
 
Name Smith, Anna - 0ata Jan. .2nd, 1908, 
 
 Residence JJ . 1 G-— -■ Str. 
 
 Age 46 Sex F. Cond. M. Nat. U. S. Occup. Housewife 
 
 Family Hist. Father died of apoplexy at. 45; mother died at 63, from 
 Bright's disease. 
 
 Ptev. Hist. Has had six children, the first at 21, the last at 36, all 
 normal labors. Nursed all the children. Menopause two 
 years ago. Had typhoid at 16, complicated by phlebitis of 
 .left thigh.. Has had severe attacks of headache for last 
 four years. Attacks last a day or two, then clear up. 
 Two months ago noticed a lump ia left breast, while bath- 
 ing. Lump was not painful, felt hard and was about the 
 size of an English walnut. When first noticed the lump 
 
 (Over) could be freely moved. Paid no attention to it. Since 
 
 (.IBRAAY BUREAU, A3S0B9 
 
 Fig. 1. — Front View of History Card with History. 
 
 then has noticed that skin became attached to the lump and 
 that it had increased to the size of goose-egg. Has not 
 lost flesh. Lump feels a little tender now. Examination 
 shows a mass as described in outer upper quadrant of left 
 breast. Nipple not retracted. Gland at outer edge of 
 pect. major enlarged. No other gland palpable. Re- 
 garded as malignant, probably scirrhus. Advised excision 
 of breast. 
 
 Jan. 12. Removed small section of mass. See' report. 
 Cephalic vein dilated, probably involvement of glands on 
 axillary sheath. 
 
 Fig. 2. — Reverse Side of History Card. History Continued. 
 3 o 
 
Name Smith, Anna. 
 
 , 
 
 
 
 Date 
 
 Jan. 
 
 3, 1908. 
 
 Quantity (24 hours) 43 oz . 
 
 
 
 Specific C 
 
 ravity 
 
 1010 
 
 
 Color Light amber 
 
 
 
 Reaction 
 
 Acid 
 
 
 Sediment S li ght floCCUlent 
 
 deposit. 
 
 
 
 
 
 
 Urea .021 gr. per c.c. 
 
 
 
 
 
 
 
 Indican Slight 
 
 
 
 
 
 
 
 Microscopic Examination A cons i derab l e number 
 
 of 
 
 granular 
 
 and 
 
 a few 
 
 hyaline 
 
 casts. 
 
 
 
 
 
 
 
 Albumin A small amount. 
 
 
 
 
 
 
 
 Suear Negative* 
 
 
 
 UBRAMv'auRtA* 
 
 »saos 
 
 
 
 Fig. 3. — History Card for Recording Result of Urinary Examination. 
 
 Name Smith, Anna 
 
 
 
 Date 
 
 Jan.. 
 
 4, 
 
 1908. 
 
 Pathological Report 
 
 
 
 
 
 
 
 (a) Blood Examination ShOWS 
 
 simple anemia* 
 
 
 
 
 
 
 (b) Miscellaneous Matter (Sputum 
 
 Transudations, Specimens, 
 
 etc.) 
 
 Specimen from tumor of 
 
 breast-— scirrhus carcinoma. 
 
 
 
 
 
 
 Fig. 4. — History Card for Record of Pathological Report. 
 4 
 
RECORDING THE HISTORY 5 
 
 record. The latter is an exceedingly useful one upon which may 
 be added the microscopical findings of neoplasms, exudates, etc. 
 On the reverse side of the blue card there is a place for a record 
 of autopsy. 
 
 The cards suitable for a certain size of cabinet are readily ob- 
 tained in the market, and may be printed either as indicated here 
 or in a manner best suited to the method of the practitioner. In 
 this way the effect of diet and medication is recorded, and when 
 the time for operation arrives much valuable data is available. 
 
 It would be too cumbersome and unwieldy, to say nothing of 
 the time used by a busy general practitioner, to expect that a 
 complete history will be kept of every case of bronchitis or con- 
 stipation which comes under observation. However, the plan 
 offered or a similar one should be used in cases which demand 
 operative relief, or in those which require repeated visits or ex- 
 aminations for the purpose of diagnosis. 
 
 For instance, the recording of the circumference of the neck 
 in a case of goitre and subsequent measurements made from time 
 to time will show the ratio of the increase in size of the growth 
 and thus the element of error in this regard is avoided. 
 
 Farther than this, a systematic method of recording the history 
 of cases tends to develop accuracy in the observation of details, 
 an exceedingly important factor in differential diagnoses. 
 
 The illustrations show memoranda which record the history of 
 a case of carcinoma of the breast, Figs. 1 and 2 (Fig. 2 is the 
 reverse side of Fig. 1) show little of value in the accessory history, 
 except perhaps that the father's death from apoplexy at the age 
 of 45 might be regarded as arousing suspicion of inherited syph- 
 ilis, this being, however, rendered negative by the fact that the 
 patient had six healthy children. The headache carries out an 
 accord with the urine analysis (Fig. 3). The fact that the 
 cephalic vein became dilated soon after the first examination of 
 the patient, would seem to justify the belief that considerable in- 
 volvement of the glands about the axillary vein had occurred in 
 the interim, which called for immediate, radical operative relief. 
 
 The urine analysis as reported (Fig. 3) is that of a small 
 granular kidney and suggests general arterial disease. It also 
 calls for the precautions taken up under these heads further on 
 (page 15). There was nothing in the patient's history beyond the 
 
6 GENERAL CONSIDERATIONS 
 
 headaches mentioned which might have suggested the existence of 
 nephritis, and indeed these might have been dne to many other 
 causes. However, the examination of the nrine established a rea- 
 sonable causative relationship. The bearing that discovery of the 
 conditions mentioned has on the kind of narcotic to be adminis- 
 tered at the operation, is also an important one. 
 
 The fact that nephritis exists would, too, determine the tech- 
 nic of the operation with the view of shortening the time over 
 which the surgical manipulations were carried, if this were con- 
 sistent with achieving the intent. 
 
 Fig. 4 shows the pathological report which, as already stated, 
 is recorded on a blue card to facilitate ready identification when 
 filed among a large number of histories. The blood examination 
 need not be recorded in detail. The conclusion from the exami- 
 nation may simply be recorded as shown in the illustration. The 
 simple anemia in this case shows that there may have been al- 
 ready some modification in general nutrition as the outcome of the 
 presence of the affliction, though the body weight is not reduced 
 and the appearance of the patient has not undergone any mani- 
 fest change. The report of the microscopical examination shows 
 the tumor to be a scirrhous carcinoma. In these cases the prog- 
 nosis, as a rule, is not necessarily unfavorable. However, balanc- 
 ing this against the fact that the cephalic vein is dilated and that 
 this means pressure on the axillary vein, the prognosis becomes 
 less favorable, on the ground that the glandular involvement is 
 probably considerable in extent and may have taken on a form of 
 carcinomatous proliferation, the character of which is more malig- 
 nant than that which obtained in the original focus of disease. 
 
 A complete history of this kind, though not carried out in 
 great detail, makes quite possible a rational conception of the 
 entire situation, and is invaluable to the attending physician, and 
 especially to the surgeon who may not have an opportunity to 
 elicit the facts thus furnished. 
 
 OFFICE ARRANGEMENT 
 
 The facility with which examinations are made and wounds 
 cared for, is not a little enhanced by the apparatus and elasticity 
 of its arrangement at the disposition of the practitioner. For the 
 
Fig. 5. — Office Equipment. 
 
 Fig. 6. — Office Equipment 
 
GENERAL CONSIDERATIONS 
 
 general practitioner a suitable arrangement of examining table, 
 instrument table, instrument closet, and chair is shown in Fig 5. 
 
 The appearance of the office is not altogether a question of 
 scenic effect. As a rule, the display of awe-inspiring white en- 
 ameled furnishings have an objectionable effect upon timid pa- 
 tients and the arrangement shown is less liable to provoke fear 
 than if the furnishings were those of the enameled steel variety. 
 
 However, it is to be borne in mind that in the examination of 
 genito-urinary cases and, indeed, in instances where lavage of sur- 
 faces or irrigation of cavities is necessary either as a part of an 
 examination or in the after-treatment of operative cases, the en- 
 ameled steel table with drainage is exceedingly valuable and is 
 easily kept clean. 
 
 The arrangement in Fig. 6 shows an enameled outfit, which, 
 however, is less desirable than the outfit shown in Fig. 7, which 
 
 Fig. 7. — Office Equipment. 
 
 permits of drainage during the lavage of the perineum, etc. Be- 
 tween the outfits shown in Figs. 5 and 6 there is not much choice, 
 except as far as the question of whether wooden or steel furnish- 
 ings are used, except that the enameled outfit gives the impression 
 
OFFICE ARRANGEMENT 
 
 9 
 
 of being more cleanly, which perhaps is only true as far as the 
 table is concerned. 
 
 Of these three outfits Fig. 5 is recommended for the office of 
 the general practitioner. Fig. 7 shows a more elaborate outfit 
 suitable for the surgeon's office. The Trendelenburg posture is 
 useful when small operations under local anesthesia are performed 
 in the office. 
 
 In each instance it is best to have the examining chamber 
 
 O o, 
 
 Con s ulting 
 
 Room 
 
 Kece pti on 
 
 O 
 
 Fig. 8. — A Simple form of Consulting 
 and Reception Room. The Examin- 
 ing table in the consulting room is 
 placed conveniently to the light, which 
 falls on the back of the operator 
 as he sits at the foot of the table; 
 this corner of the room is screened 
 off. (Kelly.) 
 
 Fig. 9. — Arrangement of Examining 
 Room Separated from the Consult- 
 ing Room. The patient arranges the 
 clothing behind the curtain indicated 
 by the wavy lines. (Kelly.) 
 
 separate from the consulting room if this be feasible. In the 
 event of this being impracticable, the outfit shown in Fig. 5 is 
 perhaps the least liable to arouse annoyance in the minds of timid 
 patients and will disturb less the symmetrical appearance of the 
 practitioner's office, especially if he be compelled to spend much 
 of his time there, using the chamber for other purposes. 
 
 Kelly suggests the arrangement of the practitioner's office as 
 shown in Figs. 8 and 9. The arrangement in Fig. 8 may be em- 
 
10 GENERAL CONSIDERATIONS 
 
 ployed when the available space is limited. A portion of the con- 
 sulting room is used for the purpose, and the outfit shown in Fig. 
 5 may be arranged as shown. A more elaborate arrangement is 
 shown in Fig. 9, including a reception room, a consulting room, 
 and a separate examining room. The toilet arrangements in the 
 examining room are placed at one end and behind curtains. The 
 outfit shown in Fig. 7 can advantageously be used with this ar- 
 rangement of space. 
 
 BRONCHITIS 
 
 Rollier considers the existence of bronchitis as a strongly pre- 
 disposing condition favoring postoperative broncho-pneumonia. 
 As the outcome of observation extending over many years he re- 
 gards the administration of creosotol of signal benefit. The drug 
 is given by mouth in doses reaching 1.00 mornings, and intro- 
 duced into the rectum together with peptonized milk in doses of 
 2.00 at night. 
 
 The habits of life of the patient should be regulated with a 
 view to overcoming the condition in the bronchi. If it be expe- 
 dient a sojourn in a dry climate for several weeks before the 
 operation should be indulged in. The excessive use of tobacco 
 should be controlled, and if feasible, smoking should be entirely 
 abstained from. During an attack of acute bronchitis, which may 
 be regarded as infective in origin, no operation involving the ad- 
 ministration of narcosis by the air passages should be undertaken. 
 
 In cases of chronic bronchitis, potassium iodid should be ad- 
 ministered for a week before the operation and stopped twenty- 
 four hours before beginning the narcosis, on the ground that the 
 agent increases the secretion of the respiratory mucosa, an unde- 
 sirable condition as regards the inhalation of narcotics. It is best 
 to furnish the patient with a saturated solution of potassium 
 iodid, of which he is instructed to drop five drops into a half 
 tumbler of water to be taken three times daily after eating. The 
 dose is increased three drops a day until slight iodism is produced. 
 If the time set for the operation arrives before iodism is estab- 
 lished the agent is withdrawn, as indicated above. If sharp iodism 
 occurs just before the time set for the operation, a postponement 
 of the surgical procedure for twenty-four hours is desirable. In 
 case iodism occurs a week before the operation, tbe drug is with- 
 
PULMONARY TUBERCULOSIS 11 
 
 drawn for a day and again administered in doses of half the 
 quantity taken at the time iodism occurred, and this dose is main- 
 tained to within twenty-four hours before the beginning of the 
 operation. 
 
 PULMONARY TUBERCULOSIS 
 
 Patients suffering from advanced pulmonary tuberculosis are 
 exceedingly unfavorable subjects for operation. However, per- 
 sons with a slight or moderate invasion of the lung by a tubercu- 
 lous process should not be deprived of the opportunity for relief 
 from afflictions susceptible of relief by surgical intervention. 
 
 The exhausting effect of malignant disease, or perchance uri- 
 nary calculus, should not be permitted to go on because of an exist- 
 ing pulmonary tuberculosis. It should be mentioned in this con- 
 nection that pulmonary tuberculosis of itself is not a necessarily 
 fatal disease, and that under proper care and management re- 
 covery takes place in a not inconsiderable number of cases. The 
 chief factor to bear in mind is that the addition of mixed infec- 
 tion is usually the determining causative factor productive of a 
 fatal outcome. In cases of lung tuberculosis where operation is 
 necessary, beyond the usual treatment of over feeding, additional 
 precautions should be taken to prevent the occurrence of an added 
 infection of the lung, chiefly of the class which is generally desig- 
 nated under the head of " Grippe." 
 
 Patients thus afflicted should be carefully protected from ex- 
 posures on the ground that additional tax upon the heat unit crea- 
 tors may be avoided. The indiscriminate employment of the so- 
 called fresh air treatment should be avoided. It is difficult to see 
 how placing a patient, suffering from pulmonary tuberculosis, on 
 a fire-escape and allowing the chill night air to extract his calorics, 
 is going to be of aid in combating the invasion of an exhausting 
 infection. It is probable that a well ventilated room is less apt 
 to be the habitat of pathogenic bacteria than one not so treated. 
 However, the general medical laws of reason and judgment must 
 not be disregarded in favor of a fad which, to say the least, is not 
 founded on generally accepted physiological facts. 
 
 There are two general factors which render patients suffering 
 from pulmonary tuberculosis unfavorable subjects for operation. 
 One is the exhausting effect of the operation itself and the other 
 
12 GENERAL CONSIDERATIONS 
 
 the pernicious effects which the administration of a narcotic by 
 the respiratory tract has directly upon the lung tissue. In a general 
 way, the latter is perhaps the more important determining factor. 
 
 With regard to the former, the patient should be fed along the 
 lines now so generally understood as to need no prolonged discus- 
 sion here. Eggs, milk, meat, and these in frequently repeated 
 doses, should be given. The over-feeding should be maintained 
 until within five hours of the operation and the starvation period 
 curtailed as much as possible. 
 
 Rectal feeding should be begun immediately after the opera- 
 tion, indeed before the patient leaves the operating table, and the 
 various measures destined to allow of early nourishing carefully 
 observed (page 287). 
 
 Creosote should be given by the mouth for a week or more be- 
 fore the operation, preferably in a keratin coated pill, to obviate 
 gastric disturbances, and the patient should be ordered to inhale 
 vaporized creosote for several hours daily with the view of ren- 
 dering less liable the occurrence of a complicating infection of the 
 lung, rather than because it is believed that these measures will 
 benefit the tuberculous process in the lung itself. 
 
 - Various forms of vaporizers are on the market, any one of 
 which will serve the purpose. In the event of none of these being 
 available, the creosote may be mixed with alcohol and dropped 
 on a sponge fastened in the apex of a tin funnel and then held 
 before the nose and mouth. 
 
 Too often does the surgeon see cases of latent pulmonary tuber- 
 culosis develop an acute exacerbation after a surgical operation, 
 which carries off the patient in a short time. How often this will 
 be avoided by taking the extra precautions here mentioned, it is, 
 of course, difficult to say. However, the physician who gets his 
 case ready for the surgeon might well consider the proposition 
 from this aspect and perhaps avoid unfavorable outcome as the 
 result. 
 
 TUBERCULOSIS OF GLANDS, BONES, AND OTHER PARTS 
 
 Tuberculosis of glands, bones, and other parts should be handled 
 along the same lines as indicated in connection with lung tuber- 
 culosis, though the added danger of the baneful effect of the nar- 
 
NEPHRITIS 13 
 
 cotic on the lung tissue does not enter as a factor here. The special 
 precautions to be taken with a view to rendering the surface of 
 the body asceptic when operation is undertaken for bone tubercu- 
 losis which has broken down, will be taken up with skin steriliza- 
 tion (page 51). 
 
 NEPHRITIS 
 
 Albuminuria does not necessarily mean kidney lesion. The 
 presence of casts may mean kidney disease, but the kind of kidney 
 disease and perhaps its extent are determined by a complete chem- 
 ical, quantitative, qualitative, and careful microscopical examina- 
 tion of the urine. It is not improbable that the evidence of the 
 clinical significance of kidney lesion is to an extent standardizable 
 by the condition of the heart, blood vessels, and the liver. The 
 simple presence of albumin in the urine does not call for especial 
 measures of treatment. 
 
 Kidney disease without manifest arterial and cardiac disease 
 calls for special precautions during the period of preparation for 
 operation. Alcohol should be absolutely avoided, bearing in mind, 
 however, the precautions in this regard taken up under alcohol 
 (page 23). It may be said here that the tendency toward radi- 
 calism in this connection is perhaps more justified than obtains 
 when nephritis does not exist.' The additional tax upon the kidney 
 parenchyma in eliminating alcohol seems to justify this. 
 
 The aim of the physician should be to render as light as pos- 
 sible the labor of the kidney, in the separation and elimination 
 of the end products of metabolism. It is generally believed that 
 the kidney is most largely concerned in eliminating the end prod- 
 ucts of proteid waste and digestion. The diet, therefore, should 
 contain the least quantity of organic nitrogenized constituents con- 
 sistent with the general health. Meats and eggs are to be avoided. 
 The proteids exist in most starchy foods, and probably in sufficient 
 quantity to avoid error in nutrition which might occur as the re- 
 sult of their entire withdrawal. A purely milk diet would be, 
 logically, of perhaps the most service in this connection, milk con- 
 taining comparatively small quantities of nitrogen. However, 
 some license should be given the patient and white chicken meat 
 and fish allowed once daily. 
 
 Large quantities of water should be partaken of. It is not 
 
14 GENERAL CONSIDERATIONS 
 
 improbable that the washing of the kidney in this way is service- 
 able, on the theory that the effort on the part of the cell lies along 
 the lines of converting an end product of metabolism from alkaline 
 medium into an acid excretion. It would seem probable that the 
 urea and other soluble constituents of the urine are mechanically 
 washed out of the kidney in this way. 
 
 The kidney, however, is not the only organ concerned in elimi- 
 nating the end products of metabolism. The skin and intestines 
 are important eliminating organs, and the labor of the kidney may 
 be greatly lightened by using these vicarious channels of elimina- 
 tion during the period of preparation for operation. The adminis- 
 tration of pilocarpine, steam baths, and the maintenance of the 
 body at a temperature at which the skin acts freely, are useful 
 measures. 
 
 Catharsis and colic lavage are to be used freely. The former 
 is perhaps well achieved by . the administration of sodium phos- 
 phate in hot water before breakfast, and the latter employed at 
 night, using a quart or more of normal saline solution for the pur- 
 pose. If the nephritis be a part of general arterial and cardiac 
 disease, a judicious mingling of the rules laid down in each par- 
 ticular class of cases is to be employed. The proteids should be 
 increased to lessen the work of the digestive organs and a daily 
 examination of the urine made to act as a guide for the variations 
 in amount of these articles of diet. Although this detail is some- 
 what laborious, it is well to bear in mind that the condition of the 
 patient at the time of the operation in this regard is an exceed- 
 ingly important and perhaps determining factor. The conserva- 
 tion of a diseased organ like the kidney may place it in a position 
 to take care of the end products of ferments entering the circula- 
 tion as the outcome of reparative process, and even in cases where 
 infection does not take place the presence or absence of these bodies 
 in the blood may be regarded as a predisposing factor toward 
 infection. 
 
 The physician should give the patient a written set of orders 
 each evening to govern the diet, amount of water to be taken, time 
 and length of steam bath, temperature of the room, and the char- 
 acter and quantity of clothing to be worn in the house and when 
 in the open air. 
 
 The conclusions in these regards, the physician arrives at as 
 
CARDIAC AND ARTERIAL DISEASES 15 
 
 the result of the analysis of the urine made that day, and the 
 variations in the quantitative analyses shown as the outcome of 
 the regime of the day before. It is true that persons afflicted 
 with kidney lesions would demur at this radicalism if it were 
 extended over a prolonged period of time, and perhaps, too, the 
 fact that diseased kidneys frequently seem to have no determin- 
 ing influence on the general health of patients would seem to 
 make the effort unnecessary. However, during the period of 
 preparation for operation, the writer regards the measures indi- 
 cated as essential and admonishes the physician to see to their 
 execution. 
 
 Again, the evident concern for the patient and the manifest 
 interest evinced by the practitioner in the effort for a successful 
 outcome of the operation, will place the physician in a more de- 
 sirable position both with the patient and his colleague, the surgeon. 
 
 It is not infrequently the experience of the surgeon to have 
 sent to him for immediate operation a case which has to be de- 
 layed while the preparations stated are made. This involves an 
 ignominy to the physician which should be avoided. 
 
 CARDIAC AND ARTERIAL DISEASES 
 
 These conditions are so closely allied and so frequently co- 
 exist that they may be considered together. 
 
 In preparing for operation patients who suffer from either 
 or both of these conditions, the aim of the attendant must be to 
 lessen the labor which these organs are called upon to perform, 
 rather than to attempt radical curative measures. Cardiac val- 
 vular disease with compensatory hypertrophy of heart muscle, the 
 outcome of previous endocarditis of rheumatic origin or the sequel 
 of an acute infectious disease, does not call for special measures 
 beyond resting the heart muscle as much as possible and giving 
 the patient a diet which will tax as little as is possible the cir- 
 culation during digestion. 
 
 The indiscriminate administration of cardiac stimulants such 
 as digitalis is to be avoided. The pulse rate during rest and after 
 exertion should be carefully noted, and efforts allowed within the 
 range indicated. 
 
 If there be compensatory hypertrophy, the heart should not be 
 
16 GENERAL CONSIDERATIONS 
 
 expected to do additional work during the period of preparation 
 for operation, though absolute confinement to bed might, on the 
 other hand, have a sufficiently depressing effect upon the patient 
 to over-balance the beneficial effect of the conservation of the vital 
 forces by absolute rest. 
 
 The handling of these cases requires some tact and consider- 
 able ingenuity. Most practitioners would regard systematic exer- 
 cise as a valuable aid in bringing the patient's general tone to its 
 most useful level. However, in cases of cardiac valvular disease 
 the form of exercise should be modified so as to stop short of 
 giving rise to dyspnea. 
 
 Many laymen have the notion that exercise in the form of 
 golf or horse-back riding, and the like, would be of service in 
 rendering them better fitted to withstand a severe strain of the 
 so-called vital forces. In most instances this is true, but if the 
 physician discovers a heart lesion during the preliminary exami- 
 nation it is his duty to acquaint the patient with the conditions 
 and advise modification of mode of life consistent with the facts 
 presented. 
 
 The taking of nourishment is influenced, both as regards quan- 
 tity and character by the mental state of the patient, and if it be 
 apparent that the restrictions with respect to exercise are the 
 cause of apprehension or mental depression, which interferes with 
 nutrition, a drive in the open air or a daily walk at the rate of two 
 miles an hour should be allowed, both of these to be so timed that 
 the usual meal is taken soon after a period of rest, which should 
 follow the exertion. Fifteen to thirty minutes of rest is sufficient 
 for the purpose. 
 
 Unnecessary exertion during digestion should be avoided. The 
 picture presented by the engorged lacteals and veins of the mesen- 
 tery concerned in extracting from the digestive tract the nutritive 
 constituents of articles of diet, during digestion, when animals 
 are subjected to celiotomy at this period, is a strong appeal in 
 favor of conserving the energies of the patient in this class of 
 cases. The circulation, of which the heart is the chief vis a tergo 
 should not be additionally taxed as the result of physical exertion 
 at this time. 
 
 It is perhaps proper, in this connection, to call attention to 
 the fact that the human animal is the only one which voluntarily 
 
CARDIAC AND ARTERIAL DISEASES 17 
 
 engages in physical exertion immediately after eating. All of the 
 lower animals repose during digestion, a teleological example it 
 would be w T ell for the physician to have his patient emulate, es- 
 pecially in instances where the circulatory organs have undergone 
 pathological changes. 
 
 In this class of cases, too, the diet should consist largely of 
 proteids, which leave comparatively little residue after the nutri- 
 tive constituents of articles of diet have been extracted from the 
 ingesta, and which do not severely tax the organs concerned in 
 furnishing the necessary ferments to the digestive tract, occupied 
 in converting into glucose the carbohydrates, or of emulsifying 
 the fats into readily absorbable form. 
 
 This, of course, does not apply to the class of cases in which 
 nephritis exists as a part of a general arterial disease. However, 
 the question of administering the proteids in cases of nephritis is 
 taken up under that head (page 13). 
 
 If the heart fiber be sufficiently impaired to justify the use of 
 artificial stimulation, a careful record of the medication adminis- 
 tered should be kept, and this should form the basis of the conduct 
 of the case during, and immediately after, the operation. Then, 
 too, the technic of the actual operation may be varied in order 
 to meet the indications during the procedure, if cognizance be taken 
 of the degree and character of stimulation employed in a given 
 case. For instance, a careful repair by sewing of the layers of 
 the broad ligament after pan-hysterectomy might be omitted as 
 a refinement in technic which is not essential to the consum- 
 mation of the intent of the operation, if the symptoms presented 
 by the patient indicate that the artificial tone of the heart fiber, 
 the outcome of stimulation, is giving evidence of feebleness. In- 
 deed, a knowledge of the exact conditions in this regard may de- 
 cide the surgeon's technic in a given case and cause him to abandon 
 the more complex method of procedure for one less desirable but 
 perhaps equally effective, as far as relief is concerned, when all the 
 conditions are taken into account. 
 
 A simple test with regard to the tone of the cardiac muscle 
 fiber is one suggested by Katzenstein. Both external iliac arteries 
 are compressed for from two to five minutes. The normal heart 
 does not accelerate its action under these conditions, but if there 
 be cardiac insufficiency the pulse rate becomes perceptibly in- 
 
18 GENERAL CONSIDERATIONS 
 
 creased. If the heart muscle is insufficient, the blood pressure 
 is lowered, if no insufficiency exists it rises. Kocher advises the 
 use of the Riva-Roeci apparatus to determine the blood pressure. 
 
 In cases of varicose condition of the veins of the lower extremi- 
 ties the danger of thrombi and embolism should be borne in mind. 
 An elastic stocking should be worn during the day and the legs 
 elevated while the patient assumes the recumbent position, meas- 
 ures which should be employed for several weeks before the 
 operation. 
 
 RHEUMATISM AND GOUT 
 
 Beyond the endocardial and endarterial changes caused by these 
 afflictions the employment of special measures is called for when 
 patients thus afflicted are about to be subjected to operation. The 
 reduction of resistance accompanying all operative procedures is 
 liable to precipitate an outburst of rheumatic inflammation of 
 the various serous membranes of the body. It is not uncommon 
 for persons afflicted with the so-called rheumatic or gouty diathesis 
 to have an attack of " rheumatic fever " immediately after a major 
 operation. 
 
 Persons afflicted in this way who are about to be subjected to 
 operation should be given much the same preparation as for nephri- 
 tis (page 13). Beyond this, the salicylates and colchicum should 
 be given for a week or more preceding the operation. A useful 
 method is to combine asperin in doses of ten grains with colchi- 
 cin, which are administered three times daily after eating. Of 
 course, a surgical operation during an acute attack of either 
 rheumatism or gout is only justifiable in the event of the occur- 
 rence of some grave condition which would justify the measure 
 despite the added dangers as the result of the complication. 
 
 In the subacute or latent forms of the diseases it is well to 
 combine small doses of iodid of potassium with the salicylates 
 and colchicum. The dose of iodid of potassium need not exceed 
 five grains three times daily. When the three agents are given 
 together they should be administered in solution, and well diluted, 
 perhaps best in an alkaline water and taken during digestion. 
 
 These precautions need not be limited to cases which present 
 more or less indefinite manifestations at the time the operation 
 is decided upon. If it appear in the history of the case that the 
 
RHEUMATISM AND GOUT 10 
 
 patient has had rheumatism or gout, and especially if he be past 
 the meridian of life, it is wise to take measures of safety. 
 
 The writer recalls a case of irreducible hernia which had be- 
 come inflamed. The patient, a man of fifty-five, was subjected 
 to herniotomy, which was successfully done. At the end of a week 
 meningitis developed, which, in view of the simultaneous involve- 
 ment of several of the joints, was regarded as of rheumatic origin. 
 Caffeine salycilate was given hypodermically, together with other 
 anti-rheumatic treatment, and the patient ultimately recovered. 
 Later it was ascertained that he had had two attacks of acute 
 articular rheumatism during the ten years before, and had had 
 various more or less indefinite manifestations since that time. It 
 has been the writer's custom to use the precautions referred to 
 in cases to be operated upon which present a rheumatic or gouty 
 history, and to follow the operation with an enema containing 
 a drachm of sodium salycilate, which may be combined very read- 
 ily with other nutritive or remedial agents indicated at the time 
 for other reasons. 
 
 In cases of this sort an endocarditis is an exceedingly menac- 
 ing complication and should be given due consideration in in- 
 stances in which cardiac symptoms are manifest, which are not 
 in accord with the other symptoms, which may be properly re- 
 garded as logically consequential to surgical trauma. This is also 
 true with respect to pleurisy. It is not uncommon to have patients 
 who have been subjected to operation develop pleurisy several days 
 after the operation. This has. been ascribed to exposure to cold, 
 the narcotic used, and various other causes. In a not inconsider- 
 able number of cases, close questioning will reveal a history of 
 a previous attack of rheumatism, and the diagnosis clears up. 
 
 In most instances, when the pain and dyspnea first appear, 
 the attendant immediately thinks of a septic embolus and sees 
 visions of suppurative pneumonia, empyema, general sepsis, and 
 death. Of course the examination of the blood and the absence 
 of the characteristic febrile movement of sepsis contribute much to 
 making clear the diagnosis. However, if it be known that the 
 patient has already had rheumatism, the case is more readily 
 treated and a reasonable assurance of recovery may be given. The 
 simultaneous involvement of the serosa of a joint or several joints 
 may lead to a correct conception of the condition presented, but this, 
 
20 GENERAL CONSIDERATIONS 
 
 too, may lead the attendant to arrive at the fallacious conclusion 
 that he is confronted with a case of general sepsis with pyemic 
 metastases. 
 
 SYPHILIS 
 
 During the more or less acute manifestations of the secondary 
 stage, or during the time of the presence of the lesion correspond- 
 ing to the port of entrance of the infection and the secondary 
 manifestation, may be regarded as a contra-indication to opera- 
 tion, unless the indication for measures of relief by surgical pro- 
 cedure are imperative and necessary to recovery. The double 
 reason for this lies in the fact that the surgical trauma would not 
 readily repair and, too, because of the danger of communicating 
 the disease to the operator and assistants. 
 
 If emergency arises during the periods of the disease men- 
 tioned the operation should be preceded by thoroughly mercu- 
 riarizing the patient immediately before and after the operation. 
 This is best done by intramuscular injections of mercury, either 
 gray oil ('Fournier) or some one of the preparations of mercuric 
 salicylate, bichlorid or cyanid now on the market. 
 
 The operator and assistants should take especial precautions 
 to avoid contamination and the operation be carried on under 
 antisepsis rather than asepsis. 
 
 Irrigation of the operative wound with bichlorid solution dur- 
 ing the procedure seems a rational indulgence, bearing in mind, 
 of course, that serous membranes are exceedingly subject to chem- 
 ical irritation and that solutions of moderate strength should be 
 used in the peritoneum and on joint surfaces. In wounds of the 
 extremities and, indeed, in bone trauma the tolerance for mercury 
 is considerable. If the case be one which gives a history of syphilis 
 of long standing and the operation be not imperatively indicated, 
 the administration of anti-syphilitic medication may be given by 
 the mouth, taking the precautions with regard to salivation and 
 gastro-intestinal disturbances usually employed. 
 
 It is not to be assumed that because a case has had no mani- 
 festations for several years that the problem may be disregarded. 
 On the contrary, cases of syphilis which have apparently com- 
 pletely recovered will burst out into distinct syphilitic manifesta- 
 tions a few days after operation. Theoretically it may be justifi- 
 
HEMOPHILIA 21 
 
 able to assume that the disease has been under control and that the 
 lessened resistance, which is the outcome of the operation, has 
 permitted of an outburst. The writer may, in this connection, 
 quote a case of a woman of twenty-eight who was subjected to 
 cholecystectomy for colelithaisis. On the third day after the 
 operation a widely spread skin lesion developed, which, after care- 
 ful inquiry respecting the husband's and her own history, was 
 determined to be syphilitic. The eruption cleared up very readily 
 under appropriate anti-syphilitic treatment, not until, however, a 
 small ulceration of the tongue appeared. The latter was scraped 
 and the presence of the spirochete, pallida demonstrated. 
 
 It has happened in the experience of most surgeons that 
 wounds which have shown no evidence of infection are sluggish, 
 do not heal, and the stitches cut through leave a pale open surface 
 but sparsely covered with flabby granulations. These cases, if they 
 be not tuberculous, will usually heal very readily if anti-syphilitic 
 medication be administered, and the attendant faces the annoy- 
 ance of the conviction that, had his patient been subjected to the 
 precautionary measures indicated, this might have been avoided. 
 
 Wounds which do not heal promptly and are regarded as re- 
 tarded by the syphilitic condition should be frequently cleansed 
 with solutions of corrosive sublimate, and after the lavage the 
 wound and contiguous skin dried, using ether for the purpose, 
 and the surface of the traumatised part covered with the ordinary 
 mercurial ointment. 
 
 At each dressing the residual ointment is removed with ether, 
 the wound lavaged with corrosive sublimate solution, and again 
 covered with the ointment. This should be repeated every two 
 days, and will be found to cause healing to take place quite rapidly. 
 
 HEMOPHILIA 
 
 Hemophilia is an affliction which is probably attended with 
 some abnormality in the structure of the blood vessels which ren- 
 ders them more liable to rupture, in addition to the absence, or at 
 least modification, of the so-called fibrin ferment in the blood. 
 
 If the peculiar diathesis be recognized before surgical trauma 
 is inflicted, early measures should be taken to increase the pa- 
 tient's general condition, with a view to improving the arterial 
 
22 GENERAL CONSIDERATIONS 
 
 tone. How much exercise and proper nourishment will contrib- 
 ute to this, it is, of course, difficult to say. However, an effort in 
 this direction should be made and a regime initiated with this in 
 view. Bleeders should never be subjected to operative procedure, 
 except when it would appear that the risks are justified in making 
 the effort, in view of the character of the affliction for which the 
 operation is undertaken. Considerable effort has been made to 
 modify the conditions by administering in these cases various sub- 
 stances, with a view to increasing the coagulability of the blood, 
 at least for a sufficient period of time to permit of operative work 
 and subsequent healing. Most of these, like ergot and lead ace- 
 tate, have proven of little value. 
 
 Thyroid extract seems to have been of considerable service. 
 Fuller and Taylor report successful results in operations on bleed- 
 ers in which this agent has been administered before and after 
 the operation. Taylor s work would seem to show that normal 
 blood is not influenced as regards coagulability by the extract, and 
 that it acts upon the blood of the bleeder which seems to be defi- 
 cient in so-called fibrin ferment. 
 . In suspected or recognized hemophilia, if feasible, the blood 
 should be tested and the time required for coagulation noted. The 
 extract is then administered in doses of from three to five grains 
 three times daily after eating, and at the end of forty-eight hours 
 the blood again tested, when a diminution of time required for 
 coagulation to take place should show an increased rapidity of 
 50 per cent. 
 
 The tests are cumbersome and difficult to manage. Taylor 
 used W 'right's method. 
 
 It is, of course, not feasible to subject cases of hemophilia to 
 the proper chemical test required to prove the efficiency of the 
 thyroid extract, in each instance, especially as the practitioner is 
 not in a position to make the necessary test, because of lack of 
 particular training in this department. However, it would seem 
 to be proper to administer the agent in cases of hemophilia, with- 
 out recourse to the test in a given instance, accepting, as indeed we 
 all do, the outcome of the investigations of reputable laboratory 
 workers. 
 
 Thyroid extract is liable to give rise to cardiac disturbances, 
 and the dosage should be regulated in accord with the manifesta- 
 
ALCOHOL 23 
 
 tions in this regard. The administration of the extract need not 
 extend over a longer period of time than is included in a week 
 before and a week after the operation. 
 
 In cases of jaundice and allied conditions which favor persist- 
 ence of bleeding following surgical trauma, the extract has been 
 found of service in controlling the hemorrhage. (See Obesity, 
 page 31). 
 
 Calcium Chlorid has been used for the purpose, eighty grains 
 being administered in divided doses daily for two days before the 
 operation. The Mayos have used this agent in cases of severe 
 jaundice. They do not regard the time tests of the coagulability 
 of the blood as reliable. 
 
 Gelatin. Hare recommends the administration of gelatin to 
 control the hemorrhage, using the following formula for the pur- 
 pose: 
 
 Gelatin 
 
 Sodii Chloric! aa 10.0 
 
 Aquae dest 1,000 c.c. 
 
 The mixture is sterilized by heat and 60 c.c. are injected into 
 the buttock. This is increased to 120 c.c. if repetition is necessary. 
 Usually two injections are used. Gelatin has been used more 
 largely to control oozing after operation. It might be rational to 
 use the thyroid extract as a preparatory measure, and, if oozing 
 occur after the operation the gelatin injections may be used. 
 Hare regards the mixture of use applied locally to check oozing. 
 
 ALCOHOL 
 
 There can be no doubt that from a scientific standpoint the 
 human animal is better off without the use of alcohol in any form. 
 It is also probably true that the moderate use of alcohol does no 
 great harm. It is exceedingly probable that the use of grape al- 
 cohol is less harmful than that of grain alcohol. It is, however, 
 also true that the vast majority of people use alcohol to varying 
 extent and in varying amounts. The physician is confronted by a 
 clinical fact. 
 
 It is not the purpose of the writer to enter into the discussion 
 of the place alcohol occupies in the treatment of wasting diseases 
 
24 GENERAL CONSIDERATIONS 
 
 or prolonged febrile movement, as a discussion of this sort does 
 not belong here. It is, however, proper that the matter be taken 
 up in its connection with the preparation of chronic alcoholics for 
 severe operations. 
 
 If Bunge is right that a normal individual weighing 140 
 pounds can oxidize two ounces of alcohol in twenty-four hours, 
 almost the entire human race may be regarded as chronic alco- 
 holics, for most men take more than two ounces of alcohol in the 
 day. Two ounces of alcohol is equivalent to four ounces of 
 brandy, and about the same or a little greater amount of whisky. 
 Most Americans take an ounce and a half of whisky at a drink. 
 If three drinks of whisky in the day be the basis of what may be 
 regarded as not excessive, one gets a pretty good standard for a 
 working basis. It is a simple matter to apply this to wines and 
 beers. Average amount of alcohol in brandy, 50 per cent. ; 
 whisky, 40 per cent. ; beer, 4 per cent. ; claret, 8 per cent. ; white 
 wine, 10 per cent. ; champagne, 10 per cent. 
 
 Given a man of forty-five or more who has habitually taken 
 a whisky and soda with his lunch, a cocktail or two before dinner 
 and a light wine with his dinner, and possibly the equivalent of 
 two drinks of whisky during the evening, one must regard him as 
 a chronic alcoholic, and he undoubtedly is. If this man is de- 
 prived of alcohol as a matter of policy he probably would not re- 
 gard himself subjected to great hardship, and, beyond a more or 
 less indefinite discomfort together with a certain irritability of 
 temper which he does not associate with the real cause, no symp- 
 toms would develop. But let the conditions arise making neces- 
 sary a severe surgical operation, and the symptoms arising from 
 the withdrawal of alcohol, added to the natural feeling of appre- 
 hension attendant upon the contemplation of a severe ordeal and 
 the withdrawal of alcohol, become a question of considerable 
 moment. 
 
 The physician has no right to act the part of the social re- 
 former in this class of cases. The mental state of a patient 
 about to be subjected to a severe surgical operation is at best a 
 much disturbed one. The symptoms attendant upon the with- 
 drawal of alcohol are closely allied to the natural state of mind 
 of the patient, i.e., irritability, insomnia, and apprehension out of 
 proportion to the conditions presented, and this should be avoided 
 
ALCOHOL 25 
 
 if feasible. It is wiser for the physician to take charge of the 
 administration of alcohol himself, adjusting the quantity and 
 character of the beverage to meet the indications. 
 
 It is not sufficient to lay down a general rule in this regard. 
 Inquiry should be made as to the patient's habits, and if he is 
 made to understand that the detail is entered into for scientific 
 reasons, and that no humiliation is involved to him, the occur- 
 rence of dangerous complications after operative procedure, the 
 outcome of deceit or false timidity may be avoided. 
 
 If there be sufficient time between the making of the diag- 
 nosis and the operation, an effort should be made to have the pa- 
 tient entirely free from the use of alcohol at the time of the oper- 
 ation, but if this be not feasible, as shown by the symptoms pre- 
 sented, alcohol should be given up to the day of the operation, 
 and if necessary introduced into the rectum together with other 
 remedial agents in a manner which will be taken up under the 
 head of rectal alimentation. 
 
 Patients possessed of naturally great firmness of character, 
 but who use alcohol as the result of congeniality, a part of a 
 metropolitan life, are apt to take it upon themselves to suddenly 
 stop the use of alcohol because of the general instructions given 
 by the physician that alcohol is inimical to health. This sacrifice 
 should not be blindly encouraged. The patient himself is not in 
 position to judge of the matter. 
 
 Careful inquiry should be made in this connection and the 
 patient advised just how much alcohol and in what form it 
 should be taken. The patient then considers the use of alcohol 
 as a medication, and its proper and physiological use will not be 
 regarded as intended to produce an artificial complacency during 
 a severe trial of fortitude, a proposition a well-balanced man is 
 likely to shrink from, perchance to his own detriment. In these 
 cases it is best to reduce the amount of alcohol to two ounces in 
 twenty-four hours and control the increase or decrease of dosage 
 as meets the indications. 
 
 If brandy or whisky is used it should be largely diluted. The 
 salts in vichy water and similar waters separate the small quan- 
 tity of resin in distilled beverages, and it is best to use carbonated 
 or still plain water as a diluent. In persons who use large quan- 
 tities of alcohol a more stringent policy should be pursued. 
 
26 GENERAL CONSIDERATIONS 
 
 It has been the experience of all surgeons to see delirium 
 tremens, and, indeed, meningitis alcoholica, develop after opera- 
 tion on patients whom the surgeon had had no idea were alcoholic. 
 Had this been taken into consideration and the case treated along 
 the lines stated above, this might have been avoided. Among 
 postoperative complications which are in no wise consequential 
 to the procedure, may be included pneumonitis and infection of 
 the superficial wound ; more rarely infection of the deep wound. 
 Both these may be regarded as the result of lessened resistance, 
 in part the outcome of the complete withdrawal of alcohol. 
 
 When a patient who consumes large quantities of alcohol is 
 about to be subjected to operative procedure he should be placed 
 under the care of a competent nurse for several days, and, if fea- 
 sible, for a week. Alcohol should be given as indicated above, and 
 this supplemented with the bromides and chloral at night and sys- 
 tematic exercise and bathing during the day. It should not re- 
 quire more than a week to reduce the quantity of alcohol neces- 
 sary to prevent manifestation dependent upon its withdrawal. 
 
 The diet should be light and nutritious, consisting mainly of 
 eggs, milk, lean meat, stale bread, and fresh vegetables. An exces- 
 sive amount of carbohydrates should be avoided on the ground 
 that the glycogenic function of the liver should not be severely 
 taxed, having been concerned in wrestling with the end product 
 of this class of substance for so long a period of time. All the 
 eliminatory organs should be used with a view to lessening the 
 burden of metabolism, the skin, the kidneys, and the intestinal 
 canal. This is readily accomplished by steam baths, massage, 
 the drinking of large quantities of water, and lavage of the colon. 
 
 In advising the use of these measures, the physician must 
 state to the patient the hour at which the steam bath is to be 
 taken, the quantity of water to be partaken of in twenty-four 
 hours, and the time at which the colic lavage should be made. 
 The time the patient is to be in the steam bath should be advised ; 
 the kind of steam bath also. 
 
 If it be convenient of course the public Turkish bath may be 
 used, but, if this be not feasible for any reason, one of the appa- 
 ratuses on the market may be employed in the patient's house. 
 
 It is probable that about fifty ounces of water should be taken, 
 beginning with a glass of hot water before breakfast. This should 
 
ALCOHOL 27 
 
 have a pinch of salt added to it. Most men are habituated to 
 emptying the bowel immediately after breakfast, and this time 
 should be devoted to the colic lavage. The steam bath, and sub- 
 sequent massage should be given at five o'clock in the afternoon, 
 preferably after the patient has taken a walk or drive in the open 
 air. He should be permitted to lie down for an hour after the 
 bath, but should not be encouraged to sleep, so that he might not 
 become wakeful after dinner. 
 
 The time could be well taken up with perusal of light and 
 amusing literature. After dinner it is best to allow the patient 
 to play cards or attend some place of amusement if the conditions 
 permit. Cheerful surroundings are a valuable adjunct in these 
 cases. If insomnia occurs recourse to hypnotics need not be 
 taken at once. If feasible, an attendant or member of the family 
 should stay in the room with the patient, and after he has retired 
 read to him or engage him in conversation on any subject other 
 than his health or the " curse of rum." Under no circumstances 
 should the patient be allowed to go to bed with the room darkened 
 and morgue-like silence maintained. The notion that the patient 
 can force himself to sleep is a fallacy. On the contrary, as soon 
 as it is manifest that the patient is restless and irritable, his at- 
 tention should be engaged in other matters and ultimately a hyp- 
 notic administered as a last resort, if these measures fail in their 
 purpose. 
 
 As to the mode of administration of alcohol, a light wine 
 taken with meals is of course the least harmful method of use. 
 However, much will depend upon the previous habits of the pa- 
 tient. It is a singular fact that grain alcohol drinkers have a 
 repugnance for grape alcohol, and if grape alcohol be given a 
 grain alcohol drinker, he will get its physiological effects and re- 
 gard himself as cured of his alcoholic appetite because he no 
 longer needs grain alcohol. All alcoholic beverages should be 
 given well diluted and during gastric digestion. 
 
 Alcohol should not be given before meals for obvious reasons, 
 but it is to be borne in mind that the aim in the class of cases 
 under consideration is to place the patient under the most favor- 
 able possible conditions to withstand a surgical operation, and if 
 the withholding of alcohol at times to which the patient is habitu- 
 ated is going to increase the symptoms related above, a fair com- 
 
28 GENERAL CONSIDERATIONS 
 
 promise would be to allow the administration of alcohol before 
 meals, well diluted and together with an " apertiff," like anchovy 
 or caviar. 
 
 If the operation becomes necessary before the patient is en- 
 tirely weaned from the use of alcohol, or if an operation becomes 
 imperative in a patient who is alcoholic, alcohol should not be 
 given by the mouth for five to six hours before the operation. In 
 these cases an enema consisting of eight ounces of peptonized 
 milk (cold process), forty grains of sodium bromid, and thirty 
 grains of chloral hydrate, together with two ounces of brandy, 
 should be administered two hours before the operation, and this 
 should be repeated three hours after the operation, the latter to 
 be again repeated in case vomiting be a marked after effect and 
 oral administration of alcohol thus made impossible. 
 
 The subsequent administration and dosage of alcohol are con- 
 trolled by the symptoms manifested later on. As a rule, alcohol 
 will not be indicated for more than three days after the opera- 
 tion, and indeed it is observed in hospital practice that patients 
 who were markedly alcoholic at the time of admission to the hos- 
 pital convalesce and recover without the need of alcohol, if the 
 the case has been rationally treated during the period of time 
 mentioned. 
 
 TOBACCO 
 
 Much of what has been said of alcohol may be applied to to- 
 bacco. While a discussion regarding alcohol is not strictly limit- 
 able to the male sex, it may be said that women, as a rule, are not 
 alcoholics and still less users of tobacco. It is, however, true that 
 most male adults use tobacco in some form. Most commonly the 
 tobacco is smoked. 
 
 Here, again, no discussion of the moral or pathological effect 
 of the use of tobacco will be entered into. It is sufficient to as- 
 sume that the patient smokes or uses tobacco, and to consider what 
 influence indulgence of the sort has on the mental and physical 
 condition of the patient in its bearing on an imminent operative 
 procedure. 
 
 It may be said that tobacco has a disturbing influence on the 
 circulation, giving rise to what is known as the tobacco heart. 
 Whether this is the outcome of an effect on the cardiac centers or 
 
TOBACCO 29 
 
 on the muscle fiber of the heart itself makes no difference as far 
 as its bearing in these cases is concerned. It is to be borne in 
 mind that withdrawal of tobacco is accompanied by tumultuous 
 heart action together with certain symptoms associated with func- 
 tional disturbances of the nervous system, such as restlessness, 
 apprehension, irritability, and insomnia, much the same group of 
 symptoms applying to alcohol. Here, again, the attendant must 
 exercise rational judgment in advising the patient, bearing in 
 mind that it is best to have the patient entirely free from the use 
 of tobacco at the time of the operation, but if this be not feasible 
 without great hardship to the patient, conservatism should be ex- 
 ercised and tobacco allowed in sufficient quantity to control the 
 symptoms. 
 
 A mild Turkish tobacco or a carefully " cured " American to- 
 bacco should be used. However, if the patient be habituated to 
 the flavor of Havana tobacco, and it appear that he craves for the 
 subduing effect of this particular brand, it should be allowed in 
 as moderate a quantity as possible. It is confusing to the surgeon 
 to standardize the import of pulse rate in patients who have the 
 tachycardia, which is the outcome of the sudden withdrawal of 
 tobacco, and this should be taken into consideration in arriving 
 at a conclusion as to the significance of circulatory disturbances 
 during operations, which may be fallaciously ascribed to impend- 
 ing shock or to overdose of narcotic. The anesthetist, too, would 
 have one disturbing factor removed if conversant with the con- 
 ditions in this regard. 
 
 During the after-treatment of a surgical case this is a consid- 
 eration of some import. More especially if there be a dispropor- 
 tion in pulse rate to number of respirations, and if the possibility 
 of this being the outcome of the withdrawal of tobacco be not taken 
 into account it might be erroneously considered as indicative of 
 infection. 
 
 During convalescence the bearing which the use of tobacco 
 may have on quick recovery is not a minor factor. There can be 
 no doubt that reaction from severe surgical operations is to some 
 extent, at least, influenced by the mental status of the patient, and 
 if a man of sixty who has had an amputation done for gangrene 
 of the leg is permitted to sit on a veranda and smoke, he will con- 
 valesce more rapidly, provided he has been habituated to the use 
 
30 GENERAL CONSIDERATIONS 
 
 of tobacco. It is difficult to see how smoking can possibly have 
 any effect upon the genesis of reparative processes, but if the 
 general wide principle be borne in mind that the elements from 
 which the cell makes its component parts are derived from the 
 ingesta which enters the gastro-intestinal canal, and that patients 
 will take more nourishment under the conditions mentioned, we 
 have the rationale of the proposition made clear. 
 
 MORPHIN, COCAIN, ETC. 
 
 Morphinism and the use of allied substances is not widely dis- 
 tributed, yet is sufficiently frequent a condition to be taken into 
 consideration. 
 
 Patients who use narcotics or anodynes are not good subjects 
 for operative manipulation. However, surgical interference at 
 times becomes necessary with this class of patients, and the condi- 
 tions must be given due consideration. The physician has here to 
 deal with a more grave and more distinctly determining compli- 
 cation than obtains with either alcohol or tobacco. 
 
 Patients habituated to the use of opium or other narcotics and 
 anodynes require prolonged treatment to effect a cure, and present 
 more acute symptoms when the drug is withdrawn than obtains 
 with the agents mentioned. 
 
 Much depends upon the quantity taken daily and the reason 
 for the indulgence. If the drug be taken to relieve pain, the re- 
 sult of the condition for which the operation is undertaken, the 
 drug need not be withdrawn and only controlled as to amount and 
 perhaps mode of administration, the relief of the affliction by the 
 operative measure, rendering permanent withdrawal of the drug 
 a comparatively easy method. If the patient use the drug simply 
 as the outcome of a perverted appetite, an effort should be made 
 to effect a cure before the operation. Although the writer feels 
 that efforts of this sort are crowned only rarely with definite and 
 lasting success. The patient should be confined under observation 
 and the dosage of the drug gradually reduced, and if possible the 
 patient should be entirely free from the use of the drug at the 
 time of the operation. If this be not feasible, sufficient of the 
 drug should be given to avoid the occurrence of confusing symp- 
 toms. If the operation be imperatively indicated and is under- 
 
OBESITY 31 
 
 taken before control of the habit is possible, the drug should be 
 given on the day of the operation and surely immediately after. 
 The writer had an unfortunate experience of this sort. The 
 patient, a lady of 55, was subjected to hysterectomy for uterine 
 fibroid complicated by tubal abscess. Not until she developed un- 
 favorable symptoms which were exceedingly confusing did the 
 patient's son make the attendants aware of the fact that the patient 
 had used large quantities of morphin daily. The drug was given 
 at once, but the patient died before the symptoms were controlled. 
 
 OBESITY 
 
 Operative technic involving remotely situated parts and or- 
 gans is made exceedingly difficult by the presence of an undue 
 amount of adipose tissue. Obese persons do not repair trauma 
 with the same promptness as obtains in those endowed with a nor- 
 mal amount of adipose tissue. Adipose tissue of necessity has less- 
 ened resistance to infection. In instances where operation is to 
 be undertaken at a more or less remote date an effort should be 
 made to reduce the amount of fat before the surgical measure of 
 relief is undertaken. In operations requiring celiotomy this is 
 an exceedingly important consideration, as fat persons have a 
 large amount of adipose tissue in the subperitoneal tissue and in 
 the omentum. 
 
 Most writers divide adiposity into two classes, the hereditary 
 and the acquired or dietetic kinds. The hereditary form of obesity 
 is rare. Its occurrence is explained on the theory that the cell 
 takes on a maternal or paternal impression and ultimately develops 
 that impression. Cases of so-called hereditary obesity are difficult 
 to manage and require prolonged and persistent treatment. The 
 regime for these cases is similar to that of acquired obesity. To 
 save repetition it will be taken up under that head. 
 
 Acquired obesity is absolutely and alone the outcome of ex- 
 cessive introduction of articles of diet into the digestive tract. 
 Tissue is not built up from the air. With this principle in mind, 
 firmly fixed and unswayed by the subterfuge of the patient, all 
 cases of obesity can be reduced in weight. The hardship to the 
 appetite and love of indulgence should be maintained during the 
 period devoted to the preparation of the patient for operation and 
 
32 GENERAL CONSIDERATIONS 
 
 lie be given the mental reservation that they may be indulged 
 again when the operation is over. This is not unlike promising 
 a child candy if he will eat meat first, but the method has its 
 redeeming features. 
 
 Carbohydrates contribute most largely to the accumulation of 
 fats in the body. However, large quantities of proteids will also 
 be converted into fats. This latter fact must be borne in mind, 
 and the patient must not be permitted to indulge himself up to 
 distention with proteids. 
 
 The presence of a lung or heart condition causing fatigue read- 
 ily, contributes to obesity by reducing the amount of work the 
 patient feels capable of doing. Exercise will reduce adipose tissue, 
 but if the exercise tend to overtax the heart it must be judiciously 
 employed. 
 
 On the whole, a diet such as is employed in diabetes is as use- 
 ful as any. (See Diabetes, page 34.) 
 
 All obese persons will lose weight on a diet consisting entirely 
 of lean meat and hot water. However, this is a rather severe 
 procedure and difficult to carry out. The practitioner need not 
 cling absolutely to the principle of the withdrawal of the carbo- 
 hydrates, if it be manifest that the patient's resistance is becoming 
 low. A small quantity of starchy food may be given, but it should 
 not be indulged in except to prevent the occurrence mentioned. 
 For instance, sugar may be allowed with coffee once daily and a 
 little stale bread allowed at dinner. Alcohol in all forms should 
 be avoided, most certainly malt liquors should be absolutely with- 
 held. 
 
 The fats and oils are perhaps less objectionable than the 
 starches, but as little of these as exist in butcher's meat may be 
 allowed. Butter should be avoided. This applies also to milk 
 and its preparations. 
 
 The market has been flooded with various nostrums exploited 
 as fat reducers. ]None of these have proven of value unless the 
 diet be modified at the same time. 
 
 Thyroid extract has been used with perhaps more success than 
 anything of similar nature. The extract is given in tablets of five 
 grains, three times daily, after eating. The patient should be 
 watched for circulatory disturbances during its administration — 
 i.e., rapid pulse, slight dyspnea, dizziness and faintness. When 
 
DIABETES 33 
 
 these symptoms occur administration of the agent should be dis- 
 continued. 
 
 In healthy persons who are obese as the outcome of indulgences 
 alone, the measures indicated are surely effective. Exercise is a 
 most valuable aid to the desired end. It is best to place the 
 patient in the hands of a skilled trainer, one who opposes the 
 patient's efforts and grades his resistance according to the capa- 
 bilities of the patient rather than let him employ apparatus. If 
 this be not feasible, the patient must be instructed just how far 
 he is to go with his work. 
 
 It is a somewhat ridiculous picture to see a man with a wob- 
 bling paunch running about a track grunting and groaning, with 
 two or three sweaters wrapped around him, taxing a sluggish heart 
 with a view to preparing himself for a surgical operation. On the 
 whole, the diet is the sheet anchor, and under no circumstances 
 must the attendant permit of any modification of regime beyond 
 the ones mentioned. 
 
 DIABETES 
 
 Diabetics, beyond taking very badly the narcotics by inhala- 
 tion, are unfavorable surgical subjects, as they do not readily re- 
 pair trauma. In diabetes of other than dietetic origin this may 
 be due to general arterial disease. 
 
 Purely dietetic diabetes, or at least glycosuria, is readily rem- 
 edied as regards the preparation of patients for operation. The 
 other forms, while not so certainly benefited by treatment, never- 
 theless become much more favorable subjects for operation if the 
 patient be subjected to dietetic regime for a period of several weeks 
 before the operation, and certainly will make more rapid repair 
 of the wound if the regime be maintained during convalescence. 
 
 In these cases it is not sufficient to inform the patient what 
 he may not eat, but a complete diet list should be furnished, stat- 
 ing exactly what he may partake of. If there be any doubt in 
 the patient's mind as to the propriety of his partaking of any 
 special dish, he need only be informed to consult his diet list, and 
 if the article in question be not listed it is not proper for him to 
 consume it. 
 
 The accompanying diet table is one which will be found to 
 meet the indications. 
 
34 GENERAL CONSIDERATIONS 
 
 DIET-TABLE 
 
 In the strict anti-diabetic diet, any and all articles not men- 
 tioned in this table are interdicted. This applies especially to 
 milk, which should never be used in any form. 
 
 BREAKFAST 
 
 Beefsteak — Beefsteak with fried Onions — Broiled Chicken 
 — Mutton or Lamb Chops — Kidneys, broiled, stewed, or deviled 
 — Tripe — Pig's Feet — Game — Ham — Bacon — Deviled Turkey or 
 Chicken — Sausage — Corned-beef Hash, without Potato — Minced 
 Beef, Turkey, Chicken, or Game, with poached Eggs. 
 
 All kinds of Fish — Fish-roe — Fish-balls, without Potato. 
 
 Eggs cooked in any way except with Flour or Sugar — Scram- 
 bled Eggs with chipped Smoked Beef — Picked salt Codfish with 
 Eggs — Omelets plain or with Ham, with Smoked Beef, Kidneys, 
 fine Herbs, Parsley, Truffles, or Mushrooms. 
 
 Radishes — Cucumbers — Water-cresses — Butter — Pot-cheese. 
 
 Tea or Coffee, with a little Cream and without Sugar. 
 
 Light red Wine for those who are in the habit of taking Wine 
 at Breakfast. 
 
 LUNCH 
 
 Chicken Salad, Lobster Salad (meat of the Claws only), or 
 any kind of Salad except Potato— Fish of all kinds, Chops, Steaks, 
 Ham, Tongue, Eggs, or any kind of Meat — Head-cheese. 
 
 Red Wine or dry Sherry. 
 
 DINNER 
 
 Soups — Consomme of Beef, of Veal, of Chicken, or of Turtle 
 ■ — Consomme with Okra — Ox-tail — Turtle — Terrapin, without the 
 Liver — Chowder, without Milk or Potatoes — Mock Turtle — Mul- 
 lagatawny — Tomato — Gombo filet. 
 
 Fish, etc.- — All kinds of Fish — Lobsters (meat of the Claws 
 only) — Terrapin, without the Liver. (No Sauces containing 
 Flour or Milk.)' 
 
 Relishes. — Pickles — Radishes — Celery — Sardines — Anchovies 
 — Olives. 
 
 Meats. — All kinds of Meat, cooked in any way except with 
 
DIABETES 35 
 
 Flour — all kinds of Poultry, without dressings containing Bread 
 or Flour — Calf's Head — Kidneys — Sweet-breads — Lamb-fries — 
 Ham — Tongue — all kinds of Game — Veal, Fowl, Sweet-breads, 
 etc., with Currie, but not thickened with Flour. (No Liver.) 
 
 Vegetables. — Truffles — Lettuce — Romaine — Chiccory — Endive 
 — Cucumbers — Spinach — Sorrel — Beet - tops — Cauliflower — Cab- 
 bage — Brussels Sprouts — Dandelions — Tomatoes — Radishes — 
 Oyster-plant — Celery — Onions — Water-cresses — Artichauts — 
 Jerusalem Artichokes — Parsley — Mushrooms — All kinds of 
 Herbs. 
 
 Substitutes for Sweets — Saccharine to sweeten coffee, tea, etc. 
 Wine-jelly, without Sugar — Gelee au Kirsch, without Sugar — 
 Gelee au Rhum, without Sugar — Gelee au Cafe, without Sugar — 
 Omelette au Rhum, without Sugar — Omelette a la Vanille, with- 
 out Sugar. 
 
 MISCELLANEOUS 
 
 Butter — Cheese of all kinds — Eggs cooked in all ways except 
 with Flour or Sugar — Sauces without Sugar, Milk, or Flour. 
 
 Almonds — Hazel-nuts — Walnuts. 
 
 Tea or Coffee with a little Cream and without Sugar. 
 
 Alcoholic Beverages. — Claret — Burgundy — Dry Sherry — (No 
 sweet Wines.) 
 
 PROHIBITED 
 
 Bread, Calce, etc., made with Flour — Milk — Sugar — Desserts 
 made with Flour or Sugar — Vegetables, except those mentioned 
 above — Sweet Fruits. 
 
 The dietetic regime should be assiduously carried out during 
 the repair of the wound. During convalescence the ultimate re- 
 covery, that is, return to vigor, may be delayed as the outcome of 
 rigid adherence to the ritual. In these instances a certain modi- 
 fication of the diet is permissible, careful watch being kept of the 
 presence of sugar in the urine, which may reappear or increase in 
 quantity as the result of the ingestion of carbohydrates. If none 
 appear with a diet to which moderate amounts of carbohydrates 
 are added, the diet may be constituted in this way for a consider- 
 able period of time, the urine being kept under espionage for the 
 purpose of developing the fact whether sugar is present or not. 
 
36 GENERAL CONSIDERATIONS 
 
 If a small quantity of sugar appear in the urine as the outcome 
 of dietetic license, this may be regarded as a minor matter com- 
 pared to the benefit derived from the administration of moderate 
 quantities of carbohydrates during recovery from a surgical opera- 
 tion. If the sugar is not made to disappear entirely from the 
 urine as the result of the diet, and the administration of a mode- 
 rate amount of carbohydrates in the diet be followed by a sharp 
 increase of glycosuria, it is best to maintain the anti-diabetic 
 regime with rigidity. 
 
 As already stated, the wound is slow to heal in cases of gly- 
 cosuria, and the immediate repair of the wound should provide 
 for drainage for this reason, with the view of removing secretions, 
 which, if retained, are likely to favor infection. 
 
 TRAINING OF TOLERANCE FOR MANIPULATION OF 
 
 CAVITIES 
 
 In a general way it may be said that patients who have been 
 subjected to manipulation in certain portions of the body are more 
 tractable to the measures which become necessary immediately 
 after operative procedure. For instance, a case of carcinoma of 
 the tongue which is to be subjected to excision will have to be 
 fed by means of a sterile stomach tube for some time after the 
 operation. 
 
 The postoperative vomiting and the presence of infective se- 
 cretions in the mouth require thorough cleansing of the cavity and 
 the introduction of food by tube. 
 
 The gagging and rebellion at the measure when first under- 
 taken, immediately or soon after the operation, are exhausting and 
 disturbing. In these cases it would be well to create a tolerance 
 for that sort of thing by educating the patient in this regard. The 
 mouth should be kept clean as a matter of course because of the 
 disease, and if the physician sees to it himself that the patient be- 
 come habituated to the procedure, it will be of considerable aid to 
 the attendant after the operation has been performed, in carrying 
 out the measures required at that time. So is it with regard to 
 feeding with the stomach tube. In all operations about the mouth 
 considerable blood secretions and solutions are swallowed by the 
 patient during the operation, and this should be removed by wash- 
 
TRAINING OF TOLERANCE FOR MANIPULATION OF CAVITIES 37 
 
 ing. In addition, if the patient be trained to assist in the intro- 
 duction of the stomach tube before the operation, the necessary 
 manipulation will be found much easier after the operation is 
 performed. 
 
 The same principle applies to the rectum, urethra, and vagina. 
 Conditions in these situations which necessitate operation usually 
 call for more or less prolonged after-treatment, and if the patient 
 be accustomed to manipulation the expediency of the after-treat- 
 ment will be much enhanced. 
 
 These form a factor of some importance, especially when the 
 operation is undertaken for conditions which have already severely 
 taxed the resistance of the patient. There is no doubt that primary 
 union or rapid repair will take place most readily if the nutrition 
 and general condition of the patient is at its highest possible level 
 during the period immediately following a severe operation. The 
 pain, annoyance, and apprehension attendant upon the first post- 
 operative manipulation may be avoided or at least considerably 
 lessened if the factors stated above be regarded. 
 
 This is best exemplified in children and women and applies 
 to a lesser extent to men. It also argues for the viewpoint from 
 which this book was written, that a large proportion of the neces- 
 sary work in surgical practice is advantageously taken up by the 
 general practitioner, whose relationship to the patient is such as 
 to warrant the expectation that the best possible ultimate results 
 will be obtained if this apparently unimportant element of the 
 problem be handled by him. 
 
CHAPTEE II 
 PREPARATION OF THE PATIENT 
 
 The sick room — The bed — Catharsis — General preparation of the patient — Diet 
 — Preparation of the operative field in clean cases — Preparation of the 
 operative field in infected cases — Attire of patient about to be removed 
 to operating room. 
 
 THE SICK ROOM 
 
 The sick room should be large and sunny, with a southern 
 exposure. It should be entirely emptied before being occupied 
 by the patient. This means that all pictures and ornaments are 
 to be removed, including hangings and curtains. The walls and 
 
 ceiling should be wiped with a solution of corrosive sublimate 
 (1-1,000) after the dust from mechanical cleansing has settled. 
 Dust screens, consisting of gauze fastened to the ordinary adjust- 
 able fly screens, should be placed in the windows. The window 
 38 
 
THE BED 
 
 39 
 
 shades should be removed, unrolled, wiped with corrosive subli- 
 mate solution, and replaced. All sewer connections, stationary 
 wash basins, etc., should be sealed. The pictures, etc., should not 
 be replaced, for if the patient becomes delirious they might pro- 
 voke illusions. 
 
 THE BED 
 
 The bed should be single, with freshly-aired linen and a rubber 
 sheet beneath the sheet. A plain iron bed is preferable for the 
 purpose, and this should be of the height from the floor, usually 
 used in hospitals (26 inches to the top of the fabric). (Fig. 10.) 
 
 Fig. 11. — Bed Suitable for Head Cases. 
 
 The illustration shows a bed with a rather high head-piece. This 
 is desirable in certain cases, especially when it is expedient after 
 the operation to raise the upper portion of the patient's body on 
 pillows, such as is the case following gastro-enterostomy. On the 
 other hand, the bed shown in Fig. 11 is more serviceable in cases 
 involving operations on the scalp and skull, the low head-piece 
 making these parts more readily accessible, in changing dressings, 
 etc. An ordinary iron bed may be raised on improvised wooden 
 stilts having a socket for the reception of the bedposts (Fig. 12). 
 
 This arrangement renders the patient more accessible to the 
 attendant and nurse. A desirable refinement which contributes 
 not a little to the facility with which the necessary manipulations 
 are performed. Also, the space under the bed is more readily 
 
40 
 
 PREPARATION OF THE PATIENT 
 
 kept clean, and the fact that this is visible prevents the placing 
 of bed pans or other objectionable apparatus under the bed. 
 
 If feasible, the bed should be so placed as to render both sides 
 of the patient readily accessible at the same time. This enables 
 the attendant to approach the patient from one side of the bed, 
 and the nurse to supply needed dressings, etc., from the other. 
 
 A serviceable arrangement of the sick room is shown in Fig. 12. 
 
 Fig. 12. — Arrangement of Bed and Sick Room in Private Practice. 
 
 The light comes into the chamber from two directions. The 
 patient utilizes that coining from behind the bed for reading, 
 and the light entering at the side is available for the purpose of 
 dressing the wound, scrutinizing the patient, etc. 
 
 When convalescence is established, various ornaments may be 
 placed in the room, and these replaced by others at intervals with 
 the view of interesting the patient. 
 
 Besides the bed, the room should contain a small oblong table 
 covered with a clean towel or folded sheet upon which dressings, 
 medicines, etc., for use of the nurse may be placed. Bed pans, 
 catheters, etc., should be placed in a convenient closet not within 
 sight of the patient. 
 
 The temperature of the room should be maintained at about 
 
CATHARSIS 41 
 
 70° F., and it should be ventilated thoroughly at least once a day, 
 taking care that the patient be protected from sudden changes of 
 temperature. 
 
 The room must be kept scrupulously clean during the after- 
 treatment. Dusting should be done with a damp cloth. The nurse 
 in charge of the case should take care of the cleansing of the room 
 herself, and this labor should not be turned over to domestics or 
 members of the patient's family. 
 
 The patient should be kept in bed for the entire day before 
 the operation and half the preceding day. 
 
 CATHARSIS 
 
 Thirty-six hours before the operation five grains of calomel 
 are administered. This is followed the next morning by half an 
 ounce of Sal Roehelle. At noon an enema of soap and water is 
 given and if regarded necessary, because of moderate action from 
 the measures already employed, the enema is repeated in the even- 
 ing. Subsequent to this no further disturbance of the contents 
 of the bowel is permitted, on the ground that a stool just before 
 an operation is objectionable for obvious reasons, among which 
 may be mentioned the fact that during the straining incident to 
 the primary stage of narcosis a stool may be discharged, render- 
 ing the precautions already mentioned negative. 
 
 Because of this possibility some surgeons do not administer a 
 cathartic for twice twenty-four hours before the operation. When 
 it is remembered that the gut is an exceedingly important elimina- 
 tive organ, and that decomposition of the end products of diges- 
 tion will take place at times in a few hours, and that the technic 
 of abdominal operations is not a little more difficult when distended 
 gut is persistently obtruded into the wound, the latter rule is per- 
 haps not as universally to be recommended as the former. Indeed, 
 the practitioner should in this regard, as in all other problems, 
 not cling to a hard and fast rule, but make use of the general prin- 
 ciple laid down and modify it to meet the immediate indications. 
 
 If the operation is to be performed in the morning the thirty- 
 six hour rule is a good one, but it is to be remembered that the 
 morning hour for operation is not always without objections, not 
 the least of which is the fact that the immediate preparation of 
 
42 PREPARATION OF THE PATIENT 
 
 all the paraphernalia necessary to a major operation consumes 
 much time, and that, as a rule, the assistants who do this work are, 
 for many causes incident to the common mode of life, apt to be 
 late at their posts and to hurriedly and perhaps more or less in- 
 differently perform their duties. It is not by any means uncom- 
 mon to find that the best interests of the patient are conserved by 
 a more leisurely preparation for the operating room during hours 
 most usually devoted to work by the vast majority of people. 
 
 If, then, the operation is to be performed in the afternoon, the 
 last enema should be given at 7 a.m. ; that is, beginning the morn- 
 ing of the day preceding the operation the calomel is given at 10 
 a.m., the saline at 3 p.m., the first enema at 8 p.m., and the last 
 cleansing enema at seven of the morning of the day of the opera- 
 tion, and the operation done at 2 o'clock or later in the day. 
 
 With this arrangement, the patient goes to bed at the usual 
 hour the night preceding the day before the operation and remains 
 in bed the next day and, indeed, until the time of operation. The 
 bath is, of course, given on the evening preceding the day before 
 the operation. 
 
 GENERAL PREPARATION OF PATIENT 
 
 Kocher insists that the patient be given a complete bath the 
 day before the operation. The bath is taken in a warm bath room, 
 and the patient liberally lathered with soap by an assistant. 
 Kocher regards mechanical cleansing as more effective than the 
 effort to neutralize infective material with antiseptics. The sur- 
 gical cleansing includes the scalp, hair, finger nails, mouth, 
 pharynx, and genitals. 
 
 He regards antiseptic applications as irritating and liable to 
 provoke eczema, and believes it is sufficient to wash the operation 
 field with ether and alcohol after it has been shaved and thor- 
 oughly cleansed with soap and water; this is to be followed by 
 an aseptic protective dressing. In the presence of skin disease, 
 however, antiseptics are to be employed. 
 
 Kocher also advises cleansing of mucous membranes which 
 are in communication with the air. The mouth and nose should 
 be cleansed. Tartar is removed from the teeth, preferably by the 
 dentist, this to be followed by thorough cleansing with soap and 
 
GENERAL PREPARATION OF PATIENT 43 
 
 water and lavage with a one-fourth per cent, carbolic acid solution. 
 Strong antiseptics in the mouth and nose give rise to hyperse- 
 cretion and do more harm than good. Nasal crusts are readily 
 removed with a solution of sodium bicarbonate (page 362). Plugs 
 of sebum are to be removed from the tonsil. 
 
 Moynihan has each patient furnished with a new tooth-brush 
 and a bottle of antiseptic mouth wash, and the nurse is instructed 
 to cleanse the mouth every two or three hours during the day. 
 Harvey Cushing has shown that by careful attention to cleansing 
 of the mouth, and by the sterilization of the food, the alimentary 
 canal may be rendered comparatively sterile. The import of the 
 latter proposition will be more extensively considered in connec- 
 tion with the preparation of patients for operations on the gastro- 
 intestinal canal (page 424). Parotiditis and aspiration pneu- 
 monia are both liable to occur from neglect of thorough cleansing 
 of the teeth and mouth. 
 
 The fact that absolute inactivity on the part of the patient 
 immediately after an operation is necessary for many reasons, 
 makes it difficult for the nurse to give attention to the care of the 
 hair. In female patients this is an important factor. The head 
 is to be shampooed the day before the operation, which may be 
 done at the time the bath is given. After thorough drying, an 
 ointment containing a small portion of sulphur should be rubbed 
 into the scalp. This will prevent the caking of excessive secretion 
 of sebum, especially should the patient be bedridden for a consid- 
 erable period of time after the operation. The hair is then braided 
 and fastened to the top of the head. If delirium occur, the pres- 
 ence of the hair on the back of the head is objectionable and a 
 source of annoyance as the patient tosses from side to side. 
 
 In male patients it is best to cut the hair quite short and rub 
 in the sulphur ointment. The beard should be trimmed close if 
 shaving is not permitted. The almost inevitable vomiting fol- 
 lowing operations soils the beard, and should cleansing be post- 
 poned as the outcome of the necessity of maintaining absolute 
 quiet for a considerable time, is a source of infection which should 
 be avoided. 
 
 The scalp encrusted with sebaceous secretion is an exceedingly 
 favorable " nahrboden " for bacteria, and it is not uncommon to 
 see a patient scratch the scalp and hold the finger nails charged 
 
44 PREPARATION OF THE PATIENT 
 
 with bacteria over the wound as the surgeon changes the dress- 
 ing. Patients will reach for the region of the surgical trauma 
 when painful manipulations take place, and though ordered to 
 " keep the hands away," usually disregard the admonition until 
 after the damage is done. 
 
 Incidentally it would be well for the surgeon to bear in mind 
 the necessity for a clean scalp, as it not infrequently happens that 
 sebum falls from the head to the wound as the surgeon is bending 
 over the patient changing a dressing. Indeed, hospital internes 
 serving with the writer are not permitted to wear a beard, and are 
 compelled to keep the hair of the scalp short. As a rule, this is 
 not a hardship to members of the house staff, as they are usually 
 at a time of life when a beard is not worn. However, it is respect- 
 fully suggested that surgeons do away with beards or at least wear 
 them closely trimmed. 
 
 DIET 
 
 It would seem most rational to administer to patients about 
 to be operated on a diet which will leave the least residue, require 
 the least possible effort in the process of digestion, and at the same 
 time not reduce the resistance of the patient. If the patient pre- 
 sents no complication, such as is taken up in the preceding chap- 
 ter, the matter is a simple one. These considerations have been 
 sufficiently discussed and do not call for reiteration here. 
 
 Unless specially contraindicated the meal taken thirty-six 
 hours before the operation may consist of all the three general 
 divisions of substances of diet, i.e., proteid, carbohydrate, and 
 fat. It is difficult to see why any hardship should evolve on the 
 patient in this respect, as this meal will undoubtedly be entirely 
 consumed by the next morning. If restriction be made at all the 
 patient is ordered to use only lean meat, and well hydrated carbo- 
 hydrates, i.e., a light dinner may be taken consisting of chicken, 
 a fresh vegetable, and toasted bread. 
 
 During the day before the operation, i.e., when the patient is 
 in bed, the diet should be more restricted. Much has been said 
 of the value of fluid forms of proteids of various kinds, yet it is 
 no doubt the opinion of most clinicians that none of these contain 
 the essential albuminoid or proteid necessary to the proper nour- 
 ishment of the human animal. None of the preparations on the 
 
DIET 45 
 
 market to-day are regarded by the writer as of genuine nutritive 
 value. They have a certain place, they please the sense of taste 
 perhaps, or render other substances less monotonous, yet they con- 
 sist very largely of the inorganic salts and certain flavors extracted 
 from meat fiber, and do not contain the necessary and eminently 
 essential proteid. 
 
 However, milk contains all the elements necessary to the main- 
 tenance of human life, and, indeed, in a readily assimilable form. 
 It has been proven again and again that adult life can be main- 
 tained indefinitely on a purely milk diet. Not alone is this true, 
 but the physical endurance of individuals who are subsisting en- 
 tirely on milk is as great as that of persons taking ordinary ar- 
 ticles of diet. 
 
 Milk is deficient in iron. However, for the purpose of prepar- 
 ing a patient for operation, this fact may be disregarded. It is 
 perhajDS true that the casein of milk causes fermentation in certain 
 individuals. This may be overcome by the addition to the milk 
 of lime water, or by peptonizing it. As a general rule, milk ob- 
 tained from a properly regulated dairy, properly handled, in a 
 manner now so widely understood, is as universally useful an ar- 
 ticle of diet as can be employed during the day immediately pre- 
 ceding an operation. The quantity should, according to the 
 weight of the patient, be between two and four quarts in the day, 
 but rarely less than the two quarts. Eggs, given raw or made into 
 a custard, may be allowed, and if the milk be given besides, the 
 quantity may be correspondingly reduced. 
 
 The writer warns against the indulgence in fads in this re- 
 gard. The starvation of patients for a day or two before an oper- 
 ation is absolutely unscientific and irrational. It is perfectly 
 easy to see that a patient about to be subjected to a severe strain 
 upon the vital forces is better able to withstand the trial if the 
 energies have been conserved by the proper administration of food, 
 which is, of course, the only source of energy there is. Whatever 
 objections there may be to a diet of milk and eggs as regards its 
 disturbing influence on digestion in certain cases need not be 
 considered in this connection. The patient will be in bed, under- 
 going preparation for an operation, and if he have some digestive 
 disturbance this may be readily neutralized by catharsis, etc., 
 which is, as already stated, a part of the preparation for opera- 
 
46 PREPARATION OF THE PATIENT 
 
 tion, and if, last of all, the digestion of milk and eggs be accom- 
 panied by distress, it is well for the patient to accept the situa- 
 tion for the period of time indicated, in order to achieve the bene- 
 fits of increased resistance, the outcome of the diet. 
 
 Of course no food whatever is given for six hours before the 
 operation. The last nutritive substance introduced into the 
 stomach may consist of properly prepared milk. 
 
 PREPARATION OF THE OPERATIVE FIELD IN CLEAN 
 
 CASES 
 
 It is quite impossible to sterilize absolutely the skin. This is 
 due to the fact that the hair follicles and ducts of the sebaceous 
 and sudoriperous glands are the habitat of bacteria and that these 
 cannot be removed or entirely destroyed. It is probable that great 
 activity of the skin, i.e., sweating, will mechanically remove bac- 
 teria from the location mentioned. This explains the rationale 
 of a warm bath before an operation. The perspiration is fertilized 
 as it passes along the ducts through the skin. If perspiration be 
 prolonged the sweat becomes quite sterile. However, the quantity 
 of excretion must be large before this is accomplished. 
 
 In this connection it is proper to say that rarely, if, indeed, 
 ever, is the technic of an operation achieved without contami- 
 nation of some kind. Infection is the outcome of fertilization. 
 Infection, at the same time, requires a certain dosage of fertiliza- 
 tion. The aim of the surgeon should, therefore, be to lessen, as 
 much as is possible, the dose of infective substance and thus ac- 
 complish an aseptic result. This justifies the elaborate prepara- 
 tion employed in properly conducted operating rooms. 
 
 Again, it is worthy of note that infection occurs more readily 
 in even the best equipped operating rooms than it does in private 
 residences where no case has ever before been subjected to opera- 
 tion. This should be explained by the facts stated above. 
 
 Infection, too, is rare where large quantities of fluids are used 
 in cleansing, provided the fluid is free from bacteria, i.e., the bac- 
 teria present in a given area will exhaust themselves in a sterile 
 media and die, if they have to fertilize an overwhelmingly large 
 sterile area. This is along the lines of the law of dilution and 
 sedimentation. A typhoid stool deposited fifty or sixty miles 
 
PREPARATION OF OPERATIVE FIELD IN CLEAN CASES 47 
 
 away from the place where water is used for drinking purposes 
 will be so diluted after the water has traveled the distance as to 
 do no harm, especially if the watershed be added to by tributaries 
 free from typhoid bacteria en route. 
 
 This principle should be borne in mind. Cleansing of the skin 
 has its physics as well as a chemistry and a physiology. As a gen- 
 eral rule, antiseptics must remain in contact with bacteria for a 
 long time in order to destroy them. It would be better to lavage 
 a given area of skin with several gallons of boiled water than to 
 sop on the area a small quantity of an aseptic solution, i.e., if the 
 contention expressed above is logical. 
 
 Bacteria are certainly more readily attacked in fluid sebum 
 than when they inhabit dry collections of sebaceous matter which 
 plug up the excretory passages of the skin. We have, then, the 
 epidermis, the excretory ducts, and the hair to consider as the 
 parts in which bacteria habitually reside. 
 
 The hair is removed by shaving. The excretory ducts are 
 opened by warmth and consequent perspiration, the epidermis is 
 softened with water and the residual sebum is saponified with 
 soap which is sufficiently alkaline to form a saponification with 
 the fat in the sebum, and is mechanically removed by liberal lav- 
 age with sterile water. 
 
 The problem is thus discussed rather at length, on the ground 
 that the laying down of hard and fast rules is not wise, for the 
 surgeon has not always available everything which would make 
 possible the carrying out of certain measures, and if the principle 
 here laid down is borne in mind, the desired result may be achieved 
 in many ways. Certain methods of skin cleansing will be here 
 stated, but they may be modified at will, provided the general prin- 
 ciple is adhered to. 
 
 Dry serum may be rendered fluid by oil. Therefore, the skin 
 to be sectioned may be gently anointed with olive oil which has 
 been boiled. This is left in contact with the skin for several 
 hours, and is applied immediately after the general bath. The 
 area is then thoroughly soaped and the hair shaven. 
 
 Shaving is an art. Aside from the pain and annoyance to the 
 patient consequent to the use of a dull razor, especially in un- 
 trained hands, the skin is likely to be scratched and the little raw 
 surfaces left are favorable places for the invasion of infection. 
 
48 PREPARATION OF THE PATIENT 
 
 JSTurses should be trained to shave properly. In male cases it is 
 best to have the part shaven by a barber if this be feasible. Fe- 
 male patients, as a rule, and occasionally male patients, object to 
 being shaved on portions of the body usually covered by the cloth- 
 ing. Frequently female nurses are diffident about attacking the 
 area with a razor. In these instances, if there be ample time for 
 preparation, it is perhaps justifiable to use a depilatory mixture. 
 The following formula has been compiled by Dr. W. E. Dreyfuss, 
 and is efficacious : 
 
 Barii sulphid parts 25 
 
 Saponis pulvis parts 5 
 
 Talci veneti pulv parts 35 
 
 Tritici farine parts 35 
 
 Benzaldehydi q. s. 
 
 Make teaspoonful of the powder into a paste with three teaspoon- 
 fuls of water, and apply to the parts with an ordinary shaving 
 brush in a moderately thick and even layer. After four to five 
 minutes the parts should be moistened with a sponge and after 
 another five minutes the hair can be removed by washing off the 
 mass. The part is then deluged with a large quantity of sterile 
 water of a temperature of 100° F. 
 
 For this purpose the patient is placed on a large-sized " Kelly 
 pad" (Fig. 13). The illustration shows three forms of Kelly 
 pads suitable for various purposes. A is a form very serviceable 
 in dressing abdominal wounds, the apron being carried over the 
 edge of the bed or table, and the cleansing fluid allowed to run 
 down on either side of the patient's body, being led into a proper 
 receptacle by means of the apron. B and C are similar in essential 
 respects, except that the apron of B may be hooked upon itself 
 and form a receptacle for the cleansing fluids. Both B and C are 
 largely employed in cases of operations and cleansing of wounds 
 with the patient in the lithotomy position. The pad rests under 
 the patient's buttocks, and the apron hangs over the end of the 
 table. The pad is made of rubber and the edge is furnished with 
 an air compartment which is blown up through the little metal 
 tube visible at the edge. The metal tube is supplied with a valve 
 which permits air to enter, but none to come out. This arrange- 
 ment prevents the cleansing fluids from wetting the bed. Next, a 
 
PREPARATION OF OPERATIVE FIELD IN CLEAN CASES 49 
 
 sterile pad is applied to the part, wet with sterile water, and left 
 in contact with the skin for several minutes. The water again 
 
 a b c 
 
 Fig. 13. — Kelly Pads. A, used for cleansing abdomen; B and C, used for cleans- 
 ing perineum with patient in lithotomy position. 
 
 should be warm, not hot, as hot water irritates, but warm enough 
 to aid in emptying the sweat ducts. It also softens the epidermis, 
 which is then more readily removed. After removing the wet pad 
 
 Fig. 14. — Rubber Sponge for Cleansing Skin. 
 
 the skin is thoroughly soaped with tincture of green soap, using a 
 piece of gauze or a rubber sponge (Fig. 14), not a brush. These 
 
50 PREPARATION OF THE PATIENT 
 
 sponges may be boiled, and they make a lather more readily than 
 gauze. The writer has seen the skin made to bleed by an over- 
 strenuous assistant, and has been compelled to postpone the open- 
 ing of a knee joint for this reason. The soaping should be gentle 
 and somewhat prolonged, causing a free lather, which is ultimately 
 displaced by a liberal lavage with sterile water. 
 
 Ether is next poured over the skin. The ether is used with the 
 view of removing the small portion of oil which still occupies the 
 excretory ducts. This is a useful measure when properly used, but 
 it is to be remembered that ether evaporates very rapidly, and if it 
 have in solution any oil, will leave the latter in contact with the 
 skin in the form of an exceedingly thin film, which is, of course, 
 not fluid because of the refrigeration from the ether ; thus the appli- 
 cation of ether may do more harm than good. 
 
 The application of ether to be eifective must be immediately 
 dislodged by a large quantity of sterile water at a temperature of 
 about 80° F., for ether boils at the temperature of the body and 
 may, when mixed with hot water, burn the dependent parts of the 
 body, especially if proper drainage be not provided for. 
 
 The part is now covered with a protective dressing, consisting 
 of a thick layer of sterile gauze, on top of which a layer of cotton 
 is placed, the latter being impervious to bacteria. The dressing is 
 held in place with appropriate binders or bandages. 
 
 The measures related above have proven effective in the hands 
 of the writer. However, if they be not feasible because of the 
 cumbersomeness of the manipulations, antiseptics may be used. 
 
 Moynihan has the skin cleansed with soap and water much in 
 the same way as is mentioned, using a wipe for the purpose. An 
 antiseptic compress is then applied and left for twenty-four hours. 
 The compress consists of two or three layers of lint soaked in 1 
 per cent, formalin, 1 in 60 carbolic', or 1 in 2,000 biniodid of 
 mercury solution. He prefers the former, believing a deeper pene- 
 tration of the skin and glands is obtained. In any event, the lat- 
 ter two solutions are quite apt to irritate. There can be no objec- 
 tion to this method if it be supplemented with large quantities of 
 sterile lavage. At the end of twenty-four hours a second washing 
 is performed and a second compress applied. Moynilian does not 
 insist upon the second washing, as it is a trifle trying to a delicate 
 skin. 
 
PREPARATION OF OPERATIVE FIELD IN INFECTED CASES 51 
 
 Whatever method is used, the case should be cleansed again 
 upon the operating table. It would seem that as a general rule 
 the second washing may be omitted. If there should be any small 
 furuncles or cracks in the skin, they should be rendered sterile 
 with pure carbolic acid. The acid is applied with a cotton daub 
 twisted on the end of a probe and the acid neutralized with alcohol 
 at the end of a few moments. The actual cautery may be em- 
 ployed for the purpose. 
 
 PREPARATION OF THE OPERATIVE FIELD IN INFECTED 
 
 CASES 
 
 Operation on patients who present infection require slightly 
 different preparation. 
 
 The general principle is that of antisepsis rather than asepsis. 
 If infection exists, it means that the character of the fertilization 
 is such as to have overcome resistance, and it is probable that the 
 method of sterilization of the field of operation effective in clean 
 cases requires additional chemical aid. 
 
 That it is feasible to obtain aseptic repair of the skin in the 
 presence of infection is proven by the fact that operations per- 
 formed within an area of erysipelas have given this result. These 
 operations in the hands of the writer have been undertaken under 
 antisepsis. It is not improbable that the incision within the zone 
 of erysipelatous inflammation and the liberal lavage with corro- 
 sive sublimate solution has a beneficial effect upon the erysipelas 
 itself, a conclusion which is justified on the ground that the in- 
 fected tissue was made more accessible to the direct contact with 
 the antiseptic. 
 
 Indeed, the writer has attacked the mastoid cells, the lateral 
 sinus and the internal jugular vein through an erysipelatous zone 
 with favorable outcome. Maylard has removed sequestra from 
 long bones in cases where sinuses existed, both in tuberculous osteo- 
 myelitis with mixed suppurative infection, and in suppurative 
 osteomyelitis of long standing with aseptic healing. In these cases 
 microscopical examinations of scrapings of the epidermis contigu- 
 ous to the sinuses and of small portions of skin excised from the 
 region of the sinuses have shown no bacteria. 
 
 The preparation of these cases is as follows : The skin is an- 
 6 
 
52 PREPARATION OF THE PATIENT 
 
 ointed freely, but not forcibly, with 20 per cent, oleate of mercury. 
 The applications extend over several days and are employed over 
 the entire field of operation twice daily. Before each application 
 following the first one the residual oleate and the softened epi- 
 dermis is removed by careful, prolonged, but gentle soaping with 
 a gauze wipe and the combination of soap, oil, sebum, and bac- 
 teria mechanically removed with a solution of corrosive sublimate 
 1 in 1000. The solution is poured onto the field from a pitcher 
 and a gallon used at each sitting. 
 
 This procedure is carried out morning and evening for three 
 days before the operation. At the last cleansing — i.e., the one on 
 the evening before the day of the operation — the sinuses, if any, 
 are wiped out with pure carbolic acid and this neutralized with 
 alcohol. Then a dressing is applied similar to that mentioned 
 above. (Page 50.) 
 
 ]STo application of the oleate is made at this time. Here again 
 modification of detail is permissible, i.e., carbolic acid solution 1 
 per cent, or formalin solution 1 per cent, may replace the corrosive 
 sublimate solution. Carbolic acid solution will soften the epi- 
 dermis more, but will also cause maceration of the true skin if 
 applied for too long a time. This objection does not apply to 
 formalin, but the latter is more irritating than corrosive sublimate. 
 
 The theory is palpable. The skin is penetrated by the oleate 
 of mercury, the bacteria destroyed and later removed by lavage. 
 It is probable that repeated application of the procedure is neces- 
 sary to accomplish the desired end. As in clean cases, the bath and 
 warm water are used. Indeed, the method is quite similar to that 
 used in clean cases except for the employment of antiseptics and 
 the somewhat more protracted preparation. 
 
 To prevent contamination of the operation field from the con- 
 tiguous skin Murphy of Chicago employs the following measure. 
 
 After preparation of the skin in the usual way a " rubber 
 dam " is applied to the field of operation, consisting of a thin sheet 
 of elastic rubber of about the thickness of the rubber gloves. The 
 rubber sheet is sterilized in the same way as is dry catgut and 
 can be procured in the market done up in sterile packages ready 
 for use. After the skin is prepared the rubber is slightly moist- 
 ened with ether, rendering a minute section of the diameter of 
 the rubber fluid, it is then stretched over the skin with consider- 
 
ATTIRE OF PATIENT 53 
 
 able traction and put in place. The rubber immediately adheres 
 closely to the skin and prevents the invasion of the wound by in- 
 fective substances. The incision is made through the rubber, and 
 when repair is made the sutures are taken through it. At last 
 the rubber is lifted at one end, and after incising it where the 
 sutures penetrate it, removed. 
 
 The rubber dam is not affected by antiseptic solutions used 
 during the operation, and, being more elastic than the skin, does 
 not interfere with free manipulations of the part. In cases where 
 suppurative discharges are prolonged, or in cases subjected to 
 colostomy or cholecystotomy, or in the presence of fistulse of vari- 
 ous kinds, the dam may be used over a considerable period of time 
 and replaced at intervals to allow of cleansing of the skin beneath. 
 
 ATTIRE OF PATIENT ABOUT TO BE REMOVED TO 
 OPERATING ROOM 
 
 The attire of patients about to be subjected to operation should 
 be arranged to render accessible the part to be attacked, with a 
 minimum of exposure of the rest of the body, and at the same 
 time protect the patient from undue exposure to either cold or 
 heat. 
 
 The former propositon, i.e., protection from cold, is, as a rule, 
 carefully taken care of. The latter, however, is perhaps too fre- 
 quently disregarded. It is to be remembered that heat stroke may 
 occur as the outcome of neglect of precautions in this regard. 
 When the abdomen is opened the general rule is to prevent con- 
 tact with cold air on the part of the contents of the abdomen. This 
 is obviously a correct principle. Yet the writer cannot help but 
 feel that a patient covered in part by impervious rubber sheeting, 
 layers of woolen blankets to absorb irrigating fluids, sterile sheet, 
 and layers of sterile towels, together with immediate contact with 
 three or more adults who surround the operating table in various 
 capacities, is getting about as much heat as is necessary, if not 
 more. 
 
 A glance at the bluish face, with little streams of sweat run- 
 ning down the neck of a narcotized patient should sound a warn- 
 ing in this connection. Especially is this true in operating rooms 
 where the apparatus for the sterilization of instruments and uten- 
 
54 
 
 PREPARATION OF THE PATIENT 
 
 sils is located in the operating room. The necessity for having 
 available means of rapid sterilization of instruments, etc., during 
 an operation will be gone into more extensively under a separate 
 head, yet mention of the proposition in this connection seems 
 proper. 
 
 The writer has seen cases of exceedingly high temperature im- 
 mediately following operations, with some delirium and rapid 
 pulse, which have aroused alarm and caused some confusion as to 
 diagnosis. The fact that the temperature was readily reduced with 
 cold applications, and that no subsequent evidence of infection 
 appeared, seemed to justify the belief that the disturbance was 
 due to heat stroke. Indeed, in the summer service at the large 
 hospitals the standardization of postoperative fever is slightly at 
 variance with what obtains during the other seasons. A tempera- 
 ture of 103° F. immediately 
 following an operation does not 
 arouse much alarm unless it 
 persists into the second or third 
 day. 
 
 As a rule, the temperature 
 of the sick room or hospital 
 ward should be such as to per- 
 mit of disrobing the patient 
 without the occurrence of chilly 
 sensations. This, as stated, 
 should be about 72° F. Dur- 
 ing convalescence the tempera- 
 ture of the sick room may be 
 lowered to 68° F. However, 
 the general notion of comfort 
 in disrobing is a good standard 
 to go by. Ordinarily a patient 
 should be able to disrobe in a 
 ward or sick room without feel- 
 ing cold. The artificial meth- 
 ods of producing heat should 
 be so regulated as to permit of 
 this and at the same time allow 
 
 Fig. 15. — Patient Attired for Con- 
 veyance to Operating Room. 01 free ventilation. 
 
ATTIRE OF PATIENT 55 
 
 Of course, this is not an easy problem, yet if the room be kept 
 at 70° F. and the ventilation arrested during the dressing of 
 wounds, scrubbing, etc., and then immediately therafter the ven- 
 tilation be reestablished, the desirable result is obtained. 
 
 Before removal to the operating room the hair is wrapped in 
 a sterilized towel. A short shirt, also sterilized, is put on and fas- 
 tened behind with a single button at the neck. This permits of 
 change of garment immediately after operation with a minimum 
 of disturbance of the patient. The legs are encased in long linen 
 stockings, which have also been sterilized. Of course, these gar- 
 ments are not sterile when the patient reaches the operating table. 
 However, they should be sterilized before being applied, on the 
 ground that this lessens the quantity of fertilizing substances in 
 contact with the patient. Fig. 15 shows a patient attired as 
 described. 
 
CHAPTER III 
 
 STERILIZATION AND PREPARATION OF INSTRU- 
 MENTS AND DRESSINGS 
 
 Sterilization of instruments — General sterilization — Steam dressing sterilizers 
 — Requisites for a major operation. 
 
 STERILIZATION OF INSTRUMENTS 
 
 All surgeons agree that boiling is the safest and most simple 
 method of sterilizing instruments. Instruments to be rendered 
 sterile should be boiled for twenty minutes. The apparatus used 
 for the purpose varies in character with the conditions under which 
 the operation is to be done. The elaborate nickel-plated boilers 
 
 Fig. 16. — Instrument Sterilizer Suitable for Hospital or Surgeon's Office. 
 
 in use in hospitals and in surgeons' offices, while desirable, are 
 not essential to the end in view. Several kinds of apparatus for 
 the purpose are shown in the accompanying cuts (-Figs. 16 and 
 17). _ 
 
 Fig. 16 shows an apparatus which is exceedingly useful and 
 
 56 
 
STERILIZATION OF INSTRUMENTS 
 
 57 
 
 very largely used. It is made of heavy copper, tinned inside and 
 nickel plated outside, with a detachable bottom tray which per- 
 mits of removal of the instruments without disturbing the boiler. 
 This particular boiler is fitted with a gas Bunsen burner, but the 
 same apparatus is obtainable furnished with either alcohol, petro- 
 leum or electric heating attachments. 
 
 Fig. 17 shows practically the same apparatus, except that there 
 is no burner attachment, and this may be employed either with 
 an alcohol flame or set directly upon a stove. For the latter pur- 
 pose the legs are detachable. This apparatus is useful for con- 
 
 Fig. 17. — Portable Instrument Sterilizer, with Detachable Legs. 
 
 veying to the scene of operation instruments, which may then be 
 sterilized by boiling as circumstances demand, in accordance with 
 the source of heat available. This illustration shows the perforated 
 tray, which permits of the easy removal of the instrument. The 
 tray is lifted by the handles shown, which are turned inward when 
 the lid of the boiler is closed. 
 
 Both of these boilers are very useful and contribute much to 
 the facility with which instruments are sterilized. Yet it is to be 
 understood that they are not by any means essential to complete 
 and thoroughly effective sterilization. 
 
 The method of procedure consists of exposing the instruments 
 to a temperature of 212° F. for twenty minutes. The instruments 
 are placed in the removable perforated tray, and after this has been 
 
58 STERILIZATION AND PREPARATION OF INSTRUMENTS 
 
 lowered into the sterilizer they are submerged in a solution of 
 sodium carbonate or borax (2 per cent.) and boiled. 
 
 It is readily seen that the object may be accomplished by any 
 apparatus which will hold water and stand heat. A fish boiler, 
 or even an ordinary saucepan found in any household, is as ef- 
 fective for the purpose as the more elaborate sterilizers described. 
 However, it is to be remembered that water and nickeled instru- 
 ments have certain incompatibilities and that a rusty instrument 
 is exceedingly objectionable. 
 
 Tor this reason the soda or borax are added to the water, the 
 theory being that as the instruments are withdrawn from the ster- 
 ilizer the soda crystallizes on their surface and in the joints of the 
 instruments, and absorbs the last few drops of water which may 
 remain in contact with them. Thus rusting is prevented. This 
 is a plea for an apparatus which permits of the withdrawal of the 
 instruments, together with the containing tray, allowing of quite 
 complete drainage of the water. 
 
 It is worthy of note that the impurities in tap-water, such as 
 the lime, salts, combined with other foreign substances, held in solu- 
 tion in the water, cling to the instruments, and cause discoloration. 
 Pure water is not likely to cause discoloration of the instruments. 
 Also, chemically pure soda or borax should be used, as these, too, 
 cause discoloration if impure. 
 
 An objection to the boiling of instruments is the fact that ex- 
 cessive heat destroys the edge of cutting instruments. It is, of 
 course, feasible to boil all other instruments and subject cutting 
 instruments and needles to chemical sterilization. This, however, 
 is expensive and slow and by no means as certain as heat. 
 
 The sterilization of instruments with smooth surfaces is read- 
 ily accomplished by immersion in pure carbolic acid for twenty 
 minutes, followed by lavage with alcohol, the latter removing the 
 carbolic acid most efficiently. Lysol, which contains some soap, 
 is largely used for the purpose and is effective. It also permits of 
 subsequent exposure to irrigating fluids with less damage to the 
 instrument than the former method. It is, however, not as cer- 
 tainly effective as the carbolic acid-alcohol method. 
 
 Mercury destroys instruments. Contact with this agent should 
 be avoided when feasible, though this is, of course, impracticable 
 when corrosive sublimate solutions are used as an irrigation dur- 
 
STERILIZATION OF INSTRUMENTS 
 
 59 
 
 ing the operation. Recently a preparation of mercuric iodid has 
 come on the market which seems to have no deleterious effect upon 
 instruments. It is used in solution of 1 in 1000, and the instru- 
 ment should be submerged for twenty minutes. In this, as in 
 other instances, pure water should be used. 
 
 Grosse of Munich has devised a method of heat sterilization 
 for knives which seems to be of value and does not cause rusting. 
 
 Fig. 18.— Glass Tube with Knives for Steam Sterilization. 
 
 ..■.-^ j 
 
 The knives are placed in a metal rack (Fig. 18), which is slipped 
 into a glass tube provided with a stopper. The entire tube, after 
 being closed, is placed in an ordinary steam pressure sterilizer 
 (page 62) and treated as described under the head of dressing 
 sterilization. 
 
 For the purpose of sterilizing a single knife, a smaller rack 
 and glass tube (Fig. 19) may be used. The 
 knife is held securely by the metal wire suitably O 
 
 bent for the purpose, so as to protect the edge. 
 The tube is closed by absorbent cotton used as a 
 stopper. After exposure to steam for ten min- 
 utes the knife is absolutely sterile, and no specks 
 are visible on it. 
 
 Traces of condensed steam are observable in- 
 side the tube upon the glass, which, however, dis- 
 appear rapidly after the tube is withdrawn from 
 the apparatus. This is explained on the ground 
 that steam generated from the small quantity of 
 hygroscopic water contained in the atmospheric 
 air inclosed in the glass container always preci- 
 pitates upon the glass, which is specifically 
 colder, and not on the steel, which has a larger 
 capacity for heat. 
 
 If it is desirable to sterilize a number of knives each in a sepa- 
 
 Fig. 19. — Single 
 Knife in Glass 
 Tube Ready for 
 Steam Pressure 
 Sterilization. 
 
60 STERILIZATION AND PREPARATION OF INSTRUMENTS 
 
 rate container for each operation, a number of tubes arrayed as 
 described may be conveniently placed in a rack, as shown in Fig. 
 
 20. This would seem 
 to involve less danger 
 of contamination dur- 
 ing handling than if 
 the four knives are 
 simultaneously placed 
 in one rack and larger 
 glass tube. 
 
 GENERAL STERILI- 
 ZATION 
 
 In well-equipped 
 hospitals all material 
 coming in contact with 
 
 -SCHEEfiEfi CajtV. 
 
 Fig. 20. — Rack for Holding Knives in Sepa- 
 rate Containers, Ready for Steam Pres- 
 sure Sterilization. 
 
 the patient is sterilized 
 by heat. Here is undoubtedly the most effective agent for the 
 sterilization of gowns, towels, dressings, etc., used in surgical 
 technic; yet it is not at all times applicable to the varying con- 
 ditions under which operations have to be undertaken. In the 
 latter instances chemical sterilization is a necessity, and, it may 
 be said, if patiently and carefully carried out, is as effective as 
 heat. 
 
 Of course a judicious combination of heat and chemical steril- 
 ization, together with mechanical cleansing, is almost always ob- 
 tainable — i.e., towels may be boiled and even gowns may be boiled 
 and put on wet in case of necessity. Yet, if it be feasible, steam 
 heat should be used for the purpose, as it renders them sterile and 
 more readily handled. 
 
 The most desirable method of sterilization will be taken up 
 first, and then the modifications necessary because of absence of 
 the desirable apparatus will be discussed. 
 
 The principle underlying the sterilization of all material com- 
 ing in contact with operative wounds is the outcome of the dis- 
 coveries of Pasteur made known in 1879. The relationship which 
 bacteria bear to infection was first demonstrated by this indefat- 
 igable worker. The researches of Koch and Wolfhuegel are based 
 
GENERAL STERILIZATION 61 
 
 upon the observations made known by Pasteur. Sterilization by 
 heat is the outcome of the experimentation of the two former 
 observers. 
 
 The first attempt to destroy pathogenic substances was made 
 by D arrow and Symington, two English physicians, who, in 1850, 
 subjected the clothing of cholera patients to dry air at a tempera- 
 ture of 220° to 250° F. by baking in a crude oven. The measure 
 was exceedingly effective. 
 
 Although various physical agents, such as heat, cold, light, and 
 dryness, possess power to destroy bacteria, heat is the most ef- 
 fective agent, and the one most readily obtained and controlled 
 for the purpose. Sunlight and certain concentrated forms of arti- 
 ficial light are capable of destroying bacteria, yet the process neces- 
 sary to accomplishing the desired end is a prolonged one, and by 
 no means as certainly effective as heat. 
 
 Cold is a feeble bactericidal force. Frost, which has been so 
 generally regarded as destructive to malarial and yellow fever 
 poisons, is now believed to destroy only the carriers of infection — 
 i.e., the mosquito — and leave the infecting agent unharmed. 
 
 Dryness destroys the cholera germ, but is a condition favorable 
 to the growth and life of bacteria generally. 
 
 Dry heat will destroy bacteria. It requires a temperature of 
 150° to 165° C. to accomplish the object, and the exposure must 
 continue for one hour. 
 
 Moist heat at a temperature of 100° C. will destroy all bac- 
 teria and spores in a few minutes. 
 
 This should be borne in mind in instances where steam heat is 
 not available for sterilization and baking of dressings, etc., if an 
 oven is used for the purpose. Steam and air have certain molec- 
 ular antagonism in a given area, until there is an equalization 
 of the difference in expansion in these two bodies. This accounts 
 for the peculiar inequality of action of apparatus for sterilization 
 which does not allow of the removal of air from the sterilization 
 apparatus before the steam is forced in. 
 
 The potency of steam heat in destroying ineffective organisms 
 depends upon the temperature. While it is true that anthrax spores 
 will be destroyed by a temperature of 90° C. in twenty minutes, 
 only five minutes of exposure to a temperature of 95° C. is 
 required. 
 
62 STERILIZATION AND PREPARATION OF INSTRUMENTS 
 
 The thermal death point of bacteria bears a certain relation- 
 ship to the coagulability of albumin. When albumin containing 
 bacteria is in solution, or in a moist state, it requires comparatively 
 little heat to destroy them. On the other hand, if the albumin 
 culture medium is dried, it will withstand a high degree of tem- 
 perature for a long time. When moist heat at 100° C. comes in 
 
 contact with a spore it is 
 killed just as soon as it 
 absorbs enough moisture 
 to allow of coagulation. 
 
 A sterilizer, then, to 
 accomplish the purpose 
 most readily and thor- 
 oughly, should be so con- 
 structed as to achieve the 
 following: elimination of 
 air from the sterilization 
 chamber, the penetration 
 of the objects with steam 
 fully saturated, the pre- 
 vention of condensation 
 of water on the objects. 
 
 STEAM DRESSING 
 STERILIZERS 
 
 In large institutions 
 where steam power 
 plants are constantly in 
 operation for the pur- 
 pose of furnishing heat, 
 power and light, steam is 
 readily available, and is 
 led into the outer jacket 
 of the steam sterilizer by 
 the means of pipes which 
 coil in the outer water 
 jacket and heat the water to the desired temperature. However, 
 in most instances, this condition of affairs is not available, and the 
 
 Fig. 21. — Steam Pressure Sterilizer for 
 Dressings, Etc. 
 
STEAM DRESSING STERILIZERS 
 
 63 
 
 water in the outer jacket is heated by means of a gas Binnen 
 burner placed beneath the apparatus. 
 
 As a matter of fact, it makes no difference from which source 
 the heat is obtained, as long as it is of sufficient quantity to de- 
 velop the temperature re- 
 quired for sterilization. 
 Oil, alcohol, etc., are as 
 effective in this regard as 
 coal or illuminating gas. 
 Electricity, while effective, 
 is expensive and requires 
 much time to produce the 
 necessary temperature, 
 though ideal in cleanliness 
 and elasticity of applica- 
 tion. For the purpose of 
 this work, it is sufficient 
 to describe the apparatus 
 usually employed with a 
 gas Bunsen burner. A 
 complete description, to- 
 gether with illustration 
 (Figs. 21 and 22), is given. 
 
 1. Fill the steam jacket 
 with clear water by open- 
 ing valve on metal funnel 
 C, turning lever No. 1 to 
 the right. The quantity of 
 water required for steriliza- 
 tion depends on the length 
 of time for which the ap- 
 paratus shall be operated. 
 It is not desirable to have 
 
 the jacket filled more than half full of water (see sectional view, 
 Fig. 22). The glass water gauge on side indicates exactly the 
 height of water jacket. 
 
 2. A permanent connection with the hydrant water supply can 
 be made through valve " G " (the clean-out valve) by connecting 
 
 Fig. 22. — Sectional View op Steam Pres- 
 sure Sterilizer Shown in Fig. 21. 
 
64 STERILIZATION AND PREPARATION OF INSTRUMENTS 
 
 a Tee back of valve " G " and using a gate valve on the Tee, to 
 which you connect your hydrant water. This method of filling 
 the water into the jacket works rapidly, and in addition offers the 
 advantage to be able to inject water at any time even though the 
 apparatus may be under pressure and in operation. The pressure 
 of the water supply at point of entrance at valve " G " must, of 
 course, exceed that of the steam pressure in the jacket ; the latter 
 being fifteen pounds per square inch, it follows that the water pres- 
 sure should at least be twenty-five pounds or more. 
 
 3. The steam jacket having been filled with a sufficient quan- 
 tity of water, throw lever handle ISTo. 1 back to the left and light 
 the burner (gas, petroleum or alcohol) leaving valve on funnel 
 open until steam issues, then close it tightly. The combination 
 steam pressure and vacuum gauge E will register the conditions 
 prevailing in the jacket and the steam pressure safety valve D will 
 blow off steam as soon as the latter exceeds the normal pressure of 
 fifteen pounds (= 1 Atmosphere). 
 
 4. The dressing material should be placed into the sterilizer 
 chamber before the heaters are lit or, as in the case of steam- 
 heated jackets, before the boiler steam is turned into the heating 
 coils. Door of sterilizer is locked securely and air filtering cup 
 valve F, which is filled with a wad of absorbent cotton, is left 
 open, handle being in vertical position as shown in drawing, Fig. 
 22. 
 
 Gradually as the temperature of the water in jacket increases, 
 the air in the sterilizer chamber becomes rarefied and finds an 
 escape through cup valve F. The sterilizer chamber, therefore, 
 in the first stage of the process serves the purpose of a hot-air 
 oven, gradually warming the dressings preparatory to letting pres- 
 sure steam into the chamber. 
 
 5. As soon as the combination steam and vacuum gauge E 
 indicates a steam pressure of fifteen pounds, the safety valve will 
 begin to operate by blowing off steam in excess of the required 
 pressure, then close the air filtering cup valve F by thrusting 
 handle into a horizontal position. 
 
 The moment has now arrived for exhausting the already rare- 
 fied air in the sterilizer chamber by creating a partial vacuum. 
 This is done by opening valve ~No. 2 on the steam exhaust pipe 
 
STEAM DRESSING STERILIZERS 65 
 
 and by throwing lever No. 1 to the right. The combination gauge 
 E will soon register a vacuum in the chamber, five inches being 
 sufficient to insure absolute results. 
 
 When this degree of vacuum has been reached, close valve No. 
 2 whereupon the pressure steam will rush into the chamber. The 
 dressing material contained in the latter, having thus been care- 
 fully prepared by the air exhaust process for an eager absorption 
 of live steam, will instantaneously and thoroughly be penetrated 
 by the same. Furthermore, since the inrushing steam, which is 
 of a temperature of 250° F. (121° C.) will meet with material 
 which has for some time been subjected to dry hot air of nearly 
 the same degree of temperature as that of the pressure steam, the 
 latter will not condense, and therefore not wet the dressings. The 
 process of steam sterilization shall last from twenty to thirty 
 minutes. 
 
 6. The dressing material can now be considered absolutely 
 sterile, and may be taken out at once if desired. It is advisable, 
 however, to let it remain in the sterilizer chamber for from ten 
 to twenty minutes longer in order to remove every trace of damp- 
 ness. For this purpose open valve No. 2, and again start the ex- 
 hausting process described under No. 5, for the time above speci- 
 fied. After this, extinguish flame or shut off steam supply, close 
 valve No. 2 and throw lever No. 1 to the left. 
 
 7. To remove sterilized dressings from the chambers, it is 
 necessary to destroy the vacuum in the latter in order to be able 
 to open the door. This is done by letting air enter the chamber 
 through the air filtering cup valve F, which is filled with absorbent 
 cotton. 
 
 Dressings thus prepared can be absolutely depended upon as 
 to their sterility. They may be left in the apparatus for an in- 
 definite time before being used without becoming infected. 
 
 The noise made by the blowing off of the steam in creating the 
 partial vacuum is exceedingly annoying. This may be overcome 
 by leading the blow off by means of a steel pipe into the open air at 
 some convenient place near the apparatus. 
 
 Of course, the handling of the material subjected to these meas- 
 ures is performed by a person whose hands are not sterile. Con- 
 sequently, the material must be placed in an outer container which 
 will allow of handling without contact with non-sterile substances. 
 
66 STERILIZATION AND PREPARATION OF INSTRUMENTS 
 
 For this purpose the gowns, wipes, towels, etc., are enclosed, in con- 
 venient quantities, in muslin wraps, and these opened at the time 
 of operation by an attendant who is definitely detailed to the work 
 of handling all material between the sterilizer and those coming in 
 contact with the wound. 
 
 Indeed, at all operations one such person is in attendance for 
 the purpose of handling the solutions, changing the posture of the 
 patient, etc., and this portion of the work may be done by this 
 person. This, however, will be more largely taken up under the 
 head of operating room teclmic. 
 
 The expense of the apparatus described is not so great as to 
 be an important factor in causing the adoption of simpler means 
 of heat sterilization. However, the object can be obtained by the 
 use of apparatus which is less expensive and less complicated. In 
 view of the fact that all dressing material, towels, wipes, etc., may 
 be sterilizecl and packed in air-tight packages and kept for a long 
 period of time, it is suggested that the surgeon had best draw upon 
 some central plant for the material mentioned, rather than rely 
 upon means which involve modification of the principles here 
 laid down. 
 
 ' Indeed, it has been found that thoroughly reliable material 
 may be obtained from commercial houses which prepare dress- 
 ings, gowns, sheets, etc., which are necessary for a given opera- 
 tion, place the entire outfit in a convenient box, and are prepared 
 to ship the same to the surgeon or the patient's house at short 
 notice. 
 
 REQUISITES FOR A MAJOR OPERATION 
 
 A specimen outfit is here described. This particular outfit is 
 designed to be used for celiotomy, and can be readily modified to 
 meet the indications of most any surgical contingency which may 
 arise. 
 
 The list given here is an elaborate one, and is elastic in the 
 sense that successful work may be done with less material, though, 
 as a general rule, it is best to err on the side of safety. Again, if 
 the surgeon is in a position to resterilize material left unused, 
 nothing has been lost. Indeed, it is suggested that the surgeon 
 furnish himself with an outfit as described which will form the 
 basis of his stock on hand and act as a guide in this regard , 
 
REQUISITES FOR A MAJOR OPERATION 67 
 
 The list does not include suture material, which is taken up 
 under separate head. 
 
 2 four-quart white enamel pitchers. 
 
 1 two-quart white enamel pitcher. 
 
 4 white enamel basins. 
 
 1 gown for self and each assistant and nurse. 
 
 1 cap for self and each assistant and nurse. 
 
 1 pair armlets for self and each assistant and nurse. 
 
 2 pair rubber gloves for self and each assistant and nurse. 
 4 demijohns of sterilized and distilled water. 
 
 6 oz. tinct. green soap. 
 
 3 sterilized nail brushes. 
 
 3 sterilized orange wood sticks. 
 
 3 bone nail cleaners. 
 
 1 bottle of chlorinated lime (8 oz.). 
 
 1 bottle soda carbonate (granular 8 oz.). 
 3 dozen sterilized gauze pads with tapes. 
 6 dozen sterilized wipes. 
 
 3 sterilized celiotomy rolls. 
 
 2 packets sterilized absorbent gauze (5 yards each). 
 
 1 pound sterilized absorbent cotton. 
 
 3 tubes iodoform gaiize, 5 yards by 6 inches. 
 
 3 tubes plain sterilized gauze, 5 yards by 2^ inches. 
 3 sterilized combined dressings. 
 
 2 sterilized binders (many tailed). 
 
 1 sterilized T binder. 
 
 3 cigarette drains. 
 
 2 rubber tube drains. 
 
 3 bottles bichlorid of mercury tablets. 
 1 bottle carbolic acid (6 oz.). 
 
 1 box boracic acid. 
 
 2 dozen bottles sterilized salt. 
 
 4 dozen sterilized cotton towels (soft). 
 1 dozen sterilized vulvar pads. 
 
 1 tube of sterile lubricant. 
 
 1 sterilized self-retaining catheter No. 16 French. 
 1 sterilized self-retaining catheter No. 20 French. 
 1 sterilized glass catheter. 
 
68 STERILIZATION AND PREPARATION OF INSTRUMENTS 
 
 1 bath thermometer. 
 
 1 rectal tube. 
 
 1 four-quart sterilized douche bag and glass nozzle. 
 
 1 roll 2-inch adhesive plaster. 
 
 1 celiotomy sheet. 
 
 2 sterilized rubber sheets. 
 
 Hypodermic tablets, strych., morph., and nitroglycerin. 
 Duck suits and canvas shoes for surgeon and assistants. 
 
 The four-quart pitchers are filled with cleansing solutions, 
 one with an antiseptic, usually bichlorid of mercury, the other 
 with saline solution. The two-quart pitcher is used for replen- 
 ishing the larger two as the necessity arises. The pitchers are 
 sterilized by boiling or by thorough lavage and subsequent im- 
 mersion in bichlorid of mercury solution. After being filled, they 
 are covered with a sterile towel (Fig. 70). 
 
 In the edge of the folded towel a safety pin is fastened allow- 
 ing of lifting of the towel (Fig. 71) by the non-sterile nurse, who 
 pours the sterile contents, as shown in Fig. 71, without contami- 
 nating them. A serviceable arrangement of pitchers is shown in 
 Fig. 70. 
 
 The enameled basins are sterilized in the same manner as 
 the pitchers, and are used for solutions employed for cleansing 
 the hands of surgeons and assistants (Fig. 76). 
 
 Gowns should be of ample size and arranged to be fastened 
 with tapes at the back of the wearer. Though the forearm is 
 cleansed before operating, it is best to cover it with sterile fabric. 
 For the purpose, gowns with long sleeves, as shown in Fig. 86, 
 or a similar gown with short sleeves and detachable armlets, may 
 be employed. The advantage of the latter is that, when the 
 sleeves become soiled during an operation, they can be quickly 
 changed without disturbing the gown. The sleeves of the gowns 
 worn by the assistants who do not come in contact with the wound 
 may be long, and will not require changing during the operation. 
 
 Caps. — The object of the cap is to prevent the falling of hair 
 and impurities from the scalp into the wound or upon the ma- 
 terial coming in contact with the patient. While aseptic results 
 are common when this precaution is not taken, it is best to em- 
 ploy the additional measure of safety. The surgeon and assist- 
 
REQUISITES FOR A MAJOR OPERATION 69 
 
 ant should wear a mask and cap combined (Fig. 8-4). This pre- 
 vents contamination from beard, mouth, and perspiration. 
 
 In operative work done in public clinics where the operator 
 lectures during the operation, this is slightly objectionable. How- 
 ever, in these instances the mask need not cover the lips, and the 
 surgeon may take the precaution to turn the head away from the 
 wound, while speaking. It is not uncommon to see perspiration, 
 the result of the high temperature of the operating room or, per- 
 chance, of certain vasomotor disturbances due to emotional causes, 
 drip into the wound. This should be avoided, though it may be 
 said that after prolonged perspiration the sweat washes the ex- 
 cretory ducts quite free from contaminating bacteria. 
 
 The mask should be made of sufficient thickness and of suffi- 
 ciently absorbent material not to require changing during an 
 operation. 
 
 Rubber gloves are either boiled and slipped on wet or, per- 
 haps better yet, boiled, dried, dusted with lycopodium, packed in 
 gauze, and sterilized under pressure, together with dressings and 
 gowns. The subject of gloves is taken up more extensively under 
 the head of cleansing of the hands (page 126). The gauntlets of 
 the gloves should extend over the cuffs of the gown (Fig. 82). 
 
 The sterilized and distilled water is used for cleansing and 
 lavage. It is more desirable to have the water distilled to remove 
 all foreign bodies, yet water may be sterilized by boiling. One- 
 half the water on hand should be hot and the other cold. Tap 
 water may be boiled in two large tin receptacles, covered up, and 
 allowed to cool. A short time before the operation one of the 
 boilers is heated, the other left cold to allow of elasticity in the 
 adjustment of temperature during the operation. 
 
 Soap is most commonly used in the form of the tincture of 
 green soap. This is employed with the view of saponifying the 
 fat on the skin. It is, however, a wasteful method, as much of 
 the fluid is allowed to escape. A jar of green soap (Fig. 76) is 
 perhaps as useful a means of keeping soap as any, though there 
 is no objection to using the ordinary laundry soap (Fig. 76). 
 
 Nail brushes should not be sufficiently stiff to scratch the 
 hands. They are boiled and placed in a glass jar together with 
 the orange sticks and submerged in bichlorid solution. The nail 
 cleaners are also boiled and placed, together with the soap, 
 
70 STERILIZATION AND PREPARATION OF INSTRUMENTS 
 
 brushes, and lime and soda containers, on a suitable table near 
 the washstand (Fig. 76). 
 
 The calcium chlorid is placed in an open dish and the sodium 
 carbonate in a similar one. These dishes are of white enamel, 
 and are placed on the table prepared for the surgeon, as shown in 
 Fig. TO. The method of use is taken up under the head of cleans- 
 ing of the hands (page 126). 
 
 1 
 
 i^ 
 
 ■, 
 
 i 
 
 
 f 
 
 Fig. 23. — Gauze Pad with Tape axd Forcipressure and Wipes of Two Sizes. 
 
 The gauze pads are prepared as follows : Cut gauze in squares 
 12 inches by 12 inches, leaving an extra margin of one-quarter 
 of an inch for seam. Place three of these squares one upon the 
 other so as to have three thicknesses of gauze. Sew around the 
 four sides, leaving an opening at one corner through which to 
 turn the pad inside out, so that the frayed edge of the seam is 
 inside. This prevents small shreds of gauze from being left in 
 
Fig. 24. — Gauze for Making Wipe. 
 
 Fig. 25. — Gauze Folded Once. 
 
 71 
 
72 STERILIZATION AND PREPARATION OF INSTRUMENTS 
 
 the wound, which act as foreign bodies when this precaution is 
 disregarded. After the pad is turned the small opening at one 
 corner is finished off and a tape 6 inches long and one-fourth inch 
 wide is attached firmly to the corner last closed, so as to have all 
 
 Fig. 26. — Gauze Folded Twice. 
 
 stitching at one place. This tape is intended for the attachment 
 of forcipressure, which latter hangs out of the wound, so that the 
 pad may not be lost or forgotten. When finished the pad appears 
 as shown in Fig. 23. 
 
 Six of these pads are folded in a gauze wrapper, then in a 
 
 muslin wrapper, then 
 labeled, and are then 
 ready for sterilization. 
 The wrapper is em- 
 ployed in hospital prac- 
 tice and in instances 
 where the surgeon has 
 
 Fig. 27. — Gauze Folded One-third of Length. 
 
 a large demand for the 
 material. In private practice, however, the wrapper may be re- 
 placed by any convenient container, such as a towel or a paper 
 box, etc. 
 
 Wipes vary in size, the usual 
 and perhaps most universally use- 
 ful size being four inches square. 
 The description here is that of the 
 size mentioned, but is equally ap- 
 plicable to other dimensions. Cut 
 gauze into oblongs 12 inches by 
 16 inches (Fig. 24), fold length- 
 wise (Fig. 25), fold lengthwise a 
 
 a second time (Fig. 26), fold one-third of length (Fig. 27), fold 
 again in the same direction (Fig. 28). Take in right hand and 
 
 Fig. 28. — Gauze Strip Folded 
 Two-thirds of Length. 
 
REQUISITES FOR A MAJOR OPERATION 
 
 73 
 
 with left hand take the outer layer of gauze at open end (Fig. 
 29), and turn wipe inside out (Fig. 30), permitting the passage 
 of both hands through the one side (Fig. 31). Turn the wipe 
 and repeat the turning process on the opposite side, allowing of 
 the manipulation shown in Fig. 32. This turns in all frayed 
 
 Fig. 29.— Manner of Holding Folded Gauze Preliminary 
 to Inverting Edges. 
 
 edges. Wipes of two by two inches are treated in the same way. 
 Fig. 23 shows the three sizes most commonly employed. The 
 packing and preparation for sterilization is similar to that de- 
 scribed under pads (page 72). 
 
 Gauze pads are used to pack off operation fields in cavities. 
 
 In certain instances, however, it is preferable to employ long 
 
74 STERILIZATION AND PREPARATION OF INSTRUMENTS 
 
 pieces of folded gauze, which permit of greater adaptability, and 
 also involve less danger of being left behind. For the purpose, 
 gauze two yards long and one yard wide is folded on itself 
 lengthwise three times, becoming thus four inches wide and 
 consisting of eight layers. The gauze is then rolled (Fig. 33) 
 
 Fig. 30. — Manner of Inverting Folded Gauze Strip. 
 
 and treated as described under sterilization of pads. At times 
 rolls of less diameter are preferable. To attain this it is only 
 necessary to reduce the size of the original piece and handle as 
 before. 
 
 Two packages containing each five yards of sterile gauze are 
 prepared. The gauze is prepared in the same way as for celiotomy 
 rolls, being four inches wide when folded, and two yards in length. 
 
REQUISITES FOR A MAJOR OPERATION 
 
 75 
 
 The gauze is used for the protective dressing. It may be cut into 
 shorter lengths or folded more narrowly to suit the necessities of 
 a given case. 
 
 Sterilized cotton is furnished in cartons by the manufacturer, 
 in varying quantities. It is best to use several packages of small 
 
 . 
 
 Fig. 31. — -Gauze Wipe Completed. Front view, showing edges 
 inverted. 
 
 size than run the risk of contamination in using larger ones on 
 more than one occasion. 
 
 Gauze for dressings and packing may be packed in tins or glass 
 tubes. Here again the container should be of the size holding a 
 quantity to be used for a certain case, and if a portion of the gauze 
 be unused, this had best be destroyed and a new container used 
 
76 STERILIZATION AND PREPARATION OF INSTRUMENTS 
 
 each time. Fig. 34 shows a desirable form of glass tube container. 
 Medicated gauzes are not as largely used in surgical practice as 
 formerly. The two kinds most commonly employed are iodoform 
 gauze and gauze saturated with balsam of Peru. 
 
 Fig. 32. — Wipe Completed (back view). 
 
 Iodoform gauze is prepared as follows : 
 
 Pulv. iodoform oz. vj. 
 
 Glycerin O. j. 
 
 Alcohol oz. viij. 
 
 Ether oz. viij. 
 
 Place iodoform in sterile basin carefully and completely break 
 
REQUISITES FOR A MAJOR OPERATION 77 
 
 up lumps with sterile spatula, add glycerin, gradually rubbing 
 into a paste. Add alcohol and mix. Add ether and mix. Roll 
 gauze, prepared as for celiotomy (Fig. 33), in mixture, until all 
 ingredients are absorbed. Place in layers in sterile towel, pin 
 
 Fig. 33. — Gauze Roll, Suitable for Packing Wounds 
 and Cavities. 
 
 tightly. Pack in oil silk, inclose in second sterile towel, and steri- 
 lize. The gauze may be cut to any desired size. 
 Balsam of Peru gauze is prepared as follows : 
 
 Balsam of Peru O. j. 
 
 Glycerin oz. 1. 
 
 Mix in basin and treat as instructions with iodoform gauze. 
 A combination of gauze and absorbent cotton is a desirable 
 
78 STERILIZATION AND PREPARATION OF INSTRUMENTS 
 
 agent for the protective dressing. It is absorbent, and the cotton 
 is impermeable to bacteria. 
 
 Combined dressing is prepared by cutting gauze 12 by 12 
 inches. A layer of this is laid flat and cotton is smoothly laid 
 on it, the latter being made smaller than the gauze so as to permit 
 
 Fig. 34. — Gauze for Packing in Glass Container. 
 
 of overlapping of one inch all around. A second layer of gauze, 
 similar in size to the first, is placed on top of the cotton (Fig. 
 35). Six of these dressings are placed in a packet and sterilized. 
 
 Fig. 36 shows a transverse section of combination dressing cut 
 squarely, for purposes of illustration, with the scissors. It will 
 be noted that the cotton fills the space between the two layers of 
 
Fig. 35. — Making Combined Dressing. The top layer of gauze is being 
 placed in contact with the layer of cotton. 
 
 Fig. 36. — Transverse Section of Combined Dressing. 
 
 Fig. 37. — Many-tailed Abdominal Binder. 
 
 79 
 
80 STERILIZATION AND PREPARATION OF INSTRUMENTS 
 
 gauze, which are quite clearly outlined in the figure. In this way 
 a smooth surface is presented for the retaining bandage. 
 
 The many-tailed hinder is made of heavy muslin or Canton 
 flannel and is arranged with a solid back and fashioned in tails 
 at the sides (Fig. 37) to allow of better adjustment to the body. 
 
 Its method of applica- 
 tion is taken up to- 
 gether with the abdomi- 
 nal protective dressing 
 (page 436). 
 
 The T hinder is 
 used for operations 
 about the perineum 
 (Fig. 38). Its appli- 
 cation is taken up with 
 operations in this re- 
 gion (page 548). 
 
 Cigarette drains are 
 made by rolling gauze 
 in rubber tissue. It is essential that the gauze extend beyond the 
 rubber tissue and that the gauze be wet in order to facilitate capil- 
 larity. (See Fig. 154.) 
 
 Ruhher tuhe drains (Fig. 39) vary in size and length. They 
 have a distinct and valuable field of usefulness in infected cases, 
 where they can be introduced at the dependent portions of wounds 
 
 Fig. 38. — T-Bandage for Holding in Position 
 Perineal Dressings. 
 
 Fig. 39. — Sterile Rubber Drainage Tube in Hermetically Sealed Glass Tube. 
 
 and cavities. They will not, like textile fabric drainage, drain up 
 hill. The figure shows a desirable method of preservation. The 
 tube is boiled and inclosed in the glass tube, submerged in sterile 
 water, and after the tube is sealed, again boiled. When introduced 
 into a wound the tube is fenestrated with the view of facilitating 
 the entrance of infective material through its entire length. The 
 mode of application of this agent is described under separate head 
 (page 189). 
 
REQUISITES FOR A MAJOR OPERATION 81 
 
 Sterilized salt is placed in bottles in powder and then sterilized 
 again under pressure. The quantity in a bottle is regulated so 
 that the entire contents of a phial are used to make the desired 
 percentage of solution when added to two quarts of water. Chem- 
 ically pure sodium chlorid should be used. However, even this 
 is apt to contain fine, insoluble particles. To obviate this a con- 
 centrated solution of the salt is made, which is carefully filtered 
 through a clay filter and placed in tubes similar to those employed 
 for drainage tubes, etc. A sufficient amount of this concentrated 
 solution is placed in a single tube to correspond to the amount of 
 salt necessary to give the required strength to two quarts of water. 
 
 When salt solution is used for infusion or hypodermoclysis, the 
 necessity for an absolutely clear solution is manifest. Hermetically 
 sealed tubes, as described, are obtainable in the market. They are 
 exceedingly convenient and are inexpensive (Fig. 40). Just 
 
 r~~ 'omr^s^ 
 
 SALT SOLOTION 
 
 Fob INTRA-VCNOUS INJECTION 
 
 Fig. 40. — Concentrated Salt Solution in Hermetically Sealed Glass Tube. 
 
 before use they should be boiled. Care should be taken in break- 
 ing open the narrow end so that no particles of glass be allowed 
 to drop into the solution. 
 
 Sterile towels should be of soft cotton. New towels contain 
 a dressing which makes them stiff. This renders them less pli- 
 able, and they do not lie close to the parts. When an instrument 
 or other apparatus is placed on a new towel it is liable to slip and 
 fall to the floor. The towels should be soaked in cold water over 
 night, washed in soap and water, cleansed by rinsing in several 
 changes of clean water, dried in the air, folded in convenient 
 squares, wrapped in muslin, and sterilized under pressure. The 
 function of sterile towels is to surround the operative field with 
 sterile surfaces. The mode of use is taken up under operating- 
 room technic (page 167). 
 
 Self -retaining catheters are described under bladder drainage. 
 In this connection, however, it is proper to state that they should 
 be boiled, placed in a glass tube similar to the one used for drain- 
 age tubes, and resterilized under pressure. They may be boiled 
 
82 STERILIZATION AND PREPARATION OF INSTRUMENTS 
 
 and wrapped in muslin and thus transported, or boiled imme- 
 diately before the operation, together with instruments. The 
 
 latter method is the safest. 
 
 Lubricating agents are best 
 used in collapsible tubes (Fig. 
 41 A). The tubes are readily 
 sterilized and are filled with a 
 jelly made of cartilage, which is 
 soluble in water. The use of lu- 
 bricants which are soluble is de- 
 sirable as compared with the 
 oleaginous ones, permitting of 
 more thorough cleansing of the 
 lubricated surface. 
 
 When using lubricant in the 
 urethra the adjustable cone (Fig. 
 41 B) is a desirable refinement, 
 permitting of the easy introduc- 
 tion of the lubricant into the 
 urethra or other canal. 
 
 Bath thermometer (Fig. 42) 
 is necessary to determine the 
 temperature of solutions used for 
 lavage of the wound. Kot in- 
 frequently solutions are used 
 which are too hot, scalding the 
 tissues and interfering with re- 
 pair of the wound. An accurate 
 determination of the temperature 
 of solutions employed will pre- 
 vent this. 
 A rectal tube (Fig. 43) should be on hand to permit of entero- 
 clysis during the operation, and for the purpose of introducing 
 various solutions into the bowel during the after-treatment. 
 
 837 
 
 Fig. 41. — A, Lubricant in collapsible 
 metal tube; B, Cones for injecting 
 lubricant into cavities. 
 
 Fig. 42. — Bath Thermometer for Determining Temperature of Solutions. 
 
REQUISITES FOR A MAJOR OPERATION 
 
 83 
 
 Fig. 43. — Soft Rubber Rectal, Tube. 
 
 Douche hags are used for irrigation, and as a reservoir for solu- 
 tions to be intro- 
 duced into the 
 bowel. They have 
 been largely re- 
 placed by glass 
 tanks, but the latter 
 are used mostly in 
 operating rooms in 
 hospitals, the for- 
 mer being more 
 readily transported 
 for use during op- 
 erations in the 
 homes of patients. 
 The bag is so much 
 more readily trans- 
 ported as to have a 
 distinct field of use- 
 fulness. A glass 
 terminal at the end 
 of the rubber tube 
 is desirable. The 
 bag should be 
 boiled before using. 
 The subject of 
 
 Fig. 44. — Celiotomy Sheet. 
 
84 STERILIZATION AND PREPARATION OF INSTRUMENTS 
 
 irrigation is taken up under operating-room technic (page 
 151). 
 
 The celiotomy sheet (Fig. 44) is a large oblong of cotton or 
 muslin with a square opening near its center. It should be large 
 enough to hang over the sides of the operating table, reaching al- 
 most to the floor, so that the lower portion of the operator's gown 
 does not come in contact with the table (Fig. 121). Frequently 
 during an operation the surgeon steps back from the operating 
 table and allows his hand to come in contact with the gown below 
 the waist. If this portion of the gown has come in contact with 
 the side of the table, it is contaminated and the hands are also 
 contaminated. This can be avoided by taking the precaution 
 mentioned. 
 
 Fig. 45. — Vulvar Pad Used to Catch Vaginal Discharges. 
 
 The sheet is folded in a small area and sterilized under pres- 
 sure. Its arrangement at the time of operation is described under 
 operating-room technic. While the sheet shown is designed for 
 abdominal operations it may be used in other situations. The 
 principle being of isolating the part to be operated upon with 
 sterile surroundings. 
 
 Rubber sheets are used to protect surrounding parts from mois- 
 ture (Fig. 119). Duck suits and canvas shoes are described under 
 attire of the surgeon (Figs. 75, 85). 
 
 Vulvar pads (Fig. 45) are placed against the vaginal outlet 
 following operations in this region, and when vaginal drainage has 
 been made following celiotomy. The pads are composed of gauze 
 with several layers of absorbent cotton held between its layers. 
 
CHAPTEK IV 
 SUTURE AND LIGATURE MATERIAL 
 
 General considerations of absorbable and non-absorbable material. 
 
 Absorbable ligature material: Catgut: Plain catgut; sterilization of catgut, 
 by biniodid of mercury, by heating in fatty liquid: Chromic catgut; steri- 
 lization of catgut with cumol: Iodin catgut — Kangaroo tendon. 
 
 Non-absorbable ligature material: Silk-worm gut — Silk — Pagensteeher thread 
 — Horse hair — Silver and gold wire. 
 
 GENERAL CONSIDERATIONS OF ABSORBABLE AND NON- 
 ABSORBABLE LIGATURE MATERIAL 
 
 The aim of suturing wounds is to hold tissue in apposition, 
 until repair by cell genesis takes place. Sutures are not concerned 
 directly in repair, they place the tissues in such relationship to 
 each other as to make repair rapid and easy, but of themselves 
 will not hold tissues together as a nail holds two boards or a bolt 
 two pieces of metal in apposition. This consideration should be 
 a plea against the strangulation of tissue, the outcome of tightly 
 drawn stitches so frequently seen. The ideal suture is one which 
 is sterile, non-irritating, is absorbed at the expiration of the time 
 required for healing, and is of sufficient tensile strength to per- 
 mit of the necessary manipulations without breaking asunder. 
 
 As a general proposition suture material which is absorbed 
 should be employed in deep suturing. Material which it is neces- 
 sary to ultimately remove may be employed in superficial repair. 
 
 Dividing suture material into two classes — the one absorb- 
 able, the other non-absorbable — we may say that the latter is less 
 apt to be a carrier of infection, on the simple and easily under- 
 stood ground, that the quality which renders them resistant to the 
 action of the circulating fluids in the body, also makes them un- 
 influenced by the manipulations necessary to complete steriliza- 
 tion. 
 
 In addition to this, the modification of consistence which an 
 
 85 
 
86 SUTURE AND LIGATURE MATERIAL 
 
 absorbable suture material undergoes in absorption, creates, at 
 a certain time of the process, a condition favorable to infection. 
 This obtains more readily in sutures a part of which lie on the 
 skin, and would argue for the employment of non-absorbable su- 
 ture material in this situation, a notion borne out by the facts as 
 observed in practice. 
 
 The complications arising in the after-treatment of operative 
 cases are commonly enough the outcome of disturbances caused 
 by sutures and ligatures. These are taken up under a separate 
 head (page 211). 
 
 The method of preparing suture material bears an important 
 relationship to postoperative occurrences, and the technic of steril- 
 ization is extensively gone into in this connection for this reason. 
 
 Absorbable suture and ligature material : Catgut, kangaroo 
 tendon. 
 
 Non-absorbable suture and ligature material : Silk, silk-worin 
 gut, Pagenstecher thread, Silver and gold wire. 
 
 ABSORBABLE LIGATURE MATERIAL 
 
 CATGUT 
 
 Catgut, so-called, would be an ideal suture material were it 
 not for the fact that it is difficult to sterilize. It is not, as the 
 name implies, made from the intestine of the cat, but is taken 
 from the small intestine of the sheep. It is obtainable in the 
 market, dry and of varying thickness. The diameter of the 
 product is designated by number, i.e., 00, 0, 1, 2, and 3. This 
 classification is somewhat arbitrary, and the diameter of the 
 product is quite variable. However, but little acquaintance in 
 a practical way renders it sufficiently accurate. 
 
 It is easy to see that the material composing the catgut is the 
 natural habitat of bacteria. The bacteria exist throughout the 
 entire thickness of the gut, and any method of sterilization to be 
 effective involves the problem of penetration of its entire thick- 
 ness by a process which does not destroy its tensile strength. The 
 writer wishes to state that for general purposes, with perhaps 
 the exception of large hospitals, suture and ligature material is 
 best and most safely handled by commercial houses who make a 
 specialty of preparing and sterilizing them. 
 
ABSORBABLE LIGATURE MATERIAL 
 
 87 
 
 The problem of sterilization of catgut is so complicated that, 
 unless special apparatus and experience is employed, unfavor- 
 able and, indeed, at times fatal outcome obtains. 
 
 Two kinds of raw catgut are generally employed, the smooth 
 
 and the rough. 
 
 Smooth catgut is of the best quality of imported (Germany) 
 banjo and violin strings, put up in boxes containing thirty 
 
 strings of each of the sizes. 
 
 Designation. 
 
 Average Length. 
 
 Banjo 1 (thinnest) 67^ in. 
 
 Banjo 2 67-| in. 
 
 Violin E 671 in. 
 
 Violin A 444, in. 
 
 Violin D (heaviest) 44£ in. 
 
 Average 
 
 Breaking 
 
 Point. 
 
 5 lbs. 
 
 8 lbs. 
 18 lbs. 
 24 lbs. 
 32 lbs. 
 
 The first three sizes are those mostly used in surgery. Each 
 string is coiled or arranged in a manner shown in Fig. 46, 
 and tied with a strand of silk. 
 Colored silk colors the solutions 
 used. 
 
 Rouffh catgut is the kind which 
 
 It 
 
 clockmakers and jewelers use. 
 
 comes in strings of five meters in 
 length, of various sizes ; 00, 0, 1, 
 2, and 3 are most commonly used. 
 (Bryant.) 
 
 A large number of methods of 
 preparing catgut for ligatures and 
 sutures have been employed. None 
 of these are effective unless care- 
 fully employed and accurately exe- 
 cuted. Of all the methods the so- 
 called cumol and dry sterilization 
 is the most certain, and is univer- 
 sally applicable. 
 
 Three kinds of prepared catgut 
 will be described : the plain, the 
 chromicized, and the iodized. The 
 
 Fig. 46. — Catgut Looped and 
 Ready for Sterilization. 
 
88 SUTURE AND LIGATURE MATERIAL 
 
 former two necessitate the removal of the fats from the raw ma- 
 terial, the latter does not. 
 
 Plain catgut is more readily absorbed than the chromic, is 
 more pliable, and consequently ties a closer knot than chromic, 
 though the latter is strongen, remains in situ longer, and is more 
 readily handled. The exact place which iodin catgut occupies 
 is difficult to state. In its preparation it frequently undergoes a 
 change which lessens its tensile strength. This is a serious ob- 
 jection. It is most useful in hospital practice, where it is used 
 soon after preparation. The simplicity of preparation is a strong 
 factor as regards its field of usefulness. On the whole, the plain 
 and chromic gut fill all wants, i.e., if properly prepared. 
 
 Removal of Fats from Catgut. — A number of coils of gut 3 
 feet in length (Fig. 46) are placed in an Erlenmeyer flask and 
 submerged in ether. Most manufacturers who prepare catgut for 
 surgical use allow the material to lie in ether for a month, chang- 
 ing the ether bath at intervals, with the view of removing the fats 
 held in solution, and substituting fresh ether which will permit 
 of additional chemical action. 
 
 If sufficient facilities for this be not available, the flask con- 
 taining the submerged gut is exposed to steam and the fats boiled 
 out with ether. The top of the flask is connected with a con- 
 denser to save the vaporized ether. Care should be taken not to 
 allow the open flame to come in contact with the ether vapor. 
 The ether should be distilled before using a second time. The 
 ether is poured off while hot, and the boiling should continue for 
 one hour. Some fat will remain in the gut after the ether ex- 
 traction is completed. This may be removed by boiling the gut in 
 alcohol, preferably absolute alcohol, though the commercial 95 
 per cent, will serve the purpose. If the percentage of water in 
 the alcohol is greater than 5 per cent., the moisture will cause 
 the gut to swell up, tangle, and lose its tensile strength. 
 
 Sterilization of Catgut. — The destruction of bacteria in gut 
 by chemical action, such as immersion in a solution of biniodid 
 of mercury in chloroform, bichlorid of mercury in alcohol, etc., 
 has been employed for many years and has given results which 
 have seemed to be desirable. However, latterly the subject of 
 catgut sterilization has been made the object of scientific investi- 
 gation, which seems to show that chemical treatment of catgut 
 
ABSORBABLE LIGATURE MATERIAL 89 
 
 does not achieve sterility. This has been shown by making cul- 
 tures from raw gut, treating them with antiseptic solutions, such 
 as are mentioned above, precipitating the antiseptic with the 
 proper chemical agent, making cultures again, and noting the 
 development of growths of pathogenic bacteria. Again, in sev- 
 eral instances tetanus has developed as the outcome of using gut 
 prepared by immersion in antiseptics. However, a number of 
 surgeons regard the sterilization of catgut by the chloroform- 
 biniodid method as efficient, and it is described here for that rea- 
 son, though employment of the method is not advised by the writer. 
 
 Sterilization of catgut by a solution of biniodid of mercury 
 is a simple method. After the gut has been subjected to ether ex- 
 traction of the fats, it is at once transferred to a saturated solu- 
 tion of biniodid of mercury in chloroform, in which it is copi- 
 ously submerged. The chloroform saturates at 1 in 1,000 of 
 biniodid of mercury. The gut is stored, thus submerged, in a 
 glass-stoppered jar (Fig. 48), and is ready for use. Sufficient 
 quantity for immediate use is removed by means of a sterile 
 dressing forceps, and the stopper is replaced. The glass con- 
 tainer should not be left open during an operation, as an error 
 is very likely to occur, the assistant being liable to use a fer- 
 tilized instrument for the purpose. 
 
 It is true that a combination of chemical agents and heat will 
 achieve the desired result, yet it is to be borne in mind that heat 
 is the most reliable bactericidal agent. 
 
 The treatment of catgut with chemical agents should be des- 
 tined to influence its pliability and tensile strength and to offset, 
 as far as possible, the destructive effect of heat. It is just as fair 
 to assume that a chemical agent of sufficient strength to destroy 
 bacteria may also probably destroy the characteristics of the gut 
 which make it of use. This is shown, in a way, in iodin catgut, 
 which is sterile after being immersed in iodin solution, yet fre- 
 quently is of no use at the time of the operation because of the 
 destructive effect of the iodin when submerged for a consider- 
 able period of time. 
 
 Heating of Catgut in Fatty Liquid. — After extraction of fat 
 and immersion in a solution of chloroform and biniodid, as 
 stated, the gut is wound on bobbins (Fig. 47). Each bobbin 
 holds several strands of three feet each. The bobbins, which are 
 
90 
 
 SUTURE AND LIGATURE MATERIAL 
 
 sterile, are put into a vessel, submerged in albolene, and heated 
 over a petrolatum bath. The temperature is run up to 275° F., 
 where it is maintained for fifteen minutes. The temperature is 
 then allowed to fall and the gut on the bobbins returned to the 
 chloroform and biniodid of mercury solution. This method is 
 a good one, but does not permit of the raising of the temperature 
 
 sufficiently high to enable one 
 to be certain that all bacteria 
 have been destroyed. 
 
 Chromicized Gut. — The fats 
 are removed, as described above, 
 and the gut is then wound on 
 bobbins (Fig. 47) or arranged 
 in coils (Fig. 46) and sub- 
 merged in the following solu- 
 tion: 
 
 Potassium bichromate . 22^ grs. 
 Distilled water 15 oz. 
 
 dissolve and add 
 
 Glycerin 2^ drachms. 
 
 Carbolic acid 2^ drachms. 
 
 The gut is allowed to re- 
 main in this solution during 
 thirty hours. It is then re- 
 moved and tightly stretched on 
 a notched board and allowed to 
 dry in the air or in an oven at 
 a temperature of 113° F. 
 
 When the gut is dry, it is 
 coiled again, and after being placed in a glass jar (Fig. 48), 
 sterilized in alcohol vapor under pressure. The various sizes of 
 catgut should be placed in separate jars, each labeled (Fig. 49) 
 with the view of obviating confusion when the contents are to be 
 used. The illustration shows a method of arrangement which is 
 satisfactory in this connection. 
 
 The chemical treatment is destined to make the gut strong and 
 
 Fig. 47.- 
 
 -Catgxjt Wound on Bobbin, 
 Ready for Use. 
 
ABSORBABLE LIGATURE MATERIAL 
 
 91 
 
 hard, so as to be maintained in the tissues for varying periods 
 without absorption. It does not sterilize the gut. Indeed, the 
 hardness of the product makes the 
 gut less readily sterilized. The ex- 
 posure to alcohol vapor under press- 
 ure is expected to do this. The 
 writer regards this as a quite uni- 
 versally useful method, but would 
 replace the alcohol vapor steriliza- 
 tion with exposure to dry heat at a 
 temperature of 250° F (see cumol 
 method, page 92). Chromicized 
 catgut is stiff and hard. To over- 
 come this the gut, after being chro- 
 micized, has been subjected to the 
 albolene boiling as described above. 
 The same objection to the employ- 
 ment of this method applies in this connection. 
 
 Sterilization of Catgut with Cumol. — The method here de- 
 scribed is regarded by the writer as the safest, and if properly car- 
 ried out, gives uniformly satisfactory results. It applies to both 
 
 Fig. 48. — Catgut Coils Sub- 
 merged in a Solution of 
 Biniodid of Mercury in 
 Chloroform. 
 
 ■BmBH 
 
 HI ji 
 
 'U?J?_ 
 
 
 
 I 1 „ 
 
 
 mm ; 
 
 
 IdP 
 
 ^)k^3^ 4 
 
 
 Fig. 49. — Convenient Arrangement of Jars Containing Catgut for 
 Immediate Use. 
 
 plain and chromic gut, for, of course, the latter is not sterilized 
 by the process which chromicizes it. 
 
 The apparatus used for drying and cumolizing catgut is de- 
 scribed as follows (Fig. 50) : The sterilizer is made throughout of 
 brass and bronze, nickel-plated. The interior, or cumol-retaining 
 cylinder, is 6 inches in diameter and 8 inches deep. The outer cyl- 
 
92 
 
 SUTURE AND LIGATURE MATERIAL 
 
 inder is 8 inches in diameter and 8y 2 inches deep, providing for an 
 intervening space of 1 inch all around between the two, and 1^ 
 inches from the bottom of the outer cylinder. This space between 
 the two cylinders is compactly filled with white sand. The top of 
 
 the sterilizer articulates 
 closely with the cast 
 bronze " faced " ring se- 
 cured to the upper end 
 of the retaining cylinder, 
 forming a steam-tight 
 joint. 
 
 The apparatus is sup- 
 ported on four legs, 
 which rest in a metal 
 tray, as shown in the 
 illustration. The heat is 
 furnished by means of a 
 Bunsen burner, though 
 an alcohol flame or other 
 source of heat may be 
 used for the purpose. 
 The heat is directed 
 against the bottom of the 
 outer cylinder, heating 
 the quartz bath uni- 
 formly, and, in turn, 
 transmitting uniform 
 heat to the cumol. The 
 cumol sterilizer is pro- 
 vided with a draw-off 
 valve, thermometer, and 
 a burner consistent with 
 the fuel at disposal. 
 The gut is cleansed and the fats extracted in the way already 
 described, cut into lengths of three feet and coiled (Fig. 47), then 
 placed in the interior cylinder of the cumolizer (Fig. 50), and 
 the apparatus closed. The temperature is raised to 80° C. and 
 maintained there for two hours, at the end of which time all mois- 
 ture is driven from the gut, thus preventing it from becoming 
 
 Fig. 
 
 50. — Apparatus for Sterilization 
 Catgut by the Cumol Method. 
 
ABSORBABLE LIGATURE MATERIAL 93 
 
 brittle during the subsequent steps of its preparation, the result 
 of conversion of the animal tissue into a glue-like substance. 
 
 The gut is then submerged in cumol, and the temperature raised 
 to 155° C. and maintained for one hour. The cumol is then drawn 
 off through a tube at least 24 inches in length attached to the lower 
 spout (Fig. 50), and the rest of the cumol driven off by main- 
 taining a temperature of 100° C. for about two hours. 
 
 The gut is then removed and stored in either glass tubes or 
 jars (Fig. 49). The gut in the jars is covered with a solution 
 of mercuric biniodid, 1 in 1,000. The latter precaution is taken 
 to prevent contamination of the gut when removing a portion of 
 the contents of the jar. 
 
 The objection to storing sterilized catgut in jars, for fear of 
 subsequent contamination, has been overcome by placing the pre- 
 
 Fig. 51. — Sterile Catgut in Hermetically Sealed Glass Tubes. 
 broken at file scratch. 
 
 Tube 
 
 pared suture and ligature material in hermetically sealed glass 
 tubes. The gut is coiled or wound on a metal bobbin, placed in the 
 glass tube, and after being sterilized in cumol, as described, at a 
 temperature of 300° F. for two hours, the tube is sealed and re- 
 sterilized for one hour at 18 lbs., in a steam pressure sterilizer 
 (Fig. 21). This is an ideal way of handling catgut. 
 
 The glass tube is scratched with a file mark near its middle, 
 and when the tube is opened it is readily broken at this point (Fig. 
 51). A sterile towel should be used for the purpose to prevent in- 
 jury from the broken glass to the surgeon's fingers. In this way 
 contamination of the material during transportation is made im- 
 possible, and it is only necessary to sterilize the outside of the tube 
 at the time of the operation. 
 
94 SUTURE AND LIGATURE MATERIAL 
 
 The latter object is attained by sterilization by boiling simul- 
 taneously with the instruments, or by submerging the sealed tube 
 in a solution of bichlorid of mercury for an hour before opening 
 it, in the manner stated. 
 
 When the gut is in the glass tube, the solution in which it is 
 submerged magnifies its diameter. To obviate error with respect 
 to the size when removed from its sterile container, each tube 
 should contain a small label registering its size, thus preventing 
 annoying delay and, indeed, unnecessary waste of material. A 
 label affixed to the surface of the tube would not fill the purpose, 
 for the obvious reason that it would come off during either the 
 heat or chemical sterilization of the tube. 
 
 As a rule, Number 2 catgut is the most widely employed. 
 Number 2 plain gut is generally employed for ligature of bleeding 
 vessels divided during operation. Plain gut, as a rule, should be 
 employed for ligature of pedicles and the omentum. The chromic 
 gut is too hard, does not allow of a tight knot, and is liable to slip. 
 Number 3 is as large as is ever necessary for the purpose of deli- 
 gating tissues. 
 
 On the whole, it may be said that the smaller the gut the less 
 is the liability of infection, as the finer kind is, as can easily be 
 seen, more readily sterilized than the heavier. In a given case it 
 would be better to use several strands of finer gut than one heavy 
 strand, for the same reason. The ISTumber 1 may be used for 
 tying smaller vessels and the and 00 for apposition of wounds 
 where cosmetic effect is a consideration, such as in the face, neck, 
 and hands. 
 
 Chromic gut is employed where apposition is to be maintained 
 for a considerable period of time. Muscle fibers which have been 
 divided should be held in place with chromic gut, though it will 
 rarely be necessary to use heavier than Number 3. Catgut in the 
 skin is unreliable, though chromic gut gives better results than the 
 plain in this situation. The writer has abandoned the use of cat- 
 gut in the skin, and uses silk-worm gut where cosmetic effect need 
 not be considered, and horsehair on the face. The question of 
 kind of suture to be used in a given portion of the body will bo 
 taken up under the head of suturing of wounds (page 211). 
 
 In this connection, mention may be made of the simultaneous 
 sterilization of a suture and needle for emergencies. The suture 
 
ABSORBABLE LIGATURE MATERIAL 95 
 
 material, as has been seen, is readily rendered sterile, but when 
 an emergency arises, a sterile needle is not always available. To 
 meet this contingency, a suture is threaded on a needle and placed 
 in a glass tube, which is then sterilized in the manner stated in 
 connection with sterilization of catgut (page 94). It is only 
 
 Fig. 52. — Emergency Sutures with Needle (^ Curved) in Hermetically 
 
 Sealed Tubes. 
 
 necessary to break the incasing glass tube to have the little ap- 
 pliance at the disposition of the surgeon. 
 
 The method is, of course, available for suture material other 
 than catgut, in which instances the sterilization and preservation 
 is carried out in accord with the means employed for sterilization 
 of the particular kind of suture material used. 
 
 Iodin Catgut. — Theoretically, iodin catgut is sterilized by the 
 iodin it is soaked in, and as it is absorbed, destroys whatever bac- 
 teria may come in contact with it from extrinsic causes during 
 absorption. Unfortunately, the chemical action of the iodin de- 
 stroys the tensile strength of the gut at the expiration of a certain 
 period of time. However, if the gut is used in large quantities, 
 as obtains in hospital practice, the iodin sterilization and preser- 
 vation is an exceedingly useful method. The gut, when treated in 
 this way, is pliable and easily handled, and, indeed, if the objec- 
 tion stated could be removed with certainty, would be an ideal 
 ligature and suture material. The raw gut is used for the pur- 
 pose ; neither the ether nor alcohol bath is necessary. 
 
 The gut is rolled on glass spools (Fig. 47) (when fashioned 
 into coils it is believed to rot more rapidly) and immersed in the 
 f ollowing solution : 
 
96 SUTURE AND LIGATURE MATERIAL 
 
 Iodin 1 per cent. 
 
 Potassium iodid 1 per cent. 
 
 Sterile water 98 per cent. 
 
 The gut is allowed to remain in the solution for eight days, when 
 it is ready for use. As a rule it is preserved in a glass jar (Fig. 
 48), though it may be put in tubes and covered with the solution 
 mentioned. (Fig. 51.) 
 
 If iodin catgut is preserved in a sealed glass tube, the latter 
 must be sterilized in cold antiseptic solution just before using. If 
 the tubes are boiled with the instruments, the catgut is disinte- 
 grated, becomes friable, and is useless. The theory of impregnat- 
 ing catgut with iodin is that, as the gut is absorbed, the iodin 
 chemically combats accidental infection. Theoretically, this looks 
 rational, yet experience has not quite sustained this view. 
 
 KANGAROO TENDON 
 
 Kangaroo tendon, as its name implies, is made from the tendon 
 of the kangaroo. It will not stand heat and must be sterilized by 
 immersion in antiseptic fluids. It is not, however, the natural 
 habitat of bacteria, as is catgut, and is rendered sterile without 
 heat. Its preparation is simple. The tendon is extracted with 
 ether, which removes the fats, immersed in a mixture of albolene 
 
 Fig. 53. — Kangaroo Tendon Sutures in Hermetically Sealed Glass Tube. 
 
 and camphor 3 per cent., containing mercuric bichlorid 1 in 
 4,000, in which it is soaked for a week. It is then put in glass 
 tubes (Fig. 53), submerged in fresh bichlorid and albolene mix- 
 ture, the tube sealed and sterilized in cold bichlorid of mercury 
 solution just before use. It must be borne in mind that it must 
 not be boiled with the instruments. 
 
 Kangaroo tendon is used where prolonged immobilization of 
 traumatized parts is indicated, such as holding the fragments of 
 fractured bones in place, for suturing fractured patella, and the 
 
NON-ABSORBABLE LIGATURE MATERIAL 
 
 97 
 
 like. It may be obtained in the market in so-called large, medium, 
 and small sizes. The large size is used to hold fragments of bones 
 in apposition and the medium and small for the same purpose as 
 regards ruptured tendons. 
 
 It is slowly absorbed, and at times, in cases in which the heavier 
 grade has been used, requires removal because of its persistence 
 in the tissues. It is used (small size) in herniotomy for radical 
 cure. 
 
 On the whole, its field of actual usefulness is small, the proba- 
 bilities being that it possesses no advantage over properly pre- 
 pared chromic gut in its application to soft parts and none beyond 
 silver wire with respect to 
 maintaining apposition of 
 bones. 
 
 NON-ABSORBABLE LIG- 
 ATURE MATERIAL 
 
 SILK-WORM GUT 
 
 Silk-worm gut is the 
 fiber drawn from the body 
 of the silk worm killed just 
 as it is ready to spin its co- 
 coon. It is smoother than 
 silk and is more easily 
 cleansed. It is obtainable 
 in the market in hanks 
 about fourteen inches in 
 length (Fig. 54). It can 
 be boiled without damage and is sterilized by boiling. The sim- 
 plicity of the measure for rendering it sterile recommends its use 
 when indicated. 
 
 It is used most frequently in the skin, and being of small 
 diameter, it leaves only small stitch-hole scars. It is not absorbed 
 and must be removed when healing has taken place. Its whitish 
 color renders it difficult to see after it has been in situ for a time, 
 more especially if the stitches are buried in the slight crust which 
 covers the line of incision. This has been overcome by dyeing the 
 
 Fig. 54. — Silk-worm Gut in Hank. 
 
98 
 
 SUTURE AND LIGATURE MATERIAL 
 
 silk-worm gut black. It is thus more readily found, and removed 
 with less disturbance to the patient, a desirable, if not essential, 
 refinement in surgical technic. For immediate use the gut is 
 stored, after boiling, in glass tubes, submerged in a solution of 
 bichlorid of mercury, 1 in 2,000, in 70 per cent, alcohol (Fig. 55). 
 About six sutures are placed in a single tube. 
 
 This suture is a desirable one for office use, especially in manu- 
 
 Fig. 55. — Iron-dyed Silk-worm Gut in Glass Tube. 
 
 facturing towns where the surgeon is called upon to make repair 
 of trauma in his office at short notice. 
 
 The finer grades are intended to take the place of horsehair. 
 However, very fine silk-worm gut is not as easily handled as the 
 stiffer horsehair, which still holds its place as an exceedingly use- 
 ful suture material, where accurate coaptation of wounds is 
 necessary. 
 
 It is the experience of the writer that stitch abscess occurs less 
 frequently when silk-worm gut is used in the skin than with any 
 other suture material. Its field of usefulness is only that of a 
 suture ; it is of no value as a ligature for obvious reasons, the most 
 determining of which is the fact that it cannot, because of its 
 stiffness, be tied in a close knot. 
 
 SILK 
 
 Silk for suture and ligature is obtainable in the market in two 
 forms, twisted and braided. The twisted is used for finer sutures 
 and the braided for retention suture and ligature of large pedicles. 
 Its advantages are that it is readily sterilized, easily applied, and 
 remains firmly tied. It is, however, readily infected and is not 
 absorbed. Silk is sterilized by boiling for ten minutes in a 1 per 
 cent, aqueous solution of sodium carbonate. 
 
NON-ABSORBABLE LIGATURE MATERIAL 
 
 99 
 
 Fig. 56. — Surgeons Silk Wound 
 on Cardboard. 
 
 Haegler seems to have shown that sterilization of silk by heat 
 is not sufficient, claiming that the drawing of the material through 
 the hands and the manipulations necessary to threading it on 
 needles cause reinfection. Of course this is true of all suture and 
 ligature material. It would, per- 
 haps, be fairer to say that silk, be- 
 cause of its nature, is more readily 
 infected during manipulation than the 
 smoother suture materials, a concep- 
 tion which seems rational. However, 
 if the silk is boiled immediately be- 
 fore an operation, it will be sterile, 
 and, indeed, it is suggested that silk 
 be kept wound on the cardboard as it 
 comes from the manufacturer (Fig. 
 56) and boiled with the instruments, 
 rather than sterilized in soda solution 
 and then preserved, wound on bobbins, 
 in antiseptic solution. However, if 
 the surgeon insist that sterile silk be 
 constantly available, the indications may be met, as done by 
 Kocher. 
 
 The silk is treated for twelve hours with ether and alcohol to 
 extract the fats. It is then boiled for ten min- 
 utes in a 1-1,000 solution of bichlorid of mer- 
 cury, and rolled on sterile glass spools (Fig. 
 57), after the hands have been cleansed and in- 
 cased in rubber gloves. The spools of silk are 
 then again boiled in a 1-1,000 bichlorid of mer- 
 cury solution. Various sizes of silk may be 
 arranged on spools in a glass jar arranged as 
 shown in Fig. 58, a very convenient method of 
 handling the material. The albumin of the 
 silk forms a chemical union with the mercury, 
 which is slowly extracted by the fluids of the 
 circulation in the body. The mercury grad- 
 ually disappears from the suture in from five to ten days. Haegler 
 does not believe that the small amount of mercury present in the 
 
 suture destroys bacteria, but checks their growth. 
 9 
 
 Fig. 57. — Silk on 
 Spools. (Bryant.) 
 
100 
 
 SUTURE AND LIGATURE MATERIAL 
 
 Silk, on general principle, should not be used for ligatures or 
 buried sutures. It is being less and less used as the art of pre- 
 paring absorbable suture material becomes perfected. 
 
 It has a distinct field of usefulness in intestinal surgery. For 
 this purpose, a very fine grade of silk is used, 
 and should be dyed black so as to permit of 
 closer scrutiny when being placed in situ. The 
 operative field is apt to be bloody, and white 
 silk soon takes on the color of the medium in 
 which it is being used. If a reliable absorbable 
 suture material of sufficient tensile strength and 
 as great pliability as silk were devised, an ideal 
 '' '^ N ,,, , JJIliNll intestinal suture would be achieved. 
 
 Silk is being; used for 
 
 deligating 
 
 large 
 
 pedicles and the broad ligament in salpingec- 
 tomy. It should never be used for the latter 
 purpose, and but rarely for the former. Silk 
 sutures or ligatures, while they, more especially 
 in regard to the latter, give the surgeon a feel- 
 ing of security as to the permanency of the knot, 
 give rise to adhesions, because of the prolonged 
 irritation common to all foreign bodies in the 
 tissues, and not infrequently they are the causa- 
 tive factor in intestinal obstruction following 
 celiotomy. In intestinal suturing the area of 
 exposed suture is so small as to be perhaps a 
 minor factor in this connection, yet non-absorbable suture ma- 
 terial in closed cavities is never as desirable an agent for repair 
 as the kind which is taken up by the circulating fluid. 
 
 For operations in private practice silk may be preserved in 
 glass tubes. The braided (Fig. 59) and the twisted (Fig. 60) are 
 both put up in this way. 
 
 Fig. 58. -Wide- 
 mouthed Bottle 
 for Ligatures. 
 (Bryant.) 
 
 PAGENSTECHER THREAD 
 
 Pagenstecher thread is a linen thread which has been dipped 
 in a solution of celluloid. It is readily obtained in the market in 
 skeins. (Fig. 61.) It is strong, of small diameter, is readily 
 rendered sterile, and is easily handled. It does not lose its slight- 
 stiffness when soaked in solutions, and consequently does not ravel 
 
NON-ABSORBABLE LIGATURE MATERIAL 
 
 101 
 
 as does silk when wet. It is destined to displace silk for intestinal 
 work. The only objection to its use is that it is not absorbed. It 
 is sterilized by boiling, and may be boiled for a practically in- 
 definite period of time without being damaged. Like anything 
 
 Fig. 59. — Braided White Silk in Hermetically Sealed Glass Tube. 
 
 which will stand heat, it is, of course, absolutely sterile after 
 boiling. 
 
 It may be boiled and preserved, like silk, in a glass jar (Fig. 
 48) or glass tubes (Fig. 59) submerged in bichlorid of mercury 
 
 Fig. 60. — Twisted Iron-dyEd Silk in Hermetically Sealed Glass Tube. 
 
 solution, 1-1,000, or placed in alcohol. It is advised that it be 
 boiled with the instruments immediately before operating. Twenty 
 minutes of boiling in a 1 per cent, solution of sodium carbonate 
 is sufficient for the purpose. 
 
 Fig. 61. — Pagenstecher Thread. 
 
 Its use is especially indicated in gastroenterostomy by sewing 
 only, and in entroenterostomy where a long, continuous suture 
 is employed. The large number of punctures made during the 
 sewing, each time drawing the suture through tissues, is likely to 
 
102 
 
 SUTURE AND LIGATURE MATERIAL 
 
 weaken silk at a given point and just as the suturing is about com- 
 pleted the suture breaks. This necessitates a replacement of the 
 entire suture, a very undesirable accident. The greater strength 
 of the Pagenstecher thread renders this occurrence exceedingly 
 unlikely. This feeling of security on the part of the surgeon en- 
 genders a certain complacency which is not disagreeable. On the 
 whole, the Pagenstecher thread is an exceedingly valuable material 
 for the purpose mentioned. 
 
 HORSE HAIR 
 
 Horse hair is used for apposing wounds of the face and neck 
 where cosmetic effect is an important consideration. It is also 
 used in repairing hare lip. The hair is extracted from the tail 
 of the horse, is washed in soap and water, and boiled for an hour 
 in 95 per cent, alcohol, when it is ready for use. It can be pre- 
 
 Fig. 62. — Silver Wire in Hermetically Sealed Glass Tube. 
 
 served in a glass jar (Fig. 48) or glass tubes (Fig. 59) submerged 
 in alcohol. 
 
 It is very easily handled, does not ravel, and because of its 
 fineness may be threaded on exceedingly small needles. The lat- 
 ter qualification means small and, at times, quite invisible stitch- 
 hole scars. Its black color renders it easily located when about to 
 be removed. 
 
 SILVER AND GOLD WIRE 
 
 Silver and Gold wire are used to hold in apposition fragments 
 of bone. Silver wire is most commonly used for the purpose. It 
 has, on occasions, been used to hold soft parts in apposition, such 
 as the cervix uteri after trachelorrhaphy, and as a deep suture fol- 
 lowing plastic repair of the female perineum. Other material 
 has, however, taken its place in almost all instances except for the 
 
NON-ABSORBABLE LIGATURE MATERIAL 103 
 
 purpose of holding together divided bones. Gold wire is at times 
 used in plastic repair of the nose. 
 
 Silver wire is, of course, readily sterilized by boiling. Twenty 
 minutes of boiling in a soda solution, such as is used for sterilizing 
 instruments, is sufficient to achieve the purpose. 
 
 It is, perhaps, at times found convenient to preserve the wire 
 in much the same manner as silk-worm gut. In these instances it 
 may, after boiling, be placed in hermetically sealed glass tubes 
 (Fig. 62) and treated as this class of vehicles all are, immediately 
 before the operation. 
 
CHAPTEE V 
 WATER AND CLEANSING SOLUTIONS 
 
 Water: Sterilization of water — Apparatus for sterilization of water — Outfit 
 for sterilization — Handling of water during operations. 
 
 Antiseptic Solutions: Carbolic acid — Mercury — Zinc chlorid, etc. — Thiersh's 
 fluid — Peroxid of hydrogen — -Plain sterile water — Saline solution. 
 
 WATER 
 STERILIZATION OF WATER 
 
 Absolutely sterile water is a necessity in operative teclmic. 
 It is obtained with greater difficulty than would appear. Chem- 
 ically pure water for lavage and cleansing is not a necessity, 
 though when water is to be used to hold chemical agents in solu- 
 tion it had best be chemically pure to obviate chemical precipita- 
 tion and, perchance, the introduction into wounds or the circula- 
 tion of insoluble chemical agents which may act as foreign bodies. 
 
 Water in which all microorganisms are destroyed in the vessel 
 from which it is drawn for immediate use achieves this object. 
 All other methods of sterilization are faulty. 
 
 Distilled water has the advantage of being transparent, though 
 the apparatus necessary for distillation is not readily kept sterile, 
 and the simple distillation of water is not sufficient for the pur- 
 pose of sterilization. 
 
 Muddy water may be sterile, though the foreign bodies may 
 be removed by filtration, and, indeed, should be. However, in an 
 emergency it would be wiser to use cloudy sterilized water than 
 to act on the notion that, because water is clear, it is clean. Where 
 water is used to fill cavities for examination, such as in cystoscopy, 
 distilled and sterilized water is advantageous. In large hospitals 
 and institutions distilling plants are installed and a large quan- 
 tity of distilled water is constantly available. If this be sterilized 
 it is of signal service for surgical purposes. 
 
 104 
 
WATER 
 
 105 
 
 APPARATUS FOR STERILIZATION OF WATER 
 
 For the purpose of sterilizing water two kinds of apparatus are 
 available. A, one which sterilizes water at the boiling point, 212° 
 F., and B, one which sterilizes water at a temperature higher than 
 the boiling point. The latter is the more certainly effectual. 
 
 For ordinary purposes, in minor or emergency surgery, water 
 boiled in a clean vessel for twenty minutes and used immediately 
 is practically sterile. Indeed, a 
 tin kitchen boiler placed on a gas 
 stove and the contents boiled as 
 stated will answer the purpose. 
 However, for office work and in 
 smaller institutions and dispen- 
 saries, the apparatuses shown in 
 Figs. 63 and 64 are recommended. 
 
 Fig. 63 shows an apparatus 
 exceedingly useful for physician's 
 office use, more especially for the 
 genito-urinary cases. The appa- 
 ratus sterilizes the water abso- 
 lutely and is constructed to with- 
 stand pressure of 50 pounds to the 
 square inch. To fill, the water is 
 poured into the funnel and the 
 quantity noted on the water gauge. 
 The burner beneath is then lighted 
 and the water heated until steam 
 
 issues from the funnel, when the valve is screwed down. Suffi- 
 cient steam pressure will then be generated to blow off safety valve 
 which is set at 15 pounds or 250° F. This temperature is main- 
 tained for fifteen to twenty minutes for absolute sterilization. The 
 capacity of the apparatus should be about two gallons. 
 
 Fig. 64 shows an apparatus similar to Fig. 63, except that the 
 water is not subjected to pressure. If the contents be heated to 
 boiling for twenty minutes, the water is practically sterile, but 
 this apparatus is not so certain in its results as the former (Fig. 
 63). 
 
 The objection to the steam pressure sterilizer (Fig. 63) is 
 that the water is liable to be either too hot or too cold when about 
 
 Fig. 63. — Apparatus for Steriliz- 
 ing Water under Pressure, 
 for Use in Surgeon's Office 
 or Small Dispensary. 
 
106 
 
 WATER AND CLEANSING SOLUTIONS 
 
 to be used. This is obviated in the apparatus shown in Fig. 65 
 by a coil within the tank, which may be connected with the cold 
 water tap. In this way the temperature of the water may be 
 modified, its range being indicated by a thermometer affixed to 
 
 the apparatus. This apparatus is de- 
 vised for office use and answers the 
 purpose very well. 
 
 Neither of these apparatuses per- 
 mits sufficient elasticity with respect to 
 the adjustment of the temperature of 
 water, which is essential to the best 
 possible work. The contingencies met 
 in operative work are well met by the 
 apparatus shown in Figs. 65 and 66. 
 
 The hydrant water supply is di- 
 rectly connected to filter M at point E. 
 The filter itself consists of a natural 
 porous stone bougie which can be taken 
 out of the metal mantle for purpose of 
 cleaning and be placed back into posi- 
 tion by releasing top, which is held 
 tight to cylinder by a heavy metal 
 clamp N. 
 
 There are two outlets F F for the 
 filtered water leading into the two 
 tanks ; both are provided with a valve. 
 These valves may both be opened at 
 the same time, or one tank may be 
 filled first and then the other. As 
 soon as the gauge glasses K K on the 
 sides of tanks indicate that the latter 
 are filled as far as gauge glasses regis- 
 ter, the water has to be turned off by closing the respective valves 
 leading from filter to tank. When both tanks are filled, first shut 
 off water supply valve E leading to filter, and then close valves 
 F F leading from filter to tanks. 
 
 The heating of the water in the tanks is now begun. The 
 steam pressure safety valve W, on dome top of tanks, is always 
 get at 15 pounds pressure, and as soon as this point is reached it 
 
 Fig. 64. — Water Sterilizer 
 Suitable for Emergency 
 Service. 
 
WATER 
 
 107 
 
 will blow off steam and maintain a boiling temperature of 250° 
 F., the equivalent of 15 pounds steam pressure. Water has to 
 be kept at this boiling point for from twenty to thirty minutes, 
 whereupon the gas or petroleum heaters G G have to be turned 
 
 Fig. 65. — Apparatus for Sterilizing and Cooling Sterile Water under 
 Pressure, for Use in Hospitals and Large Dispensaries. 
 
 out or, in the case of steam-heated apparatus, the high-pressure 
 boiler steam be shut off by closing valves A A and B B. 
 
 Contents of the tanks can now be considered absolutely sterile, 
 but the water is too hot to be available for immediate use. In 
 order to facilitate an instantaneous cooling of the hot sterilized 
 water, a cooling coil has been arranged in one of tanks marked 
 
(TOr^CW 
 
 a 
 
 KNY-SCHEERERCQl 
 N.Y 
 
 Fig. 66. — Sectional View of Apparatus Shown in Fig. 65 
 
 108 
 
WATER 109 
 
 "Cold" (Fig. 65). It consists of a heavily tinned copper coil, 
 placed in the upper part of the tanks, into which is turned a flow 
 of cold hydrant water, by admitting water at point D and provid- 
 ing for water off-flow at point C. Within from ten to twenty min- 
 utes the boiling-hot sterile water in the cylinder marked " Cold " 
 will have been cooled clown to within a few degrees above that of 
 the hydrant water used for cooling. The sterilized water contained 
 in this tank can be nsed immediately and be tapped by faucet in 
 front. Water and container both are strictly sterile, and to main- 
 tain this state of absolute sterility, an air-filtering valve XX, 
 filled with absorbent cotton is placed on dome top of each tank. 
 As water is drawn out of tanks, the air enters the latter through 
 the bacteriological filter X, the absorbent cotton in which should 
 be renewed frequently. 
 
 Tank marked " Hot " (Fig. 65) has no cooling coil, but its 
 contents are allowed to gradually cool down. By drawing from 
 both tanks, sterile water of any desired degree of temperature can 
 be obtained by mixing. If temperature of sterilized water should 
 become too low, the heating medium may be started to raise it to 
 the desired point, which can be controlled by consulting a ther- 
 mometer H in front of each tank, and accordingly regulating 
 heat supply. 
 
 Attention has already been called to the fact that hydrant 
 water, even though it may be crystal clear after passing through 
 the filter, will become cloudy when being boiled under high tem- 
 perature. Gradually the cloudiness will form precipitates which 
 settle on the bottom of the tank. To draw off these precipitates 
 a faucet is provided, flush with the lowest point in bottom of the 
 cylinder, while the draw-off cock for sterile water for surgical 
 purposes in front of the tank is about two inches above bottom. 
 
 To clean the sterilizer tanks thoroughly (which should be 
 done every three months), remove filtering stone from metal 
 jacket M, fill the latter with sal soda and proceed exactly as if 
 you were sterilizing water. The tanks should then be emptied 
 while under pressure by opening the flushing valves under the 
 tanks. 
 
 Special attention is drawn to the fact that safety valves W W 
 are always set at 15 pounds pressure per square inch when the 
 sterilizers are ready for use. They should never be tampered with 
 
110 
 
 WATER AND CLEANSING SOLUTIONS 
 
 by inexperienced hands, as by tightening the set screws the amount 
 of steam pressure in tank may be increased beyond the point of 
 safety. 
 
 OUTFIT FOR STERILIZATION 
 
 Fig. 67 shows a plan of installing a complete sterilizing plant, 
 as is employed in a large hospital. The outfit consists of a dress- 
 ing sterilizer A, a water sterilizer B ? an instrument sterilizer C, 
 an utensil sterilizer for the purpose of subjecting to steam press- 
 
 a b c d e 
 
 Fig. 67. — Complete Sterilizing Outfit Assembled for Use lx Large 
 
 Hospital. 
 
 lire pans, basins, irrigation containers, etc., D, and a blanket 
 warmer E. 
 
 This plan provides for the necessary heat to be drawn from 
 either the steam power plant of the building or from gas Bunsen 
 burners attached directly to the various apparatuses. The former 
 plan is effective, and the necessary temperature is quickly avail- 
 able. However, the fact that steam power plants are rarely in- 
 stalled in duplicate, even in the largest hospitals, and that at 
 times the boilers are shut down for repair and cleansing, sug- 
 gests that the direct heating plan has its redeeming features. 
 Also, the necessity of leading the steam through the hospital 
 building during the summer months is objectionable, especially 
 in regions where the climate is very warm. If feasible, the plant 
 should be set up in a room adjoining the operating room, with 
 
WATER 
 
 111 
 
 the view of obviating the enervating influence of excessive tem- 
 perature upon the patient and the surgeon during operations. 
 
 As stated farther on, the instrument and utensil sterilizer 
 may be placed in the operating room, so that immediate steriliza- 
 tion of appliances during the operation is possible without the 
 necessity for the assistant in charge of this portion of the work 
 leaving the zone of operation. 
 
 The sterile water tanks are readily connected with the operat- 
 ing room by piping the outlets through the partition separating 
 the chamber used for the purpose from the operating room. 
 
 The utensil sterilizer, instrument sterilizer, and the dressing 
 sterilizer are described under separate heads. 
 
 Tig. 68 shows a diagrammatic scheme of the water, instrument, 
 
 DREssims Sterilizer 
 
 Hater Sterilizer 
 
 Ihstrvment Sterilizer Utensil Sterilizer. Blanket Warmer. 
 
 B B ff ff 
 
 Ground Plan- 
 
 Fig. 68. — Plan of Sterilizing Plant for Use in Large Hospitals. 
 
 utensil sterilizer and blanket warmer. The upper diagram shows 
 the plant in profile section, the lower in transverse section. This 
 plant is arranged for obtaining heat from either the steam power 
 plant or from gas Bunsen burners. This arrangement is very de- 
 sirable, overcoming, as it does, the objections to employment of the 
 single source of heat mentioned above. 
 
112 
 
 WATER AND CLEANSING SOLUTIONS 
 
 This plant is an elaborate one, and has a large field of use- 
 fulness. It illustrates the principle involved, and in instances 
 where this refinement is not available, forms the basis of modifi- 
 
 Fig. 69. — Combined Water, Dressing and Instrument Sterilizers Conven- 
 iently Assembled for Use in Surgeon's Office. 
 
 cations in detail which may be necessary as the outcome of cir- 
 cumstances. 
 
 For use in the surgeon's office the outfit shown in Fig. 69 is 
 very useful. It is in all respects similar to that described with 
 
WATER 
 
 113 
 
 Fig. 70. — Convenient Arrangement of Pitchers Containing Sterile Water 
 and Solutions for Use During the Operation. 
 
 regard to the dressing, water, and instrument sterilizers, except 
 that it is arranged on a stand to conserve space and subserve 
 availability. In this 
 connection it is proper 
 to state, as applies also 
 to the hospital outfit, 
 that modification of ap- 
 paratus is permissible, 
 provided the principles 
 involved are adhered to. 
 The water tanks are 
 arranged to sterilize the 
 contents in each tank, 
 one of which is fitted 
 with the cooling coil 
 (Fig. G6). Each tank 
 has a capacity of about 
 six gallons, and the 
 dressing sterilizer is of 
 sufficient capacity to 
 sterilize at one sitting 
 enough material to suf- 
 fice for a single major 
 operation, or enough 
 
 Fig. 71. — Method of Handling Sterile Water 
 or Solution in Pitcher without Contami- 
 nating Contents. 
 
114 
 
 WATER AND CLEANSING SOLUTIONS 
 
 sponges, towels, gauze, etc., for office use for several days. The 
 instrument boiler is 8 inches wide, 6 inches deep, and 15 inches 
 in length, giving an internal capacity sufficient for all practical 
 purposes. 
 
 HANDLING OF WATER DURING OPERATIONS 
 
 Water is handled during operations by the non-sterile nurse 
 or attendant. Whatever the apparatus employed for sterilizing 
 
 Fig. 72. — Drawing Sterile Water without Risk of Contamination. 
 
 water for surgical purposes may be, be it either a tin wash boiler, 
 a basin, or an elaborate plant, such as described, it is essential to 
 avoid contamination during transportation from the receptacle 
 used to the wound. 
 
 The attendant who handles sterile material during an opera- 
 tion cannot safely handle pitchers, irrigators, etc., and although 
 this matter is taken up under operating-room technic, attention 
 is called to it in this connection. Perhaps the most desirable and 
 
WATER 115 
 
 elastic method of handling water is in pitchers. The pitchers are 
 sterilized by boiling (page 151), and arranged on a table of con- 
 venient size. It is preferable to have available three pitchers of 
 white enamel for the purpose, the larger two for pouring the 
 
 
 V 1 
 
 
 ^ i m 
 
 
 
 ■c 
 
 
 
 ft 
 
 
 M m 
 
 
 
 
 
 \ 1 
 
 BK *" 1WM " 
 
 Fig. 73. — Wrong Way to Hold Basin Containing Sterile Water or 
 
 Solution. 
 
 contents on the field of operation, and the second, a somewhat 
 smaller one, for replenishing the larger two. The larger ones 
 should hold a gallon, and the smaller half that quantity. 
 
 A convenient arrangement of pitchers is shown in Fig. 70. 
 It will be seen that each pitcher is covered with a sterile towel 
 fastened to the handle of the pitcher, and has a safety pin at- 
 tached at the lip side of the pitcher. In order to fill the vessel, 
 the nurse takes the pitcher by the handle, grasps the safety pin 
 10 
 
116 WATER AND CLEANSING SOLUTIONS 
 
 with the other hand (Fig. 71), and throws the towel hack over 
 the hand on the handle. The hand released from the safety pin 
 now turns the faucet of the water tank, and the pitcher is filled. 
 At no time do the hands come in contact with the water or with 
 
 Fig. 74. — Proper Way of Holding Basin with Sterile Contents. 
 
 apparatus in contact with water (Fig. 72). When the contents 
 of the pitcher are to he applied to the operation field the same 
 procedure as shown in Fig. 71 is employed. 
 
 In the event of a tin hoiler or other apparatus being used, the 
 hand corresponding to the one turning the faucet is employed in 
 tilting the receptacle. If a basin be used, care should be taken 
 not to allow the thumbs to encroach on the inside (Fig. 73), but 
 the basin must be held as shown in Fig. 74. The temperature of 
 
ANTISEPTIC SOLUTIONS 117 
 
 water and watery solutions employed for surgical purposes should 
 not be left to guessing. For purposes of accuracy an ordinary 
 bath thermometer is of practical use (Fig. 42). The apparatus 
 is sterilized by prolonged immersion in mercuric chlorid solu- 
 tion 1 in 1,000. The thermometer is placed in the pitcher or 
 other apparatus by lifting the sterile towel by the safety pin. 
 The nurse handles the thermometer, carefully avoiding contact 
 with all except the handle, which it is, of course, not necessary to 
 place in the pitcher. 
 
 ANTISEPTIC SOLUTIONS 
 
 Solutions destined to destroy bacteria by chemical action are 
 of doubtful utility. Chemical agents of sufficient strength to de- 
 stroy bacteria have a deleterious effect upon tissue. As a general 
 rule, solutions containing antiseptics require one hour in which to 
 destroy bacteria. However, these agents inhibit the growth of 
 bacteria, and when used in conjunction with other means of steril- 
 ization have a distinct place in surgical technic. The most valu- 
 able function antisepsis and antiseptic solutions fill is in the 
 disinfection of instruments and apparatus which come in contact 
 with the wound. They are of service in cleansing the skin of the 
 patient and the surgeon's and assistant's hands. 
 
 CARBOLIC ACID 
 
 Carbolic acid, mentioned first by right of seniority, is very 
 frequently employed for the purpose. It is cheap, readily obtained, 
 and in strong solution quite effective. Since it has been deter- 
 mined that alcohol neutralizes its caustic effect when the latter is 
 applied early after the former, it is used extensively undiluted. 
 When pure carbolic acid is applied to a surface it must be dis- 
 placed by a large amount of alcohol within a few moments after 
 its application. If too long a time be allowed to elapse, the alcohol 
 is no longer effectual. It is also necessary to use a large quantity 
 of alcohol to accomplish the purpose. In solution, carbolic acid is 
 used in the following proportion : 
 
 Carbolic acid crystals 1 part. 
 
 Alcohol 1 part. 
 
 Sterile water 20 parts. 
 
118 WATER AND CLEANSING SOLUTIONS 
 
 In this proportion carbolic acid is used for washing the skin and 
 for immersion of instruments during an operation in an infected 
 case. Prolonged contact with the hands constringes the tissues, 
 produces anesthesia, and is not infrequently followed by annoy- 
 ing dermatitis. For purposes of cleansing, weaker solutions are 
 used, though not as effective as the stronger. 
 
 Sterile water 40 parts. 
 
 Alcohol 1 part. 
 
 Carbolic acid crystals 1 part. 
 
 Carbolic acid solutions have a certain field of usefulness, es- 
 pecially under conditions where asepsis is not readily obtained. 
 Occasional lavage of the hands or soiled instruments in a solution 
 of carbolic acid during the operative procedure is a useful indul- 
 gence. Towels wrung out in a solution of carbolic acid, 1 in 40, 
 are used to cover portions of the body contiguous to the operation 
 field and, while not intended to take the place of towels sterilized 
 by heat, are valuable supplementary agents during prolonged 
 operations undertaken for the relief of infection. It is compre- 
 hensible that a towel sterilized by heat is more readily contami- 
 nated by contact with infective material than one which is satu- 
 rated with carbolic acid solution after heat sterilization. 
 
 During the operation, instruments are placed on the parts sur- 
 rounding the operation field and, although these areas are covered 
 with sterile towels, it is not amiss to cover these with towels treated 
 as mentioned, at intervals. This applies equally well to antisep- 
 tics other than carbolic acid. In operations undertaken under con- 
 ditions where a large supply of sterile towels is not available, such 
 as not infrequently obtains in private practice in the country, this 
 should be borne in mind, and perhaps will meet very effectually 
 the indications during an emergency. 
 
 For practical purposes a concentrated solution of carbolic acid 
 is kept in a stock bottle and a certain quantity of this added to the 
 water in accordance with the capacity of the vessel employed and 
 the strength of the solution it is desirable to use in a given instance. 
 It is to be borne in mind that carbolic acid is heavier than water 
 and does not dissolve rapidly. The water and acid should be thor- 
 oughly mixed before using the solution, to avoid collection of the 
 latter at the bottom of the receptacle, thus preventing contact of 
 
ANTISEPTIC SOLUTIONS 119 
 
 the acid with the wound as the last of the mixture comes in con- 
 tact with it. Especially is this true when carbolic acid solutions 
 are used in an irrigator. If the carbolic acid be poured into the 
 irrigator last, after the water, it gravitates to the rubber tube and 
 is expelled first in concentrated form. Under these conditions the 
 solution is best made in a pitcher first, and after being dissolved 
 poured into the irrigator. 
 
 MERCURY 
 
 Mercury is perhaps the most universally used antiseptic. It 
 is employed in solution of 1 in 1,000 to 1 in 10,000, according to 
 the purpose for which it is designed. It is cheap, effective, in- 
 odorous, and will keep indefinitely. It is poisonous, however, and 
 should not be left in contact with raw surfaces nor allowed to stay 
 in large cavities for fear of mercurialization. It is not uncommon 
 to see salivation and, indeed, even sloughing of the oral mucosa 
 follow its indiscriminate use in wounds of large area. The salts 
 of mercury, chiefly the bichlorid, are used combined with sodium 
 bicarbonate to avoid chemical change in the salt and to enhance 
 solubility. 
 
 For use, the salts are kept in concentrated solution to be diluted 
 to the required extent at the time of operating. However, the 
 most convenient form is that of a tablet containing 
 
 Mercury bichlorid grs. 1h 
 
 Sodium bicarbonate grs. 7 A 
 
 The sodium carbonate may be replaced with sodium borate or 
 ammonium chlorid. 
 
 One of these tablets to a pint of water makes a solution of 
 1 in 1,000. The modification of relationship to the solvent to con- 
 form to the necessities is purely a matter of mathematics. The 
 manufacturers put the tablet up together with a small amount of 
 aniline dye, which, when the tablet dissolves, renders the solution 
 blue. This avoids mistakes in identifying the solution during the 
 operation, differentiating it from others prepared at the same time. 
 
 Again, on occasions, the white bichlorid of mercury tablets 
 have been mistaken by children for confections and swallowed 
 with fatal result. It is advised that the colored tablet be employed. 
 Corrosive sublimate is the form of mercury most generally used. 
 
120 WATER AND CLEANSING SOLUTIONS 
 
 It is effective, as stated, but has an exceedingly pernicious effect 
 upon instruments. To obviate this the mercuric iodid is used, 
 which is quite devoid of deleterious influences in this regard. 
 
 Mercuric iodid % gr. 
 
 Sod. bicarb 16 grs. 
 
 One tablet dissolved in four ounces of water makes a 1 in 5,000 
 solution. 
 
 Mercuric iodid in 1 in 5,000 solution is as effective in destroy- 
 ing bacteria as bichlorid of mercury in a solution of 1 in 1,000. 
 It does not coagulate albumin and does not corrode instruments. 
 
 The mercuric iodid disk, or tablet, is the outcome of work done 
 by McClintoch. 
 
 Cumston advises the following: 
 
 Mercury cyanid gm. .50. 
 
 Sodium borate c. p gm. 1.0. 
 
 This tablet dissolves very readily and is regarded as more certainly 
 effective than either the bichlorid or iodid of mercury. One tablet 
 to a pint of water makes a solution of 1 in 1,000. 
 
 ZINC CHLORID, ETC. 
 
 Solutions of chlorid of zinc, 1 in 15; iodin, 1 in 500; sulpho- 
 carbolate of zinc, 1 in 80 ; a saturated solution of boracic acid, 
 sulphurous acid, 1 to 2, or a saturated solution of iodoform in ether 
 have been used for cleansing wounds. They are, however, rarely 
 used for cleansing the operation field, and while possessed of some 
 antiseptic virtues, are not by any means as effectual in preventing 
 infection as the agents mentioned. 
 
 Their particular field will be discussed in the treatment of 
 postoperative wound infection. 
 
 TRTERSH'S FLUID 
 
 Thiersh's Fluid is composed of one grain of salicylic acid and 
 six grains of boric acid to the ounce of water. As can be seen from 
 its composition, it is not antiseptic. It is used for cleansing ser- 
 ous and mucous membranes, such as the peritoneum, joint cavities, 
 the conjunctiva, the mucosa of the mouth, etc. It is best, made 
 
ANTISEPTIC SOLUTIONS 121 
 
 freshly just before using, the powder being arranged so as to have 
 sufficient of the soluble ingredients to make a pint of the solution 
 in the proportions mentioned, i.e., 16 grs. of salicylic acid and 96 
 grs. of boric acid are placed in a packet, and when dissolved in a 
 pint of sterile water make the proportion stated. 
 
 PEROXID OF HYDROGEN 
 
 Peroxid of Hydrogen, while not employed to cleanse the field 
 of operation in clean cases, should be on hand to neutralize in- 
 fective substances met in operations on infected cases. Peroxid 
 of hydrogen owes its bactericidal qualities to its deoxidizing 
 properties. 
 
 It consists of water with an added atom of oxygen. The lat- 
 ter is but unstably associated and is apt to be lost if the container 
 be not very firmly stoppered. When in contact with the wound, 
 an active effervescence takes place, which is believed to cause pene- 
 tration of the liquid into remote portions of the operative field, and 
 to mechanically dislodge offending substances, at the same time 
 acting as a germicide. Heat destroys its efficacy. It is, therefore, 
 slightly warmed before use, by immersing the container in hot 
 water for a short time. When once the container has been opened, 
 the contents soon become ineffective, and it is recommended that 
 small receptacles be on hand which contain the amount to be used 
 at a sitting and to conserve economy. 
 
 When applied to cavities with small openings, provision should 
 be made for ample return of the liquid, as the effervescence is likely 
 to invade surrounding healthy tissue and thus infection be spread. 
 It is used either pure or diluted 25 to 50 per cent, with sterile 
 water. It is only moderately germicidal in the pure state. It is 
 advised that it be used undiluted. As an antiseptic it does not take 
 the place of carbolic acid nor mercuric chlorid. It is useful, how- 
 ever, in replacing these in situations where the antiseptics men- 
 tioned are irritating. 
 
 PLAIN STERILE WATER 
 
 Sterile water, when brought in contact with the tissues, ex- 
 tracts from them certain constituents which are essential to it. 
 Tissue lavaged with plain water decolorizes. This is true both 
 of wounds and untraumatized membranes. The part that the in- 
 
122 WATER AND CLEANSING SOLUTIONS 
 
 organics play in nutrition is unknown, yet it is proven that they 
 are essential to life. Mechanically sterile water is an ideal cleans- 
 ing fluid. It is cheap, may be obtained in indefinite quantity, and 
 by the process of dilution removes infective substances from the 
 wound or normal tissues. However, it may be regarded as hungry 
 for something to hold in solution, a quality which is objection- 
 able in surgical technic. If this quality applied only to infective 
 material it would be an exceedingly fortunate circumstance, but of 
 course water is not selective in its action and attacks all substances 
 with which it comes in contact, few of which effectually withstand 
 the effect of its prolonged contact. 
 
 SALINE SOLUTION 
 
 The addition of salt to water overcomes to a considerable 
 extent the objection mentioned in connection with sterile water. 
 JSTo doubt some mechanical law is conserved by the addition of 
 sodium chlorid to sterile water. Saline solution is made by dis- 
 solving in a quart of filtered water, sterilized at a temperature of 
 240° F., a dram and a half of sodium chlorid. 
 
 The sodium chlorid should be chemically pure and sterile. 
 The latter is achieved by heat. It is not sufficient to sterilize the 
 salt to render it harmless. All foreign substances must be removed, 
 and, though this is regarded as accomplished by using the chem- 
 ically pure preparation, close scrutiny of the solution shows fine 
 particles suspended in the mixture. These must be removed by 
 filtration after the solution is made. More especially is this true 
 if the solution is to be used for intravenous injection or hypoder-. 
 moclysis for the relief of shock (page 259). Having on hand 
 a concentrated solution in sealed tubes (Fig. 40) overcomes all 
 objections. These tubes are filled with solution prepared as here 
 recommended, the tubes are easily sterilized by boiling, and are 
 opened and the contents diluted to the desired extent at the time 
 of the operation, with sterile water. 
 
 Solutions of sodium chloric! may be permitted to remain in 
 contact with living tissues for a considerable period of time with- 
 out deleterious effect. Of course the solution has no bactericidal 
 qualities, and its sphere of usefulness is quite restricted to mechan- 
 ical cleansing of the operative field. It is largely used for the 
 purpose of lavaging clean wounds, especially those which involve 
 
ANTISEPTIC SOLUTIONS 123 
 
 invasion of serous cavities and the mucosa of the stomach and 
 intestines. 
 
 When infection is present, it should not be used except for the 
 occasional, intermittent removal of antiseptic solutions. It is 
 probable that, when infection exists, the prolonged contact of saline 
 solution with the wound area promotes infection, on the ground 
 that a condition of affairs is present which favors bacterial flora. 
 The lavage of normal tissues with saline solution stimulates nutri- 
 tive processes, a conception borne out by the fact that fertilization 
 of the ova of the lower forms of animal life is conserved by the 
 presence of salt solution. The latter proposition has been amply 
 proven by painstaking experimentation. 
 
 It is quite probable that in surgery the use of large quantities 
 of saline solution in a clean wound is not objectionable on this 
 score, yet it is also probably true that the tendency has been to 
 use indiscriminately a new method of cleansing wounds without 
 proper regard for the actual problem presented in a given case. 
 On general principles, it may be said that saline solutions should 
 not be employed for the purpose of cleansing infected wounds 
 except in the manner stated above, and in all instances of this sort, 
 it should be finally displaced by a mildly antiseptic solution, such 
 as carbolic acid or corrosive sublimate. In no instances should 
 saline solution be permitted to remain in an infected cavity, proper 
 and useful as the measure may be when infection is not present. 
 
CHAPTER VI 
 THE PREPARATION OF OPERATOR AND ASSISTANTS 
 
 The operating suits — Cleansing of the hands — Canton flannel gloves — Gowns — 
 Gloves during operation — Caps and masks. 
 
 It seems hardly necessary to dwell on the question of personal 
 cleanliness as applied to practitioners of surgery. However, in 
 private practice the surgeon not infrequently calls upon unskilled 
 assistants who are likely to assume that when they are covered 
 with a sterile gown during the operation, all other precautionary 
 measures are unnecessary. Indeed, it not infrequently happens 
 that the surgeon slips the operating gown over his waistcoat and 
 regards this measure as sufficient modification of attire to meet 
 the indications. 
 
 In this connection it is to be remembered that infection is a 
 question of dosage of fertilization and the gown worn during 
 operating soon becomes soiled with the mixture of solutions and 
 secretions from the operation field. These soon soak the gown, 
 and when the latter is permitted to come in contact with clothing 
 worn underneath, the hands are liable to come in contact with 
 the soaked area and thus become contaminated from infective 
 material beneath the gown. 
 
 The surgeon and assistants should take a complete bath at a 
 time as near the hour set for operating as possible. In hospital 
 practice this is perfectly feasible. However, in private practice, 
 when operations are performed in private houses or in the coun- 
 try, this is not always possible. As a matter of discipline, how- 
 ever, the surgeon should arrange the hour of taking a complete 
 bath in such a way as to permit as short a time as is feasible to 
 elapse between the taking of the bath and the operation. 
 
 Particular attention should be paid to hair and beard (page 
 137). 
 
 124 
 
THE OPERATING SUITS 
 
 125 
 
 THE OPERATING SUITS 
 
 It is the custom in private practice, and it not infrequently 
 happens in hospital work, for the surgeon to remove his coat, 
 waistcoat, and shirt, and slip a rubber apron over the rest of the 
 attire. In hospital practice this is 
 usually the habit on part of the visit- 
 ing- surgeon, the assistants in the form 
 of the house staff being attired in 
 freshly laundered duck suits. The 
 writer advises against this habit on the 
 part of the operator. In private prac- 
 tice the method of procedure stated is 
 carried out both by the surgeon and 
 his assistants, chiefly for lack of other 
 means at command under the circum- 
 stances. As a general rule, the 
 method is effective enough. ISTo one 
 would refrain from operating because 
 refinements in this connection were 
 not available. However, the proper 
 and safe attire of the surgeon and as- 
 sistants is so easily obtained and trans- 
 ported as to make it a matter of but 
 little discomfort to take the necessary 
 precautions. 
 
 It is recommended that the sur- 
 geon disrobe completely and replace 
 the street clothes with a canvas or 
 duck suit, consisting of loosely fitting 
 trousers held in place with a draw- 
 string at the waist and a sleeveless blouse tied with tapes in front. 
 The feet should be incased in canvas rubber-soled shoes (Fig. 75). 
 
 This outfit is easy to cleanse, does not take up much room, 
 and can be placed in the bag carrying other necessities. It is 
 worn next the skin, and when the operation is completed, the 
 surgeon replaces it with his original attire, which is not soiled, is 
 dry and clean, and promotes a feeling of comfort and cleanliness 
 which is not disagreeable. ISTot infrequently the surgeon leaves 
 
 Fig. 75. — Linen or Duck Suit 
 Worn by Surgeon. 
 
126 PREPARATION OF OPERATOR AND ASSISTANTS 
 
 the operating room with wet underwear and bespattered shoes 
 and goes out into the streets in a condition favorable to contract- 
 ing bronchitis or worse, to say nothing of the disagreeable im- 
 pression made by the bespattered shoes and odorous disinfectant 
 and ether-impregnated clothing. 
 
 It will be seen that the attire shown in the illustration is held 
 in place by tapes. The operating suit has to be relaundered after 
 each operation, and if provided with buttons these are very likely 
 to be broken or torn off in the process of washing and ironing. 
 For this reason it is best to use tapes for the purpose. The rub- 
 ber-soled shoes are desirable, as it not infrequently happens that 
 irrigating and cleansing solutions flow to the floor during opera- 
 tions, and the surgeon is compelled to stand in a messy pool. The 
 shoes are worn without socks, and are carefully cleansed after 
 each operation. 
 
 The attire of the surgeon and assistants should be completed 
 outside the operating room. . In hospital practice a special cham- 
 ber is set aside for this purpose. The surgeon disrobes, and the 
 operating suit is placed in a convenient place ready for wear. 
 
 In private practice a chamber contiguous to the operating 
 room is used for the purpose, and the operating suit, wrapped in 
 a muslin container, is removed from the bag by the nurse and 
 the surgeon puts it on. The last visit of the operator to the pa- 
 tient just before narcosis begins should, however, be made in 
 street costume in order not to arouse apprehension which the 
 operating suit would be liable to cause, were the surgeon or -his 
 assistants to present themselves in a garb so indicative of their 
 work. 
 
 The surgeon and assistants, after attiring themselves in the 
 manner stated, are now ready to make the final preparation for 
 the surgical manipulation. 
 
 CLEANSING THE HANDS 
 
 In some hospitals, and at times in private practice, the me- 
 chanical cleansing, i.e., the scrubbing of the hands and forearm, 
 is performed in a chamber contiguous to the operating room. 
 The writer regards the performance of this act best done in the 
 operating room. In private practice this is quite impossible, as 
 
CLEANSING THE HANDS 
 
 127 
 
 few, if any, extemporized operating rooms have running water 
 connections. In hospitals this is, of course, provided for. Again, 
 in some hospitals the entrance to the operating room is provided 
 with a swing door which permits of access without contact of the 
 hands. However, the less possibility there is of contact with ex- 
 trinsic substances after the cleansing of the hands is begun the 
 better. The basin used should be roomy and should permit of 
 submersion of the entire hands and forearms. 
 
 For convenience, a table is placed beside the wash basin hold- 
 ing a glass jar with sterile brushes, orange sticks, and a nail file 
 submerged in a solution of carbolic acid 1 in 100, a jar of green 
 soap, and two enameled dishes, one containing chlorid of lime 
 and the other sodium carbonate (Fig. 76). A large quantity of 
 
 Fig. 76. — Table with Material for Cleansing Hands. 1, Tray with calcium 
 chlorid; 2, Tray with sodium carbonate; 3, Jar containing nail brushes and 
 orange sticks; 4, Ordinary toilet soap; 5, Jar of green soap. 
 
 water and a liberal amount of soap should be employed. The 
 normal epidermis is most thoroughly impregnated with bacteria, 
 and the object of the scrubbing is not to destroy the bacteria, but 
 to remove them, and this can only be done by removing a portion 
 of the epidermis. Consequently it is advised that the hands be 
 permitted to remain in warm water for a few minutes before the 
 soap is applied and thus the epidermis be macerated and in a con- 
 dition favorable to removal. This manipulation should take 
 place in a roomy wash basin, the supply cocks of which are ma- 
 nipulated by the foot (Fig. 77). The illustration shows a de- 
 
128 
 
 PREPARATION OF OPERATOR AND ASSISTANTS 
 
 sirable arrangement in this regard. The two upper cocks are con- 
 nected with the sterile water tanks (Fig. 77), and are supplied 
 with a hand valve which readily identifies them from the lower 
 outlet connected with the general water supply. After the hands 
 and forearm have been soaked for several minutes they are rinsed 
 
 Fig. 77. — Wash Stand Used for Cleansing Hands. The two upper outlets are 
 connected with the sterile water tanks placed in a contiguous room. The table 
 with the material necessary for cleansing the hands is placed beside the basin. 
 
 in the water and the supply in the basin drained off and replaced 
 with fresh water. The hands and forearms are now coated with 
 green soap from the jar (Fig. 76), and the soap thoroughly 
 rubbed into the skin. For this purpose green soap which has 
 been sterilized by heat is the most useful agent. It contains con- 
 siderable free caustic potash which, together with the serum and 
 exfoliated epidermis, makes a mixture in a condition favorable 
 to removal. Haste should be avoided at this time to permit of a 
 thorough incorporation of the soap with the skin. During the 
 time that the soap is in contact with the skin the finger nails are 
 cleansed with a sharpened orange stick or nail file. The former 
 is preferable as being less liable to injure the skin contiguous to 
 the nail. 
 
 The tincture of green soap and the ordinary toilet soaps (Fig. 
 
CLEANSING THE HANDS 129 
 
 76) are used in this connection, and are perhaps as effective as 
 the green soap, however, for the reasons stated the green soap is 
 recommended. 
 
 This mixture is now lavaged with clean water, using the fin- 
 gers as in an ordinary toilet. The water in the wash basin is 
 again replaced, and with fresh green soap the hands and fore- 
 arms are freely lathered with the aid of the brush taken from 
 the glass jar. The brush should be used gently and should 
 not be sufficiently harsh to scratch the skin which is now par- 
 ticularly liable to this accident as the outcome of the previous 
 manipulations. This lather is then washed away with clean 
 water. 
 
 This constitutes the mechanical cleansing of the hands and fore- 
 arms, which should require seven to ten minutes. It is the most 
 important step in the preparation. It is difficult to see how chem- 
 ical action alone can achieve sterility of the hands, and indeed it 
 has been proven that it does not. Indeed, if any neglect occur 
 it would conserve most the interests of the patient to disregard 
 certain manipulations destined to destroy bacteria by chemical 
 action (antisepsis) than to err in the mechanical cleansing. After 
 the hands and forearm have been treated as described, they are 
 coated with chlorid of lime made into a paste with water, and 
 this is supplemented- by applying, while the lime is still on the 
 skin, the sodium carbonate. This mixture liberates chlorin, and 
 is intended to destroy bacteria. Wier of New York first intro- 
 duced this method, and it is generally employed. 
 
 Care should be taken not to scratch the skin with rough por- 
 tions of either the lime or soda. The application gives rise to a 
 sensation of warmth which soon disappears, however. After the 
 feeling of warmth leaves, the mixture is removed with a solution 
 of bichlorid of mercury 1 to 1,000, using a piece of sterile gauze 
 for the purpose. Care should be taken to remove entirely the lime 
 and soda, for if they be permitted to remain in contact with the 
 skin for a protracted period of time dermatitis is liable to ensue. 
 Indeed, frequent employment of the measure is extremely liable to 
 produce dermatitis, a fact which makes the measure objectionable 
 if employed at frequent intervals. It is the habit of the writer to 
 employ the measure for the first operation, and to omit this par- 
 ticular step from the technic of cleansing of the hands and fore- 
 
130 PREPARATION OF OPERATOR AND ASSISTANTS 
 
 arms previous to subsequent operation performed at the same sit- 
 ting. Experience would justify the omission. 
 
 After removing the lime and soda in the corrosive sublimate 
 solution, the hands and forearms are immersed in alcohol, this 
 rinsed off in a solution of carbolic acid 1 in 100, and finally the 
 latter removed with sterile water. 
 
 To facilitate removal of the lime and soda mixture, the hands 
 and forearms may be rinsed in a solution of sodium carbonate 
 (2 per cent.) before immersion in the corrosive sublimate solu- 
 tion, a measure which aids somewhat in obviating the occurrence 
 of dermatitis. For convenience the latter three manipulations 
 
 Fig. 78. — Immersion Bowls Containing Antiseptic Solutions for Cleans- 
 ing Hands and Forearms. 
 
 are performed in an apparatus shown in Fig. 78. The containers 
 for the purpose should be roomy and permit of complete immer- 
 sion of the parts. The center one shown is the most desirable 
 form. 
 
 This method of cleansing the hands is as effective as any 
 known to the writer. It is not claimed that the hands and fore- 
 arms are sterile after its employment. However, it may be said 
 that absolute sterility of the hands cannot be achieved as the 
 outcome of even the most thorough and painstaking cleansing, a 
 
CLEANSING THE HANDS 131 
 
 fact borne out by bacteriological examination of the skin and 
 finger nails of persons who have subjected them to the method of 
 cleansing generally regarded as effective for the purpose, as shown 
 by clinical facts. It is a singular fact that the nearest approach 
 to sterility of the hands is obtained after the operator has per- 
 formed one or two operations, the bacterial flora being less 
 marked in proportion to the length of time the hands have been 
 in contact with aseptic or antiseptic material. This should argue 
 that the perspiration mechanically cleanses the skin and that ulti- 
 mately the growth of bacteria in the skin is exhausted as the out- 
 come of copious dilution of its culture medium by material not fer- 
 tilized. At best an inhibition of the growth of bacteria, the outcome 
 of the combination of mechanical cleansing and antiseptic lavage 
 only is achieved. Yet it may, too, be said that in the vast ma- 
 jority of instances this attainment suffices for practical purposes. 
 On the other hand, infection is in the opinion of the writer most 
 uncommonly the result of contamination with instruments, and, 
 indeed, the appurtenances used in surgical manipulations, and 
 that the surgeon's hands and the conditions which obtain in 
 the wound are the two elements entering into the proposition 
 which are most difficult to keep free from infective causative 
 factors. 
 
 Modification of the above method of preparation is employed, 
 and indeed certain variations are perfectly permissible. How- 
 ever, as far as the mechanical cleansing is concerned, no method 
 yet presented is more useful and none as good. The lime and 
 soda mixture may be replaced by coating the hands with a satu- 
 rated solution of potassium permanganate, which is later dis- 
 placed with oxalic acid, or similar antiseptic preparations may be 
 used in place of either of these, but the rest of the manipulations 
 are not susceptible of modification, and should be carried out as 
 stated. 
 
 The cleansing of the hands takes place while the surgeon is 
 still attired in the canvas suit mentioned and before incasing him- 
 self in the sterile apparel in which the operative work is done. 
 During the manipulations of getting into these the hands are quite 
 likely to become fertilized, and it is suggested that sterile canton 
 flannel gloves be worn at this time. 
 
 11 
 
132 
 
 PREPARATION OF OPERATOR AND ASSISTANTS 
 
 CANTON FLANNEL GLOVES 
 
 Canton flannel gloves (Fig. 79) are too cumbersome to be 
 used during operations, but are of service in the capacity men- 
 
 Fig. 79. — Canton Flannel, Gloves. (Bryant.) 
 
 tioned, and indeed may be kept on until just before the operation 
 is begun, for it not infrequently happens that the operator desires 
 to indulge in some manipulation which might contaminate the 
 hands, and if these be protected with the canton flannel gloves, 
 which are subsequently removed, no harm will arise as the result. 
 
 GOWNS 
 
 The operator and assistants should wear sterile gowns. The 
 gown should be commodious and fasten behind. A description of 
 the gowns has already been given (page 68). In this connection 
 
GLOVES DURING OPERATIONS 133 
 
 it is well to state that the gown worn by the operator and first 
 assistant should have long sleeves, preferably unattached to the 
 gown, that they might be replaced during the operation when 
 soiled by blood or secretions, and those of the other assistants, not 
 coining in contact with the wound, may be short. When the gown 
 is once put on the surgeon must avoid contact with foreign sub- 
 stances. It not infrequently happens that the surgeon is all ready 
 to proceed, but the patient is not quite narcotized. During this 
 time there is a tendency on part of the operator to become im- 
 patient, and it has been the writer's experience to see the surgeon 
 seat himself on a chair with all the attire for operation on and 
 engage in conversation with the assistants or spectators, the sub- 
 ject of which is not infrequently a dissertation on the stupidity 
 of the assistant administering the narcosis. It is suggested that 
 the surgeon, who of necessity is in a more or less tense state of 
 mind, do not put on the final sterile attire until the patient is on 
 the table, in the meantime protecting the hands and forearms with 
 the canton flannel gloves. This permits of greater ease and free- 
 dom during a perhaps trying period of time, allows of the giving 
 of whatever instruction is desired to spectators, and in the last 
 moment the donning of the final attire, which requires only a few 
 moments and assures the absence of contamination. The kind of 
 gown worn during operations by the writer is shown in Fig. 85. 
 
 GLOVES DURING OPERATIONS 
 
 This subject cannot be dismissed with the bald statement that 
 the interests of the patient are best conserved by the wearing of 
 rubber gloves by the operator and assistants. In discussing the 
 subject Kocher's views have been considered as having had a some- 
 what determining influence on those of the writer. 
 
 If the hands could be covered with an impermeable glove which 
 under no circumstances permitted of contact between the skin of 
 the operator and the wound, the entire problem would be solved 
 except as regards the question of the tactile sense. The latter is 
 at all times an important factor in surgical manipulations. The 
 writer feels that as the outcome of training, the tactile sense may 
 be developed, so as to be of sufficient practical acuteness despite 
 the presence of the glove, in the majority of instances. Yet there 
 
134 
 
 PREPARATION OF OPERATOR AND ASSISTANTS 
 
 are undoubtedly instances when the interests of the patient are 
 best conserved if the necessary manipulations are carried on with- 
 out this handicap. 
 
 If it be true that infection is a question of dosage, it appears 
 to be justifiable that all assistants wear gloves in all instances and 
 the operator in most cases, abstaining from their use, however, 
 when the manipulations become inaccurate and prolonged. If in 
 these instances the hands be cleansed as stated and frequently sub- 
 merged in a cleansing solution during the operation, it is the 
 writer's belief that the indications are met on the most rational 
 basis. 
 
 It is to be borne in mind that infective bacteria inhabit the 
 
 Fig. 80. — Hand and Wrist Covered with Rubber Glove and Gauntlet. 
 
 Forearm Bare. 
 
 ducts of the sudoriparous and sebaceous glands of the skin. After 
 cleansing the skin these are not removed. If the hand be incased 
 in rubber gloves these glands are stimulated into hypersecretion 
 and a thin coating of bacteria-incorporated sweat lies in a layer 
 between the skin and the adove. If a solution of continuitv occur 
 in the glove as the outcome of contact with an instrument, such as a 
 needle, scalpel, scissors, or the wound itself, this mixture is quite 
 forcibly projected into the wound. This is objectionable. To ob- 
 viate this it is perhaps best to wear cotton gloves for the first por- 
 tion of the operation. These will absorb the perspiration and can 
 
GLOVES DURING OPERATIONS 
 
 135 
 
 be frequently changed so as to avoid saturation, that is, a clean 
 pair is substituted before the infective perspiration has permeated 
 
 Fig. 81. — Hand Covered with Rubber Glove, Forearm Bandaged with 
 Sterile Gauze, Gauntlet Turned Over Bandage. 
 
 to their outer surface. After a certain period of time the per- 
 spiration dilutes the bacteria to a sufficient extent to render the 
 
 Fig. 82. — Forearm Covered by Long Sleeve of Gown, Gauntlet of Rubber 
 Glove Turned Over Sleeve. 
 
 skin quite free from bacteria. It would seem to be most rational 
 to wear cotton gloves during the technic of the first portion of 
 
136 
 
 PREPARATION OF OPERATOR AND ASSISTANTS 
 
 the operation, that is, during the approach to the area where more 
 delicate manipulations are necessary, and substitute rubber gloves 
 at this time, or, if necessary, the operator may rinse the hands at 
 this time in a solution of bichlorid of mercury 1 in 1,000, which 
 is displaced with sterile water and proceed with the operation with 
 bare hands. 
 
 Cotton gloves are less liable to be injured during the manipula- 
 tions involved in tying ligatures and inserting sutures. The rub- 
 
 Fig. 83. — Ends of Fingers Covered with Rubber Finger Cots. 
 
 ber gloves should be provided with a gauntlet which covers the 
 wrists (Fig. 80). Some surgeons prefer to incase the forearm in 
 a sterile gauze bandage (Fig. 81). The most useful method is 
 to cover the entire arm with the long sleeve (Fig. 82). Not a 
 few surgeons regard the ends of the fingers as most likely to be 
 fertilized, and protect these with finger cots (Fig. 83). How- 
 ever, this is not recommended for prolonged operations, though 
 exceedingly convenient when the means for thorough cleansing of 
 the hands be not attainable and the operation consist of a simple 
 opening of an abscess or a cellulitis. 
 
 CAPS AND MASKS 
 
 During operations caps and masks are worn by the operator 
 and first assistant. Surgeons use various protectors for the hair 
 
CAPS AND MASKS 
 
 137 
 
 and face. The object 
 being to prevent the 
 falling of perspiration 
 and loose hair into the 
 wound. The cap does 
 not achieve the object 
 as well as the mask and 
 hood combined. Many 
 models are in vogue, 
 the one which is as use- 
 ful as any is the Crile 
 mask, shown in Fig. 
 84. It is effective, light 
 and readily put on. 
 
 Fig. 85. 
 
 -Surgeon Attired for 
 Operating. 
 
 Fig. 84. — Crile Mask. 
 
 Fig. 85 shows the complete attire 
 of the surgeon ready for operation. 
 The gown is put on first, next the 
 gloves, the gauntlets of which are 
 turned over the wrist, and the mask 
 is put on by the non-sterile nurse, 
 as it would be quite impossible for 
 the surgeon to do this himself with- 
 out contamination of the hands. 
 
 The attire of the first assistant is 
 in all respects similar to that of the 
 operator. The assistant handling in- 
 struments and suture material may 
 wear a gown with short sleeves, a cap 
 in place of a mask, but should wear 
 gloves. It is warned that if the latter 
 test the tensile strength of ligature 
 and suture material with the hands, 
 care be taken not to incise the gloves 
 with the material. 
 
 The assistant administering the 
 narcosis need not indulge in the elab- 
 orate preparation nor the attire men- 
 
138 
 
 PREPARATION OF OPERATOR AND ASSISTANTS 
 
 tioned, but should be attired in freshly laundered duck or be cov- 
 ered with a gown. In the event of the operation involving the 
 head this assistant makes the same preparation as the operator. 
 The nurse handling sponges, towels, dressings, etc., should be 
 
 prepared in the same way as the 
 operator, but instead of wearing a 
 cap ties the hair up in sterile gauze. 
 Fig. 86 shows the attire of the so- 
 called " sterile " nurse. 
 
 The extra sterile manipulations 
 are performed by a second nurse, who 
 should wear the hair tied in gauze, 
 be attired in freshly laundered uni- 
 form, but need not wear a gown simi- 
 lar to that worn by the sterile nurse. 
 The object of this is that during the 
 operation the operator is less apt to 
 confuse the nurses, and not call upon 
 the non-sterile nurse to perform a 
 duty which belongs to the sterile 
 nurse, and vice versa. This is a 
 wise precaution to take. 
 
 The non-sterile nurse replenishes 
 solutions and pours cleansing fluids 
 on the operation field. The method 
 of handling pitchers is already de- 
 scribed (page 115). The handling 
 of basins is an important matter. 
 Nurses are apt to contaminate the 
 interior of these vessels while han- 
 dling them. Fig. 73 shows a commonly employed, erroneous way. 
 It will be seen that the thumbs encroach upon the inside of the 
 bowl. Fig. 74 shows the proper way of handling a basin. 
 
 Fig. 86. 
 
 -Attire of 
 Nurse. 
 
 ' Sterile ' 
 
CHAPTEE VII 
 THE OPERATING ROOM 
 
 The hospital operating room: Artificial illumination — Operating table — 
 Dressing table — Instrument table — Narcotist's table — Adjustable tray for 
 instruments — Surgeon's lavatory — Utensil sterilizer — Irrigation — Arrange- 
 ment of tables, etc., in operating room — Dressing of tables in operating 
 room: the operating table; the instrument table; the anesthetist's table; 
 adjustable instrument tray; dressing table — Final preparation of patient 
 — Disposition of operator, assistants and nurses. 
 
 The operating room in private practice: Operating table: portable operat- 
 ing table; extemporized operating table — Sterile water — Suture and 
 ligature material. 
 
 THE HOSPITAL OPERATING ROOM 
 
 In hospitals and sanitaria, special chambers are arranged for 
 the purpose of performing surgical operations. In private prac- 
 tice it is not possible to obtain the favorable conditions found in 
 these institutions. It is intended to describe first the operating- 
 room arrangement, which is most desirable, and which exists to 
 a greater or lesser degree in these institutions, and later take up 
 the subject as applied to private practice where modifications of 
 this arrangement are necessary, and thus, while setting up a stan- 
 dard, show how this may be modified under certain circumstances, 
 with favorable and satisfactory outcome. In describing what the 
 writer regards as the most acceptable and useful arrangement, in 
 this regard, it is intended that a standard should be made for com- 
 parison for the benefit of the operator who works in private resi- 
 dences, that the best might be as closely as possible approached, 
 though this involve considerable modification as regards the ap- 
 paratus employed. 
 
 The operating room should be at the top of the building, be 
 large and readily ventilated and lighted on three sides with win- 
 dows, and be furnished with a skylight. The skylight should be 
 so situated as to allow of light falling on the operating table at 
 
 139 
 
140 THE OPERATING ROOM 
 
 an angle which will at the same time permit of lateral illumina- 
 tion. That is, it should be possible to have the light from the side 
 windows fall on the perineum when the patient is in the lithotomy 
 position and at the same time permit the patient being placed in 
 the Trendelenburg posture without changing the location of the 
 operating table for the purpose of obtaining the necessary light 
 nor of turning it around after the perineal work is finished, or 
 the reverse. For instance, in combined vaginal section and celi- 
 otomy, the former requires light from the side windows. When 
 the celiotomy is to be made, if light from one end of the room only 
 is obtainable, it becomes necessary to turn the table about so as to 
 have the light fall into the wound during the intra-abdominal 
 manipulations. If the light from the skylight comes in the oppo- 
 site direction from the side windows necessity for this is obviated. 
 This applies with equal force to the reverse. If after a celiotomy 
 is completed it becomes expedient to make vaginal drainage, this 
 may be accomplished without moving the table for the purpose of 
 obtaining the necessary illumination. The skylight should be per- 
 manently sealed, as the ropes or reach rods which are necessary to 
 open and close windows in a skylight will, when manipulated dur- 
 ing an operation, shake down dust, and this is to be avoided. If 
 the side windows are carried sufficiently high up, efficient venti- 
 lation through these openings is at all times available. If pos- 
 sible, the operating room should derive its principal source of 
 light from the north. 
 
 The floor of the operating room should be tiled, the tiles set 
 in four inches of cement, and should have a smooth surface, to 
 permit of cleansing and to avoid absorption of foreign substances, 
 including blood, pus and secretions, which inevitably find their 
 way to the operating-room floor during surgical manipulations. 
 The center of the floor should be provided with a drain and the 
 surface of the floor arranged to permit of the flow of cleansing 
 fluids to this point. Various mixtures of cement and plaster 
 have been used to make solid flooring, none of which are, how- 
 ever, as permanently lasting as the tiling. 
 
 The junction of the floor and walls should be provided with a 
 curved tile which permits of ready cleansing and avoids, too, col- 
 lection of dust and foreign particles in this situation. The walls 
 should be tiled to the height of six feet and the upper portions 
 
THE HOSPITAL OPERATING ROOM 141 
 
 made of cement painted with four or five coats of enameled paint. 
 The junction of wall and ceiling should be arched rather than 
 make an acute angle to avoid collections of foreign substances in 
 this situation. The entire interior of the room should be white, 
 to facilitate the detection of objectionable material and enhance 
 illumination. 
 
 ARTIFICIAL ILLUMINATION 
 
 Artificial illumination should be by electricity, and the cur- 
 rent governed from a side-wall switch to avoid shaking down of 
 dust, the outcome of manipulations at the chandelier. The chan- 
 delier should be furnished with a reflector and the electric light 
 bulbs grouped in a cluster to avoid the throwing of confusing 
 shadows on the operation field. The source of light should be suf- 
 ficiently high over the table to avoid contact with the operator 
 during manipulations such as suturing with a long suture during 
 celiotomy in the Trendelenburg posture. 
 
 The section of wiring conveying the electric current to the 
 operating room should be heavily fused and the wires themselves 
 made of ample capacity to carry a current of sufficient strength, 
 to be available for the animation of motors for the purpose of run- 
 ning burrs and drills, and also for the purpose of heating a cautery 
 knife. It is an annoyance, to say the least, to have the steps of 
 an operation interrupted as the result of a fuse " burning out " 
 while the operator is manipulating in the opened abdomen, and 
 thus be compelled to delay the procedure until the necessary re- 
 pair is made, simple as this is. 
 
 When electric light is not available, the chandelier in the oper- 
 ating room should be so located as to make it possible to carry on 
 the operation at some place other than immediately beneath it, 
 and when it becomes necessary to use the artificial light the table 
 may be moved to immediately beneath it. 
 
 Of course, in instances when operations are performed at night, 
 the gas jets are ignited before the operation is begun and no manip- 
 ulations in this connection are necessary during the operation. 
 However, it not infrequently happens that the operation is begun 
 with ample available daylight and the contingencies of the sur- 
 gical problem make continuance of the effort a prolonged one, so 
 that darkness occurs before the operation is finished. Indeed, a 
 
142 THE OPERATING ROOM 
 
 thunderstorm will frequently obliterate the daylight at midday, 
 and it becomes necessary to employ artificial light in the midst of 
 an operation. Under these circumstances, it is of course not feas- 
 ible to ignite the gas "without manipulating the chandelier, and 
 dust is shaken down on the operating field unless the precaution 
 mentioned is taken. 
 
 If, however, the gas chandelier be located immediately over 
 the operating table, the wound and contiguous area should be cov- 
 ered with a sterile sheet while the gas is lighted by the non-sterile 
 nurse, and later the same person removes the sheet, together with 
 the dust, after which the operation is proceeded with. 
 
 The apparatus necessary to the sterilization of water and dress- 
 ings (Fig. 66) should be set up in a chamber contiguous to the 
 operating room. The water sterilizers, however, should be piped 
 into the operating room, that the supply in use may be replen- 
 ished without the attendant being forced to leave the room. The 
 dressings, sponges, etc., are packed in convenient parcels which 
 can be transported to the scene of operation without danger of 
 contamination. 
 
 The instrument (Fig. 16) and utensil sterilizers (Fig. 96) 
 should, however, be in the operating room, as conditions con- 
 stantly arise making immediate resterilization of this appliance 
 necessary. An instrument is dropped to the floor or is fertilized 
 by contact with infectious material quite frequently during an 
 operation, and means for rapid sterilization should be at hand. 
 The same may be said of pans and basins and pitchers, and when 
 these are at once placed in the sterilizers they become available for 
 use after a short period of time, a desirable provision which tends 
 to obviate delay and annoyance during the operation. 
 
 OPERATING TABLE 
 
 The table shown here (Figs. 87-90) is as serviceable as any in 
 the market, and provides for the requisites of most contingencies 
 arising during operative work. There are many tables on the 
 market which will serve the purpose, indeed in some instances the 
 surgeon does more satisfactory work as the outcome of familiarity 
 with a table which may be less complete in every jDarticular than 
 obtains in the table shown here, but it may also be said that this 
 particular table may be regarded as a standard which if it have 
 
THE HOSPITAL OPERATING ROOM 
 
 143 
 
 any fault is too elaborate, and that on general principles the cen- 
 tralization of too many possibilities is liable to mean mechanical 
 complications. 
 
 It is, for instance, perfectly feasible to attain the Moynihan 
 position for easier access to the bile passages by placing a sand 
 
 Fig. 87.- 
 
 -Operating Table Showing Appliance for Raising the Upper 
 Abdomen or for Use in the "Kidney" Position. 
 
 bag under the patient, yet the Cunningham adjustable elevating 
 attachment is certainly more readily adjusted to varying condi- 
 tions than the former. The table here shown is the result of the 
 ingenuity of Dr. Francis Marh oe of New York City. The table 
 frame is of tubular iron ; the drainage pan attached to the base is 
 wider than the top of the table, assuring drainage on the sides 
 when lavage is made, preventing the solution from running on 
 the floor or soaking into the lower garments of the surgeon and his 
 assistants. The base is designed to permit of the tops being low- 
 ered, the plane at the foot end facilitating the Hartley position. 
 The foot end is adjustable to any angle; it is also arranged to 
 
144 
 
 THE OPERATING ROOM 
 
 drop back, permitting the use of weighted specula in the lithotomy 
 position. Close scrutiny of the cut (Fig. 88) will show that the 
 foot-piece not only drops down at an angle of 90°, but also slips 
 backward, allowing an overhanging of the end of the center sec- 
 
 Fig. 88. — Operating Table Showing Appliances for Lithotomy Positions 
 and Wire for Screening off Narcotist. 
 
 tion to permit of the manipulation stated. This prevents the as- 
 sistant's hand, while holding a speculum, from getting in the way. 
 
 The Trendelenburg posture is achieved by means of the Dela- 
 tour side-wheel attachment with rack and pinion, which is con- 
 trolled by the narcotist, thus obviating disturbance of the celiotomy 
 sheet during changes of posture. A foot pedal at the end of the 
 table near the head section allows of raising of this section by the 
 narcotist as occasion arises. 
 
 The Cunningham elevating attachment is adjustable, and is 
 either used with the side braces to maintain the kidney position 
 or without these braces for the Moynihan position for work on the 
 biliary passages. The Lange table is attached when necessary to 
 
THE HOSPITAL OPERATING ROOM 
 
 145 
 
 the foot section and serves as a foot rest in the Hartley position. 
 The wire screen shown in Figs. 87-90 holds the celiotomy sheet 
 away from the narcotist and isolates the head of the patient from 
 the rest of the table, a desirable arrangement in instances in which 
 local or spinal anesthesia is employed. The patient is thus un- 
 able to see the manipulations, a factor which has a bearing on the 
 mental shock, so often the sequel of operations undertaken with 
 local anesthesia. Beyond this the table is furnished with shoulder 
 supporters to prevent the patient from sliding upward when in 
 the Trendelenburg position and lithotomy stirrups. Fig. 87 shows 
 the table with screen frame and Cunningham elevating attachment. 
 Fig. 88 shows the foot rest, the foot section dropped and a heel 
 cup and lithotomy stirrup attached. Fig. 89 shows the table in 
 
 Fig. 89. — Operating Table Arranged for Hartley's Position. 
 
 the Hartley position with the foot rest attached to prevent slipping 
 of the patient. In neither of these illustrations are the shoulder 
 supports shown, which are of course only attached when the Tren- 
 delenburg posture is to be employed. Fig. 90 shows the table in 
 the Trendelenburg position with shoulder supports attached, though 
 the head section should perhaps be best slightly raised to show 
 
146 
 
 THE OPERATING ROOM 
 
 the most generally employed Trendelenburg position. If the foot 
 section is dropped when the patient is to be placed in the Tren- 
 
 Fig. 90. — Operating Table in Trendelenburg's Position. 
 
 delenburg posture, the weight of the legs prevents undue pressure 
 on the shoulders from contact with the supporters, though it also 
 makes tense the abdominal muscles. 
 
 DRESSING TABLE 
 
 A table for dressings, wipes, towels, etc., should be available. 
 Tig. 91 shows a steel white enameled table frame with two glass 
 shelves. The dimensions of this table are about 24 by 36 inches, 
 of ample size to hold sufficient material for an ordinary operation, 
 and is not so large as to be unwieldy. If an extensive operation or 
 two or more operations are to be performed successively, two of 
 these tables may be arranged contiguous to each other. 
 
Fig. 91. — Table for Dressings 
 
 Fig. 92. — Table for Instruments. 
 
 12 
 
 147 
 
148 
 
 THE OPERATING ROOM 
 
 INSTRUMENT TABLE 
 
 Fig. 92 shows a roomy steel frame table with, two glass shelves 
 suitable for instruments during the operation. This table should 
 be the same size as shown as a dressing table (Fig. 91). Of course 
 either table may be used for either of the purposes mentioned. 
 
 A table as shown in Fig. 91 may be used for suture material 
 containers, jars of catgut (Fig. 49), needles, etc. The instru- 
 ment and suture material tables should stand beside each other as 
 both these classes of surgical desiderata are usually handled simul- 
 taneously. 
 
 NARCOTIST'S TABLE 
 
 The table shown in Fig. 93 is used by the narcotist, to hold 
 the receptacles containing the narcotic, stimulants, a hypodermic 
 syringe, etc. The table is of steel, white enameled, as are the other 
 
 tables, and has a 
 glass shelf. The 
 lower shelf is of en- 
 ameled steel and 
 holds the pus basin 
 used to receive the 
 vomit during or im- 
 mediately after the 
 operation. The rack 
 below the lower shelf 
 is intended for tow- 
 els which may be 
 used to wipe the pa- 
 tient's face or lips 
 during the opera- 
 tion. 
 
 ADJUSTABLE TRAY 
 FOR INSTRUMENTS 
 
 During an opera- 
 tion a certain num- 
 ber of instruments 
 are more or less con- 
 
 FlG . 93.— Narcotist's Table. stantly in USC To 
 
THE HOSPITAL OPERATING ROOM 
 
 149 
 
 facilitate the work an adjustable 
 table frame with an enamel tray 
 (Fig. 94) is placed close to the 
 surgeon, and the assistant han- 
 dling the instruments places the 
 instruments for immedate use 
 upon it. The table is usually 
 placed to extend over the operat- 
 ing table. By means of the set 
 screw the tray is raised or lowered 
 by the telescoping of the upright 
 to meet the necessities. 
 
 When an instrument is tem- 
 porarily laid aside it may be 
 placed upon this tray, rather than 
 upon the area contiguous to the 
 wound. The latter is usually 
 soiled with blood and secretions, 
 
 which makes it an objectionable place to lay instruments upon. 
 Again, if during the operation the patient should struggle the in- 
 struments are less liable to be thrown to the floor, if placed upon 
 the tray, than if the body of the patient be used for the purpose. 
 
 Fig. 94. 
 
 Adjustable Instrument 
 Tray. 
 
 Fig. 95. — Surgeon's Lavatory. 
 
 SURGEON'S LAVATORY 
 
 The surgeon's lavatory 
 should be, as already stated 
 (page 127), sufficiently 
 roomy to permit of the sub- 
 mersion of the hand and 
 forearm. The basin shown 
 in Fig. 95 is fitted with a 
 knee lever attachment allow- 
 ing of the delivery of either 
 cold or hot water. The knee 
 lever at the left side in the 
 center opens or shuts the 
 waste. The material neces- 
 sary to cleansing the hands 
 is placed on the glass shelf 
 
150 
 
 THE OPERATING ROOM 
 
 immediately above the wash basin and is thus readily available. 
 The toilet soap is placed in the small soap tray affixed to the wall 
 
 Fig. 96. — Operating Room Utensil Sterilizer. 
 
 beneath the shelf. The water outlet is arranged in a " goose- 
 neck " which permits of lavage of the hands and forearm with 
 running water. 
 
 This apparatus is very convenient and quite useful for the 
 
THE HOSPITAL OPERATING ROOM 
 
 151 
 
 purpose. It is well to bear in mind, however, that it represents 
 a refinement which, while acceptable, is in no wise essential to 
 cleansing of the hands. The ordinary, roomy wash basin will suf- 
 fice very well for the purpose, and indeed has the redeeming 
 feature of being less complicated in its mechanism. 
 
 UTENSIL STERILIZER 
 
 The utensil sterilizer (Fig. 96) should be, as already stated, 
 located in the operating room. It is fitted with a foot pedal, by 
 means of which the cover may be raised and the tray elevated 
 without the need of using the hands. 
 
 The appliance is used for the purpose of sterilizing pitchers, 
 basins, irrigating vessels and the like. It is fitted with either the 
 direct Bunsen burner flame or is 
 connected with the steam pressure of 
 the power plant in the building. The 
 former method of heating is prefer- 
 able. The contents should be ex- 
 posed to a temperature of 212° F. 
 for half an hour, which will com- 
 pletely sterilize it. 
 
 IRRIGATION 
 
 For the purpose of lavage dur- 
 ing the operative procedure, besides 
 the pitchers already mentioned (page 
 115), it is well to have at the dis- 
 position of the surgeon an irrigator, 
 especially as the latter may be used 
 for infusions, enteroclysis, and hypo- 
 dermoclysis. A useful apparatus for 
 the purpose is shown in Fig. 97. A 
 glass receptacle of a gallon capacity 
 is swung from the hook at the top 
 of an upright. The receptacle is 
 connected at the bottom with a rubber 
 tube. A thermometer (Fig. 42) is 
 prevent the contamination with the 
 
 Fig. 97. — Operating Room Ir- 
 rigating Apparatus. 
 
 placed in the retort, and to 
 infective material a sterile 
 
152 
 
 THE OPERATING ROOM 
 
 towel is made to cover the open top. The rubber tube is led into 
 a basin affixed to the stand containing a solution of mercury bi- 
 chlorid, 1 in 1,000. The tube is shut off by means of a forceps, 
 which is released when it is desired to have the solution flow, the 
 various " cut-off " appliances in the market rarely being efficient 
 for a sufficient period of time to render their employment desirable. 
 
 Dressings. 
 
 Table for Basins, &o. 
 
 Nurse. £) 
 
 (3 Burse 
 
 Chief Assistant. 
 
 o 
 
 ARRANGEMENT OF TABLES, ETC., IN OPERATING ROOM 
 
 Fig. 98 is a diagrammatic presentation of a convenient method 
 of arranging the tables in the operating room, and also the ar- 
 rangement of the assist- 
 ants to serve best the con- 
 tingencies. Fig. 99 shows 
 the tables, irrigator, wash 
 basin, and instrument case 
 as arranged in a well- 
 equipped operating room. 
 Of necessity modifications 
 of arrangement to suit the 
 available space is permis- 
 sible. For instance, the 
 instrument case is, in 
 many institutions, placed 
 in an adjoining room; 
 however, if the operating 
 room is sufficiently large, 
 it had best be kept there, 
 with the view of obtaining 
 without delay instruments 
 which have either been for- 
 gotten by the assistant or 
 which may be called for to 
 meet an unforeseen contingency. The delay of sending out of 
 the room a nurse during the operation for the purpose of obtain- 
 ing an instrument or appliance is objectionable. 
 
 o 
 
 Second Assistant. 
 
 Spare Instruments. 
 
 Fig. 98. — Diagram of Arrangement of 
 Apparatus and Assistants During a 
 Celiotomy Operation. (Bryant.) 
 
THE HOSPITAL OPERATING ROOM 
 
 153 
 
 DRESSING OF TABLES IN OPERATING ROOM 
 
 The Operating Table. — The glass surface of the operating table 
 presents a hard surface for the patient to lie on. While it would 
 
 Fig. 99. — Tables, Etc., Used in Operating Room. 
 
 conserve perhaps best both cleanliness and drainage to place the 
 patient immediately upon the glass surface of the table, it has 
 
 Fig. 100. — Operating Table Covered with Pads. 
 
 been found that the subsequent discomfort to the patient, the out- 
 come of prolonged contact with a hard surface, is exceedingly ob- 
 jectionable, To obviate this, the table is covered with two pads 
 
154 THE OPERATING ROOM 
 
 composed of cotton which are incased in rubber sheeting and then 
 covered with a linen case to fit the pad. These are fastened to 
 the operating table with tapes (Fig. 100), an arrangement which 
 does not interfere with drainage, and the linen cases are removed 
 and replaced with fresh ones after each operation, conserving 
 cleanliness. 
 
 The Instrument Table. — The instrument table is covered with 
 a sterile towel (Fig. 101) or sheet, and the instruments after 
 
 Fig. 101. — Instrument Table Covered with Sterile Towel. 
 
 being taken from the sterilizer are placed upon it. Fig. 102 
 shows a serviceable arrangement in this connection. In this in- 
 stance two tables are placed contiguous to each other and covered 
 with a sterile sheet. Upon the sheet sterile towels are placed, 
 which may be replaced when this set becomes soiled. A pan of 
 sterile water of moderate temperature is placed beside the in- 
 struments for two purposes : first, the instruments as they come 
 from the sterilizer are very hot and cannot be handled. If they 
 be submerged for a few minutes in cool sterile water this is ob- 
 viated ; and, second, during operations, the instruments become 
 soiled and may be cleansed in the sterile water, thus permitting 
 of easier manipulation than obtains when instruments are slip- 
 pery from a coating of blood or secretions. Fig. 103 shows the 
 pan with a portion of the instruments submerged for the purpose 
 mentioned. 
 
 The Anesthetist's Table. — The anesthetist's table need not be 
 protected by sterile material unless the operation involves the 
 head and face. Fig. 104 shows the arrangement universally 
 
Fig. 102. — Instruments Spread on Sterile Towel, Ready for Use. 
 
 Fig. 103. — Instruments Ready for Use, a Portion of Which are Suh- 
 merged in Sterile Water. 
 
 155 
 
156 
 
 THE OPERATING ROOM 
 
 found useful. The modified Esmarch mask is used in the writ- 
 er's cases -for the administration of ether by the so-called open 
 method, and if for any reason chloroform is to be used, it may be 
 dropped on the same apparatus. 
 
 The chloroform and ether bottles and bottles containing stimu- 
 lants are placed together. The pus basin is used for receiving the 
 vomit, and the hypodermic syringe is placed in a glass receptacle 
 submerged in carbolic acid solution (1-40). Besides this a grad- 
 
 
 
 
 
 
 Fig. 104. — Table Arranged with Material Necessary to Narcotist. 
 
 uate and a glass containing small squares of gauze are kept oil 
 hand, the latter being employed to moisten the patient's lips or 
 wipe out the pharynx. For the latter purpose a sponge holder, 
 shown in the illustration, is employed. Besides this a Whitehead 
 mouth gag, a tongue depressor, and scissors should be placed ready 
 for use. The two towels are intended to be used as necessity 
 arises, though the gauze seen in the pus basin will serve all pur- 
 poses for which towels are ordinarily employed. However, the 
 greater absorbing capabilities of the gauze recommends its use 
 in preference to the towel, though the latter may become of ser- 
 vice in the event of profuse vomiting. 
 
 The Adjustable Instrument Tray. — The adjustable tray is first 
 covered with a sterile pillow slip, which is tucked about the stand 
 
THE HOSPITAL OPERATING ROOM 157 
 
 (Fig. 105). Upon this a sterile towel is placed, and the instru- 
 ments in immediate use are laid upon this (Fig. 106). From 
 
 Fig. 105. — Adjustable Instrument Tray Covered with Sterile Pillow- 
 case Tucked About Stand. 
 
 time to time the assistant in charge of the instruments replaces 
 various tools with duplicates and cleanses the former, holding 
 
 Fig. 106. — Adjustable Instrument Tray with Sterile Towel and Instru- 
 ments in Immediate Use. 
 
158 THE OPERATING ROOM 
 
 them ready, upon the larger table (Fig. 102), to take the place 
 of the set in use when occasion arises. From time to time the 
 nurse changes the sterile towel without disturbing the sterile 
 pillow case. 
 
 Dressing Table. — The table for dressings, wipes, etc., is in- 
 
 Fig. 107. — Dressing Table Arranged for Extensive Operation or when Sev- 
 eral Major Operations are to be Performed in Immediate Sequence. 
 
 tended to hold material handled by the sterile nurse. Fig. 107 
 shows a table dressed for an extensive operation or for several 
 operations to be performed in rapid succession. The jars con- 
 tain medicated gauze, sterile absorbent cotton, and sterile gauze 
 bandages. The packets contain sterile gauze, wipes, and ab- 
 dominal pads. Beside this, the table holds sponge holders, two 
 
THE HOSPITAL OPERATING ROOM 
 
 159 
 
 glasses for emergency, and a basin with sterile water for the pur- 
 pose of rinsing soiled sponge holders. 
 
 This is the arrangement which the writer employs. However, 
 immediately after the various materials have been disposed upon 
 the table, they are covered with a sterile sheet (Fig. 108), and 
 when anything is to be used the nurse lifts the edge of the sheet 
 and obtains it. This lessens the chances of accidental contamina- 
 
 Fig. 108. — Dressings, Etc., Protected by Sterile Sheets. 
 
 tion from dust or other sources, such as sputtering of cleansing 
 solutions which have been forcibly projected against the wound 
 area. The jars, of course, need not be covered, as they are opened 
 only when a portion of the contents is removed and the covers 
 are immediately replaced. 
 
 Fig. 109 shows a table which is arranged for operations in 
 small sanitaria, where a single assistant handles towels, dressings, 
 
160 
 
 THE OPERATING ROOM 
 
 instruments, and solutions. The table is fitted with a frame over 
 which sterile towels are laid. The latter are usually submerged 
 in sublimate solution after being boiled with the view of prevent- 
 ing contamination from surroundings. The tray holding towels 
 and dressings are of agate-covered metal, and while not as clean- 
 looking as the white enameled ones holding instruments, are just 
 as useful for the purpose. The spirit flame is intended for the 
 
 Fig. 109. — Table Arranged with Instruments and Dressings Suitable 
 for Small Sanatoria. 
 
 heating of instruments which may have become accidentally con- 
 taminated. The writer has found this arrangement exceedingly 
 satisfactory, especially when the number of assistants is small. 
 The larger glass jar contains rubber gloves, and the glass carafe 
 solution prepared in the manner shown in Figs. 138 and 139. 
 
 FINAL PREPARATION OF PATIENT 
 
 The preparations just related take place while the patient is 
 still in the contiguous chamber being narcotized. The description 
 following is based on the steps taken when celiotomy is made, but is 
 equally applicable to operations on other portions of the body. In 
 
THE HOSPITAL OPERATING ROOM 
 
 161 
 
 hospitals and institutions the patient after being properly attired 
 (Fig. 15) is placed on a carriage upon which he is finally trans- 
 
 Fig. 110. — Carriage for Transportation of Patient to Operating Room, 
 Covered with Pad. 
 
 ported to the operating room. This carriage is of enameled steel, 
 the top of which is padded with a folded blanket enveloped in a 
 
 Fig. 111. — Carriage Covered with Blanket and Small Pillow. 
 
 sheet (Fig. 110). A blanket is draped over this, and a flat pillow 
 placed at one end for the patient's head (Fig. 111). Upon this 
 a sheet, folded into a square, is placed so as to correspond to the 
 
162 THE OPERATING ROOM 
 
 thorax and abdomen of the patient (Fig. 112). This is used to lift 
 the patient from the carriage to the operating table. 
 
 Fig. 112. — Carriage with Folded Sheet over Blanket. 
 
 Fig. 113 shows the patient as he lies on the folded sheet and 
 blanket. A large sheet is now tucked about the patient in the 
 manner shown in Fig. 114, which is of assistance in controlling 
 
 Fig. 113. — Patient Placed on Carriage. 
 
 the struggling which occurs quite often at the beginning of nar- 
 cosis. 
 
 The sheet and blanket are now folded over the body, and a sec- 
 
THE HOSPITAL OPERATING ROOM 163 
 
 ond short blanket is thrown across the thorax, as shown in Fig. 115. 
 When the patient is narcotized he is wheeled into the operating 
 
 Fig. 114. — Restraining Sheet Placed about Patient. 
 
 room, the blankets and sheet are unfolded, and he is lifted with the 
 aid of the short sheet (Fig. 112) to the operating table. The part 
 to be operated upon is now exposed, and the contiguous portions 
 
 Fig. 115. — Patient Completely Prepared for Narcosis and Subsequent 
 Transportation to Operating Room. 
 13 
 
164 
 
 THE OPERATING ROOM 
 
 of the body covered with folded blankets (Fig. 116), which are 
 covered with rubber sheets (Fig. 117) to protect the latter from 
 moisture. 
 
 The assistant now proceeds to give the part the final prepara- 
 tion. For this purpose the nurse has prepared a bottle of sterile 
 
 Fig. 116. — Surrounding Parts of Operative Field Covered with 
 Woolen Blankets. 
 
 tincture of green soap, a mixture of alcohol and ether, a flask of 
 solution of bichlorid of mercury 1 in 1,000, and another con- 
 taining sterile water. These are conveniently arranged on a tray 
 or table (Fig. 118). The flasks are both stoppered with cotton, 
 and the one containing the mercury solution has a small label af- 
 fixed for purposes of identification, though it would be best to 
 have the mercury solution colored blue. 
 
 The assistant, who wears gloves and has not yet donned his 
 
THE HOSPITAL OPERATING ROOM 
 
 165 
 
 sterile gown, gently scrubs the skin with tincture of green soap 
 and sterile water poured on the skin by the non-sterile nurse. 
 This is displaced with sterile water from the flask, and the solu- 
 tion of alcohol and ether poured over the surface. The object of 
 this application is to dissolve the grease from the sebaceous glands 
 
 Fig. 117. — Woolen Blankets Protected from Moisture avith 
 Rubber Sheets. 
 
 not removed by the scrubbing. The ether and alcohol are removed 
 with a copious quantity of water poured from a pitcher, as shown 
 in Fig. 71. The temperature of the water used for this purpose 
 should be about 80° F., in order to prevent burning of the skin 
 on the dependent portions of the body. 
 
 The non-sterile nurse now lavages the part with the bichlorid 
 solution, and this is finally displaced with a large quantity of 
 sterile water. 
 
166 THE OPERATING ROOM 
 
 A useful method of sterilizing the skin preliminary to opera- 
 tions under local anesthesia is employed by Grossich. A ten or 
 twelve per cent, iodin tincture is applied to the field of opera- 
 tion and surrounding skin, with a brush, without any preliminary 
 scrubbing. The microscope has shown that the tissues take up the 
 iodin much more readily when dry, and that it penetrates deeply 
 into all the nooks and crevices, which does not occur with the usual 
 preliminary scrubbing with soap and water. The water macerates 
 
 ^^^^ta—^oWKiM^^^H 
 
 
 
 
 mrnim i 1 
 
 MM ' Hi 
 
 Or fl 
 l II 
 
 
 1 m 
 
 
 / • ml 
 
 ( 
 
 POISON 1 
 
 wu~P 
 
 
 
 
 •■■"-aBBBBl 
 
 Fig. 118. — Convenient Arrangement of Articles Necessary to Final 
 Cleansing of Skin with Patient on Operating Table. 
 
 the epidermal cells, causing them to plug the openings. The parts 
 are shaved, dried and then painted with the iodin. After anes- 
 thesia is produced, the field of operation is again painted with tinc- 
 ture of iodin, and finally the completed suture is again swabbed 
 with it. Grossich states that if the iodin is applied after the parts 
 have been recently scrubbed with soap and water, there is liable 
 to be suppuration. It is indispensable that the tissues should be 
 dry when the iodin is applied. 
 
 The assistant removes the rubber gloves, rinses his hands in 
 sterile water, puts on the gown, incases the hands in fresh gloves 
 and has the nurse put the mask in place. 
 
THE HOSPITAL OPERATING ROOM 
 
 167 
 
 The rubber sheets are covered at the ends nearest the operation 
 field with sterile towels (Fig. 119), and the patient covered with 
 the celiotomy sheet, which is provided with an oblong opening to 
 correspond to the part to be operated upon (Fig. 120). It is neces- 
 sary that the sheet be of sufficient dimensions to drape well down 
 
 Fig. 119. — Rubber Sheets Covered with Sterile Towels. 
 
 over the sides of the operating table (Fig. 121). The field of 
 operation is protected additionally by four sterile towels fastened 
 together in the manner shown in Fig. 122, which are placed in 
 situ as shown in Fig. 123. This arrangement allows of the re- 
 moval of the square of towels when soiled and its replacement at 
 necessary intervals during the operation without disturbing the 
 underlying sheet. 
 
Fig. 120. — Operative Field Isolated by Celiotomy Sheet. 
 
 Fig. 121. — Side View of Arrangement of Celiotomy Sheet. 
 168 
 
THE OPERATING ROOM IN PRIVATE PRACTICE 
 
 169 
 
 DISPOSITION OF OPERATOR, ASSISTANTS AND NURSES DURING THE 
 
 OPERATION 
 
 The relationship of the assistants during the operation to the 
 field of operation should be considered from the view point of 
 expediency and with the view of forestalling infection. 
 
 The prime consideration is that of not permitting any of the 
 assistants or the apparatus to interfere with the source of light. 
 In operations on the ab- 
 domen the head of the 
 patient should be turned 
 toward the light if the 
 Trendelenburg posture is 
 to be employed, and the 
 feet point toward the light 
 if the patient is to remain 
 flat throughout the opera- 
 tion. In the former in- 
 stance the assistant ad- 
 ministering the narcosis 
 is liable to throw a shadow 
 on the field of operation, 
 if there has been no pro- 
 vision made for reverse 
 illumination as described. 
 However, this obtains only 
 
 during the first portion of the operation when the patient is still 
 lying flat. When the Trendelenburg posture is assumed the pa- 
 tient's abdomen will be higher than the head of the assistant ad- 
 ministering the narcosis, if he be seated (which he should be), and 
 the difficulty mentioned is overcome. This calls for a source of 
 light as high up as is feasible, and in all operations this should be 
 borne in mind. The illustration (Fig. 124) shows a serviceable 
 arrangement of tables and assistants. 
 
 Fig. 122. — Sterile Towels Arranged in 
 Manner to Surround Operative Field. 
 
 THE OPERATING ROOM IN PRIVATE PRACTICE 
 
 Using the description of the operating room as described as a 
 standard, as nearly as possible an arrangement should be attempted 
 when operating in private practice. As already stated, sterile 
 
170 
 
 THE OPERATING ROOM 
 
 material for wipes, dressings, sterile towels and dressings are 
 obtainable in the market, packed in impervious packages, which 
 simplifies very much the problem. If the surgeon have not at his 
 command apparatus which will sterilize with certainty this class 
 of material, it is best to obtain it in the market. As regards the 
 
 Fig. 123. — Sterile Towels Applied to Surroundings Contiguous to 
 Operative Field. 
 
 technic of sterilization, this has already been described (page 
 62). 
 
 Towels and sheets are perhaps less readily obtainable than 
 dressings, and it is, under these circumstances, at times necessary 
 to meet the indications in another way. The writer has obtained 
 favorable results as regards asepsis in private practice by baking 
 towels and sheets and gowns in the kitchen oven, followed by 
 
171 
 
172 THE OPERATING ROOM 
 
 immersion in hot bichlorid solution 1 in 1,000 for twenty minutes. 
 This necessitates the wearing of a wet gown, which is exceedingly 
 uncomfortable; however, this is a minor objection. Certain it is 
 that neither the gowns nor towels or sheets may be regarded as 
 sterile as the outcome of the baking process. Again, the contact 
 of the mercury solution with instruments destroys them, though 
 this, too, is a minor consideration. 
 
 It is to be borne in miud that aseptic results are more readily 
 obtained in private practice than in even the best equipped hos- 
 pitals, though the technic of asepsis seems not to be so thorough. 
 This is perhaps due to the probable absence of pyogenic bacteria 
 in private residences as contrasted with hospitals, where infected 
 cases are frequently operated upon. 
 
 This consideration, however, should not engender a com- 
 placency which may be the causative factor in an unfavorable out- 
 come. The chamber selected for the performance of the opera- 
 tion should be well lighted and the arrangement of the necessary 
 apparatus so designed as to interfere as little as possible with this 
 desideratum. A room sufficiently large for the purpose is likely to 
 have two windows, though one of slightly less dimensions with one 
 large window is preferable, as the operating table is best placed 
 in the center of the room, and the shadow of the space between the 
 two windows falls on the table if it be thus placed. If a room 
 with two windows is used, it is best to have the table stand in the 
 zone of light from one of them and arrange the accessory para- 
 phernalia accordingly. 
 
 The curtains and shades should be removed from the windows 
 to avoid obscurity of illumination from this cause, though their 
 removal is imperative for other reasons. To avoid the espionage 
 of curious neighbors the window glass may be covered with a thin 
 layer of soap applied with a piece of gauze. This prevents out- 
 siders from looking into the room and does not interfere markedly 
 with illumination. If the room is to be prepared on the same day 
 as the operation, care must be taken not to make sufficient upheaval 
 in the set arrangement of the room to provoke dust which will not 
 have time to settle by the time of the operation. 
 
 In this instance the curtains, shades, hangings, all furniture 
 and pictures should be carefully removed, taking the precaution of 
 wiping them off with a damp cloth before manipulating them. 
 
THE OPERATING ROOM IN PRIVATE PRACTICE 173 
 
 The carpet should not be removed, but may be covered with sheets 
 dampened with a solution of mercuric chlorid 1 in 1,000. The 
 walls should be gently wiped with gauze moistened with the corro- 
 sive sublimate solution. 
 
 If the operation is to be performed more leisurely, the pictures, 
 shades, hangings, furniture, including carpets and ornaments, are 
 removed, the walls dusted and the windows left open for several 
 hours, during which the dust is permitted to settle. The room is 
 then fumigated by burning sulphur after it has been carefully 
 sealed. All windows, doors and chimney joints are sealed with 
 gummed paper or adhesive plaster strips. The sulphur is ignited 
 at night and the resulting fumes permitted to remain in the cham- 
 ber until the following morning. The room is then opened, the 
 seals removed and fresh air admitted. The walls, ceiling and 
 floor are thoroughly wiped with the solution of bichlorid of mer- 
 cury 1 in 1,000, using a large piece of gauze for the purpose. 
 When the mercury solution contained in a piece of gauze is ex- 
 hausted, it is thrown away and a clean piece used. The assistant 
 who does the wiping should be admonished not to rub a certain 
 area of room with a piece of gauze and then resoak it in the solu- 
 tion, but to throw it aside and use a fresh supply. The floor is 
 scrubbed with green soap and hot water. The mantel and stationary 
 furnishings may be covered with clean sheets. The latter prepa- 
 rations should be completed for several hours before the operation. 
 In the interim no one should be allowed to enter the chamber 
 except those directly concerned in the operative procedure. 
 
 THE OPERATING TABLE 
 
 The transportation of an operating table permitting of the 
 elasticity given by the kind of apparatus in use in hospital or office 
 practice is impracticable. To overcome the discomfort of the im- 
 provised table, manufacturers at the instigation of surgeons have 
 made portable tables which in all essential regards meet the indi- 
 cations. A number of these portable tables are on the market, 
 each one of which has its exponents, and, indeed, each one presents 
 certain advantages over the other. 
 
 Portable Operating Table. — The table shown is one designed by 
 Dr. J. Bently Squiers of ISTew York City, constructed of cold- 
 drawn steel tubing fitted with milled tool steel rack and pinion 
 
Fig. 125— Squiers' Portable Operating Table, Showing Trendelenburg 
 Posture and Crank for Obtaining Same. 
 
 Fig. 126.— Method of Folding Squiers' Portable Operating Table. 
 174 
 
THE OPERATING ROOM IN PRIVATE PRACTICE 175 
 
 with crank for elevating the top (Fig. 125). To fold the table 
 (Fig. 126) it is only necessary to fold back the top, which is 
 hinged together, bend the hinge in the center of the bottom braces, 
 which fold, and the two ends slide together by the side braces fold- 
 ing. There is no fastening of screws or clamps necessary to set 
 up or fold the table. When folded for transportation the table 
 appears as shown in Fig. 127. The case (Fig. 137) is extremely 
 
 Fig. 127. — Squiers' Portable Operating Table Folded for Transportation. 
 
 light and is fitted with a handle. The weight of the table is 28 
 pounds. The Trendelenburg posture is shown in Fig. 125. For 
 operations on the head and face the head-piece is raised or lowered 
 as desired; the arrangement for lithotomy position is shown in 
 Fig. 128. The dimensions of the table are 19 inches wide, 67 
 inches long and 34 inches high. When folding for transportation, 
 the dimensions are 6 inches thick, 20 inches wide and 35 inches 
 long. This table may be regarded as forming a standard. Modi- 
 fications of construction to suit the taste and class of practice of 
 the surgeon are simple questions of mechanical art. 
 
 The portable apparatuses designed to be placed on the ordi- 
 nary deal table to permit of Trendelenburg posture, lithotomy 
 position, etc., are also much in vogue. These are extremely use- 
 ful and satisfactorily efficient, if it be not necessary to change the 
 posture of the patient during the operation. The disturbance of 
 the arrangement of the sterile surroundings consequent upon the 
 manipulations involved under these conditions makes them less 
 acceptable than a table fitted with legs, as the Squiers table or a 
 similar apparatus. 
 
176 
 
 THE OPERATING ROOM 
 
 The additional weight of the frame and legs is a minor con- 
 sideration. On general principles a portable table should be de- 
 signed with the view of obtaining the greatest elasticity as regards 
 necessities which may arise, and there can be no doubt that the 
 kind of table here described is constructed with this in view. 
 
 Fig. 128. — Squiers' Portable Operating Table Arranged for Lithotomy 
 
 Position. 
 
 An operation for removal of a neoplasm of the neck which is 
 to be performed in the patient's home calls for neither a portable 
 complete table nor an adjustable frame, and in this instance the 
 ordinary deal table is of sufficient utility. Indeed, it may be said 
 that the display of unnecessary armamentarium in surgical work 
 is undesirable ; yet the portable operating table is Avell nigh indis- 
 pensable in operations on the abdominal and pelvic organs. 
 
THE OPERATING ROOM IN PRIVATE PRACTICE 
 
 177 
 
 The Extemporized Operating- Table. — For this purpose the or- 
 dinary deal kitchen table makes a useful substitute in operations 
 
 Fig. 129. — Extemporized Operating Table. 
 
 blanket. 
 
 Kitchen table covered with 
 
 which permit of the supine position and may be tilted to obtain 
 a moderate degree of Trendelenburg elevation. However, it is to 
 be remembered, as already stated, when the Trendelenburg posture 
 
 Fig. 130. — Extemporized Operating Table Covered with Blanket and 
 
 Rubber Sheet. 
 
 or the lithotomy position is necessary, special apparatus for the 
 purpose should be employed. 
 
178 THE OPERATING ROOM 
 
 The deal table usually found in kitchen or laundry is more 
 useful than the dining-room table, as the latter is likely to be too 
 
 Fig. 131. — Small Pillow and Sheet Placed ox Extemporized Operating 
 
 Table. 
 
 wide to allow of easy access to the patient from both sides. The 
 kitchen table should be covered with a folded blanket (Fig. 129) 
 
 Fig. 132. — Drainage Pad Placed ox Extemporized Operatixg Table. 
 
 in order to prevent pressure soreness following the operation. Xext 
 a rubber sheet (Fig. 130) is placed on the blanket and this covered 
 
THE OPERATING ROOM IN PRIVATE PRACTICE 
 
 179 
 
 with a sheet and a small pillow (Fig. 131) placed in situ for the 
 patient's head. Drainage is provided with the Kelly pad (Fig. 
 132), the pad being, of course, placed on the portion of the table 
 corresponding to the part to be operated upon. The bottom of the 
 
 111 K^ra 
 
 Fig. 133. — Kelly Pad Arranged on Extemporized Operating Table, to 
 drain into Pail. 
 
 pad is folded over and led into a pail (Fig. 133). Care should 
 be exercised in selecting a table with firm strong legs, as the com- 
 bined weight of the patient and the fact 
 that the operator and assistant are likely to 
 lean on the table are apt to break the legs 
 off where they join the top. If there be any 
 doubt as to the stability of the table, it may 
 be reinforced by wiring the legs together 
 near their bottoms. 
 
 If the lithotomy position is to be em- 
 ployed, the apparatus shown in Fig. 134 
 will be found extremely useful. The 
 clamps are readily fastened to any table 
 and the uprights are maintained at any 
 height by means of the set screws. At sub- 
 sequent dressings, the clamps may have the 
 stirrup shown in Fig. 135 inserted instead 
 of the upright. 
 14 
 
 Fig. 134. — Clamps and 
 Uprights for Lith- 
 otomy Position on 
 Extemporized Oper- 
 ating Table. 
 
180 
 
 THE OPERATING ROOM 
 
 Tables for narcotist, suture material, instruments and dress- 
 ings are readily extemporized from those ordinarily found in dwell- 
 ings. As a matter of fact, 
 the operating table and one 
 table (Fig. 186) are perhaps 
 the only portable apparatuses 
 necessary. Fig. 137 shows a 
 case which will carry both 
 the portable operating table 
 and the small metal table for 
 instruments, which may be 
 placed close to the surgeon 
 and take the place of the ad- 
 justable instrument tray. 
 Dressings, wipes, etc., have already been taken up (page 158). 
 Their disposition in the improvised operating room need not differ 
 materially from that which obtains in hospital operating rooms. 
 
 Fig. 135. — Clamp and Stirrup for Extem- 
 porized Operating Table. 
 
 Fig. 136. — Portable Operating and Instrument Table. 
 
 STERILE WATER 
 
 The question of sterile water is not solved by the presence of 
 several gallons of distilled water. Distilled water, as already 
 
THE OPERATING ROOM IN PRIVATE PRACTICE 181 
 
 stated, is not sterile, though boiled water which is used soon after 
 boiling is practically sterile. In this contingency it is well to boil 
 the distilled water in a large wash boiler and to fill the pitchers 
 with a dipper which has been boiled with the water. Frequent 
 immersion of the hand into the wash boiler in order to manipulate 
 the dipper is objectionable. This may be obviated by the use of 
 a dipper with a sufficiently long handle to protrude over the top 
 of the boiler, a corner of the boiler cover being notched for the 
 
 Fig. 137. — Portable Operating and Instrument Table Folded for 
 Transportation, and Case for Same. 
 
 purpose, though this should not be done until after the boiler has 
 been exposed to high temperature. 
 
 An exceedingly useful method of handling water is used by 
 Lesser. A flask of thin glass, especially prepared to withstand 
 high temperature, is filled with distilled water and the mouth 
 covered with cotton between two layers of gauze (Fig. 138). 
 The neck of the bottle has a piece of wire twisted about it, by 
 means of which it is suspended when used as an irrigator. A 
 number of these bottles are placed directly on the fire (Fig. 138), 
 and the water boiled for twenty minutes. A Bunsen burner may 
 be used, or the flask may be placed on the kitchen stove. For the 
 purpose of lavaging the parts the non-sterile nurse simply lifts 
 
Fig. 138. — Flask Filled with Water, W hich is Boiled for Twenty 
 Minutes Immediately before Use. 
 
 Fig. 139. — Flask of Sterile Water with Rubber Tube Connection 
 for Irrigation. 
 182 
 
THE OPERATING ROOM IN PRIVATE PRACTICE 
 
 183 
 
 the gauze cover and pours the contents on the surface to be 
 cleansed. For irrigation the cotton plug is removed and a rubber 
 cork pierced with a bent glass tube is substituted. The portion 
 of glass tube in the bottle is connected with a piece of soft rubber 
 tubing, the end of which is covered with gauze for the purpose 
 of avoiding the abstraction of foreign particles in the event of the 
 water not being distilled. If the water 
 has been distilled the gauze screen is 
 not used. 
 
 The portion of glass tube protruding 
 is connected with a long piece of rubber 
 tubing (Fig. 139). To withdraw the 
 water, the tubing and glass tube and 
 cork are submerged in sterile water 
 and filled. This constitutes a siphon, 
 and the connection with the reservoir 
 is made as shown (Fig. 139). The 
 tube is closed with a clamp when not 
 in use. Midway between the bottle and 
 the terminal end of the rubber tubing 
 is connected a glass tube with a bulbed 
 enlargement. This gives opportunity 
 for standardizing the flow of water in 
 washing into cavities. It also permits 
 of recognition of the flow in itself, thus 
 obviating the annoyance of doubt as to 
 whether the fluid is flowing or not. 
 Fig. 140 shows the bulb connection, 
 which in this instance was partially Fig. uo.— Glass Bulb Cox- 
 
 r*TT t •<! -t,- c , • NECTION IN RUBBER TUBE 
 
 filled with a solution of potassium per- to CoNTROL Flow of 
 manganate to favor clearness in the Irrigating Fluid. 
 illustration. 
 
 Fig. 141 shows the irrigating apparatus suspended from a 
 stand. In private practice an ordinary clothes hook placed in a 
 convenient situation may be employed. The basin near the bot- 
 tom of the stand is filled with a solution of bichlorid of mercury 
 1 in 1,000. In this instance the bulb is submerged in the basin. 
 Care must be taken not to contaminate the tube connections when 
 the siphonage is arranged. 
 
184 
 
 THE OPERATING ROOM 
 
 The advantage of the method lies in the fact that the water 
 is sterilized in the container, from which it is delivered on the 
 operative field without intermediate handling. 
 
 Theoretically this method of sterilizing and employing water 
 should be more certain than one which involves handling of the 
 water between the sterilizer and 
 the wound. However, the in- 
 flexibility of the method with 
 respect to the adjustment of 
 desirable ranges of tempera- 
 ture, and the fact that the ap- 
 paratus now employed for the 
 purpose is so well arranged, 
 would argue for employment 
 of the latter in hospitals and 
 sanatoria, leaving the flask 
 method for use in private prac- 
 tice. 
 
 It is of course feasible to 
 sterilize water by other means 
 than those shown here. For 
 instance, there is no reason 
 why containers other than those 
 made of glass should not be 
 employed for the purpose, pro- 
 vided the principle of not 
 handling the water after it is 
 boiled is borne in mind. In 
 the event of the water thus 
 treated being too hot, the flasks 
 may be immersed in cold 
 water for varying periods of 
 
 time, in accord with the desired temperature. It is a good plan, 
 if feasible, to boil all the flasks twenty-four hours before the oper- 
 ation and heat half of them, to almost the boiling point, im- 
 mediately before the operation. Thus the surgeon has at his 
 disposition water of quite extreme temperature, a condition of 
 affairs which permits of considerable adjustability in this con- 
 nection. 
 
 Fig. 141. — Flask Used as Irrigator 
 Suspended by Wire Attached to 
 Neck. 
 
THE OPERATING ROOM IN PRIVATE PRACTICE 185 
 
 SUTURE AND LIGATURE MATERIAL 
 
 Suture and ligature material in private practice is used in the 
 same form as obtains in hospital practice. However, the transpor- 
 tation of suture material which will not stand boiling is unsafe, 
 unless it be inclosed in sterile tubes (Fig. 53). Silk, silk-worm 
 gut and celluloid thread (Pagenstecher thread), may be safely 
 transported and boiled with the instruments or separately. It is 
 to be borne in mind that iodine catgut will not stand heat, and, 
 if used from sealed tubes, the tubes must be sterilized by pro- 
 longed immersion in strong antiseptic solutions, which latter may 
 be diluted with sterile water immediately before handling the 
 tubes to prevent the chemical action of the antiseptic upon glove 
 or hand. 
 
 As a general proposition, it may be said that operations in 
 private houses are less liable to be complicated with wound infec- 
 tion, and that the results obtained in operating under these con- 
 ditions are uniformly good, though the technic of the surgeon is 
 somewhat hampered by the inflexibility of the operating table 
 and by the fact that the source of light is not as readily made as 
 serviceable as obtains in hospital practice. 
 
 On the whole, a surgeon supplied with a portable table, and 
 whose assistants exercise reasonable care in the technic of achiev- 
 ing cleanliness, is in a position to do satisfactory work in patients' 
 homes. 
 
CHAPTEK VIII 
 DRAINAGE OF OPERATIVE WOUNDS 
 
 Drainage in uninfected cases — Drainage in infected cases — Drainage agents: 
 — Tube drainage; silk- worm gut drainage; catgut drainage; rubber tissue 
 drainage; textile fabric drainage. 
 
 The drainage of operation wounds, the question of its intro- 
 duction, its maintenance, and the length of time agents intro- 
 duced for the purpose of drainage should remain in situ are 
 important factors in the treatment of wounds, the outcome of 
 surgical procedure. 
 
 It may be said, in a general way, that drainage of operation 
 wounds is not as universally employed at this time as has ob- 
 tained in the past. A clearer understanding of the processes of 
 repair of surgical trauma and the part taken by secretions, the 
 result of reparative process, and a better knowledge of the ability 
 on part of the body to take care of certain exudates are respon- 
 sible for this. 
 
 Yet it is to be understood that drainage has a clear and def- 
 inite place in surgical technic, and that, while an unfavorable 
 outcome may result if it is not employed, rarely indeed would its 
 establishment be followed by other than delay in repair of the 
 wound or possibly in the abdomen, by the occurrence of hernia. 
 Certain it is that, if it be doubtful in the mind of the surgeon 
 whether drainage in a given case is to be established or not, it is 
 wisest to employ it. Indeed, in these doubtful cases the subse- 
 quent behavior of the case, as determined by the symptomatology, 
 will not infrequently permit of the removal of the drainage agent 
 at a time when the reparative process would have been so little 
 interfered with as to practically preclude the likelihood of hernia 
 or undesirable cosmetic outcome. 
 
 In a general way it may be said that infection in the opera- 
 tion field calls for drainage, the absence of infection justifies dis- 
 
 186 
 
DRAINAGE IN UNINFECTED CASES 187 
 
 regarding it. However, there are situations and conditions where 
 infection is present when drainage is not alone unnecessary, but a 
 prejudice to the best possible ultimate outcome, such as the re- 
 moval of pyosalpinx by the abdominal route, in which instance 
 the character of pus is such as to render drainage unnecessary, 
 and the presence of a drain extending through the abdominal wall 
 favors the occurrence of ventral hernia, while the irritation of the 
 peritoneum arising from the presence of the drain agent is liable 
 to produce adhesions of the abdominal contents which are un- 
 desirable. 
 
 Again, if the operation field be extensive, such as obtains in 
 the removal of large neoplasms, and there has been much trauma 
 to the surrounding tissues, the conditions are exceedingly favor- 
 able to the development of infection, the outcome of accidental 
 fertilization. Under these conditions it would be best to establish 
 drainage. 
 
 It may also be said that the necessity for drainage in unin- 
 fected operative cases bears a direct proportion to the thorough- 
 ness with which hemorrhage has been arrested. The presence of 
 blood clots in the blind spaces of an extensive wound favors infec- 
 tion, and the forcible manipulation of wounds of dimensions in- 
 adequate to the gentle manipulation of the area invaded also 
 markedly favor the development of infection. 
 
 If, on the other hand, the complete arrest of all oozing in a 
 wound of extensive dimensions is going to prolong the surgical 
 manipulations, and possibly call for the use of excessively hot 
 solutions or strong astringents in order to arrest it, it would be 
 wisest to introduce drainage in order to permit of the discharge 
 of serum and the expulsion of blood clots early during the process 
 of repair. 
 
 The necessity for drainage in a given class of cases is perhaps 
 best taken up in the discussion of the care of operation wounds 
 under the special heads, and, indeed, this will be found done. 
 However, the general principles involved are properly taken up 
 at this time. 
 
 DRAINAGE IN UNINFECTED CASES 
 
 The theory of drainage in cases where infection does not exist 
 at the time of the operation is to either remove secretions, the out- 
 
188 DRAINAGE OF OPERATIVE WOUNDS 
 
 come of the process of healing, which would prejudice complete 
 and rapid repair, or to provide an avenue of escape for infective 
 material which may have been accidentally introduced during the 
 operation. The exudate consequent upon the process of non-sup- 
 purative repair ceases at the end of three times twenty-four hours 
 after the operation, and infection introduced during the operation 
 should manifest itself in modification of the normal expression of 
 metabolism, i.e., temperature and pulse rate, within that time. 
 
 What exudate occurs during this period of time may be re- 
 garded as physiological if no infection has been introduced. This 
 means that at the end of this time the drainage agent may be re- 
 moved if there be no indication to the contrary. The drainage, 
 too, will have filled its office in having maintained an avenue of 
 escape for non-infected exudates which might mechanically inter- 
 fere with union, and therefore it, too, may be removed. 
 
 Taking into consideration the longer period of incubation of 
 infective processes, the character of which is of so little virulence 
 as to require a longer period of time than this to develop, and 
 which may be regarded as capable of no greater harm than local 
 manifestations of minor import and the consequent pathologic 
 process, they are readily taken care of with less unfavorable out- 
 come to the ultimate result than would obtain had the drainage 
 been prolonged. Certainly it is warrantable to assume that no 
 particularly dangerous occurrence will manifest itself later than 
 the fourth day after the operation, and the infrequent times when 
 late infection occurs does not justify jeopardizing the chances of 
 a favorable immediate outcome by over-precaution, more so as 
 in the vast majority of cases the practice suggested has been found 
 to be a good one, as the outcome of prolonged experience in cases 
 of this sort. 
 
 DRAINAGE IN INFECTED CASES 
 
 Drainage in infected cases is most generally necessary. The 
 instances when it may be ignored are rare, though it may be said 
 that infections of organs covered by peritoneum make the excep- 
 tion, i.e., an infected organ which is attacked by the surgeon 
 through its peritoneal covering does not necessarily call for drain- 
 age of the entire peritoneal sac. 
 
 This exception relates, however, only to instances in which 
 
DRAINAGE AGENTS 189 
 
 the infective process in the given part is of a character which jus- 
 tifies the belief that the virulence of the infective process has been 
 exhausted as the result of a prolonged combat between the in- 
 vading infection and the resistance of the part, and the operating 
 is undertaken for the relief of pain and affliction, the outcome of 
 a now quiescent process, or with the view of forestalling occasional 
 exacerbation of the disease and possible excursions into contiguous 
 parts, organs, and tissues. 
 
 Again, drainage may be discarded in cases where the infection 
 has not jet markedly involved the peritoneum, and the operation 
 radically removes totally the source of infection. This contention 
 is elastic, however, in the sense that a moderate amount of infec- 
 tion of the peritoneum will recover without drainage for the rea- 
 son that the causative focus has been removed and that the peri- 
 toneum will take care of a certain amount of exudate, provided 
 this be not fluid pus. 
 
 Another consideration which influences the decision in this 
 regard is the fact that localized areas of peritoneum are not drained 
 by the introduction of drainage agents unless the area be isolated 
 by adhesions, and if this be not the case, it is a question whether 
 the surgeon is justified in running the risk of contaminating con- 
 tiguous healthy portions of the peritoneum in an attempt to obtain 
 dependent drainage. However, this is more largely taken up in 
 connection with the after-treatment of abdominal operations. 
 
 In the presence of free pus in this situation, or if there be a 
 reasonable assurance that the area of operation has been exposed 
 to infection, drainage should be always employed. It is a firmly 
 established rule in surgery that all drainage should aim to exercise 
 its office at the most dependent portion of the area of operation, 
 and should be so arranged as not to be interfered with as the result 
 of a posture on part of the patient which would render futile the 
 intent. 
 
 DRAINAGE AGENTS 
 
 TUBE DRAINAGE 
 
 Tube drainage is employed in cases where large quantities of 
 fluid pus is to be removed ; also in cases of extensive trauma where 
 there is a reasonable inference that from the character of the injury 
 extensive infection is liable to be manifested. It is rarely used in 
 
190 DRAINAGE OF OPERATIVE WOUNDS 
 
 clean operative wounds, even though exudates are likely to occur, 
 in which latter instances other drains are employed. 
 
 Glass tubing has been quite abandoned except in cases of tuber- 
 culous peritonitis and, perchance, for drainage of empyema. 
 
 Rubber tubing has quite displaced all other material. Rubber 
 tubes should be of sufficient caliber to take care of the indications, 
 
 Fig. 142. — Glass Jar Containing Rubber Drainage Tubes of Various Sizes, 
 Submerged in Corrosive Sublimate Solution 1 in 1,000. 
 
 with a slight excess of size beyond what is expected in a given case. 
 Drainage should not be indiscriminately used, but when employed 
 should be ample for the purpose. The quality of rubber used is 
 important, as sterilization by heat is exceedingly desirable and in- 
 ferior quality of rubber disorganizes when exposed to great heat. 
 In hospitals and office practice rubber tubing of various caliber 
 
DRAINAGE AGENTS 
 
 191 
 
 is, after being boiled, kept in glass jars submerged in aqueous solu- 
 tion of bichlorid of mercmy 1 in 1,000 (Fig. 142). This prac- 
 tice is not safe, as the removal of a portion of the contents may 
 result in accidental fertilization. Care should be taken to remove 
 the portion of tubing to be used with sterile forceps. 
 
 In private practice tubing of the desired caliber is sterilized 
 in a glass container in which, after hav- 
 ing been boiled, it is placed, together 
 with a sufficient quantity of water, and 
 again exposed to heat. The container 
 is then sealed, and fertilization during 
 transportation or while stored is im- 
 possible. This is the safest method of 
 handling rubber tubes for drainage. 
 However, it is quite proper to convey 
 non-sterile tubing to the scene of opera- 
 tion and boil it with the instrument or 
 separately. This is a thoroughly effi- 
 cient method provided the tubing be 
 used immediately. 
 
 When using the tube it is cut to 
 the desired length and fenestrated as 
 shown in Fig. 143. When cutting the 
 fenestra a curved scissors should be 
 used to make oval openings. If the 
 tube be bent at an acute angle and tri- 
 angular pieces be cut out with straight 
 scissors, the resultant fenestrum is dia- 
 mond-shaped, and the tube is liable to 
 kink at this point and become obliter- 
 ated when placed in situ. In order to 
 prevent the tube from slipping into the 
 cavity it is draining, a safety pin is 
 fastened to its protruding end in the 
 
 manner shown in Fig. 143. The pin should be pushed through 
 the side of the tube and not cross the caliber of the tubing at its 
 center to avoid obstruction of the flow of discharges. 
 
 The protrusion of the tube beyond the skin should be as slight 
 as possible, just sufficient to allow for the safety pin and a pad 
 
 Fig. 143. — Rubber Drain- 
 age Tube Fenestrated 
 and Safety Pin At- 
 tached. 
 
192 
 
 DRAINAGE OF OPERATIVE WOUNDS 
 
 of gauze underneath the latter. This precaution avoids oblitera- 
 tion of the end of the tube by pressure from the protective dressing 
 (Fig. 144). The object of the gauze pad is to prevent contact of 
 the pin with the wound, which might cause irritation if this pre- 
 caution were not taken. 
 
 Tube drainage being usually employed for the drainage of pus 
 
 Fig. 144. — Rubber Tube Drainage in situ. 
 
 cavities, the dressing is changed at frequent intervals. This is 
 the more imperative at the expiration of the twenty-four hours 
 following the operation because the trauma resulting from the 
 surgeon's manipulations causes a certain amount of hemorrhage. 
 The oozing of blood into a cavity causes the formation of blood 
 clot, and this is liable to, and, indeed, most usually does, invade 
 the tube, obstructing its lumen. Therefore, the tube should be 
 
DRAINAGE AGENTS 
 
 193 
 
 removed at the end of twenty- four hours, the clot from the lumen 
 and those formed in the cavity expressed, and the tube reinserted. 
 Disregard of this precaution frequently leads to constitutional dis- 
 turbances, the outcome of absorption of the retained secretions. 
 
 Fig. 145. — Triplex Rubber Drainage Tube. 
 
 A so-called triplex drainage tube has recently been employed 
 by the writer with success. The tube is made of pliable rubber 
 (Fig. 145), and consists of three small tubules molded together. 
 The smaller lumen acts slightly like a capillary tube. The ar- 
 rangement also permits of washing of 
 a cavity through one of the openings, 
 while the other two furnish ample 
 avenue of escape of secretions and 
 allow of free escape of the cleansing 
 fluid. Fig. 146 shows a transverse 
 section of the tube. 
 
 SILK-WORM GUT DRAINAGE 
 
 Silk-worm gut is employed for 
 drainage purposes in cases where 
 
 ,iii i -.i ,i Fig. 146. — Transverse Sec- 
 
 tnere has been much oozing, with the ™ „„„„ nT7 „ Di: ,„ 
 
 o' tion or Triplex Rubber 
 
 view of draining off serum and fluid Drainage Tube. 
 
194 
 
 DRAINAGE OF OPERATIVE WOUNDS 
 
 blood. It is rarely used when infection exists at the time of the 
 operation, though in the event of a small abscess cavity being 
 present, it may be used in place of tube drainage. It is often 
 employed in cases of removal of tuberculous glands which have 
 no surrounding mixed infection, and the operator feels that drain- 
 age for a few days is a wise precautionary measure. 
 
 For the purpose several strands of silk-worm gut are used, the 
 number employed depending upon the 
 area requiring the measure, which are 
 looped in the manner shown in Fig. 
 147. The loop spreads out the under- 
 lying cavity, and by capillarity the 
 fluid exudate is caused to emerge at 
 the twisted ends. In cases of moderate 
 infection a strand at a time may be 
 removed from the wound as the dis- 
 charge becomes less, thus maintaining 
 drainage in proportion to the indica- 
 tions. Fig. 148 shows the silk-worm 
 gut drain placed in situ. 
 
 CATGUT DRAINAGE 
 
 Catgut drainage is employed in 
 much the same way as is silk-worm 
 gut. It is, however, never used in the 
 presence of purulent infection. It has 
 the presumable advantage of being ab- 
 sorbed and need not be removed. In a 
 clean case its employment assures an 
 avenue of escape for the fluid exudates, 
 and the fact that it is absorbed prevents 
 the necessity of disturbing the dress- 
 ings in order to remove it. It is also 
 employed in operations upon bones fol- 
 lowing which absolute immobilization 
 is desirable, and is exceedingly serviceable when complete rest of 
 the part is regarded as essential. On the whole, it may be re- 
 garded as having an exceedingly restricted field of usefulness. 
 Fig. 149 shows the arrangement of the catgut for the purpose. 
 
 Fig. 147. — Silk-worm Gut 
 Looped for Drainage 
 Purposes. 
 
DRAINAGE AGENTS 
 
 195 
 
 It is wiser to use a large number of strands of fine catgut than a 
 few heavy ones, for the reason that offensive exudates are more 
 thoroughly removed by having the way of egress indicated in 
 multiplicity, and the circulating fluid is more apt to act quickly 
 
 Fio. 148. — Silk-worm Gut Drain in situ. 
 
 if the surface exposed to absorption is large, 
 catgut drain in situ. 
 
 Fig. 
 
 150 shows 
 
 RUBBER TISSUE DRAINAGE 
 
 Rubber tissue for drainage is employed in much the same class 
 of cases as silk-worm gut and tube drainage, except that it should 
 be used to drain cavities of moderate dimensions. The rubber tis- 
 sue is prepared by boiling and is stored in a flat glass dish sub- 
 merged in sterile saline solution (Fig. 151). 
 
 For the purpose of drainage the tissue is cut to the desired 
 15 
 
196 
 
 DRAINAGE OF OPERATIVE WOUNDS 
 
 size and rolled upon itself into a tubular form (Fig. 152). Silk- 
 worm gut, catgut, and rubber tissue drains are not cut at the level 
 of the skin, but are, because dependent upon capillarity for action, 
 
 j)ermitted to protrude to a considerable 
 extent from the wound. 
 
 All of these agents act better when 
 the portion of protective dressing with 
 which they are in immediate contact is 
 moistened with sterile water, as capil- 
 larity is more effective when it need 
 not overcome the resistance of non-satu- 
 rated surroundings. The rationale of 
 this is illustrated by the housewife who 
 moistens a new lamp-wick at the burner 
 before she attempts to ignite it. Rubber 
 tissue drains have the advantage of not 
 forming attachment to the tissues, and 
 thus interference with action is not 
 likely to occur. Also, when they are 
 removed, the edges of the wound are not 
 disturbed, and the patient is saved pain 
 and annoyance 
 tissue drain in situ 
 
 Fig. 153 shows rubber 
 
 Fig. 149. — Catgut Arranged 
 for Drainage. 
 
 TEXTILE FABRIC DRAINAGE 
 
 Various forms of medicated gauze 
 are used for the purpose. Their action 
 is similar to that of the preceding. As 
 a general rule, it may be said that drains which act by capillarity 
 should take the place of tube drainage when dependent drainage 
 cannot be obtained. Tubes will not drain " up hill " ; capillary 
 drains, while not as effective when draining upward, still will act 
 when not placed in dependent positions. Textile fabric presents 
 the best mechanical agent to accomplish the purpose. However, 
 gauze is not resistant to pressure, becomes adherent to the sur- 
 rounding tissues, and thus its action is considerably interfered 
 with. To obviate these objections, the so-called " cigarette drain " 
 has come into use. 
 
 It consists of gauze rolled to the desired thickness, the diam- 
 
DRAINAGE AGENTS 
 
 197 
 
 eter depending upon the size of cavity to be drained, and this sur- 
 rounded with rubber tissue, leaving a portion of gauze at either end 
 uncovered (Fig. 154). This arrangement acts like a wick, the 
 end which is buried in the wound collects the exudates, which are 
 led along the gauze inclosed in the rubber tissue and discharged 
 by means of the distal end into the protective dressing. In this 
 
 Fig. 150. — Catgut Drain in situ. 
 
 instance the gauze should be moist, and the two ends especially 
 should be quite soaked with salt solution or, in certain cases, with 
 antiseptic solution. 
 
 This drain is the one most generally used in surgery. It is 
 clean, easily handled, and effective. It may be used in aseptic or 
 infected wounds. In the latter instance, however, it must be 
 changed frequently, as the gauze very soon becomes the nahr- 
 boden for bacteria. However, the fact that its replacement is 
 attended with so little disturbance makes this fact only slightly 
 objectionable. Fig. 155 shows the " cigarette drain " in situ. 
 
 The arrangement of silk-worm gut, catgut, rubber tissue, and 
 the cigarette drains is shown in Figs. 148 to 155. The silk- 
 
198 
 
 DRAINAGE OF OPERATIVE WOUNDS 
 
 worm gut and catgut drain will be seen to extend to a considerable 
 
 extent beyond the margins of the wound. This favors capillarity. 
 
 The silk-worm gut drain allows of removal of a strand or two 
 
 Fig. 151. 
 
 -Glass Jar for Storing Sterile Rubber Tissue in 
 Corrosive Sublimate Solution 1 in 1,000. 
 
 at a time as the discharge from the wound becomes less. The cat- 
 gut drain, as already stated, need not be removed, being absorbed. 
 However, there is some irregularity with regard to the time re- 
 
 Fig. 152. — Rubber Tissue Rolled on Itself for Drainage Purposes. 
 
 quired for absorption of this agent, and at times these drains 
 also require removal. 
 
 The cigarette drain should protrude slightly from the wound, 
 the gauze being, of course, made to extend beyond the rubber tissue 
 envelop. The rubber tissue drain protrudes to the extent shown. 
 
DRAINAGE AGENTS 
 
 199 
 
 Rubber tissue drains do not act by capillarity and simply provide 
 an avenue of egress for the discharges. Logically, rubber tissue 
 drains should be employed only at dependent portions of the wound. 
 
 Fig. 153. — Rubber Tissue Drain in situ. 
 
 Their most useful field is that of drainage of uninfected wounds 
 where much trauma has been necessary. They occupy a position, 
 
 Fig. 154. — Cigarette Drain. 
 
 as regards efficiency, about between cigarette drains and silk-worm 
 gut drains. 
 
 The indication for their use may be illustrated as follows. 
 Given a celiotomy for infection in the female pelvis with many 
 adhesions and considerable trauma to the abdominal wound, the 
 outcome of severe manipulations during the operation, it not un- 
 
200 
 
 DRAINAGE OF OPERATIVE WOUNDS 
 
 commonly occurs that the sheath of the rectus sloughs. In this 
 instance rubber tissue drainage under the skin is a wise measure. 
 Given, on the other hand, a case of neoplasm of the neck which 
 requires much dissection without any particular mauling of the 
 tissues, the employment of silk-worm gut drainage for a few days 
 subsequent to the operation is sufficient to meet the indications. 
 Rubber tube drainage, except in rare instances such as em- 
 
 Fig. 155. — Cigarette Drain in situ. 
 
 pyema, or suppurative osteomyelitis, need not be maintained for 
 more than three or four days. It may then be replaced by rubber 
 tissue drainage, and ultimately by a silk-worm gut drain, and this 
 removed strand by strand as indicated by the amount and char- 
 acter of the discharge from the wound. Prolonged maintenance 
 of drainage is prejudicial to repair, and in no instance should 
 drainage agents be caused to make undue pressure on the tissues. 
 
CHAPTER IX 
 SUTURING OF OPERATIVE WOUNDS 
 
 Needles — Needle holders — Suturing of wounds: The continuous suture; the 
 interrupted suture; harelip pins. 
 
 The object of suturing wounds is to hold tissues in apposition 
 until repair takes place. Forcible apposition of wound surfaces 
 attains no desirable object, and is objectionable for the reason that 
 normal interchange of nutritive elements is interfered with, caus- 
 
 Fig. 156. — Suture Properly Tied. Knot drawn to one side. 
 
 ing pressure necrosis, and unnecessary deformation of needle 
 punctures is provoked, resulting in unsightly scaring. Wounds 
 subjected to pressure from sutures are liable to infection for the 
 reasons stated. 
 
 201 
 
202 
 
 SUTURING OF OPERATIVE WOUNDS 
 
 A properly introduced suture causes the edges of the wound 
 to lie in gentle contact with each other (Fig. 156). A skin sut- 
 ure should not produce wrinkling within its confines. As a gen- 
 eral rule, a suture which wrinkles the skin is too tightly drawn 
 (Fig. 157). It may be said that wounds should be held in appo- 
 
 Fig. 157. — Suture Improperly Tied, Causing Strangulation of the Tissues. 
 
 sition without tension. If approximation without tension is not 
 feasible, relaxation sutures should be introduced to obviate the 
 tension of the tissues immediately contiguous to the wound. 
 (Figs. 179, 180, 181, 182.) 
 
 When sutures are introduced in the faulty manner shown in 
 Fig. 157, the skin is puckered, the outer surface of the skin is 
 brought in contact, and union of the edges of the wound does not 
 take place. In another class of cases the skin is turned outward 
 with the same result. In either instance the surgeon is confronted 
 with a failure of accurate healing, and the ultimate outcome is a 
 faulty cosmetic result. This may not be a matter of great import 
 in instances when the operation involves the unexposed portions 
 of the body, but is of great significance when the face is attacked. 
 
NEEDLES 
 
 203 
 
 In any event it means somewhat protracted healing, which is un- 
 necessary and should be avoided. 
 
 NEEDLES 
 
 The suturing of wounds is accomplished by means of needles 
 of various kinds. Much has been written with regard to the em- 
 ployment of various kinds of needles in the several parts, organs, 
 and tissues of the body. An extended consideration of the rela- 
 tive value of the several kinds of needles to be used in given parts 
 does not properly belong here. It is, however, proper to state, in 
 a general way, that needles which puncture the tissues are best 
 used in the skin and superficial parts, while needles which sepa- 
 rate the tissues are of most service in apposing muscles and serous 
 membranes. 
 
 The diameter of the needle to be used for a certain repair de- 
 pends upon the thickness of the suture it is intended to carry 
 through the tissues, and the latter depends upon the amount of 
 tension to be overcome and the length of time, immobilization, 
 and apposition of the divided parts is to be maintained. 
 
 Needles intended to puncture the tissues are usually made 
 
 Fig. 158. — Straight 
 Surgical Needle 
 with Cutting 
 Edges. (Bryant.) 
 
 Fig. 159. — Half- 
 Curved Surgical 
 Needle with 
 Cutting Edges. 
 (Bryant.) 
 
 Fig. 160.— Full- 
 Curved Surgical 
 Needle, with 
 Cutting Edges. 
 (Bryant.) 
 
 with cutting edges, and these are made either straight (Fig. 158), 
 half curved (Fig. 159), or full curved (Fig. 160). In suturing 
 skin where cosmetic effect is to be considered, the flat Hagedorn 
 
204 
 
 SUTURING OF OPERATIVE WOUNDS 
 
 needle is universally employed. These needles are readily ob- 
 tained in varying forms from the straight variety (Fig. 161), 
 the half curved (Fig. 162), and the full curved (Fig. 163). 
 
 A 
 
 Fig. 161. — Straight 
 Hagedorn Needle. 
 {Bryant.) 
 
 Fig. 162.— Half- 
 Curved Hagedorn 
 Needle. {Bryant.) 
 
 Fig. 163.— Full- 
 Curved Hagedorn 
 Needle. {Bryant.) 
 
 %\ 
 
 The puncture made by the surgical needle causes trauma, as 
 shown in Fig. 164 c, d, i.e., the stitch hole is horizontal to the 
 wound, as would be expected from the nature of the needle, which 
 cuts its way through the tissues, as indicated in Fig. 164, d. When 
 the suture is tied, the conformation of the stitch hole is as indi- 
 cated in the same illustration. 
 When ultimate repair takes 
 place the residual scar is likely 
 to be offensively manifest. 
 When the Hagedorn needle of 
 either conformation is used the 
 stitch hole corresponds to the 
 illustration shown (Fig. 
 164, b). When, now, the su- 
 ture is tied, there is a slight 
 elongation of this hole without as great a degree of solution of 
 continuity of tissue (Fig. 164, a). This would argue for the use 
 of the Hagedorn needle in all situations in which cosmetic effect 
 is a factor. 
 
 The round needle employed for approximation of peritoneal 
 surfaces may also be obtained in varying sizes and of varying de- 
 grees of curvature, from the ordinary cambric needle to the heavy, 
 
 Fig. 164. — Needle Wounds. (Bryant.) 
 
NEEDLES 
 
 205 
 
 curved kind used for repair of the broad ligament (Fig. 165). 
 Beyond this, many forms and kinds of needles are obtainable, an 
 extended list of which will be 
 found in the catalogues of all in- 
 strument manufacturers. The 
 general rule here offered is well 
 borne in mind, however, and may 
 be regarded as a guide in selecting 
 an assortment of needles intended 
 to meet the requirements of opera- 
 tions on various parts of the body. 
 
 When sutures are to be deeply 
 placed a long needle with a handle 
 is frequently employed. Of this 
 instrument many kinds are upon 
 the market. They possess the ad- 
 vantage of puncturing the tissues 
 deejjly and accurately. A few 
 of the sort most commonly used are shown in Figs. 166-168. 
 
 Fig. 166 shows the Coe needle, which is largely employed to 
 insert interrupted sutures into the abdominal wall following celi- 
 
 Fig. 165. — Round Needle for Ap- 
 proximating Serous Surfaces 
 and Muscular Fiber. On the 
 right, cambric needle for intestinal 
 suture. (Kelly.) 
 
 Fig. 166. — Coe's Needle with Handle. 
 
 otomy. The needle is first introduced and the suture threaded 
 with the eye protruding distally. The suture is then drawn 
 through the tissues in the reverse direction. The difficulty in 
 
 Fig. 167. — Hagedorn Needle with Gentile Handle. 
 
 threading the suture through the eye, which is of course filled 
 with blood, makes this needle less useful than if such were not the 
 case. In instances in which the abdomen is very fat the instru- 
 ment will be found of service. 
 
 Fig. 167 shows a needle devised to overcome the difficulty with 
 
206 SUTURING OF OPERATIVE WOUNDS 
 
 respect to threading the suture mentioned, by notching the side 
 of the instrument near its cutting end. This renders insertion of 
 the suture more easy. However, not infrequently the skin is 
 caught in the notch and considerable difficulty is experienced in 
 placing the suture. 
 
 Fig. 168 shows a needle used for placing sutures in operations 
 for the relief of hernia. The needle is bent at right angles to the 
 shaft and is furnished with a roomy eye for the purpose of carrying 
 
 Fig. 168. — De Garmo's Femoral Needle. 
 
 kangaroo tendon sutures, which are largely used for the purpose. 
 The same objection with respect to the difficulties in threading 
 the sutures mentioned is applicable in this connection. It has, 
 however, a useful place in the class of cases for which it is intended. 
 These needles are commonly used in placing relaxation sutures 
 and in suturing the skin of the abdominal wall and after extirpa- 
 tion of the mammary gland in patients who have a large quantity 
 of subcutaneous fat. However, they do not form an essential ac- 
 quisition to the surgeon's armatarium and may be properly re- 
 garded as refinements, and, after all, are of questionable utility. 
 As a general rule, it may be stated that each puncture of the skin 
 increases the liability of infection, and as the needles with a handle 
 must of necessity first transfix the skin and then draw the suture 
 through in the opposite direction, a single manipulation as obtains 
 with the threaded needle is the more desirable manipulation. In- 
 deed, when introducing the interrupted suture, the writer employs 
 several needles in repairing an extensive wound, on the theory that 
 the repeated entrance of the skin with the one needle is more likely 
 to result in skin infection than if a fresh needle be used after 
 several sutures have been placed in situ. More especially is this 
 the case in repair of the intestine, where each suture is introduced 
 with a different needle, with the view of forestalling the convey- 
 ance of infection by means of a needle and suture which may in- 
 advertently have punctured the lumen of the gut. 
 
NEEDLE HOLDERS 
 
 207 
 
 NEEDLE HOLDERS 
 
 Needle holders are universally employed for the introduction 
 of sutures. Here again an extended discussion is out of place. 
 However, it may be said that the instrument should be used for 
 the purpose in place of the fingers whenever practicable. Instru- 
 ments are always less liable to be the habitat of infective bacteria 
 than the fingers for obvious reasons, and the manipulations neces- 
 sary to the introduction of sutures, coining as they do at the end 
 of an operation, find the fingers of the operator frequently con- 
 
 ' Fig. 169. — Hartley-Markoe Needle Holder. {Bryant.) 
 
 taminated as the outcome of the operative procedure. Indeed, it 
 is the habit of the writer to turn the closure of the wound over to 
 an assistant whenever this is a consideration worthy of being taken 
 into account from the nature of the operation. 
 
 As in the case of needles and suture carriers, innumerable 
 models of needle holders are obtainable in the market, each one 
 of which bears a name of an inventor. As a general proposition, 
 the life of utility of a needle holder depends upon the resistance 
 
 Fig. 170. — Sand's Needle Holder. (Bryant.) 
 
 of its biting surfaces. As this depends upon the elasticity of the 
 metal surface, no needle holder will be found serviceable in per- 
 petuity. It is, therefore, well for the surgeon to have within easy 
 reach tAvo needle holders at all times, as the limit of elasticity of 
 the metal may be reached at any time. The disregard of this pre- 
 caution is often responsible for a display of irritability on part 
 of the operator which, being enhanced by the exhausting effects 
 of a prolonged operation, at times culminates in the offending in- 
 
208 
 
 SUTURING OF OPERATIVE WOUNDS 
 
 strument being thrown violently upon the floor, and if there be no 
 second instrument at hand, the rest of the suturing must be accom- 
 plished with the fingers. This being an undignified and unde- 
 
 Fig. 171. — Luer's Needle Holder. (Bryant.) 
 
 sirable outcome, the precaution mentioned is best borne in mind. 
 
 A number of needle holders are depicted in Figs. 169 to 173. 
 
 Each has its advocates, but, no doubt, acquaintance with the mech- 
 
 Fig. 172. — Halsted-Leur Needle Holder. (Bryant.) 
 
 anism of any of them will develop efficiency in its use. Fig. 173 
 shows a holder furnished at its biting surface with a piece of soft 
 metal which will conform to the size of most any needle. It is to 
 
 Fig. 173. — Ermold Needle Holder. 
 
 be remembered that this piece of metal ultimately undergoes per- 
 manent deformation for the reason already stated, and that this 
 should be frequently replaced. In addition, the lock at the ter- 
 
NEEDLE HOLDERS 
 
 209 
 
 mination of the handles closes at one bite and releases at the next, 
 which makes this an exceedingly comfortable instrument to work 
 with, especially when working in deep cavities. 
 
 Fig. 174 shows a needle holder which Kelly uses to hold curved 
 
 J 
 
 Fig. 174. — Kelly Needle Holder 
 for Round Needles. (Kelly.) 
 
 Fig. 175. — Needle Holder Showing Method 
 of Grasping Round Needle. (Kelly.) 
 
 needles. The handles are heavy and serrated, permitting of a firm 
 grasp, and the ends tapering, which permits of working in deep 
 cavities. The biting surfaces are of soft copper, allowing of 
 
210 
 
 SUTURING OF OPERATIVE WOUNDS 
 
 adaptability with respect to the size of needle employed. The 
 criticism made in connection with the Ermold needle holder re- 
 specting permanent deformation of the soft metal applies here. 
 The lock is operated with the thumb and is a convenient one. It 
 is not, however, as readily handled as obtains with the Ermold 
 holder. 
 
 Fig. 175 shows the manner of grasping the needle near its eye. 
 At this point the needle is usually of greatest strength and is less 
 
 Fig. 176. — Continuous Suture Ready to be Tied. Half-curved surgical needle. 
 
 liable to break when being manipulated. On the other hand, the 
 long lever distal to the bite makes this manner of holding the needle 
 less firm when being inserted into resisting tissue, in consequence 
 of which the needle rotates in the holder, giving it a direction in 
 passing through the tissues, other than was intended. This may 
 be overcome by grasping the needle nearer its middle when using 
 it under the conditions mentioned. 
 
SUTURING OF WOUNDS 
 
 211 
 
 SUTURING OF WOUNDS 
 THE CONTINUOUS SUTURE 
 
 The continuous suture is the one most universally used (Fig. 
 177). When there is reasonable assurance that infection has not 
 
 Fig. 177. — Continuous Suture Completed and Tied. 
 
 Fig. 178. — Interrupted Suture Properly Introduced and Tied. Knots 
 
 drawn to one side, 
 lu 
 
Fig. 179. — Relaxation or Tension Sutures. The approximation sutures are 
 improperly tied. The knots should be drawn to one side. 
 
 Fig. 180. — Tension Sutures Threaded on Buttons to Obviate "Cutting." 
 One suture ready to be tied, the other tied. 
 
 212 
 
Fig. 181. — Tension Sutures Looped over Pledgets of Gauze. 
 
 Fig. 182. — Method of Introducing Harelip Pins to Relieve Tension in Wound. 
 
 213 
 
214 
 
 SUTURING OF OPERATIVE WOUNDS 
 
 occurred during the operation, it is a most desirable form of suture, 
 as it permits of accurate apposition of the edges of the wound, and 
 if it be necessary to remove it, the patient is subjected to a mini- 
 mum of annoyance in accomplishment of the act, as it needs be 
 only loosened at its distal ends and withdrawn. This, of course, 
 applies only when the suture material is of the non-absorbable 
 variety. Fig. 176 shows the continuous suture introduced and 
 
 Fig. 183. — Suture Material Looped Over Harelip Pins, Drawing Edges 
 of Wound Together. 
 
 ready to be tied. The needle is the one-half curved surgical kind, 
 usually used for the purpose. Fig. 177 shows the suture finished, 
 and the ends cut short. 
 
 The usual rule is to employ this class of suture in the deep 
 tissues and not in the skin, for the reason that abscess in the suture 
 punctures is exceedingly liable to happen in the latter situation 
 
SUTURING OF WOUNDS 
 
 215 
 
 despite all precautions, and the continuous suture forms a path 
 along which infection may easily travel. In the illustrations the 
 suture is shown introduced into the skin for the sake of clearness. 
 
 THE INTERRUPTED SUTURE 
 
 The interrupted suture is shown in Fig. 178. Care should 
 be taken not to draw the edges of the wound too tightly together 
 
 Fig. 184. — Ends of Harelip Pins Cut Off. 
 
 (Fig. 157), but to simply bring them into apposition (Fig. 156), 
 for the reasons already stated. If there be much tension in the 
 wound, relaxation sutures are introduced. These may consist of 
 simple deep sutures introduced in the manner shown in Fig. 179, 
 or threaded on buttons (Fig. 180), or looped over pledgets of gauze 
 
216 SUTURING OF OPERATIVE WOUNDS 
 
 (Fig. 181), with the view of obviating undue pressure on the 
 tissues. 
 
 HARELIP PINS 
 
 Some surgeons prefer to supplement the approximation sut- 
 ures with the introduction of harelip pins. These pins are intro- 
 duced quite widely from the edges of the wound (Fig. 182), and 
 heavy suture material is looped over the protruding ends (Fig. 
 183), bringing the edges of the wound together. The ends of the 
 pins are at last cut off as in the manner shown in Fig 184. 
 
 Harelip pins are likely to cut into the soft tissues, especially 
 if there be much tension, the outcome of the effort to approximate 
 the edges of the wound. This makes the employment of the pins 
 less serviceable than the button suture or the loops padded with 
 gauze pledgets. 
 
CHAPTEK X 
 THE DRESSING OF OPERATIVE WOUNDS 
 
 Antiseptic powders — Iodoform and its modifications — Application of powder 
 — The protective dressing — Gauze for dressings: Medicated gauze; sterile 
 gauze; the combined dressing. 
 
 ANTISEPTIC POWDERS 
 
 After approximation of the edges of the wound, it is customary 
 to apply to it and the surrounding surfaces some antiseptic pow- 
 der. This is, however, not so universally done at this time as 
 obtained formerly. The use of certain agents seems to go in cycles. 
 At times an agent which has been quite universally employed by 
 every one falls into disuse, to be, perhaps, again exploited and to 
 have as wide a vogue as ever. 
 
 The fact is, that the use of antiseptic dusting powders has a 
 rationale which has its justification in chemistry and bacteriology 
 as applied to their employment in this connection. Before the 
 employment of asepsis, dusting powders and certain remedial 
 agents were applied to wounds with the idea of stimulating repair. 
 A more accurate knowledge of the genesis of cells following sur- 
 gical trauma has shown that the real usefulness of antiseptics lies 
 in their power to destroy bacteria, although no one could deny that 
 the application of a sterile mercury ointment to a wound in the 
 person of a syphilitic who has been subjected to operation has a 
 beneficial effect, and that the introduction of iodoform into the 
 superficial wound of approach in removal of tuberculous glands is 
 a scientific and rational indulgence. Then, too, if there be in- 
 fection in the operative field, it is more reasonable to expect benefit 
 from antiseptic lavage than from mechanical cleansing, especially 
 with saline solution. For if there is a medium which makes a 
 favorable culture field for bacteria, it is a normal salt solution. 
 This is well illustrated by the fact that salt solution is used where 
 
 217 
 
218 THE DRESSING OF OPERATIVE WOUNDS 
 
 tissues are to be guarded against interference with nutrition, such 
 as in skin grafting. 
 
 Two factors enter into the immediate after-treatment of oper- 
 ative wounds. One is the prevention of contact of infective mate- 
 rial with the wound, and the other the destruction of bacteria which 
 may be in immediate contact with the wound and which will 
 cause infection if the conditions are favorable. 
 
 It is, as already shown, quite impossible to sterilize the skin 
 absolutely. Taking the problem up from that standpoint, nothing 
 could be more favorable to the invasion of the wound by infective 
 bacteria than to have it and the contiguous skin covered with a 
 thin layer of serum and coagulated bloo(,l. Oozing is never so 
 absolutely arrested as to prevent this contingency. Even though 
 primary union is obtained in a given instance, the skin near the 
 wound and the area of union is always found covered with this 
 coating when the dressing is removed. The fact that serum is so 
 largely used as a culture medium in the bacteriological laboratories 
 would suggest that the statement just made had some foundation 
 in fact. 
 
 Assuming that the hair follicles, sebaceous glands, and sudo- 
 riparous glands are the habitat of bacteria and that the skin im- 
 mediately contiguous to the wound is coated with a culture medium 
 favorable to their growth and development, it is easy to see how 
 infection would find its way to the wound, and, indeed, the much 
 discussed stitch abscess may be attributed in a certain number of 
 instances to this cause. It is, of course, not to be forgotten that 
 division of the hair follicles by the puncturing needle is an impor- 
 tant causative factor in this connection, yet the one mentioned 
 should not be disregarded. 
 
 Indeed, the growth of bacteria always requires a favorable cul- 
 ture medium. It is the experience of all surgeons that stitch ab- 
 scess does not occur as frequently when silk-worm gut is used in 
 approximating the wound as when catgut is employed for the pur- 
 pose. This does not by any means permit of the conclusion that 
 the catgut was not sterile. It may simply mean that catgut is a 
 far more favorable culture medium for bacteria than is the smooth, 
 hard silk-worm gut. The fact that catgut undergoes a physical 
 change while in situ may, too, contribute to this difference, i.e., 
 the gradual absorption of the catgut probably changes it into 
 
IODOFORM AND ITS MODIFICATIONS 219 
 
 a more favorable culture medium for bacteria, an assumption 
 supported by the fact that infection in the stitch holes occurs 
 not infrequently on the eighth, and even as late as the twen- 
 tieth day. 
 
 Assuming a wound approximated by a continuous catgut sut- 
 ure, the line of which, together with the immediately contiguous 
 skin, is coated with a layer of wound secretion, no great stretch 
 of the imagination is required to see a colony of bacteria invading 
 the crust, either from a neighboring hair follicle or from one of 
 the perforations made -by the needle, growing rapidly, and extend- 
 ing along the entire suture line. These are conditions exceedingly 
 favorable to infection of the superficial wound and, indeed, the 
 outcome is of sufficient frequency to be a familiar picture to the 
 surgeon, and more especially to the practitioner who carries out 
 the after-treatment and is, at the end of a week, confronted with 
 a state of affairs for which he is not infrequently made respon- 
 sible by the patient and, too, greeted at times with certain sar- 
 castic remarks from the .operator. 
 
 In contrast to this, it is also easy to see that, given a wound 
 closed by interrupted sutures of silk-worm gut, the edges and sur- 
 rounding skin of which is covered with an antiseptic which im- 
 pregnates the secretions, infection is not so liable to occur. And, 
 indeed, this is quite the fact. At times an infection of a single 
 stitch will occur, and be it said that this may be the case despite 
 all precautions. However, infection of the entire wound is cer- 
 tainly less apt to obtain if the latter conditions prevail. 
 
 IODOFORM AND ITS MODIFICATIONS 
 
 An effort has been made to obviate contamination of the 
 wound by sealing it firmly with collodion. This has proven un- 
 satisfactory, however, as it retains the secretions from the wound 
 in a confined place, does not destroy the bacteria in the stitch 
 holes, and infection occurs. The general surgical principle of 
 the confining of secretions applies here with equal force, though 
 the quantity of secretion is very small. If, however, the collo- 
 dion be thoroughly impregnated with an antiseptic, the bacteria 
 may be destroyed. It is, nevertheless, a better principle to per- 
 mit bacteria to exhaust themselves in a large antiseptic area 
 
220 
 
 THE DRESSING OF OPERATIVE WOUNDS 
 
 than to depend upon the bactericidal effect of small quantities 
 of antiseptics. 
 
 Iodoform has maintained its place in this field of usefulness. 
 It has been shown to be of itself less resistant to the invasion of 
 bacteria than is suggested by its manifestly beneficial effect 
 clinically demonstrated. It is probable that the combination of 
 the agent with blood liberates free iodin upon which its useful- 
 ness depends. The objectionable odor of iodoform has led to 
 many modifications in its preparation, of which aristol is an ex- 
 ample. It is probable that aristol is quite as efficacious as the 
 former, and is free from odor. Iodol, naphthalan, and similar 
 preparations are largely used for the purpose, all of which have 
 exponents. Orthoform, vioform, bismuth and the like are all of 
 usefulness. Vioform is largely used in Berlin. 
 
 APPLICATION OF POWDER 
 
 Care should be taken to sterilize the agent before use, pro- 
 vided heat will not cause a chemical change rendering it inert. 
 In any case' the container should be sterilized before the opera- 
 tion. Ordinarily the powder is applied to the 
 wound and surrounding parts with a sprinkler 
 (Fig. 185). This apparatus is exceedingly con- 
 venient and cleanly if sterilized each time it is 
 used. Repeated use of the sprinkler without this 
 precaution is warned against. 
 
 A safe and convenient method of use is to 
 place the powder into a sterile jar, covered with 
 wide-meshed gauze. The powder may then be 
 applied without fear of causing contamination. 
 About enough powder for an operation may be 
 prepared from the stock package for each opera- 
 tion, and the small quantity remaining may be 
 discarded. Fig. 186 shows a jar prepared in 
 this way. The mixture of blood, serum, and 
 antiseptic powder certainly presents a medium 
 Fig. 1S5. — Anti- less favorable to the growth of bacteria than do 
 
 SEPTIC POWDEE ^ secretions al(me . 
 
 Sprinkler. 
 
 (Bryant.) Before applying the powder, the wound is 
 
THE PROTECTIVE DRESSING 
 
 221 
 
 washed with a solution of corrosive sublimate 1-1,000, and the 
 secretions from the wound together with the solution are wiped 
 away. Covering of the 
 wound with inordinate 
 quantities of powder 
 serves no useful pur- 
 pose; indeed, in the in- 
 stance of iodoform, 
 poisoning may occur. 
 Of course this is not 
 likely to be the case if 
 the iodoform be used on 
 a sutured wound, and 
 applies more largely to 
 its application to ex- 
 tensive raw surfaces. 
 •However, the possibil- 
 ity of its occurrence is 
 to be remembered. 
 Again, iodoform at 
 times gives rise to der- 
 matitis, and, indeed, 
 some individuals posses 
 an idiosyncrasy in this 
 regard. The condition 
 
 disappears as soon as the cause is removed. Patients found sus- 
 ceptible in this way should be informed of the conditions with the 
 view of obviating a recurrence of the event. 
 
 In wounds which are drained, too liberal a use of powder 
 may obstruct drainage, and care should be taken to avoid this. 
 As a general proposition, a moderate use of these agents conserves 
 the interests of the patient better than too liberal application. 
 
 Fig. 186. 
 
 -Powder Sprinkler Used in Opera- 
 ting Room. 
 
 THE PROTECTIVE DRESSING 
 
 The protective dressing is applied to wounds for the purpose 
 of absorbing discharges and to prevent the entrance of infect- 
 ive agents. The immobilization of parts in order to conserve 
 repair is a problem entirely distinct from the two propositions 
 
222 
 
 THE DRESSING OF OPERATIVE WOUNDS 
 
 stated, though, of course, the three objects are attained simul- 
 taneously. 
 
 If the theory offered with regard to the susceptibility of ex- 
 udates from wounds being exceedingly favorable to the develop- 
 ment of infection be true, there is no question as whether sterile 
 dressing material or material impregnated with antiseptics is the 
 more rational. However, the contact with the skin of material 
 saturated with wet antiseptics is objectionable on the ground that 
 irritation is a frequent result. Indeed, this applies also to dry 
 antiseptic dressing material, for the moisture from the skin, to- 
 gether with the secretions from the wound, cause the dry anti- 
 septic to go into solution. However, there is no doubt that too 
 
 Fig. 187. — Flat Gauze Applied Immediately to Wound. 
 
 radical a view of either method is unnecessary, and that the best 
 method of action is found in a judicious application of both prin- 
 ciples. 
 
 As a general proposition, it may be said that infected wounds 
 should be dressed with a preponderance of antiseptic material 
 over the unmedicated dry material, while clean wounds require 
 less employment of the antiseptic dressings. Taking the invasion 
 of the dressing by bacteria from the skin in one direction (out- 
 ward), and the assault of infective material from the other (in- 
 ward), it would seem fair to assume that the point at which these 
 two will meet depends upon the distance necessary to be traveled 
 by each, and the character of the medium they have to penetrate. 
 Copious discharges from wounds which entirely saturate the pro- 
 
GAUZE FOR DRESSINGS 
 
 223 
 
 tective dressing constitute an easy avenue of approach in either 
 direction, for obvious reasons. The mechanical hindrance to the 
 entrance of bacteria is best subserved by cotton. 
 
 It would seem rational to place in immediate contact with the 
 wound a layer of dry gauze which is sterilized by heat only. This 
 prevents contact with medicated dressing more externally situ- 
 ated, and obviates the danger of irritation to the skin. This is 
 best applied in several layers folded flat (Fig. 187). The secre- 
 tions from the wound soon saturate this layer of gauze, and the 
 next layer of gauze may be saturated with an antiseptic and 
 dried with heat. Theoretically, bacteria which may invade this 
 layer should be destroyed by coming in contact with an antiseptic 
 
 Fig. 188. — Fluffed Gauze Placed Over Flat Gauze Shown in Fig. 187. 
 
 solution of which they themselves form the solvent. However, if 
 the case be already infected this layer may be moist at the time of 
 application, and thus more readily take up the secretions. 
 
 GAUZE FOR DRESSINGS 
 
 Gauze for dressings consists of cheesecloth of varying num- 
 ber of strands per square inch. The closer the mesh the slower 
 will absorption of fluids take place ; on the other hand, obviously, 
 the closer the mesh the more fluid will the gauze take up. As a 
 general rule, gauze with 24 x 32 threads per square inch will be 
 found efficacious for all practical purposes. 
 
 This layer of gauze should be applied "fluffed" (Fig. 188). 
 
224 
 
 THE DRESSING OF OPERATIVE WOUNDS 
 
 Thus the irregularities in outline of the part are equalized when 
 the final bandaging is done and a smooth surface is presented. 
 This layer of gauze may be simple sterile gauze as is used by a 
 large number of surgeons. However, the considerations men- 
 tioned are worthy of taking into account in determining the ques- 
 tion of medicated gauze. The preparation of iodoform gauze 
 has already been described (page 76). 
 
 Gauze is prepared by immersing cheesecloth of the desired 
 number of threads to the square inch in cold water for twelve 
 hours, with the view of dissolving the starch. It is then boiled 
 for several hours, dried, and cut into various sizes determined by 
 the purpose for which it is to be employed. It is then sterilized 
 under pressure, as already described (page 62). The impregna- 
 tion of the gauze, with antiseptics is accomplished by immersing 
 the gauze, after boiling, in a solution containing the desired anti- 
 septic and, after drying again, sterilizing under pressure. The 
 antiseptics most commonly used for the purpose are carbolic acid 
 1 in 20, corrosive sublimate 1 in 1,000, mercuric cyanid 1 in 
 1,000, and the iodoform gauze mentioned. 
 
 Corrosive sublimate gauze is made 
 
 as follows : 
 
 
 Strength. 
 
 1 in 1,000 
 
 1 in 500 
 
 1 in 400 
 
 Absorbent Cotton (Dry) 
 
 Corrosive Sublimate Sol. 1-1000 
 Water (Sterile) q.s. ad 
 
 13 oz.(10yds.) 
 12J oz. 
 32 oz. 
 
 13 oz. (10 yds.) 
 25 oz. 
 32 oz. 
 
 13 oz. (10 yds.) 
 
 31 oz. 
 
 32 oz. 
 
 If facilities for sterilization under pressure be not available there 
 can be no doubt that immersion in antiseptic solutions is in- 
 dicated. 
 
 Gauze, both sterile and medicated, is put up in convenient 
 packages by the trade, and if facilities for sterilization be not 
 convenient, these preparations will be found exceedingly useful. 
 
 Where elaborate dressing is necessary it is well to use gauze 
 folded into a long strip about four inches in width. This is ap- 
 plied to the part in much the same way as a bandage (Fig. 189). 
 Its removal, if saturated with secretions, is, however, attended 
 with more disturbance to the patient than the " fluffed " gauze, 
 which permits of ready saturation and piecemeal removal when 
 the wound is redressed. 
 
GAUZE FOR DRESSINGS 
 
 225 
 
 Cotton for the protective dressing has many advantages over 
 the fluffed or roll gauze, and is applied in the vast majority of 
 instances. It interferes mechanically with the entrance of bac- 
 
 Fig. 189. — Roll Gauze Applied Over Fluffed Gauze Shown in Fig. 188. 
 
 teria, but is very readily saturated with secretions and, for this 
 reason, is not as serviceable used next the wound as is the gauze. 
 Absorbent cotton is readily obtained in the shops, and if it be used 
 supplementary to gauze, need not be medicated, though in this 
 
 Fig. 190. — Combined Dressing Applied Over Roll Gauze Shown in Fig. 189. 
 
 instance there is no objection to using it medicated if there be 
 especial indication for its use. It has, however, a tendency to 
 " ball " when applied, and is best employed in the form of com- 
 
226 THE DRESSING OF OPERATIVE WOUNDS 
 
 bined dressing (page 77), which consists of a layer of cotton 
 placed between two pieces of gauze. This is a very convenient 
 dressing, and when applied presents a smooth surface which is 
 easily held in place (Fig. 190) with several strips of adhesive 
 plaster over which the retaining bandage is applied. With this 
 arrangement of the protective dressing it is believed that the 
 bacteria in the parts surrounding the wound are destroyed, or at 
 least their growth is inhibited and their entrance from without 
 effectually prevented. The attendant should err on the side of 
 elaborate dressing rather than the reverse. A clear appreciation 
 of the intent of the dressing will explain this admonition. 
 
 Oil silk, rubber tissue, paraffin paper, and other impermeable 
 agents should, for obvious reasons, be applied between the band- 
 age and the cotton. Secretion must be permitted to invade the 
 dressing and not be confined close to the wound. If the imper- 
 meable layer be placed too near the wound, this will be prevented. 
 The agents mentioned are valuable protection in regions where 
 the dressing is apt to be soiled by excretions, such as the urine 
 and feces. They are, too, very useful to retain moisture if, for 
 any reason, the dressing needs to be kept wet. 
 
 The illustrations show the various steps in applying the pro- 
 tective dressing in a case of wound of the thigh. This site is 
 selected for convenience. It is, of course, understood that the 
 method of procedure applies equally to other situations. 
 
CHAPTER XI 
 
 SHOCK AND SECONDARY HEMORRHAGE 
 FOLLOWING OPERATIONS 
 
 Shock following operations — Shock bed — Treatment of shock: hypodermic 
 injections; mechanical pressure; transfusion, the direct transfusion of 
 blood, suture method of blood-vessel anastomosis, instruments and mate- 
 rial, the operation; the cannula method of blood-vessel anastomosis: gen- 
 eral management of a transfusion; the donor; the recipient — Infusion — 
 Needling of artery — Hypodermoclysis — Enteroclysis. 
 
 Secondary hemorrhage following operations: The Mikulicz tampon; removal 
 of Mikulicz tampon. 
 
 SHOCK FOLLOWING OPERATIONS 
 
 The two most important causative factors in shock from opera- 
 tions are the extent of trauma and loss of blood. These two fac- 
 tors do not, however, bear any direct proportion to the consequent 
 manifestations in a given case. The variations in this regard may 
 be considered as belonging to that mysterious problem called life. 
 So-called life has been made the subject of more or less intricate 
 investigation for ages. The problem is more wisely, if not with 
 the hope of elucidation, turned over to the clergy. Certain it is 
 that severe trauma may be attended with very little shock, and 
 profound modification of the so-called vital forces may attend a 
 comparatively moderate degree of injury. This, is not quite so 
 indefinite an outcome with regard to loss of blood, though here, 
 too, the rule applies, if with somewhat less force. Comparatively 
 slight loss of blood may be attended with considerable shock, 
 though rarely, indeed, is great loss of blood not attended with 
 shock, albeit this may be more severe in a given case than appears 
 consistent with the quantity of the circulating fluid lost. In a 
 general way, it may be said that loss of blood rarely entails shock 
 of the same degree of severity as occurs with severe trauma, and 
 that the former is more rapidly recovered from than the latter. 
 17 227 
 
228 SHOCK AND SECONDARY HEMORRHAGE 
 
 Indeed, persons who have received severe injury die very soon 
 after the infliction of the trauma, while shock from loss of blood 
 is compensated for by a physiological modification of functions 
 which gives opportunity for compensation, as shown in cases of 
 division of the common iliac artery with the knife, when the fatal 
 outcome is quite delayed, in contradistinction to the immediate 
 fatal result of injury to this vessel as the outcome of gunshot 
 wound. In the latter instance the impact of the projectile is an 
 important factor in the fatal issue. 
 
 An extended discussion of the mechanism of shock does not 
 belong here. However, an understanding of the problem is neces- 
 sary in order to comprehend the rationale of the treatment sug- 
 gested. For a thorough acquaintance with this exceedingly im- 
 portant factor in the after-treatment of operative cases, the reader 
 is referred to Crile's masterful work, " Surgical Shock." 
 
 Shock may be regarded as a sudden depression of the vital 
 powers arising, as stated above, from trauma or loss of blood acting 
 on the nervous system, and inducing exhaustion or inhibition of 
 the vasomotor mechanism. Shock from mental emotion need not 
 be considered here. By overstimulation of sensory nerves the vaso- 
 motor center is exhausted or inhibited, vaso constrictor power is 
 lost, the arteries and capillaries are depleted or nearly emptied of 
 blood, and the blood accumulates in the veins. The blood pressure 
 is lowered, cardiac action is impaired, respiration is impeded, and 
 quantities of dark colored blood collect in the somatic veins, but 
 more especially in the veins of the splanchnic area. 
 
 In shock the abdominal veins and, indeed, veins in other 
 parts of the body are distended, there is an insufficiency of blood 
 in the arteries, and a lessened amount of blood reaches the heart 
 and the vital centers of the central nervous system. This means 
 that, while the total quantity of blood in the body may not be 
 reduced, as obtains in cases of shock without loss of blood, suffi- 
 cient blood is not circulating to maintain the functions of the 
 vital centers. 
 
 Collapse is a term used to designate a severe condition of 
 shock, and is employed by some writers as a name for a condition 
 of shock produced by mental disturbance rather than by physical 
 injury. Crile regards collapse as an inhibition of the vasomotor 
 centers and shock as the outcome of exhaustion of these centers. 
 
SHOCK BED 229 
 
 This conception is, however, not accepted by all writers. Shock 
 and collapse may co-exist. Indeed, it may be said that if any dif- 
 ference exist between shock and collapse it is only as regards de- 
 gree. Taking a comprehensive view of the rationale of the ter- 
 minology, it would seem proper to regard collapse as a more severe 
 degree of shock. At any rate, this permits of uniformity and 
 avoids confusion. Shock is, of course, modified in degree, though, 
 as already stated, no absolute standard can be made in this 
 connection. As a general rule, shock is more severe in so- 
 called nervous persons than in those of lymphatic temperament, 
 and, of course, is more severe in persons suffering from organic 
 disease. 
 
 Sudden death from shock is explained on the ground that a 
 reflex stimulation of the nucleus of the pneumogastric nerve in the 
 medulla occurs, which arrests cardiac action. This is called death 
 by inhibition. 
 
 Anything which extracts heat from the body favors the oc- 
 currence of shock. This is a quite rational conception if it be true 
 that animal heat and energy are mutually convertible. So it is 
 also true that the conservation of animal heat during operative 
 manipulations tends to prevent shock, and the application of arti- 
 ficial heat immediately following an operation would seem to meet 
 one of the indications presented by the clinical picture of post- 
 operative shock. As a rule, the bed of the patient is prepared with 
 this in view while the operation is in progress, and as a routine 
 the bed is in all institutions prepared in the following way. 
 
 SHOCK BED 
 
 As a rule, patients are best managed after surgical operations 
 on a bed which has no mattress. Not infrequently considerable 
 manipulation is necessary for the first few days after an opera- 
 tion, and this is best accomplished on a hard surface, as is obtained 
 by the wire bed-spring. As already stated, the bed should be so 
 located as to permit of easy access to the patient from both sides 
 at the same time. The wire mesh spring is covered with a folded 
 blanket and sheet. This is, in turn, covered with a rubber sheet 
 corresponding to the middle third of the bed, and contact with the 
 rubber is avoided by placing upon the rubber sheet a linen sheet 
 
230 SHOCK AND SECONDARY HEMORRHAGE 
 
 Fig. 191. — Shock Bed with Slip Sheet. Blocks for raising foot of bed. 
 
 folded on itself to the necessary size, and the ends twisted about 
 the side bar" of the bed, as shown in Fig. 191. The two blocks 
 
 Fig. 192. — Shock Bed. With foot-end elevated and hot-water bags in place. 
 The rubber sheet at head of bed prevents soiling with vomit. 
 
SHOCK BED 
 
 231 
 
 on the floor are used to raise the foot of the bed, as shown in Fig. 
 192. Next three hot-water bags are placed on the bed and a small 
 rubber sheet is laid at its head, with the view of preventing soiling 
 of the bed linen from vomit, which is usually much in evidence 
 immediately after narcosis. The center draw sheet, too, is very 
 liable to be soiled as the outcome of involuntary evacuations from 
 the bladder and rectum at this time, and the arrangement here 
 shown permits of rapid change of this portion of the bed linen 
 with a minimum of disturbance to the patient. Fig. 192 shows 
 the bed arranged as mentioned with the top sheet and blanket 
 turned down and the pillow fastened to the head of the bed ready 
 to be placed under the patient's head when the necessity for its 
 absence no longer obtains. Fig. 193 shows the bed completed 
 
 Fig. 193. — Shock Bed Completely Prepared for Receipt of Patient. 
 Blocks are only employed when indication arises. 
 
 as it should be before the patient is placed upon it. This prepara- 
 tion is exceedingly elastic. The blocks are, of course, used only 
 if shock occurs, thus aiding the circulation toward the vital centers 
 by gravity. The hot-water bags are in the last moment removed 
 from the center of the bed and placed in contact with the patient 
 as the indications arise. Care should be taken not to burn the 
 
232 SHOCK AND SECONDARY HEMORRHAGE 
 
 patient with the apparatus used to furnish artificial heat. It is 
 to be remembered that the patient is not conscious at this time, and 
 is in no position to standardize sensory impressions, and severe 
 burns have occurred as the outcome of lack of precaution in this 
 regard. 
 
 After the patient has been put to bed it is convenient to have 
 close at hand a few articles which are. used in meeting common 
 
 Fig. 194. — Bedside Table with Appliance Used Immediately After 
 the Operation. 
 
 contingencies. A pus basin, towel, a few squares of gauze, a mouth 
 gag, and a pair of dressing forceps are arranged upon a table 
 placed at the bedside. Fig. 194 shows a serviceable arrangement 
 in this regard. The pus basin may be apposed closely to the 
 patient's cheek and effectually catches the vomit. In some in- 
 stances the lower jaw is firmly apposed to the upper teeth and the 
 
TREATMENT OF SHOCK 233 
 
 vomit regurgitates and may be aspirated into the larynx and 
 trachea. Indeed, it has happened that patients have choked to 
 death from this cause. The mouth gag meets here the indication 
 and is left in situ until sufficient consciousness recurs to obviate 
 this possibility. As soon as the mouth is opened the gauze wipes 
 are introduced into the pharynx with the dressing forceps, and 
 the vomit removed. The towel is used to remove excessive quan- 
 tities of vomit from the face. To facilitate removal of the vomit 
 from the upper passages it is at times wise to raise the patient's 
 shoulder with a pillow and turn the head to the opposite side, and 
 to raise the foot of the bed with the shock blocks (Fig. 192). 
 
 These manipulations are routine and are employed after opera- 
 tions irrespective of whether shock occurs or not. The application 
 of heat has already been shown to be a reasonable precaution with 
 the view of preventing shock, and it is, of course, equally reason- 
 able to assume that if unnecessary disturbances from vomiting be 
 avoided this desideratum is additionally conserved. 
 
 In private practice or in an emergency this rather ideal condi- 
 tion of affairs may not be practicable. However, the hot-water 
 bottles may be replaced by hot bricks, bottles filled with hot w T ater, 
 a hot stove lid, or, indeed, any apparatus which will accomplish 
 the purpose. The table, too, need not be of white enameled steel, 
 and equally good service will be rendered by an ordinary household 
 table or a flat wooden chair. 
 
 TREATMENT OF SHOCK 
 
 Beyond the measures mentioned of conserving animal heat and 
 aiding the circulation by gravity, the treatment of shock is in prin- 
 ciple to be directed toward increasing the blood pressure by creat- 
 ing peripheral resistance either by drugs acting on the blood-ves- 
 sels themselves or by mechanical pressure (Crile). The infusion 
 of salt solution into a vein (Fig. 207) is of value, but its effect is 
 transitory except in cases of loss of blood. The writer warns 
 against the indiscriminate use of infusion of salt solution. It not 
 infrequently happens that the house staff in the hospital will in- 
 fuse in this way a patient who suffers from shock, the outcome of 
 the severity of the operative trauma, and who has lost very little 
 blood. In these cases saline infusion is not indicated. The in- 
 
234 SHOCK AND SECONDARY HEMORRHAGE 
 
 discriminate use of strychnia is also deprecated. It is of little 
 value as a stimulant except, perhaps, in collapse from mental im- 
 pression. Crile has demonstrated this experimentally. Atropin, 
 ether, digitalis, and alcohol should be given with caution, and only 
 when especially indicated, though the writer is free to admit that 
 these special indications are not clearly denned. In a general way, 
 it may be said that they are of temporary service as supplemen- 
 tary to the methods more largely discussed here. It is diffi- 
 cult to see how amyl nitrate or nitroglycerin can be of use 
 if the mechanism of shock is actually understood. Indeed, 
 this conception is borne out clinically. Each of these remedial 
 agents may have an especial field of usefulness in stimulating 
 the heart, but they are of little service in the treatment of sur- 
 gical shock. 
 
 The drug which has given palpable results and owes its bene- 
 ficial action to an effect it produces by raising the blood pressure, 
 which is in accord with our understanding of the mechanism of 
 the affliction, is adrenalin chlorid. Adrenalin chlorid is on the 
 market in a solution of 1 in 1,000. Ten to thirty minims of this 
 may be given hypodermatically every one or two hours. It is, how- 
 ever, best to watch the effect of administration and vary the dosage 
 and intervals of administration according to the indications as 
 shown by the pulse and respiration. The agent may be added to 
 the saline venous infusion or injected with salt solution under the 
 skin or, as is perhaps most frequently done in cases where moderate 
 shock is to be combated, added to the colic injection. The indica- 
 tions for its employment in the latter three ways will be taken up 
 under a separate head. 
 
 Senn advises the administration hypodermatically of thirty 
 minims of sterile camphorated oil every fifteen minutes. As the 
 quantity of actively circulating blood is small, the amount of 
 oxygen delivered to the tissues is greatly reduced. The inhala- 
 tion of oxygen is, therefore, indicated. However, it is to be re- 
 membered that the red-blood corpuscles will take up only a certain 
 amount of oxygen and their carrying capacity does not increase as 
 the quantity of blood is reduced. This suggests that the remedy 
 is of doubtful value. There is no objection to its use, however, 
 and, indeed, as soon as the blood in the larger veins begins to cir- 
 culate, respiration may be assisted in this way. 
 
TREATMENT OF SHOCK 
 
 235 
 
 HYPODERMIC INJECTIONS 
 
 A word in this connection 
 regarding hypodermic injec- 
 tions. The usual practice is to 
 employ for the purpose a long 
 needle (Fig. 195A), which is 
 obliquely introduced through 
 the skin as it is " pinched " up 
 by the other hand (Fig. 196). 
 The objection to this is that 
 a considerable number of hair 
 follicles and glandular elements 
 of the skin are punctured, fa- 
 voring infection and subsequent 
 abscess formation. Asjain, a 
 
 O 7 
 
 wide area of sensory terminal 
 fibers are subjected to trauma, 
 causing considerable pain. The 
 writer orders the injection 
 made with a very short, slen- 
 der needle (Fig. 195B), which 
 is introduced at' right angles 
 to the surface of the skin (Fig. 197), thus avoiding the contin- 
 
 A B 
 
 Fig. 195. — Hypodermic Syringes. 
 
 A, Long needle usually employed. 
 
 B, Short needle. 
 
 Fig. 196. — Usual Method of Making Hypodermic Injections. 
 
236 
 
 SHOCK AND SECONDARY HEMORRHAGE 
 
 gencies mentioned. Small as this difference may seem, it is an 
 important factor when repeated injections are to be made in rapid 
 
 Fig. 197. — A Useful Method of Making a Hypodermic Injection. 
 
 succession. A lesson in this regard may be gleaned from morphin 
 habitues, who use this method and are but rarely afflicted with 
 abscess. 
 
 MECHANICAL PRESSURE 
 
 Mechanical pressure may be made by firmly bandaging the 
 extremities with textile fabric or, better still, with elastic rubber 
 
 Fig. 198. — Crile's Inflated Rubber Suit for Treatment of Shock. (Bryant.) 
 
 bandages. Theoretically, the extremities are thus excluded from 
 the circulation and what reduced amount of blood is still making 
 
TREATMENT OF SHOCK 237 
 
 the cycle is restricted to the vital organs. This measure is a simple 
 one and is useful. It should be done rapidly so as not to un- 
 necessarily expose the patient to the influence of the atmosphere. 
 Crile employs a complete double rubber suit (Fig. 198), which 
 completely encases the patient, and the space between the two lay- 
 ers of rubber is inflated with air. This is perhaps of considerable 
 service, but its field of application must of necessity be restricted 
 to a certain class of cases and under certain conditions. 
 
 TRANSFUSION 
 
 Transfusion is employed to overcome shock. Blood intro- 
 duced directly from one person to another, or the introduction of 
 defibrinated blood, has been largely used for the purpose. How- 
 ever, with a better understanding of the mechanism of shock, the 
 introduction of saline fluid into the body has largely displaced the 
 former method. The intent of the introduction of fluid into the 
 circulation is not to supply nutritive constituents to the body of 
 the afflicted, but to furnish a mechanical agent upon which the 
 circulating organs can work until the normal relationship is estab- 
 lished. The object is accomplished mechanically by a salt solu- 
 tion as well as by blood either directly from another or defibri- 
 nated outside the body by mechanical manipulation, and is not 
 liable to undergo chemical changes either in the technic of in- 
 troduction or in the body of the recipient which might have dele- 
 terious effects. 
 
 Heretofore the avenue of communication between the donor 
 and recipient has consisted of mechanical appliances, and if it be 
 true that coagulation of the blood is prevented in the body as the 
 outcome of contact with living tissue, the passage of the circu- 
 lating fluid through the cannula must of necessity permit of a cer- 
 tain chemical change in the blood which may result in coagula- 
 tion and, perchance, the formation of emboli. This does not 
 apply to defibrinated blood with regard to emboli, but it is difficult 
 to see how blood which has been subjected to the necessary ex- 
 trinsic manipulations which obviate clotting can be of use in any 
 other than a mechanical way. 
 
 The objections with respect to the direct method of transfu- 
 sion of blood have been largely overcome by the technic employed 
 
238 SHOCK AND SECONDARY HEMORRHAGE 
 
 by Crile, from whose work, " Hemorrhage and Transfusion," the 
 text on this subject is quoted. 
 
 Crile states : 
 
 The transference of blood from one individual to another can be 
 safely and efficiently done only by the union of the supplying vessel 
 of the donor to the receiving vessel of the recipient in such a manner 
 that the continuity of the intima of each vessel is continuous with that 
 of the other. 
 
 The problem' is applied, in this connection, only to shock. The 
 question of hemolysis is, of course, not taken up at this time for 
 this reason. 
 
 The Direct Transfusion of Blood. — By following Carrel's technic 
 it is possible to sew together the ends of two severed blood-vessels in 
 such a way that when the blood is allowed to flow through, the joint 
 does not permit leakage, the flow is uninterrupted, and clotting does 
 not occur. This method can not only be used for temporary anasto- 
 mosis, but for permanent restoration of function. As developed by 
 the author, in performing transfusion directly from one individual 
 to another, the suture method was employed in all early experimental 
 and clinical work, but it was found that a special cannula and method 
 of using it took less time. In the latter work the cannula has come to 
 supersede the suture for making all temporary anastomosis. Both 
 methods, however, will be described in detail. 
 
 The operator will find the technic of the direct anastomosis 
 without special cannula of valuable service in instances such as 
 arise in connection with surgical operations, in the event of the 
 necessary special instruments not being available. 
 
 The Suture Method of Blood-vessel Anastomosis. — Instruments 
 
 and Material. — From an experience with over 100 blood-vessel anas- 
 tomoses made in the laboratory, and more than 60 clinical cases, the 
 following instruments and materials have been found to be most 
 helpful. (See, also, Fig. 199.) 
 
 1. Scalpel. 
 
 2. Blunt director. 
 
 3. Small, sharp-pointed, straight scissors for dividing the ves- 
 sels, snipping off fragments of the adventitia, etc. 
 
 4. Ordinary dissecting forceps. 
 
i 
 
 Fig 
 
 199. — Instruments Used in Performing a Transfusion by End-to-end 
 Anastomosis by the Cannula Method. 1. Scalpel. 2. Blunt dissector. 3, 
 4. Fine-pointed forceps. 5, 6. Crile clamps for temporary closure of blood- 
 vessels. 7. Fine-pointed scissors. 8. Hemostat with transfusion cannula locked 
 in place. 9, 10, 11. Three of the set of four cannula. 12, 13, 14. Mosquito hemo- 
 stats for placing the blood-vessels. (Reduced to about one-half actual size.) 
 
 — Crile. 
 
 239 
 
240 SHOCK AND SECONDARY HEMORRHAGE 
 
 5. Minute tissue forceps with exact approximation at the points 
 (those used by watchmakers have been found to be useful). 
 
 6. Half a dozen mosquito hemostats to use in securing the 
 minute branches of the radial artery and the small venous branches. 
 
 7. A pair of small Crile artery forceps. 
 
 8. Xo. 16 English needles (Kirby's). 
 
 9. No. 1 Chinese silk. 
 
 10. Sterilized vaselin. 
 
 11. Ordinary means for closing a wound, and dressings. 
 
 After experimenting with different kinds and sizes of needles it 
 has been found that the No. 16 round needle as made by Kirby, of 
 London, is the best. A No. 11 or 12 size is larger and easier to handle, 
 but has the disadvantage of causing unnecessary traumatism of the 
 intima and tends to permit oozing through the needle holes when 
 under pressure. Any other than a round needle of about this size 
 will be found to be unsatisfactory. 
 
 As a No. 16 needle is scarcely larger than a hair, the problem of 
 threading it is a difficult one. The method finally adopted to secure 
 suitable sutures was to take a piece of the No. 1 Chinese silk or " 000 
 linen " about 2 feet in length, attach a hemostat to the lower end, 
 carefully separate the upper end into its component strands for a long 
 enough distance to permit each being grasped by the hands of the 
 operator and a hand of an assistant, and then, allowing the hemostat 
 to swing free and pull downward as the twist in the silk made it 
 revolve, hold the silk until it was untwisted down to the hemostat. 
 This gave strands capable of being threaded through the tiny eye 
 of the needle, and with these strands the sewing was -done. 
 
 In order to thread a needle, such a strand is gently pulled at the 
 end in the direction of its long axis until the end breaks. This leaves 
 tiny fibrils, which may then be twisted together and passed through the 
 eye. To preserve the threaded needle, it is passed in and out at 2-inch 
 intervals through a long, narrow strip of gauze, from which it can 
 easily be withdrawn when needed. By placing several threaded 
 needles in one strip they may all be sterilized together. 
 
 Operation. — Having the ends of the vessels to be united sufficiently 
 near each other, the adventitia of the artery is drawn down over the 
 end by means of the fine-pointed dissecting forceps, and cut squarely 
 off with the small straight scissors. By so doing the adventitia left 
 on the vessel retracts and leaves a free field for inserting the sutures. 
 The vein is likewise prepared. Tben, with the fine silk strand thor- 
 oughly saturated with sterile vaselin or oil, the needle is passed 
 
TREATMENT OF SHOCK 
 
 241 
 
 through all the coats of the 
 artery from without inward 
 near the cut surface, and 
 passed through the end of 
 the vein wall in the oppo- 
 site way. The two vessels 
 are brought intimately in 
 contact by tying the suture. 
 The ends of the suture are 
 not cut close to the knot, 
 but about four inches from 
 it. This gives a stay suture 
 to hold while completing the 
 technic. Two more similar 
 stay sutures are inserted 
 with the circumference of 
 each vessel divided into 
 thirds "between them, and 
 if the stays be drawn taut 
 the closely approximated 
 ends of the artery and vein 
 are divided into three equal 
 parts, so as to form an equi- 
 lateral triangle (Carrel and 
 Guthrie). 
 
 With the three stay 
 sutures successfully placed 
 the problem becomes a 
 comparatively easy one. 
 Tension is brought to bear 
 on any two of the stays — it 
 is immaterial which two as 
 long as the third one lies 
 underneath. On the third 
 Stay an inch below the ves- Fig. 200.— Diagrams of Stages of End-to- 
 sels is attached a mosquito END Anastomosis of Two Blood-ves- 
 
 , n . , . ,, , sels by the Suture Method. (Carrel.) 
 
 hemostat which IS allowed 4, Method of placing the three stay-sutures, 
 
 to pull theill down, and They are equidistant and pass through the 
 
 entire thickness of the vessel walls. B, The 
 stay-sutures tied, and the lower angle retracted by the weight of a hemostat. C, 
 placing the over-and-over continuous suture between two of the stay-sutures. The 
 vessels are lifted by the upper sutures in the hands of an assistant, so as to make an 
 angle between the vessels. This permits easy sewing with the straight needle. D, 
 The anastomosis completed. (Crile.) 
 
242 SHOCK AND SECONDARY HEMORRHAGE 
 
 thus prevent the needle from being passed through the lower 
 part of the vessel walls when the final sutures are placed. The weight 
 of the hemostat is too small to damage the walls, but great enough 
 to insure complete retraction of the lower angle. With the three 
 stays thus held a continuous ■• over-and-over suture is run between 
 the upper two, placing the stitches as close together and as near the 
 ends of the vessels as possible, except near the stays, where they are 
 placed a little farther away in order to include the stay stitch holes. 
 With one third completed, the tension is shifted to the next two stays, 
 and the hemostat shifted to the third stay, which is thus brought 
 underneath. This is repeated once more, and by that time the anasto- 
 mosis is complete and ready for the blood to flow through. It should 
 be remembered that the venous clamp should always be removed before 
 the arterial clamp. If this is not done the blood rushes against the 
 venous clamp under arterial pressure, and throws too great strain on 
 the anastomosis, and may cause leakage. Even if one or two drops 
 of blood exude when the clamps are properly removed no further 
 leakage will follow, provided, of course, that the sutures have been 
 properly placed. The operation is one of great delicacy, and it is 
 essential that the vessels should be handled with extreme gentleness, 
 and just as little as possible, to avoid running any risk of causing 
 clotting (see Fig. 200, Crile). 
 
 The Cannula Method of Blood-vessel Anastomosis. — While Dr. S. 
 J. Mixter, of Boston, was the first to call the author's attention to 
 the possibility of this method, Queirolo, as far as has been ascertained, 
 was the first to use an anastomosis tube in blood-vessel surgery as it 
 is used at the present time. Even then the fundamental principle 
 did not originate with him, but with another investigator, who used 
 it in making intestinal anastomoses. Later Payr developed the idea 
 much more extensively, and was the first to suggest using tubes made 
 of magnesium (the metal) which would be absorbed in the tissues 
 and permit the formation of permanent anastomoses. Neither Payr 
 nor Queirolo employed the short handle attached to the tubes which 
 permits easy control with hemostatic forceps until fixed in place — 
 an essential improvement. Payr suggested holding them by means 
 of clamp or other forceps with fine points which could be inserted 
 into the lumen of the tube with the entering vessel, but it is obvious 
 that this method would not be utilizable with very small vessels owing 
 to lack of room in the tube. 
 
 Queirolo' s description of his method is as follows: " The isolated 
 portion of the portal vein is drawn through a short glass tube, pulled 
 
TREATMENT OF SHOCK 243 
 
 back over its forward edge, and bound firmly upon it. . . . The 
 glass tube thus covered by the vein is now drawn into the free end of 
 the vena cava, which is then bound on the glass tube, so, however, 
 tb at the first loop which fastens the portal vein is not covered by the 
 vena cava. The artery compression forceps are loosened, and there- 
 upon the blood streams out of the portal vein into the vena cava with- 
 out touching a foreign body, and only coming in contact with the 
 vessel endothelium, for the first loop touches only the outer wall of 
 the portal vein, and the second loop only the outer wall of the vena 
 cava. . . ." (Moleschott, Untersuch., 1895, xx, 228-40). 
 
 The cannula such as the author now uses was developed in col- 
 laboration with Dr. F. W. Ditchings. To be able to use vessels of dif- 
 ferent sizes different-sized cannulae have been made, the smallest with 
 an inside diameter of 1.5 mm., the next half a millimeter larger, and so 
 on up to 3 mm. It has been found by experience that this range covers 
 all ordinary cases in the human subject. 
 
 The instruments used when the cannula is employed are the same 
 as those used in carrying out the suture technic, except that the can- 
 nula replaces the No. 16 needle and fine suture. The vessels to be 
 anastomosed are exposed in the same way (the details will be described 
 under the heading of the general management of a transfusion in 
 the following pages), and after selection of a cannula of size suitable 
 to the size of the vessels the end of the vein is either pushed through 
 the handle end of the cannula with the help of fine-pointed forceps, 
 or pulled through by' means of a single fine suture inserted in its edge, 
 the needle being left on the suture and passed through the cannula 
 ahead of the vein. The handle of the cannula is then tightly seized 
 by a pair of hemostats (the fingers are too clumsy), three mosquito 
 hemostats, or small, self-locking forceps such as oculists use, are 
 snapped at equidistant points on the end of the vein, taking care not to 
 have the tips extend up into the lumen more than is necessary to get a 
 firm hold. The end of the vein is then cuffed back over the cannula by 
 gentle simultaneous traction in the three hemostats, and tied firmly in 
 place with a fine linen thread in the groove nearest to the handle. 
 The cuffed part is next covered with sterile vaselin, being careful not 
 to get any into the open end. This facilitates slipping the artery 
 over the cuff. The hemostats are removed from the vessel edge, and 
 the artery may then be put in place. 
 
 Owing to the elasticity of the arterial wall it usually shrinks con- 
 siderably when the pressure from within is removed, as it is at the 
 free end. To obviate this it may be necessary to dilate the end very 
 gently by inserting the closed jaws of a mosquito hemostat covered 
 18 
 
244 
 
 SHOCK AND SECONDARY HEMORRHAGE 
 
 with vaselin, and opening them for a short distance. The three hemo- 
 stats are then applied to the edges just as with the vein, and the artery 
 is gently drawn over the cuffed vein on the cannula and tied in place 
 with another fine linen suture applied in the remaining groove. The 
 mosquito hemostats are removed, and finally the large hemostat which 
 has been snapped on the handle of the cannula during all this time 
 is removed. The process is then completed. After the transfusion 
 the cannula is removed, both artery and vein are ligated, and the 
 wounds are sutured (see Fig. 201.) 
 
 Fig. 201. — Diagrams of Stages of End-to-end Anastomosis of Two Blood-vessels 
 by the Cannula Method (as modified by Cvile and Hitchings) . A, Pulling the 
 vein through the cannula. Very fine pointed forceps may be substituted for the 
 single suture. B, Cuffing back the vein over the cannula with three mosquito 
 hemostats. C, The vein cuffed and tied in place in the groove next to the handle of 
 the cannula. The artery is ready to be drawn over the vein. D, The anastomosis 
 completed, and the cannula hemostat removed. The artery is tied in the remain- 
 ing groove. The short handle of the cannula is so light in weight that it does not 
 cause torsion of the vessels. (Crile.) 
 
TREATMENT OF SHOCK 245 
 
 In making a cannula anastomosis experience will show what size 
 cannula is suitable for the given vessels. As large a size should be 
 used as possible without injuring the intima of the artery by stretching 
 it too much. Usually there will be no difficulty in obtaining a large 
 vein, but the artery may be very small. If too small a cannula is 
 used, the amount of the flow will be diminished. Moreover, too large 
 a vein will take up too much room in the cannula, and the amount of 
 flow be diminished. 
 
 The author has never yet found a radial artery so small that the 
 three mosquito hemostats could not be applied to its edge to draw it 
 over the cuffed vein. If preferred, three stay sutures may be used in- 
 stead of the hemostats, but they will tear out much more easily, and are 
 not so easily or so quickly applied. In the earlier cases the artery was 
 cuffed back instead of the vein, and the vein pulled over. It was 
 found that cuffing back the artery in man obstructed the lumen of the 
 cannula too much, and was often a very difficult procedure, especially 
 when the wall was at all calcined. Besides, with a calcified wall 
 there was too much danger of tearing the intima in the process of 
 cuffing. Apparently there is no danger of clotting when done either 
 way, but to cuff back the vein is the better method. 
 
 In using the cannula two facts should be particularly remembered. 
 The first is that the long axis of the tube should coincide with the 
 long axis of the lumen of the vein and artery. A little experiment- 
 ing will show how easily the cannula may be made to slant so that 
 the opening in it will come almost in contact with the artery wall, 
 and shut off the flow in great part or completely. Actual experience 
 has shown the necessity of placing the cannula accurately. 
 
 The second and less obvious fact is that unless the right amount 
 of tension is maintained on the vessel which passes through the can- 
 nula when the blood is flowing across, particularly with a small can- 
 nula, the flow will be diminished or shut off altogether by the elas- 
 ticity of the vessel wall on tension in the cannula pulling the outside 
 part of the vessel in and blocking the way. This is more likely to 
 happen with the artery drawn through the tube than with the vein, 
 owing to the greater elasticity of the arterial wall. It may be very 
 prettily demonstrated by drawing an artery through a small cannula, 
 cuffing it back, and tying it in place. On removing the clamp con- 
 trolling the flow no blood will appear at the open end of the artery, 
 or at most the flow will be very small and weak. On putting gentle 
 tension on the tube by drawing it out a little in the direction of the 
 long axis of the artery, the wall puckered up in the cannula will be 
 pulled out and the blood will spurt sometimes as far as three feet. 
 
246 SHOCK AND SECONDARY HEMORRHAGE 
 
 The exposed vessels should he kept moist with warm normal saline 
 solution. Not only is drying harmful, but the flow is increased 
 through gradual relaxation of the arterial wall. 
 
 Experience has shown that if anything goes wrong in carrying out 
 this technic it is best to start again from the beginning, and not to 
 try to get around any of the details by substitution. For example, 
 if one of the three mosquito hemostats slips from the end of the vessel 
 which is being either cuffed or drawn over, the attempt should not be 
 continued until the vessel has been removed and the hemostat is accu- 
 rately replaced. Xot only will valuable time be lost in trying to sub- 
 stitute ordinary forceps for the slipped hemostat, but the danger of 
 tearing the intima is much greater. For the average surgeon, at 
 least, it is essential to have the instruments lock firmly in place on 
 the vessel edge. Then, if one be dropped from the hand it does not 
 have to be reapplied when picked up. For this reason ordinary for- 
 ceps are entirely unsuitable, and anyone endeavoring to use them 
 takes on himself the responsibility of the possible occurrence of clot- 
 ting, or of inability to finish the technic. Every detail has been 
 worked out over and over again, and while there is doubtless plenty 
 of room for improvement, it is felt that every detail should be exactly 
 followed, at least until the operator has convinced himself that any 
 modification is suitable. It will be found that the use of the anas- 
 tomosis cannula is much less difficult than the use of the suture 
 method, the results are more certain, and the time of operation much 
 shorter. 
 
 The General Management of a Transfusion. — Having carefully 
 considered the technic of end-to-end anastomosis of blood-vessels by 
 the suture and cannula methods, we come to its practical application 
 in performing direct transfusion from one human being to another. 
 First of all a suitable donor must be obtained. It is assumed here 
 that all the requirements have been successfully met. and that both 
 donor and recipient are in readiness. 
 
 It is of great advantage to have a thoroughly trained corps of as- 
 sistants. A full staff would include first and second assistants, a 
 nurse to handle the sponges, sutures, etc., a nurse to devote herself 
 entirely to the comfort of the patients, an instrument nurse to pass 
 between the operating and sterilizing rooms, and an orderly. If 
 special investigations are to be made — for example, of changes in the 
 blood — others must be added as needed. All should be able to work 
 noiselessly and rapidly. 
 
 The operating room should have all the ordinary equipment. Two 
 operating tables are necessary, one for each patient. They should be 
 
TREATMENT OF SHOCK 
 
 247 
 
 of the type which allows the patient to be easily changed from a hori- 
 zontal to a head-up or head-down position, so as to permit combating 
 either cerebral anemia or acute cardiac dilatation. They should be 
 well provided with pillows with which to make the patient as comforta- 
 ble as possible. Two small square tables of the same height as 
 the operating tables are also needed — one for the instruments, 
 and the other to support the arms of the patients. Two low 
 stools, one for the surgeon and one for the first assistant, com- 
 plete the list. 
 
 From twenty to thirty minutes before being brought to the operat- 
 
 
 □ 
 O 
 
 1. 
 
 Q, 
 
 a. 
 
 
 Fig. 202. — Diagram op Arrangement of Operating Room for a Transfusion. 
 1, 2. Operating tables for recipient and donor, respectively. 3. Table for arms 
 of recipient and donor. 4, 5. Stools for surgeon and first assistant, respectively. 
 6. Instrument table. 7. Table for dressings, sutures, etc. (Crile.) 
 
 ing room the donor and recipient each receive y± of a grain of mor- 
 phin hypodermically, unless there is some special reason for its being 
 contraindicated. The patients are assured that they will experience 
 no pain beyond the first needle prick. 
 
 When each is in place on his respective operating table the tables 
 are arranged so that the left arm of each will rest comfortably on the 
 small square table placed for the purpose between the operating tables 
 (see diagram, Fig. 202). In order that no glimpses of the surround- 
 ing room may be had the face of each is covered with a damp towel 
 "to avoid too much bright light and headache." The operator and 
 
248 SHOCK AND SECONDARY HEMORRHAGE 
 
 first assistant sit between the operating tables on opposite sides of 
 the small square table. The other small square table with the instru- 
 ments on it is placed conveniently for the second assistant. The 
 patients are again told that there will be no pain beyond the first 
 prick. The nurse detailed to care directly for the patients relieves 
 the monotony of waiting by changing the wet towels, bathing the fore- 
 head, giving water to drink if desired, and in short doing anything 
 permissible to afford comfort. 
 
 The next step is the dissection of the blood-vessels to be used. 
 Experience has shown that it is best to use a radial artery of the 
 donor and any superficial arm vein of the recipient near the elbow. 
 Usually the median basilic vein is the best one on account of its size 
 and easily accessible position. 
 
 Local anesthesia is obtained by injecting cocain in 1/10 of 1 per 
 per cent, solution with a few drops of 1-1,000 adrenalin chlorid solu- 
 tion. Several hypodermic syringes should be ready so that there 
 need be no delay on account of having to stop to refill a single one. 
 The injections are first made into the skin, and then more deeply 
 around the vessels. After this, firm pressure is applied by the hand 
 over a gauze sponge to insure thorough spreading of the cocain 
 through the tissues. When carefully performed there is absolutely 
 no. pain in any part of the technic until the sutures are placed in the 
 skin at the end of the transfusion. By then the effect of the cocain 
 bas usually worn away. 
 
 In making the dissection it is necessary to have good light. 
 Mosquito hemostats are used to catch every vessel that sheds even a 
 drop of blood. The field should be kept absolutely clear. The donor's 
 radial artery is isolated for a distance of about 3 cm. at the point of 
 election in the wrist. Here there are a number of small side branches 
 which must be carefully isolated and tied with No. 1 Chinese twist 
 silk (which has not been split up into strands) before being cut. The 
 artery is then tied at its distal end, and a Crile clamp is gently 
 screwed in place over the proximal part as near to the place where it 
 comes out of the undissected tissues as convenient. The clamp should 
 be screwed up with great care. Just enough pressure should be used 
 to control the flow of blood without causing injury to the vessel wall. 
 The artery is severed with sharp scissors a short distance from where 
 it is tied off, the end cut squarely across, the adventitia pulled down 
 and cut off as directed under the technic of making an anastomosis 
 by either the suture or the cannula method, and is then ready for 
 the completion of the anastomosis. The result should be that the 
 operator has about 2y 2 cm. of exposed radial artery free from branches, 
 

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 o 
 
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 249 
 
250 SHOCK AND SECONDARY HEMORRHAGE 
 
 the cut end open, and the blood prevented from coming out of it by 
 the clamp. 
 
 The next step is the dissection of the vein. It is exposed for the 
 same distance as the artery, the branches are tied off in the same way, 
 and the ligature is also applied at the distal end. The second Crile 
 clamp is applied just as before, the vein cut near the ligature, and it 
 in turn is ready for the completion of the anastomosis. 
 
 The anastomosis is made either by the suture or the cannula 
 method as described in the previous pages. The details will not be 
 repeated here. It may be said that in practically all cases the can- 
 nula method should be used rather than the suture method. In order 
 to meet possible emergencies, however, the operator should be prepared 
 to carry out either. It seems to the author that neither should be at- 
 tempted on the human subject until experience has been gained in the 
 laboratory. 
 
 With the anastomosis completed, the questions which then arise 
 are how much blood should be allowed to pass over, how fast to allow 
 it to pass over, and what will happen if the limits of safety are passed. 
 So many points must be considered in answering these and other ques- 
 tions that the problems presented by the donors and recipients will 
 be discussed separately. 
 
 The Donor. — It has been proved many thousands of times, either 
 directly through hemorrhage or indirectly through transfusion, that 
 loss of blood to even a considerable amount may occur and the indi- 
 vidual survive. In normal individuals lost blood is quickly replaced. 
 
 Another fundamental fact is that while the blood of the donor may 
 convey life to the sick person, it may also convey death in the form 
 of disease. As far as can be determined the giver of the blood should 
 be free from any constitutional or other disease which might be 
 engrafted on the patient. 
 
 A donor may usually be readily obtained. Both men and women 
 are suitable. In cases in which no immediate hurry exists the best 
 subject is selected from among the relatives and friends who are will- 
 ing to serve. The gravity of the patient's condition and the reason 
 for wishing to transfuse are carefully explained in detail, and the 
 painlessness of the operation to both donor and recipient is assured. 
 Almost always the offer to serve is made voluntarily. In fact an 
 entire family and numerous friends have frequently been eager to 
 do so. 
 
 The only difficulty which has been encountered thus far has been 
 among ignorant people, who may have a certain amount of distrust 
 of both surgeons and hospitals. Even among such people, however, 
 
TREATMENT OF SHOCK 251 
 
 but one refusal has been experienced. In this particular case the 
 parents of the patient, a nine-) r ear-old child whose legs had been 
 crushed, refused to assist, their argument being that the child was 
 so much mutilated by the injury that it was not worth saving ! 
 
 In two instances among the authors cases donors were hired. 
 In these instances the commercial attitude was apparent, and they were 
 not as tractable as those who responded to the appeal of sentiment. 
 
 After the donor has been selected he is subjected to a thorough 
 cross-questioning as to his family and personal history, and a thorough 
 physical examination. This is for his own benefit as well as for the 
 benefit of the patient, as in some cases it has been proven inadvisable 
 to bleed the would-be donor. 
 
 In all the authors cases the regeneration of the blood lost by the 
 donors was uninterrupted and rapid. This statement is based on their 
 general appearance subsequent to losing the blood, their freedom of 
 symptoms suggestive of the experience through which they had 
 passed, and, more particularly, on the blood examinations made in as 
 many cases as was possible under the particular conditions of each 
 individual case. In no case was there anything but a temporary dis- 
 turbance of the general functions. Apparently the return to normal 
 varied directly according to the amount of blood lost — the more that 
 was lost the longer the lapse of time before the return to the original 
 amount. 
 
 The amount of blood which is allowed to pass from donor to 
 recipient varies according to a considerable number of factors. These 
 may be tabulated as follows: 
 
 1. The duration of the flow. 
 
 2. The size of the radial artery and the elasticity of its wall. 
 
 3. The blood pressure of the donor. 
 
 a. The normal pressure. 
 
 b. The pressure as affected by psychic influences. 
 
 4. The method of making the anastomosis. 
 
 a. The suture method. 
 
 (1) The accuracy with which the suture is made (leak- 
 age, reduction of size of lumen). 
 
 b. The cannula method. 
 
 (1) The accuracy with which the connection is made 
 (turning the tube sideways). 
 
 (2) Adaptation of cannula to size of vessel. 
 
 (3) The tension on whichever vessel passes through the 
 cannula (see previous explanation). 
 
252 SHOCK AND SECONDARY HEMORRHAGE 
 
 (4) Whether the vein or the artery passes through the 
 cannula (on account of the varied thickness of 
 wall). 
 
 (5) The resistance offered by the vascular system of 
 the recipient. 
 
 It is necessary to discuss but two of these factors here, as the others 
 are discussed in appropriate places elsewhere. From the donor's 
 standpoint the duration of the flow is an important consideration. 
 The best way of determining when to stop the flow is by watching 
 his symptoms. At first he will show loss of color in his mucous mem- 
 branes, pallor of the skin, slight uneasiness, slight quickening of the 
 pulse and respiration, lowering of the blood tension, and beginning 
 shrinkage in the skin of the face. Progressive hemoglobin determi- 
 nations often furnish a good index of the general condition, and may 
 be easily made. All of the symptoms are progressive, and as soon 
 as they are well marked the flow should be stopped. Often the con- 
 dition of the recipient will necessitate this long before the donor 
 shows any symptoms at all. Definite rules cannot be laid down. 
 Everything will depend on the judgment and experience of the sur- 
 geon. Temporary cerebral anemia can be readily controlled by chang- 
 ing the donor from the horizontal to the head-down position. 
 
 ' The approximate determination of the amount of blood which is 
 lost can be made by carefully weighing the donor to fractions of an 
 ounce before and after the transfusion. The conditions of the weigh- 
 ing must be the same at each time. It is futile to attempt to calculate 
 the amount of transfused blood from direct observation of the loss 
 of a few cubic centimeters in a given time from the radial artery. 
 A few experiments have been done in the laboratory which showed 
 how much the rate of flow varied as the flow progressed, and how use- 
 less the attempt was to obtain accurate calculated results. 
 
 That the blood-pressure may be markedly varied by reason of 
 psychic influences has been repeatedly demonstrated by many differ- 
 ent observers. It is largely for this reason that the elimination of 
 disturbing influences at the time of the operation is so important. 
 This is accomplished not only by the previous dose of morphin, but 
 by the noiselessness of a perfectly equipped and smoothly run operat- 
 ing room. 
 
 A final point must be considered in regard to the protection of the 
 donor against injury, and that is the possibility of his becoming in- 
 fected from contact of his artery with the vein of the recipient in 
 cases in which transfusion is performed for an infectious disease, and, 
 
TREATMENT OF SHOCK 253 
 
 more particularly, one which is acutely infectious. In the author's cases 
 of hemorrhages in typhoid fever the donors were purposely chosen be- 
 cause they had had typhoid. The possession of immunity would in itself 
 protect the donor in such a case as well as the unusual care taken to 
 avoid exposure. The author believes that there is little or no risk in 
 a chronic infection like tuberculosis or from an old septicemia or 
 mixed infection. This is largely due to the fact that there is no chance 
 for the blood being forced back from the recipient into the donor 
 against the donor's arterial pressure. At the end of the transfusion 
 there is a good margin of safety as regards any of the possible infec- 
 tion in the vein of the recipient being retained by the donor, as the 
 donor's artery may be severed at least 2 cm. from the point of anasto- 
 mosis. Moreover, the exposed tissues may be freely irrigated with 
 corrosive sublimate in 1-2,000 solution. The exact amount of risk 
 from this source must be very small, and with care as suggested it 
 hardly seems likely that the danger of infection need ordinarily be 
 feared. At all events, cases of acute infection rarely require trans- 
 fusion. 
 
 The Recipient. — The question as to what pathologic conditions 
 may be suitably treated by transfusion of blood from one human being 
 to another has not been definitely settled. The most that can be said 
 at present is that it is clearly indicated in certain conditions and as 
 clearly contraindicated in certain others. With our present knowl- 
 edge the author feels that it should be used only when all other 
 resources at command have failed. 
 
 Cases are on record in which transfusion was said to have been 
 followed by recovery when in reality the patient died of the disease, and 
 on the other hand deaths were said to have occurred from the disease 
 when they should undoubtedly have been ascribed to accidents of 
 transfusion. 
 
 As far as the recipient, is concerned, transfusion is a problem in 
 mechanics as well as in therapeutics. There are certain dangers 
 which must be avoided under both of these headings, and in the recog- 
 nition of their existence and their successful avoidance lies the respon- 
 sibility of the surgeon. There are few if any operations in which 
 more factors must be considered, and in which more care must be 
 exercised. 
 
 From the mechanical standpoint the chief danger to be feared is 
 acute cardiac dilatation and subsequent cardiac failure caused by 
 transfusion in excessive amount or at excessive rate of flow. This 
 danger is particularly great when the vitality of the patient is much 
 lowered in the course of a severe illness, or when any previous func- 
 
254 SHOCK AND SECONDARY HEMORRHAGE 
 
 tional or organic cardiac complication is present. Fortunately, as 
 has been frequently shown in the author's series of cases, a certain 
 amount of dilatation may occur and pass rapidly away without caus- 
 ing either immediate or subsequent harm. 
 
 The best treatment of acute cardiac dilatation is prevention. If 
 the blood-pressure of the donor is high and his radial artery large, 
 too rapid a flow may be prevented by partially narrowing the lumen of 
 the artery with gentle pressure of the fingers. The effect can be 
 gauged by the changes in the strength of the pulsation beyond the 
 cannula in the vein. It may be necessary to shut off the flow alto- 
 gether for short intervals, giving the heart a chance gradually to 
 assume its added burden by allowing only small amounts of blood 
 to pass across at a time. 
 
 As another means of prevention of acute cardiac dilatation, it may 
 be necessary to bleed the recipient freely before transfusion. In cases 
 of shock or of acute hemorrhage a preliminary bleeding would do 
 harm. In many cases of subacute hemorrhage it is unnecessary. 
 In all other cases either a preliminary bleeding must be performed or 
 the amount of blood transfused must be much smaller than would 
 otherwise be possible, and the care taken correspondingly great. It 
 should be remembered that reduction in the corpuscular elements in 
 the blood of the recipient does not necessarily mean reduction in the 
 fluid content (as, for example, in pernicious anemia), and also that 
 where saline infusion would rapidly pass out of the vascular system 
 blood will be retained. In cases where great weakness of the patient 
 is associated with marked reduction of the red corpuscles it may be 
 unsafe to bleed unless the bleeding be done at the same time that the 
 transfusion is progressing. 
 
 Another phase of the mechanics of transfusion is the possible 
 transudation of the blood into the tissues or body cavities with or 
 without rupture of small vessels in the parenchymatous organs. This 
 possibility may be disregarded in human beings, as symptoms of car- 
 diac distress will occur long before there is any danger of transudation. 
 
 The principal symptoms of acute cardiac dilatation are dyspnea, dis- 
 tress or pain in the precordial region, cough, and cyanosis. The pulse 
 increases in rate and may be very irregular in action, tension, and 
 volume. The right heart is chiefly affected. Percussion over the right 
 border may give dullness extending out as far as an inch from the 
 border of the sternum. Unless the strain on the heart is immediately 
 relieved the increase in severity of the symptoms is rapid, and, if 
 allowed to go too far, death will result. The rapidity with which a 
 heart will dilate and return to its previous size is sometimes remark- 
 
TREATMENT OF SHOCK 255 
 
 able. This fact should never be counted on, however, as a means of 
 getting out of difficulties brought on by over-transfusion. 
 
 When acute dilatation has once occurred it must be promptly rec- 
 ognized. The transfusion must be stopped, the operating table tilted 
 so as to raise the patient to the head-up position, and rhythmic pressure 
 made on the chest over the heart. 
 
 If recovery is not complete in a short time the transfusion should 
 be given up, and the patient put to bed in a head-up posture, given 
 carefully graded doses of nitroglycerin to insure peripheral dilatation 
 of the vessels, and digitalin hypodermically in very small closes to 
 stimulate the heart muscle directly. Small does of morphin may also 
 be given if needed, but it must be remembered that the recipient has 
 had 14 of a grain before the transfusion. Absolute rest and quiet and 
 a reduction of the amount of fluids ingested are also requisite. Such 
 a patient needs careful watching with treatment of the symptoms as 
 they arise. 
 
 The treatment of shock and of acute hemorrhage by transfusion 
 is primarily mechanical in its nature, and need not be discussed fur- 
 ther here under the general considerations. The treatment of all other 
 conditions, however, is a question of therapeutics when reduced to its 
 final analysis. The surgeon takes the place of the internist when he 
 gives a "close " of blood. 
 
 In the therapeutics of transfusion there is a possible danger to 
 be considered. In certain diseases, when similar bloods are inter- 
 mingled (i. e., blood from animals of the same species), what is ordi- 
 narily designated as " hemolysis " occasionally occurs. Agglutina- 
 tion of the red corpuscles and precipitation may also occur, hut, from 
 a practical standpoint at least, the author has had no reason to believe 
 that these two last changes may be regarded as possible sources of 
 danger. 
 
 The mistake must not be made of considering "hemolysis" as 
 destruction of the red corpuscles alone. It would be more appropriate 
 to say that "hemolysis " is a toxic condition which gains its name from 
 the fact that the red corpuscles are destroyed to a greater or less ex- 
 tent, but that one of the effects is not the cause. Hemolytic destruc- 
 tion of red corpuscles is one matter, but toxemia is another. The 
 serum of the pathologic blood may act as a poison and incidentally 
 destroy certain of the red corpuscles. When the amount is large, 
 appreciable changes probably take place in the parenchymatous organs 
 such as occur when dissimilar blood is transfused. It is a question as 
 to whether the interaction of similar serum on the red corpuscles and 
 on the other organs does not cause the formation of new toxic sub- 
 
256 SHOCK AND SECONDARY HEMORRHAGE 
 
 stances which was previously present in neither — i. e., that it is more 
 than the poisonous action of the serum alone which must be held 
 responsible. Moreover, may not a possible role of the leucocytes be 
 overlooked when the red cells alone are considered ? 
 
 The pathologic changes which follow injection of dissimilar blood 
 have been studied by Hasse and his followers and others. The extent 
 of the lesions varies considerably for a given animal, according to the 
 species from which the blood is taken, serum from one species being 
 more toxic than that from another; but the extent varies still more 
 with the amount of blood transfused. It seems reasonable that there 
 should be a direct ratio between the dosage and the effect produced, 
 just as there is in giving a drug. While a small amount of a given 
 enzyme will hydrolyze a disproportionately large amount of organic 
 substance without losing its powers, there is no evidence of any similar 
 action occurring between toxic serum and the blood or other cells of 
 the recipient. 
 
 From the above it may be deduced that the question of dosage may 
 be very important, especially when there is hemolysis of the recipient's 
 red corpuscles by the donor's serum. Therefore, in all but emergency 
 cases preliminary hemolysis tests should be made in order to handle 
 a given transfusion more intelligently and protect the recipient more 
 fully. The technic to be followed in making these tests is described 
 in a following chapter. 
 
 The author has had but one case in which serious hemolysis 
 occurred. The patient had an inoperable suppurating carcinoma of 
 the groin, and was transfused on three separate occasions from five 
 different donors. The hemolysis began to appear on the second day 
 after the third transfusion (from two donors). Death occurred ten 
 days after this transfusion. After the previous transfusions there had 
 been no gross evidences of hemolysis, although no tests were made 
 to determine whether any hemolysis occurred or not. The question 
 is whether death was due to hemolysis in the broader and more cor- 
 rect sense (i. e., from toxemia), whether hemolysis would have 
 occurred if the two donors had been used on separate occasions instead 
 of one immediately after the other, whether transfusion from either 
 of the donors alone would have caused hemolysis, and whether death 
 was due to hemolysis (toxemia) caused by the action of the cancer 
 element in the serum on the blood from the donor. 
 
 It is impossible to say whether death occurred from hemolysis 
 (toxemia from the transfused serum) alone or from a combination 
 of causes. The patient was more or less septic from the presence of 
 infection in the ulcerated cavity in the groin. He had had a long and 
 
TREATMENT OF SHOCK 257 
 
 severe illness, the bleeding before the transfusion was unusually severe, 
 and while the blood lost was more than replaced it was a severe test 
 of his strength and endurance. The cancer was hopelessly inoper- 
 able and had progressed well along toward the terminal stage. There 
 had been no appreciable hemolysis after the other transfusions, and 
 in several other cases patients had received blood from different 
 donors without its occurring. It is known that cancer serum will 
 hemolyze red corpuscles, and the hemolysis may simply have been due 
 to the complete destruction of the corpuscles from the donor (the 
 patient's blood must have been very largely substituted by the trans- 
 fused blood) without toxin formation which would affect any of the 
 patient's cells (they were already more or less immune to the toxin 
 liberated from the cancer). On the other hand, in patients in the 
 last stages of cancer the author has found that a " reverse hemolysis " 
 occasionally occurs — i. e., that the red cells from the cancer patient 
 are hemolyzed by normal serum. That death was not due to asphyxia 
 from destruction of the red corpuscles was shown by the fact that 
 there were no symptoms before death which suggested asphyxia. The 
 probability is that death was really due to a combination of factors 
 which cannot be separated to estimate the exact influence of each. 
 This case suggested the hemolysis test for cancer. 
 
 If it is found by the preliminary tests that the red corpuscles of 
 the recipient are hemolyzed by the serum of the would-be donor, the 
 advisability of transfusion should be carefully considered. This does 
 not necessarily indicate that the blood of the donor is at fault, but 
 rather that the recipient is in such a condition that any blood would 
 be toxic to him when introduced into his circulation. In all cases 
 which the author has had there has been no evidence that the blood 
 of the donor was ever at fault. Therefore it is improbable that it 
 would avail in such a situation as the above to try to use another 
 donor. This is not meant to convey the impression that the blood of 
 the donor may never be harmful in itself — in time donors may be found 
 to whom the causation of harm may be traced. So far, however, this 
 has not been done. On the other hand, if the serum of the recipient 
 hemolyzes the red corpuscles of the donor, it does not necessarily mean 
 that another donor should be chosen. It all depends on whether the 
 effective principle or principles of the serum are altered at the same 
 time that the red corpuscles are destroyed. 
 
 Following a successful transfusion certain phenomena almost 
 always occur. The stimulating effects of the new blood may be very 
 marked. A poor surgical risk may be made a good one, the delirium 
 of extreme hemorrhage or of toxemia may be replaced by a return to 
 
258 SHOCK AND SECONDARY HEMORRHAGE 
 
 normal mental conditions, or the wrinkled, aged face of prolonged 
 hemorrhage may be restored to its normal aspect and the years appar- 
 ently fall away under the very eyes of the observer. 
 
 A chill of greater or less severity followed by a corresponding 
 febrile reaction is to be expected, and usually occurs. Former writers 
 have often commented on this phenomenon. It is not necessarily an 
 indication of hemolysis, although a violent chill is apt to follow trans- 
 fusion of dissimilar blood. Ordinarily it apparently has no more sig- 
 nificance than the chill which frequently follows the infusion of saline 
 solution. In this connection it is of interest to note the observations 
 of Debove and BruM, who found after giving saline infusion a rise 
 of temperature of 1.5° C. (2,7° F.) in 19, 1° C. (1.8° F.) in 31, and 
 0.5° C. (0.9° F.) in 45 out of 95 cases. 
 
 The heart action is strengthened, the pulse becomes regular, 
 slower, of higher tension and better volume, and the respirations 
 slower and less shallow. In a hemorrhage case the change in the due 
 of the skin and mucous membranes may be very marked, while the 
 red cells and hemoglobin increase in proportion as shown by the red 
 counts. In a certain number of cases the recipient has vomited a 
 small amount of watery, grayish material. The actual ease histories, 
 however, should be consulted for the account of the changes occurring 
 in the individual cases. 
 
 As with the donors, the question arises as to how much blood 
 should be transfused. The condition of the donor and the recipient 
 and the purpose of the transfusion enter into this. Here again very 
 much depends on the judgment of the surgeon. No definite rules 
 can be given. Enough blood must be transfused to accomplish as 
 much as possible, and yet too much must not be given. Sometimes 
 in cases where the patient does not suffer from the loss of a large 
 amount of blood it seems to be as advantageous to transfuse small 
 as large amounts. The symptoms of the recipient give the best key 
 to the situation. 
 
 Crile regards the direct transfusion of blood as an exceed- 
 ingly valuable measure in the treatment of the problem of ex- 
 sanguination. Whatever varied conception may be permissible 
 from a biologic or chemical viewpoint, it is fair to state that 
 Crile' s work is entitled to serious consideration. The writer's 
 conception in this regard is expressed by the extensive quotation 
 placed in this volume. 
 
 It is to be borne in mind, however, that the technic of the 
 
TREATMENT OF SHOCK 
 
 259 
 
 procedure is not readily mastered, and that, if the measure is 
 undertaken for hemorrhage, delay or a possible failure are ob- 
 jectionable occurrences in this class of cases. As far as shock 
 from injury of magnitude, due to accidental trauma or pro- 
 longed manipulation of important organs during an operation, is 
 concerned, the writer feels that the objections which may be 
 brought to bear against direct transfusion do not apply with 
 equal force to infusion with saline solution. 
 
 In operating in well-equipped hospitals, the direct transfusion 
 of blood has, perhaps, a distinct field of usefulness, especially if 
 the necessary preparation is made in view of the character of 
 operation which is to be performed. 
 
 In private practice and, indeed, in the practice of surgeons 
 who operate under less favorable conditions in this regard, the 
 measure will not be found quite as serviceable. Especially is this 
 true of the practitioner who does emergency surgery, as obtains 
 in the less populated areas, the class of professional man this work 
 is expected to serve most. 
 
 INFUSION 
 
 The infusion into 
 the circulation of •so- 
 lutions destined to in- 
 crease blood pressure 
 is made either into a 
 blood vessel sectioned 
 at the site of the oper- 
 ation, or into one re- 
 motely situated in 
 some other portion of 
 the body. The latter 
 course is preferable, 
 and in either case the 
 injection is made to- 
 ward the heart. If 
 the infusion is made 
 during the course of 
 
 the operation, a vessel 
 19 
 
 Fig. 204. 
 
 -Opening the Vein with Scalpel. 
 {Bryant.) 
 
260 
 
 SHOCK AND SECONDARY HEMORRHAGE 
 
 opening into the wound may be employed. As a rule, the infu- 
 sion is best made into the vein at the bend of the elbow. 
 
 The instruments required for the purpose are shown in Fig. 
 205. The various kinds of cannulas are all useful. However, in 
 
 g hi J 
 
 Fig. 205. — Instruments Employed rx the Operation of Ixftsiox. a, Scalpel. 
 b. Thumb forceps, c. Scissors, rl, Aneurism needle, e, Ordinary dropper with 
 curved point, extemporaneous cannula. /, Toothpick for same purpose, g, Cooper's 
 cannula, h, Kelly's needle, i, Luckett's cannula, j, Fowler's, m, Harris's cannula. 
 n. Fowler's thermometer for cannula, o, Catgut and silk-worm gut. p, ^Needles. 
 (Bryant.) 
 
 case of emergency a curved glass eye dropper admirably fills the 
 requirements. The reservoir holding the solution may consist 
 of a simple fountain syringe or, if available, one of the appara- 
 tuses shown in Fig. 206 may be used. Glass receptacles have 
 the advantage of permitting scrutiny of a thermometer sub- 
 merged in the liquid without manipulation. This is, however, 
 not essential. Indeed, in operations done in private residences 
 too much apparatus becomes cumbersome, and, as a matter of 
 fact, a glass eye-dropper and a sterile fountain syringe are all 
 that are necessary to accomplish the purpose. The receptacle 
 should hang about three feet above the level of the vein. The 
 
TREATMENT OF SHOCK 261 
 
 technic of the procedure is simple, a bandage is tightly placed 
 about the limb central to the vein to be opened, and the vessel 
 exposed by a transverse incision (Fig. 204). The object of the 
 central compression is to make prominent the vein and render 
 identification more easy. However, in profound shock only little 
 
 Fig. 206. — Apparatus for Infusion. Ordinary fountain syringe. Kelly's apparatus. 
 Graduated glass reservoir and infusion tube. Fowler's apparatus with thermometer 
 attached. {Bryant.) 
 
 will -be achieved as the result, for obvious reasons. After cleans- 
 ing of the skin the vein is exposed as stated, and after isolating 
 it from the surrounding tissues a catgut ligature is passed round 
 the vessel and left untied. Care must be taken not to puncture 
 the vein at this time. The vein is now ligatured by a second 
 catgut ligature placed distally. The vein is opened by a trans- 
 verse incision made through one-half its circumference, with scis- 
 sors (Fig. 207), and the cannula is introduced, permitting the 
 fluid to flow as the anastomosis is being made, to obviate the en- 
 trance of air into the circulation. The loose ligature is now tied 
 with a half knot about the inserted cannula and the fluid al- 
 lowed to enter. After the infusion is completed, the cannula is 
 withdrawn and the encircling ligature firmly tied by completing 
 the knot, and the superficial wound is approximated with one or 
 two sutures and dressed in the usual way. The temperature of 
 the fluid should be about 118° F. Various mixtures consisting 
 of the inorganic constituents of the blood in solution have been 
 
262 
 
 SHOCK AND SECONDARY HEMORRHAGE 
 
 employed for the purpose. However, a solution composed of six 
 parts of sterile table salt to one thousand parts of filtered sterile 
 water fully answers the purpose. This corresponds practically 
 to a heaped teaspoonful of salt to a quart of water. 
 
 The dosage of fluid administered should be between one pint 
 
 Fig. 207. — Introducing the Tube in Infusion. (Bryant.) 
 
 and a quart, according to the indications, given very slowly. A 
 quart of solution should be injected in about half an hour, as too 
 rapid instillation is likely to cause edema of the lungs and thus 
 increase embarrassment to the circulation. The salt should, if 
 feasible, be chemically pure, for obvious reasons, and the con- 
 centrated solution described (page 81) is recommended for use. 
 A formula much employed in hospitals is added. 
 
 I£ Sterilized and filtered water 32 oz. 
 
 Sodium chlorid (c. p.) 1^ drms. 
 
 Sodium carbonate (c. p.) 15 grs. 
 
 M. Heat to 112° F. 
 
TREATMENT OF SHOCK 263 
 
 In large institutions where facilities for sterilization are con- 
 veniently at hand, this solution is made and kept in stock to be 
 heated at each operation. 
 
 To the salt solution adrenalin chlorid solution may be added. 
 Its prompt action when administered in this way recommends its 
 use. A teaspoonful of the adrenalin solution on the market added 
 to a quart of saline solution gives the proper proportion of dilu- 
 tion. The adrenalin may be added to the salt solution when 
 administered under the skin or introduced into the lower bowel. 
 
 NEEDLING OF ARTERY 
 
 Daivbarn in urgent cases employs a method called " needling." 
 The solution prepared as above is placed in a receptacle, which, 
 however, must be elevated to the height of six feet above the pa- 
 tient, or a Davidson syringe is used to inject the fluid. The 
 needle of an ordinary hypodermic syringe of large caliber is 
 pushed into the radial or femoral artery, according to which is 
 the most available, and the fluid is permitted to enter through a 
 rubber tube connection. This method is useful, but is only ap- 
 plicable in cases of emergency, and should be used only by the 
 surgeon who has confidence in his tactile sense. As a rule, the 
 eye is more trustworthy than the sense of touch, and the intra- 
 venous infusion had best be employed unless, indeed, the condi- 
 tions warrant indulgence in the more intricate manipulation. 
 If the needle does not enter the lumen of the vessel, it will be 
 seen to distend the surrounding tissues. This is not objection- 
 able, as will be seen later. The needle must be withdrawn and 
 re-entered if this happens. Accidental introduction of air will 
 not occur if the fountain syringe be used. However, this is liable 
 to happen if a Davidson syringe be employed for the purpose. 
 Again, the fluid in the syringe is liable to cool rapidly, but both 
 the too rapid cooling of the fluid and the entrance of air may be 
 avoided by submerging the syringe in a hot solution of salt while 
 making the injection. 
 
 HYPODERMOCLYSIS 
 
 Hypodermoclysis consists of the injection subcutaneously of 
 the solution stated. Adrenalin may be added to the solution in 
 
264 
 
 SHOCK AND SECONDARY HEMORRHAGE 
 
 the same way as when the agent is used in intravenous infusion. 
 The method is not of distinct service in shock from loss of blood, 
 except inasmuch as it contains the adrenalin. Absorption from 
 beneath the skin is necessarily slow, and, indeed, it is a question 
 
 Fig. 208. — Hypodermoclysis. 
 
 if it be as rapid as obtains from the colon. As a whole, it seems 
 fair to say that it is the less frequently indicated of the three 
 methods of introducing saline solution. The solution is placed in 
 any one of the containers mentioned, which is connected with a 
 large-sized needle, and the skin, after being cleansed, is punc- 
 tured, and the fluid slowly permitted to enter. The pectoral re- 
 gion, the buttocks, and the lastimus dorsi are favorite sites of 
 injection. No more than half a pint should be introduced in 
 one place. The skin will be found quite tense as the outcome of 
 
TREATMENT OF SHOCK 265 
 
 the entrance of this quantity, and the injection of a greater 
 amount may lead to pressure necrosis of the surrounding soft 
 parts. Indeed, this possibility, even with proper precautions, is 
 sufficiently liable to occur to constitute an objection to the method. 
 When it is borne in mind that circulation is necessary to absorp- 
 tion, it is easy to see how the fluid may remain in the region of 
 its introduction without entering the circulating fluid for a con- 
 siderable period of time. In cases of moderate shock not attended 
 with loss of blood the method may be used. But if the intent of 
 the act be to furnish a circulating medium to a depleted periph- 
 eral circulation, the measure may be said to fail to accomplish the 
 purpose. Fig. 208 shows the method being employed in the re- 
 gion of the pectoral muscle. The needle is usually steadied by 
 the hand. The temperature of the fluid should be about 110° F. 
 At times a half hour is expended in making the injection. Mas- 
 sage of the parts immediately subsequent to the injection favors 
 absorption of the fluid. 
 
 ENTEROCLYSIS 
 
 Enteroclysis means the introduction of saline solution into the 
 lower bowel. Its rationale as regards absorption lies in the as- 
 sumption that the blood is more largely collected in the vessels 
 of the abdomen, and that, because of this, it will readily take up 
 the fluid. Enteroclysis probably occupies a position between ve- 
 nous infusion and injection into the subcutaneous tissue. In a 
 general way, profound shock calls for venous infusion, less se- 
 vere shock for enteroclysis, and moderate shock without loss of 
 blood for hypodermoclysis. 
 
 As a rule, the lower bowel is thoroughly emptied before an 
 operation is begun, making a preliminary cleansing enema un- 
 necessary. However, if there be any doubt in this connection, 
 the enema should be given. 
 
 The solution employed is, in every respect, similar to the one 
 used for intravenous infusion, except that the quantity which 
 may be projected into the bowel may be much greater. Indeed, 
 it is not uncommonly possible to introduce a gallon of the fluid 
 into the colon, especially if the procedure be slowly accomplished. 
 The first pint of the solution may be more rapidly introduced, 
 but, after that, the bowel is less likely to rebel and eject the fluid 
 
266 
 
 SHOCK AND SECONDARY HEMORRHAGE 
 
 if the rest of the solution be permitted to flow into the colon 
 slowly. At the beginning of the injection the container may be 
 elevated to the height of three feet above the patient, but after a 
 pint has flowed into the bowel the irrigator should be lowered a 
 full foot. At no time should the pressure be made greater than 
 obtains from three feet of elevation of the container. 
 
 The solution need not necessarily be absolutely sterile, though 
 this is desirable, but if it be given by persons not familiar with 
 the technic of asepsis, this method is vastly superior to the former 
 two, as, of course, these require rigid asepsis. 
 
 The patient is placed on the left side and the foot of the bed 
 elevated to promote gravity (Fig. 209) ; a rectal tube (Fig. 82) 
 
 Fig. 209. — Administration of Saline Solution into Rectum. 
 
 is carefully passed through the anus and on into the sigmoid and 
 connected with the rubber tube of the receptacle by means of a 
 glass tube. The fluid is then allowed to flow as stated. Adre- 
 nalin or other remedial agents may be added to the solution. In- 
 deed, if a previous history of alcoholism be obtained, the bro- 
 
SECONDARY HEMORRHAGE FOLLOWING OPERATIONS 267 
 
 mids, etc., may be given at the same time. In the case of much 
 nervous irritation preceding the operation, the writer frequently 
 adds bromid and chloral to the enema with the view of obviat- 
 ing the necessity for the use of ojnates. These, however, are 
 not to be employed in cases where their depressing effect upon 
 the circulation is a consideration of importance. 
 
 In this connection attention may be called to the beneficial 
 effect produced by enteroclysis with large quantities of fluid for 
 the relief of thirst following postoperative vomiting. This will, 
 however, be more largely taken up later (page 283). 
 
 If the bowel shows evidence of irritation and rebellion during 
 the administration, the enema must be arrested. In these cases 
 it is best to give a pint of the fluid every hour or two, though if 
 a larger quantity is retained, the manipulation need not be re- 
 peated more frequently than at intervals of four to six hours. 
 
 SECONDARY HEMORRHAGE FOLLOWING OPERATIONS 
 
 Bleeding does not occur during profound shock. This is easy 
 to understand when the mechanism of shock is borne in mind, 
 and applies with greater force to shock from loss of blood, which 
 requires no stretch of the imagination to be regarded as a con- 
 servatism on the part of nature. Shock from loss of blood and 
 spontaneous arrest of hemorrhage is not necessarily the outcome 
 of fatal exsanguination. The circulatory apparatus conforms 
 relatively to the quantity of blood it contains. If this be lessened 
 shock occurs and the bleeding is temporarily stilled. 
 
 The indiscriminate use of stimulants following severe opera- 
 tions if large areas have been attacked favors the occurrence of 
 secondary hemorrhage. If all divided blood-vessels have been 
 secured, stimulants may be given. Nothing which raises the 
 blood-pressure should be administered if bleeding is going on. 
 This admonition applies especially to adrenalin chlorid. The 
 routine practice of giving every case stimulants as it comes off 
 the table is to be deprecated for the reasons stated. 
 
 Secondary bleeding occurs simultaneously with reaction from 
 shock. It varies in extent with the degree of the shock and the 
 quantity of blood lost. The picture presented by secondary 
 hemorrhage is practically that of shock with thirst and dyspnea 
 
268 SHOCK AND SECONDARY HEMORRHAGE 
 
 added. Sudden increase of pnlse rate, restlessness, lowering of 
 body temperature, and thirst are indicative of bleeding. If the 
 operation has involved a cavity which is subsequently closed, these 
 manifestations justify measures directed to the relief of sec- 
 ondary bleeding. If the bleeding come from a superficial wound, 
 the condition of the protective dressing will, of course, indicate 
 the bleeding before systemic manifestations present. 
 
 The indications for treatment are clear. The first step is to 
 arrest the bleeding. The patient is narcotized and the bleeding 
 arrested in the usual way. Chloroform, while a less safe agent 
 in itself, should be used for the purpose, as ether raises blood- 
 pressure. The administration of the chloroform should be care- 
 fully executed, and profound narcosis avoided if a certain mus- 
 cular resistance on part of the patient does not defeat the object. 
 When the bleeding points are controlled, adrenalin chlorid may 
 be given hypodermatically, and the field watched for recurrence 
 of the bleeding. Hemorrhage from the arteries and veins is 
 easily controlled. 
 
 Parenchymatous oozing and capillary bleeding if not ar- 
 rested with hot applications call for tamponade. The use of 
 astringents is to be avoided. 
 
 THE MIKULICZ TAMPON 
 
 For the purpose the Mikulicz tampon is exceedingly effective. 
 The tampon is introduced with its apex in the bottom of the 
 wound, and the cavity filled with strips of gauze (Fig. 210). 
 The gauze tampon should have its edges turned in to obviate un- 
 raveling, and consists of four layers of gauze (Fig. 211). 
 
 At the same time sutures may be introduced into the wound, 
 as shown in Fig. 223, to be tied when the tampon is removed. 
 When the hemorrhage is arrested, stimulants may be given and 
 the case treated as described under shock. 
 
 REMOVAL OF MIKULICZ TAMPON 
 
 The Mikulicz tampon should remain in situ for forty-eight 
 hours. At the end of this time the gauze strips are moistened 
 with a hot antiseptic or aseptic solution, in the manner described 
 under dressing of wounds. The object of having the tampon 
 
SECONDARY HEMORRHAGE FOLLOWING OPERATIONS 269 
 
 Fig. 210. — Mikulicz Tampon in situ. Gauze square rilled with strips of gauze. 
 
 square in contact with the wound surface is to permit of removal 
 of the bulk of the pressure agent without disturbance of the sur- 
 face of the wound. The tampon square is, of course, adherent 
 
 Fig. 211. — Mikulicz Tampon. Gauze fashioned into square with edges turned in. 
 
Fig. 212. — Mikulicz Tampon Grasped with Heavy Hysterectomy Forceps 
 Ready for Removal. 
 
 Fig. 213. — Mikulicz Tampon Twisted and Loosened from Sides of Wound, 
 Ready to be Lifted Out. 
 
 270 
 
SECONDARY HEMORRHAGE FOLLOWING OPERATIONS 271 
 
 to the contiguous raw surfaces, and its removal is likely to be at- 
 tended with trauma to the small vessels, which have been ob- 
 structed by coagulated blood, and when these clots are torn away 
 as the tampon is removed renewed hemorrhage may occur. After 
 the gauze strips have been withdrawn, hydrogen peroxid is 
 syringed beneath the edge of the square of gauze, and after the 
 more externally located portions are thus loosened, the protrud- 
 ing part is folded together and held in a clamp (Fig. 212) and 
 slowly and carefully twisted (Fig. 213), at the same time con- 
 tinuing the injection of hydrogen peroxid until the tampon is 
 finally lifted from its seat. 
 
 The solutions used for the purpose should be hot (110° F.) 
 with the view of arresting whatever oozing may occur. The 
 wound may now be closed with stitches previously introduced 
 (Fig. 223), or be left open as the conditions presented indicate. 
 
CHAPTER XII 
 
 VOMITING AND ACUTE DILATATION OF STOMACH 
 
 AND GUT 
 
 Postoperative vomiting: Character of vomited matter — Acute dilatation of the 
 stomach and gut : Treatment. 
 
 POSTOPERATIVE VOMITING 
 
 The postoperative care of patients varies in certain regards 
 with the character of affliction for which the operative relief has 
 been employed, and these variations will be taken up in connec- 
 tion with the various classes of operations. There are, however, 
 certain general considerations which apply with but little modi- 
 fication to all cases. The factor which enters most largely into 
 consideration of vomiting after operations is the outcome of an- 
 esthesia produced by narcotics. The prophylaxis involved in 
 this proposition with regard to restrictions of diet, catharsis, 
 etc., has already been discussed under the head of preparation 
 of the patient (page 38). Beyond this, however, various medic- 
 inal agents have at intervals been more or less actively ex- 
 ploited, which, when administered before the operation, are be- 
 lieved to have a beneficial effect in this connection. It is probable 
 that none of these is effective in all cases, and that some have no 
 influence in any. This subject is taken up to a considerable ex- 
 tent in dissertations upon narcosis generally, and does not call for 
 detailed consideration here. 
 
 It is to be borne in mind that the gastrointestinal canal is an 
 important eliminative organ when toxic substances are present in 
 the blood, and it is, of course, certain that the physiological effect 
 of narcotics is the outcome of a poisoning of the circulating fluid 
 which is in no small degree similar to toxemia from other causes. 
 The vomiting following administration of narcotics by inhalation 
 may be regarded as physiological, though, indeed, the major por- 
 
 272 
 
POSTOPERATIVE VOMITING 273 
 
 tion of the offending substance is thrown off by the lungs, kid- 
 neys, and skin. The fact that vomiting after operations is not in 
 any sense dependent solely upon the operation, is shown in in- 
 stances where narcosis is produced for the purpose of making ac- 
 curate physical examinations. In these instances vomiting fol- 
 lows in as large a number of cases as obtains when operations 
 have been done, although, be it also said, the length of time or the 
 quantity of narcotic given bears a direct proportion to the severity 
 of the vomiting. 
 
 Perhaps the measure which is most largely employed is the 
 administration hypodermically of one-quarter of a grain of mor- 
 phia and one-one hundredth of a grain of atropia one hour before 
 the operation. This measure has been universally useel by sur- 
 geons, and if not always effective with regard to the control of 
 vomiting, has some additional advantages which make justifiable 
 its employment. 
 
 In the vast majority of instances the mental status of a pa- 
 tient about to be subjecteel to surgical operation is apprehensive, 
 and the small close of morphia mentioned creates a certain com- 
 placency of mind which is not objectionable. The atropin is also 
 slightly stimulating, and its effect ujdoii the salivary secretions is 
 beneficial, as it lessens the quantity of saliva and mucous secre- 
 tion in the mouth and in a measure prevents excessive collection 
 of fluids in the air passages during the narcosis. On general prin- 
 ciples, it is difficult to see how morphia, which paralyzes involun- 
 tary muscular fibers and lessens secretions generally, can in any 
 way hasten elimination of the narcotic employed. Indeed, the 
 contrary is to be expected, yet it would seem that vomiting does 
 not occur as largely in instances where this mixture of morphia 
 and atropia has been given. The writer does not employ medic- 
 inal agents before operations with the notion of controlling 
 vomiting, for the reasons stated, though in especial cases and for 
 special indications the mixture mentioned is in a certain num- 
 ber of cases employed. 
 
 In a few instances postoperative vomiting is maintained for 
 many hours, and, indeed, for days after operation. This will, 
 however, be found to be the result of the character of operation, 
 the coexistence of nephritis, or due to a toxemia other than the 
 effect of the narcotic. In every case in which vomiting persists 
 
274 VOMITING AND ACUTE DILATATION OF STOMACH AND GUT 
 
 for more than several hours following an operation these factors 
 must be considered. Few agents remain in the circulation for 
 many hours after administration, and when it is remembered 
 that narcotics enter the circulation through the respiratory tract, 
 and are not gradually absorbed from the stomach, as is the case 
 when medicinal agents are administered, the rationale of this^ 
 statement seems clear. This means that toxemia due to sub- 
 stances in the stomach, or one which is the outcome of an avail- 
 able reservoir in the form of an area of inflammation, presents the 
 picture of a disturbed balance between absorption and elimina- 
 tion, while the source of supply is immediately withdrawn when 
 no more narcotic is administered, and last it is worthy of note 
 that narcotics are, because of their chemical and physical char- 
 acteristics, very rapidly thrown off. 
 
 Assuming that the stomach is concerned in eliminating these 
 agents, it is not difficult to conceive of a mixture of mucus and 
 secretion in the stomach, which holds the end products of the nar- 
 cotic in solution or in suspension, and that a liberal evacuation 
 of this is desirable. In order to accomplish this, many surgeons 
 administer a pint of warm saline solution to patients as soon 
 after the operation as deglutition is possible, and regard the re- 
 sultant evacuation of the stomach as eliminative and, perhaps, 
 less offensive and objectionable than gastric lavage at this time. 
 Also, for the same reasons, lavage of the stomach is done at times 
 on the operating table while the patient is still narcotized. How- 
 ever, it is to be remembered that the actual indication for this 
 measure does not occur until the stomach has been for several 
 hours concerned in eliminating the narcotic, and that perhaps 
 the only benefit which immediate lavage may accomplish is re- 
 moval of the contents accumulated during the operation, and 
 perhaps, too, it may be regarded as preparing the gastric mucosa 
 better for its impending labor. Following operations upon the 
 upper air passages, in which instances blood and secretions are 
 inadvertently swallowed by the patient, an especial indication for 
 immediate gastric lavage is presented, and the measure is prop- 
 erly employed at this time. 
 
 While the stomach is concerned in this eliminative function 
 it is quite incapable of converting nutritive substances into ab- 
 sorbable material ready for entrance into the circulating fluid, 
 
POSTOPERATIVE VOMITING 275 
 
 and, therefore, the introduction of articles of diet during the first 
 few hours immediately following the operation is contraindi- 
 cated. Indeed, these substances when introduced accumulate in 
 the stomach and act as a foreign body, which increases the irri- 
 tation of the gastric mucosa already present as the outcome of 
 its eliminative efforts, and prolongs vomiting. For this reason it 
 is the rule to rest the stomach completely as regards digestive ef- 
 forts for twelve hours after the operation. This does not mean 
 that the narcotic is not eliminated before the expiration of the 
 twelve hours, but that, unless lavage or vomiting has cleansed the 
 stomach, the condition of the mucosa is such as to render normal 
 function of the organ quite impossible. 
 
 The causative factors which enter into gastric disturbances 
 following operations do not relate alone to the narcosis. Indeed, 
 it may be said that, while this is an important consideration, its 
 consequences are most largely questions of comfort and expe- 
 diency in recovery. The fatal disturbances of the stomach which 
 are at times attributed to the carelessness of the nurse or attend- 
 ant in administering food or medication immediately after an 
 operation are the outcome of much graver influences than this. 
 
 It is, of course, best not to permit of the administration of 
 any food for the time stated. Yet, the introduction of small 
 quantities of hot water, a teaspoonful every fifteen minutes, is 
 not objectionable, and acts as a diluent to the offensive material 
 in the stomach and, indeed, in its passage over the pharyngeal and 
 esophageal mucosa is exceedingly grateful to the patient. The 
 water is, of course, not destined to relieve thirst by its local 
 action, as thirst is a local manifestation of the systemic need for 
 fluids. However, if has a certain place in this connection and 
 may be used. It may also be replaced with cold water or cracked 
 ice used in the same proportions, if there be no contraindication. 
 This is, however, largely a matter of the patient's taste, as the 
 temperature of either is about the same at the end of the six sec- 
 onds required for deglutition. Thirst as a postoperative occur- 
 rence is taken up under a separate head (page 283 ). 
 
 Summarizing the situation as so far presented, it is fair to 
 say that if vomiting be a manifestly obtrusive symptom at the end 
 of several hours after operation, a pint of warm saline solu- 
 tion may be given, and if this be ineffectual in controlling the 
 20 
 
276 VOMITING AND ACUTE DILATATION OF STOMACH AND GUT 
 
 vomiting, gastric lavage may be employed. In any event, the 
 various medicinal agents which are quite generally regarded as 
 capable of affording relief are best omitted. Rest, as far as the 
 digestive function of the stomach is concerned, is the wisest plan 
 to pursue. A direct local effect from these agents upon the 
 gastric mucosa is difficult to understand, and if the action of the 
 agent be regarded as the outcome of entrance into the circula- 
 tion, and general effect is designed, the hypodermic method and 
 the lower bowel present far more favorable avenues of approach 
 than is obtained as the outcome of deglutition. 
 
 The introduction of medicinal and nutritive agents into the 
 rectum is taken up under a separate head (page 291). 
 
 CHARACTER OF VOMITED MATTER 
 
 This, aside from, the indications it gives of diagnostic value, 
 is of great prognostic import, and in every case the nurse or at- 
 tendant must be instructed to preserve the vomit for inspection, 
 and, indeed, in some instances microscopical examination should 
 be employed to clear up doubtful conclusions in this connection. 
 Neglect of this precaution may result in a fatal outcome which 
 perhaps might have been avoided. 
 
 The presence of even minute particles of blood, as shown by 
 small dark streaks in the vomit, always arouses alarm. If the 
 vomiting is repeated, and there be an increased quantity of the 
 suspicious color, the case may be regarded as either one of dila- 
 tation of the stomach or a beginning sepsis. The former is most 
 likely to occur within twenty-four or thirty-six hours following 
 the operation, and calls for appropriate treatment at once. When 
 the vomit is due to sepsis, it does not usually occur until after 
 the second day following the operation, unless already an over- 
 whelming sepsis has existed at the time of the operation. 
 
 In the latter event, the evidence of sepsis will be manifest at 
 the time, and the vomit of blood will not be likely to cause con- 
 fusion as to its origin. Following abdominal operations for the 
 relief of infective processes, such as pyosalpinx, suppurative 
 cholecystitis, or appendicitis with abscess, the appearance of 
 blood in the vomit may readily be regarded as evidence of sys- 
 temic invasion of the septic process, the outcome of liberation of 
 infectious material into the contiguous peritoneum. 
 
ACUTE DILATATION OF THE STOMACH AND GUT 277 
 
 However, in a certain number of cases the bloody vomit is the 
 outcome of an acute dilatation of the stomach and gut due to 
 either shock, the narcotic, or the mauling of the abdominal or- 
 gans during the surgical manipulations. Especially is this true 
 with respect to attack upon the gall-bladder. In these cases, the 
 position of the patient making more accessible the operative field, 
 the interference with respiration, the outcome of delivery of the 
 liver into the wound, contributes not a little to the general dis- 
 turbance, resulting not infrequently in acute dilatation of the 
 stomach and gut. Indeed, in this class of cases the stomach it- 
 self is handled to a greater or lesser extent, depending upon 
 whether the common duct is attacked, and the trauma to the py- 
 lorus contributes a not unimportant part to the outcome. The 
 condition is more frequently a postoperative complication follow- 
 ing abdominal operations than after operations in other portions 
 of the body, a fact which would tend to show a certain causative 
 relationship in the connection mentioned. 
 
 ACUTE DILATATION OF THE STOMACH AND GUT 
 
 Acute dilatation of the stomach and gut occurs with suffi- 
 cient frequency after operations to warrant consideration here. 
 
 The condition, is perhaps well represented in the history of 
 the case here described. 
 
 Mrs. A. H., subjected to Cesarean section. Pelvis filled with 
 immovable mass, which proved upon celiotomy to be a large der- 
 moid cyst. Hysterotomy and delivery of fetus readily accom- 
 plished in the usual manner. Operation done with considerable 
 rapidity was not attended with evidence of shock of sufficient im- 
 port to call for the use of particular precautionary measures. At 
 end of twenty-two hours the patient expressed herself as feeling 
 comfortable. Temperature in rectum 100° F., pulse 115. Vom- 
 ited at this time four ounces of clear fluid slightly streaked with 
 blood. Patient, however, was not permitted to partake of nour- 
 ishment by mouth. Saline irrigation of colon ordered. 
 
 At the time of the operation no evidence of infection had 
 been manifest, and it was considered improbable that infection 
 had been introduced at the time of the operation. The presence 
 of blood in the vomit was regarded as accidental and possibly 
 
278 VOMITING AND ACUTE DILATATION OF STOMACH AND GUT 
 
 the outcome of the rupture of a small vessel in the esophagus. 
 However, the increase of pulse rate disproportionate to the ac- 
 companying symptoms was regarded as suspicious. It was diffi- 
 cult to conceive of a se] sis so overwhelming as to cause venous 
 stasis and hemorrhage into the stomach after the lapse of a bare 
 twenty-four hours following the operation. Six hours later the 
 patient vomited a pint of dark brown fluid, which upon micro- 
 scopical examination proved to consist largely of blood. The 
 pulse rate had not been accelerated at this time, being still 110 
 to 115 per minute. The temperature had risen to 101° F., which 
 excluded delayed shock. The patient at this time expressed her- 
 self as feeling comfortable and asked for food. 
 
 The clinical picture was confusing. Sepsis was regarded as 
 exceedingly improbable, and in view of the absence of symptoms 
 other than the bloody vomit, after consultation with Dr. L. K. 
 Neff, it was decided to ask Dr. Robert Coleman Kemp to see the 
 case with the view of washing out the stomach, and to obtain the 
 benefit of his advice. Several hours later, when Dr. Kemp saw 
 the case (thirty hours after the operation), the abdomen had be- 
 come distended, the patient complained of oppression in the epi- 
 gastrium, dyspnea, and the facial expression was anxious. Tem- 
 perature, 101° F. ; pulse, 120. Examination of the abdomen 
 showed what appeared to be a widely distended stomach, though 
 the tympanitis was not limited to the region of the stomach. It 
 was evident that the intestines were also distended. Dr. Kemp 
 made immediate gastric siphonage, drawing off a gallon of dark 
 brown fluid. The colon was then irrigated per rectum, the head 
 of the bed elevated, and eserin and strychnia administered hypo- 
 dermically. Immediately after the gastric siphonage and lavage 
 the distention in the upper segment of the abdomen disappeared. 
 The colic irrigation was attended with expulsion of large quan- 
 tities of gas and some liquid feces. The distention in the lower 
 portion of the abdomen was not so palpably reduced as had. ob- 
 tained in the region of the stomach. 
 
 The patient expressed herself as much relieved, the respira- 
 tions became tranquil, and the pulse rate diminished to 100 per 
 minute. At the end of another six hours the distention in the 
 upper portion of the abdomen reappeared, though it was less 
 marked than before. The same treatment was employed with 
 
ACUTE DILATATION OF THE STOMACH AND GUT 279 
 
 the same effect. The colic lavage was made continuous from this 
 time, employing the Kemp tube (Fig. 345) for the purpose. The 
 administration of eserin and strychnia was repeated. The symp- 
 toms did not reappear after this, and the patient made an unin- 
 terrupted recovery, although the pulse rate did not assume nor- 
 mal proportions for several days after the abdominal symptoms 
 had subsided, showing that a serious impression had been made 
 upon the vital processes. 
 
 This case may be regarded as typical of acute dilatation of 
 the stomach and intestines following operation in which shock 
 was not a distinct causative factor, although the narcosis may 
 have to be considered as a causative element. It illustrates, too, 
 the necessity for a close scrutiny of the vomit after operations. 
 Had the operation been undertaken for the relief of an intra- 
 abdominal infection, the first appearance of " black vomit " 
 would have been regarded as indicative of an overwhelming sep- 
 sis, and an unfavorable prognosis given. Whether the stomach 
 would have been washed out or not at this time would have de- 
 pended upon the conception the attendant had of the utility of the 
 measure as a matter of routine. The technic of gastric lavage 
 is a simple one. However, its execution is attended with con- 
 siderable annoyance to the patient and is not to be lightly under- 
 taken, especially ^as the retching and vomiting attendant upon 
 the measure are undesirable if the operation happens to involve 
 the abdomen. Fear in these cases is felt that the stitches may 
 tear out. The dilatation may be in certain cases limited to the 
 stomach, and lavage or siphonage or both of this organ may meet 
 the indications. However, it is probable that in postoperative 
 cases the dilatation is not limited to the stomach, and an effort 
 should be made to stimulate contraction of the gut by copious 
 colic lavage. 
 
 The technic of gastric lavage need not be entered into here. 
 Indeed, the discussion of colic lavage or irrigation is also some- 
 what out of place in a work of this sort. It is regarded proper 
 by the writer to state that colic lavage is best made with a return 
 tube in these cases, and ample opportunity should be given for 
 the discharge of feces and gas by rectum. 
 
 In discussing the problem here, the acute dilatations of the 
 stomach consequent to errors of diet need not be considered, ex- 
 
280 VOMITING AND ACUTE DILATATION OF STOMACH AND GUT 
 
 cept inasmuch as it should be remembered that probably the ad- 
 ministration of food by mouth soon after operations may be re- 
 garded as a contributory cause of the condition. The type of 
 cases seen after operation is what Kemp calls the mixed type of 
 gastric and intestinal dilatation. If it be true that shock causes 
 a paralysis of the splanchnic and pneumogastric areas, it is easy 
 to understand that dilatation of the gastro-intestinal tract is a 
 logical outcome in certain instances. It is not to be assumed that 
 selective action is restricted to the enervation of the stomach 
 alone in these cases, and, indeed, clinically it is manifest that the 
 intestines are also involved. This means that measures of relief 
 should not be restricted to the stomach alone, as has already been 
 mentioned. 
 
 Just how powerfully causative a factor the narcosis is in these 
 cases is not clear. It has been shown that prolonged choloroform 
 or ether narcosis without there having been any operation per- 
 formed will result in acute dilatation of the stomach. 
 
 Whether the causation be that of shock or narcosis or the 
 excessive manipulations of the abdominal contents, is not a mat- 
 ter of great importance for the purpose here considered. In any 
 event, it is certain that the condition is the outcome of a paralysis 
 of the muscular coats of the gastro-intestinal canal, and that, as 
 the result of this, a venous stasis occurs which causes hemorrhagic 
 infiltration and rupture of the capillaries in the mucosa. Blood 
 and serum are poured into the stomach and gut, are vomited in 
 the form of " black vomit," and passed per rectum in the same 
 form. If the condition be not relieved, the picture is one of de- 
 gree, varying with whether the venous stasis goes on to slough- 
 ing and perforation, or if death occurs from toxemia, death from 
 the latter cause occurring in from a few hours to two days follow- 
 ing the operation. 
 
 TREATMENT 
 
 The treatment of the condition is quite indicated in the report 
 of the case mentioned. In addition to this, the shock treatment 
 is to be employed and eserin and strychnia given, the latter to 
 guard the former. Eserin is given in doses of 1-50 to 1-30 of a 
 grain, and strychnia as it is usually used. 
 
 Kemp, after cleansing the stomach with water, to a quart of 
 
ACUTE DILATATION OF THE STOMACH AND GUT 281 
 
 which two ounces of milk of magnesia has been added, puts into 
 the stomach through the tube three to five grains of calomel, to- 
 gether with an ounce of water. The lavage is repeated in two 
 hours. It is best to err on the side of frequency in washing. 
 The fact that the patient does not vomit cannot be regarded as 
 indicative of a favorable condition of affairs. The degree of 
 distention and discomfort is the best indication as to the condi- 
 tions. Indeed, when the patient vomits, the symptoms are less 
 apt to become alarming, for very obvious reasons. Eserin, to- 
 gether with strychnia, has already been considered. The colic 
 lavage is repeated as often as necessary. Indeed, this measure 
 
 Fig. 214. — Postural Treatment for Acute Dilatation of Stomach and 
 Intestine, Following Operation. 
 
 has so many allied advantages that it may be used to a consid- 
 erable extent. 
 
 The postural treatment is regarded as exceedingly useful. 
 The patient is postured in a semi-oblique position by raising the 
 head of the bed (Fig. 214). The benefit from this is ascribed 
 to the fact that the abdominal contents are encouraged to gravi- 
 tate away from the thoracic organs. The posture is, of course, 
 
282 VOMITING AND ACUTE DILATATION OF STOMACH AND GUT 
 
 not quite so favorable to the entrance of the colic lavage fluid, 
 but as the intent of this is to facilitate discharge of the intestinal 
 contents, the position may be considered beneficial in this con- 
 nection. On the whole, the cleansing of the stomach and the 
 colic lavage are the measures which achieve the greatest amount 
 of good. 
 
CHAPTER XIII 
 THIRST AND PAIN 
 
 Thirst: Treatment of thirst — Pain 
 
 THIRST 
 
 Thirst is one of the most distressing symptoms following se- 
 vere operations. It bears a quite direct proportion to the quan- 
 tity of blood lost and the amount of fluids expelled with the 
 vomit. Given a prolonged operation, attended with considerable 
 loss of blood and followed by severe vomiting of irritating fluids, 
 as frequently obtains, and the conditions present a picture which 
 the practitioner often faces, while the operator goes on his way 
 with the complacency born of the belief that he has done a skill- 
 ful operation. Indeed, it is in these cases that the practitioner 
 is tempted to employ the various medicinal agents already al- 
 luded to in connection with postoperative vomiting. 
 
 As a rule, the patient bears a different relationship to the 
 practitioner than that which obtains toward the surgeon, and the 
 former is appealed to, and, indeed, often enough pitifully im- 
 plored to do something to afford relief. 
 
 TREATMENT OF THIRST 
 
 Opiates, for obvious reasons, increase thirst. The indication 
 is to supply fluids to the circulation. The introduction of fluids 
 into the stomach provokes vomiting and increases thirst. It is 
 in these cases that copious colic lavage is of the greatest service. 
 
 The technic of its employment is in all respects similar to 
 that employed in shock. Salt is added to obviate extraction of 
 inorganics from the epithelium of the colic mucosa. When water 
 alone is used, the cells give up their coloring matter, and the in- 
 organics are taken up in solution. Whatever the function of the 
 
 283 
 
284 THIRST AND PAIN 
 
 inorganics may be, they certainly are essential to metabolism, 
 and experimentation shows that osmosis of saline solutions is 
 more rapid than obtains with plain water. It is generally 
 regarded that salt promotes thirst. This may be true under 
 physiological conditions, but for. the purpose of obtaining 
 rapid absorption of fluids after operations, it is essential to the 
 intent. 
 
 The lips should be frequently moistened with hot water. For 
 this purpose the nurse uses a piece of cotton soaked with hot 
 water, and replaces it frequently with a clean portion. Small 
 doses of hot water, as mentioned in connection with vomiting, 
 may be swallowed at intervals. If the vomit be acid, the burn- 
 ing sensation in the pharynx and mouth may be relieved by al- 
 lowing the patient to rinse the mouth with a solution of sodium 
 bicarbonate. A small portion of the solution is usually swal- 
 lowed, and the distress in the esophagus from the same cause is 
 lessened. 
 
 If pain be not a marked symptom, opiates should be avoided, 
 as already stated. However, if thirst and restlessness be extreme 
 and not relieved by the measure indicated, morphia should be 
 given hypodermically and in one large dose, i.e., one-half a grain. 
 This will induce sleep and give opportunity for the replacement 
 of the fluids lost. 
 
 Many practitioners add atropin to the morphin. This is 
 inadvisable, as the latter ae'ent dries still more the fauces. The 
 repeated administration of small doses of morphia is a procrasti- 
 nation. It should be given in one good-sized dose when the indi- 
 cation for its use is clear. The use of codein is also a subterfuge. 
 The alkaloid of opium which is the most anodyne is morphia, 
 and if this be true, the employment of a substitute alkaloid is un- 
 scientific. 
 
 It must be remembered that the quantity of urine excreted 
 by patients from whom large quantities of fluids have been with- 
 drawn is largely reduced, and that catheterization is not apt to 
 be necessary for eight to ten hours. If morphia is given, the 
 sense of bladder fullness is likely to be dulled, and this must be 
 taken care of. Patients who require opiates after operations are 
 more likely to require withdrawal of the urine by catheter than 
 if the drug be omitted. 
 
PAIN 285 
 
 The treatment of severe thirst may be summarized into the 
 administration of a full dose of morphia (gr. ss) hypodermically 
 and the introduction of a large quantity of saline solution into 
 the rectum or colon. The morphia should not be given unless the 
 colic injection is to be made. 
 
 The morphia will not enhance the dryness of the buccal mu- 
 cosa for about fifteen minutes after its administration, during 
 which time a considerable quantity of the saline solution will have 
 been absorbed from the gut. The picture of a restless, thirsty 
 patient, mumbling, dry-lipped for water, is soon replaced 
 by one going to sleep, and the supply of water to the circu- 
 lating fluid goes quietly on as the patient sleeps. The writer 
 has frequently seen the efficiency of the measure practically 
 demonstrated. 
 
 PAIN 
 
 The character, degree, and persistence of pain following 
 operations vary, of course, with the kind of operation and the 
 affliction for the relief of which it is undertaken. As a general 
 rule, wound pain is not severe. The reparative hyperemia at- 
 tendant upon uninfected wounds is not usually sufficiently se- 
 vere to cause pain. 
 
 In a general way the technic of operations should be di- 
 rected toward the avoidance of postoperative pain. This will be 
 found feasible in a larger number of instances than would ap- 
 pear from a casual analysis of the situation. If the operator 
 would bear in mind, as. each stitch is inserted and tied, that just 
 sufficient tension to hold tissues in apposition is all that is neces- 
 sary to accomplish the purpose, much postoperative pain would 
 be avoided. The objections to tightly drawn sutures have al- 
 ready been mentioned ; the warning is sounded again in this con- 
 nection from an additional viewpoint. Buried apparatus of im- 
 mobilization should be introduced with the same factors in mind. 
 Indeed, a nail may be driven into bone without the occurrence of 
 subsequent pain, provided the contiguous tissues be so repaired 
 as not to make pressure on the former. The gall-bladder may be 
 attached to the anterior abdominal wall without entailing severe 
 subsequent suffering to the patient, provided the movements of 
 
286 THIRST AND PAIN 
 
 respiration be shown proper consideration in making the anasto- 
 mosis. 
 
 The surgeon is asked to take this into consideration during 
 the operation, as a plea coming from the attendant taking care 
 of the after-treatment. Of course, here again the question of 
 opiates comes up. And, indeed, here again the rule laid down 
 with regard to thirst is to be applied — avoidance of opiates until 
 the indication is clear, and then the administration of a full 
 dose. 
 
 The nurse should not be given an order to give a sixth of a 
 grain of morphia hypodermically every two hours until the pain 
 is relieved, but the practitioner had best give the full dose him- 
 self, watch its effect, and only repeat it when again the indica- 
 tion is imperative. In the interim measures for the more sat- 
 isfactory immobilization of the tissues subjected to trauma may 
 be taken. 
 
 Under no circumstances should opiates be administered if 
 pain be the outcome of the method in which the dressings are ap- 
 plied. In these instances the retention bandage must be taken 
 off and replaced. Especially is this true when plaster-of-Paris 
 has-been used. If severe pain occurs in a non-infected wound 
 beneath plaster-of-Paris, it should be at once removed. If in- 
 fection be. present at the time of the operation, plaster-of-Paris 
 should not be employed unless ample provision for inspection of 
 the wound be made. 
 
 If wounds are packed with gauze, the packing should not be 
 so firmly introduced as to cause pain. A tamponade made for 
 the purpose of arresting hemorrhage should not be rammed in 
 with a director as though the intent were to stop a leak in a steam 
 pipe. It is only necessary to bear in mind that the normal blood 
 pressure needs only to be overcome, and that light pressure with 
 the finger in the abdomen readily controls the flow of blood in 
 the aorta. All that is necessary is to fill the bleeding cavity with 
 gauze to moderate distention. If severe pressure is made, the 
 meshes of the gauze are buried in the tissues, and when the gauze 
 is removed, the coagulum is torn away and fresh bleeding 
 may occur. The gauze takes no part in the repair of divided 
 blood vessels and capillaries. These are obliterated by blood 
 clot and later by scar tissue, and the gauze sinrply acts as a 
 
PAIN 287 
 
 plug until this lias occurred. Packing in wounds should not 
 cause pain. 
 
 Still less necessary is it to pack firmly infected wounds. In 
 these cases the intent of the packing is to obliterate blind spaces 
 and cause infective secretions to find their way into the gauze 
 and out of the wound by capillarity. Firm packing prevents 
 the intent mechanically, and the gauze should be so placed in the 
 wound as to permit of ready egress of the offending material. 
 
CHAPTEE XIV 
 FEEDING AFTER OPERATION 
 
 Feeding by mouth — Rectal feeding. 
 
 The diet after operations varies somewhat with the character 
 of operation the patient has been subjected to. Variations in this 
 regard, arising for this reason, will be taken up under separate 
 heads. There is, however, a general principle involved which 
 should be followed in all cases, the foundation of which is that 
 the digestive functions are either arrested or greatly impaired 
 after operations, the outcome of the narcosis as already rather 
 extensively discussed, and because of shock and the disarrange- 
 ment of the vital functions to be expected as the result of a severe 
 tax upon them. As stated, no food should be given by mouth 
 while the patient is vomiting, and nothing should be given until 
 nausea has disappeared. The administration of agents to " settle 
 the stomach " should be avoided. 
 
 FEEDING BY MOUTH 
 
 As soon as nausea has disappeared, kumyss or matzoon may be 
 given in small quantities at a time (half an ounce). The second 
 dose of these agents should not be administered until a reasonable 
 period of time has elapsed to determine whether the stomach will 
 reject it or not. This should be about half an hour. The quan- 
 tity of the second dose should be about the same as the first, and 
 this may be repeated if no nausea appears in fifteen minutes. At 
 the end of three or four hours additional liquid food may be al- 
 lowed. It is not sufficient to give general instructions in this 
 regard — the orders should be definitely expressed, and execution 
 insisted upon. 
 
 If no untoward conditions arise it may be regarded as safe 
 to give almost any liquid nourishment which the patient desires 
 
 288 
 
FEEDING BY MOUTH 289 
 
 at the end of twenty-four hours. Broths, beef extracts, and the 
 nostrums on the market exploited as being readily assimilated, 
 organic, nitrogenized constituents of diet, are not objectionable as 
 far as their palatability is concerned. It is to be borne in mind, 
 however, that none of these may properly be regarded as of great 
 nutritive value. Soups and broths consist of a solution of in- 
 organics extracted from meat by various processes, all of which 
 involve the application of heat. Heat, of course, coagulates al- 
 bumin, and the longer heat is applied the firmer is the coagulum 
 and the less liable are the albuminoids to be found in the extracts. 
 It is no great exaggeration to say that soups, broths, and the 
 various so-called peptones prepared by the manufacturer have the 
 chemical composition of urine. 
 
 They do, however, have some virtue as far as the water is 
 concerned, and as they hold certain flavoring substances in solu- 
 tion or in mechanical mixture, they fill a certain place in relieving 
 the monotony of liquid food. Milk and its preparations, i.e., its 
 modifications, should be the sheet anchor in liquid nourishment 
 in postoj^erative cases, as it is in all conditions calling for the 
 administration of liquid diet. Milk contains all the ingredients 
 necessary to maintain life. It is deficient in iron, but this need 
 not be regarded as an objectionable omission when used over a 
 short period of time. 
 
 The modification of milk in order to render it more easily 
 assimilable relates to the fats and the treatment of the casein to 
 prevent its firm coagulation. As the fats are most largely di- 
 gested in the intestine and require for assimilation considerable 
 effort on the part of the digestive functions, these should be quite 
 removed and so-called skimmed milk given for the first twenty- 
 four hours after an operation. In this way most of the fat is 
 removed, though a little is partaken of. However, this small quan- 
 tity does not call for great labor on part of the pancreas, bile, 
 and intestinal juices, and need not be regarded as objectionable. 
 
 "With respect to rendering more readily assimilable the casein, 
 this may be achieved by the addition of lime water or fermenta- 
 tion with lactic acid. Knmvss and matzoon are examples of this 
 process, though the carbonic acid gas developed as the outcome of 
 this treatment may be objectionable in some instances. If this 
 be true, then skimmed milk which has had lime water added may 
 
290 FEEDING AFTER OPERATION 
 
 be used for a day or two after the operation, and gradually, as 
 the indications are presented, the quantity of fats may be in- 
 creased. The principle to be kept in view is to lessen the burden 
 of digestion and yet not withdraw nourishment. 
 
 All operative cases have fever from some cause, the most com- 
 mon, of course, being the outcome of exaggerated metabolism in 
 the effort the economy makes in repair. This rise of temperature 
 does not, as a rule, persist after the third or fourth day unless it 
 be the expression of infection. Until, then, the temperature ap- 
 proaches the normal, liquid food only should be allowed, on the 
 grounds stated. 
 
 Peculiar methods of treating postoperative cases by starvation 
 and the administration of only water or substances which are 
 soluble in water are to be deprecated. There is no other source 
 of energy, as has been stated before, than the food taken into the 
 body, and while excessive strain upon the organs concerned in pre- 
 paring nutritive constituents into assimilable substances is to be 
 avoided, the entire withdrawal of the organic nitrogenized con- 
 stituents and the fats is also unwise. Sugar is certainly soluble 
 in water, yet its conversion into glucose is an exceedingly com- 
 plicated process and unquestionably entails greater effort in diges- 
 tion than do the albuminoids, which, as is well known, are di- 
 gested very largely in the stomach. 
 
 • If physiology is to be believed, the body will be better able to 
 furnish the constituents necessary to combat the outcome of sur- 
 gical attack if it be furnished by the ingesta with the material 
 to do it. 
 
 If no infection be manifest by the fourth day, it is proper to 
 furnish the patient's digestive organs with the fibrin so necessary 
 to life, and this is best given in the form of lean meats, which 
 at first are given only once daily and later twice daily. Repair of 
 injury will be enhanced by observation of certain well-established 
 physiological laws, one of which is that man is essentially an 
 omnivorous animal, as shown by the anatomy of the digestive tract. 
 Finally, it is well to remember that the dissociation of the various 
 constituents of so-called vegetable diet requires considerable effort 
 on the part of the digestive organs. 
 
 Especially is nourishment to be maintained if the operation 
 be undertaken for the relief of an affliction which has already 
 
RECTAL FEEDING 291 
 
 severely taxed the patient's resistance. In this instance it is best 
 to err on the side of excessive nourishment, provided the digestive 
 organs give no evidence of inability to perform their functions. 
 The adjustment of this question will call for the exercise of con- 
 siderable judgment on the part of the attendant, who is admonished 
 to study carefully the case and be guided by the general rules here 
 laid down. Alcohol, morphin, and the like are, of course, to be 
 avoided. Yet, as stated under the head of preparation of the 
 patient, the time to effect cure with regard to habits of this sort 
 is not either immediately before or after an operation. 
 
 Alcohol itself presents a slightly more complex problem. It 
 is, no doubt, fair to say that it should be avoided if feasible, bear- 
 ing in mind that it has a certain place in the science of medicine 
 aside from the question of the propriety of its use from a social, 
 moral, or economic view. If the patient requires alcohol it should 
 be given under the directorate of the attendant, in response to cer- 
 tain well-known manifestations, and its administration carefully 
 controlled. 
 
 To totalize the proposition, give nothing by mouth until nausea 
 ceases, use skimmed milk, kumyss, and matzoon for the first twenty- 
 four hours, and liquid food when there is fever. As soon as the 
 postoperative fever is over give ordinary articles of diet as the 
 digestive organs show evidence of being able to handle them. 
 
 RECTAL FEEDING 
 
 If vomiting and nausea persist beyond twenty-four hours after 
 the operation, rectal feeding must be resorted to. Life may be 
 maintained for weeks by rectal alimentation. It should not be 
 reserved as a desperate measure in postoperative cases. As stated, 
 if the indications justify it, it should be begun at the end of 
 twenty-four hours. For this purpose, six ounces of milk which 
 has been peptonized by the cold process should be permitted to 
 enter the rectum from a fountain syringe through a small rectal 
 tube, every four to six hours. 
 
 The rectum, if necessary, should be cleansed by an enema be- 
 fore the first nutritive enema is given. Each nutritive enema 
 need not be preceded by cleansing of the rectum. The frequent 
 manipulations in this situation cause irritation, and if nutrition 
 21 
 
292 FEEDING AFTER OPERATION 
 
 need be carried on in this way for more than a day, one cleansing 
 enema in twenty-four hours is sufficient, though in some cases this, 
 as the outcome of natural catharsis, may be unnecessary. A nutri- 
 tive enema need not be given oftener than every four hours, and 
 one every six hours is preferable. Alcohol or medicinal agents 
 may be incorporated in the enema, bearing in mind, of course, 
 that the dosage required is larger when administered in this way. 
 
 An attempt has been made to give in this way a pint or more 
 of nutritive substance at one dose, injecting it high into the sig- 
 moid. This has not been found serviceable, however, the agent 
 being expelled soon after introduction, due to the fact that ab- 
 sorption of nutritive substances from the sigmoid and rectum is 
 slow, and large quantities of these cause irritation. This does 
 not apply to the introduction of saline solutions, no doubt owing 
 to the fact that water readily enters the circulation in this way. 
 
 If the necessity for maintaining nourishment for more than 
 two or three days arises, as is at times the case following opera- 
 tions upon the stomach or upper portion of the intestines, feeding 
 by the rectum may be varied from the method mentioned above. 
 Milk proteids are, according to Luele, Tluber, and Ewald, not 
 readily absorbed unless peptonized, and eggs alone are very slowly 
 absorbed unless twenty grains of sodium chlorid are added to each 
 egg. Raw beef juice is rapidly absorbed, as might be expected, 
 since it contains but little albumin and, indeed, not sufficient in 
 quantity to constitute a helpful nutritive constituent. Peptones 
 are well absorbed. 
 
 Glucose is rapidly taken up if it is not in concentrated solu- 
 tion, in which event it is likely to irritate the mucosa of the rectum 
 or colon and be expelled. It should not be used in solution stronger 
 than 15 per cent., nor in larger quantity than 300 c.c. at a single 
 injection, the injections being given six hours apart. Starch 
 even in the raw state is well absorbed, and is not irritating. 
 
 Fats are very slowly absorbed, which is, of course, to be ex- 
 pected, as the emulsification of these substances is carried on in 
 this situation by the intestinal secretions, which have, of necessity, 
 undergone considerable change of composition when they reach 
 the large gut, and more especially the rectum. Not more than ten 
 grammes of fat are absorbed in a day, and then only when sodium 
 chlorid has been added to the mixture. The fats of milk are 
 
RECTAL FEEDING 293 
 
 slightly more readily taken up than other kinds. Alocohol, in the 
 form of whisky, wine, or brandy, well diluted, is taken up very 
 readily. Brandy, being a grape-end product, is perhaps more 
 serviceable in this connection than the grain alcohols (whisky). 
 
 Adding up the situation, it would seem that the substances men- 
 tioned are absorbed with expediency in the following order: al- 
 cohol, albuminose or peptones, eggs with salt, beef juice, unboiled 
 starch, diluted solutions of grape sugar. Milk, while not freely 
 taken up in its raw state, when peptonized makes the best vehicle 
 for all nutritive enema ta. 
 
 Red wine has been advocated by many observers and its value 
 ascribed to its slight astringency, which quality renders it better 
 borne by the rectum. Fresh blood has been advocated by Ricketts 
 of Cincinnati, who uses from five to ten ounces of defibrinated 
 blood daily. The blood must be fresh. The extraction of the 
 fibrin means, of course, a chemical change in this fluid, which 
 robs it of some of its nutritive value. However, Ricketts reports 
 having kept a patient alive for six weeks by its use, ultimately 
 achieving a favorable result. The administration of enemata for 
 the purpose of feeding the patient should not be confused with 
 those given with the view of obviating shock, which latter have 
 already been discussed (page 264). 
 
 Tuttle uses the following formula: 
 
 3 eggs. 
 
 l/o teaspoonful of salt. 
 
 G ounces of peptonized milk. 
 
 1 tablespoonfnl of rye whisky. 
 
 The writer substitutes brandy for the whisky for the reason 
 stated above. 
 
 Ewald uses : 
 
 2 eggs. 
 
 1 glass of red wine. 
 
 1 cup of 20 per cent, solution of grape sugar. 
 
 This enema may be used when the peptonized milk is not 
 satisfactorily retained. 
 
 Boas finds the following mixture suitable in most cases, espe- 
 
294 FEEDING AFTER OPERATION 
 
 eially as a routine enenia following operations attended with pro- 
 longed vomiting: 
 
 Milk ....:. .250 c.c. 
 
 Yolk of egg 2 
 
 Salt 1 pincli 
 
 Red wine 15 c.e. 
 
 As to how long rectal alimentation may be continued is not 
 definitely settled. Hutchinson states that it is impossible to develop 
 more than 500 calories of energy daily by this means, whereas at 
 least 1,500 are required by patients to maintain the equilibrium 
 of health. The experiments of Tournier, Gross, Eivald, and 
 others do not bear him out in this claim. A patient has been kept 
 alive by this method for twenty-six days, so that an extensive 
 gastric nicer has been cured because of the functional rest to the 
 stomach ; she lost flesh, but was no more emaciated than one often 
 finds after attacks of typhoid fever or other exhausting acute in- 
 fectious disease (Tuttle). It is to be remembered, however, that 
 Hutchinson speaks of " maintaining a balance of health," which 
 is an entirely different proposition from keeping a patient alive 
 
 Fig. 215. — Wales' Soft-rubber Rectal Bougie. (Tuttle.) 
 
 who is living also on the adipose tissue and to some extent upon 
 the organic nitrogenized constituents of the body. These are not 
 so readily exhausted when supplemented by a certain nutritive 
 constituent introduced into the rectum and taken up by the circu- 
 lating fluid. As a rule, it may be said that patients who possess 
 ordinary resistance, and whose calories have not already been in- 
 ordinately taxed or exhausted by prolonged illness previous to the 
 operation, may be maintained alive and with no alarming reduc- 
 tion of weight for twenty days as the result of judicious rectal 
 feeding. This assumption is quite borne out by clinical experience. 
 The method of administering these enemata is as follows : The 
 patient is placed in the Sims's position with the hips elevated. 
 A Xo. 5 ~\Yales soft bougie (Fig. 215), well lubricated, is gently 
 introduced through the anus and into the rectum, and whatever 
 gas may be present is allowed to escape. The bougie is intro- 
 
RECTAL FEEDING 295 
 
 duced a distance of S 1 /^ inches. As already stated, the sigmoid 
 rebels more actively against the introduction of substances of this 
 sort than does the rectum, and for the purpose of nourishment, 
 enemas should not be allowed to enter the sigmoid directly. A 
 certain amount of the fluid trickles slowly into the sigmoid in this 
 way and is not expelled. 
 
 The fluid should be injected very slowly, using a fountain 
 syringe for the purpose rather than the ordinary rectal syringe. 
 The fountain syringe should not be raised more than two feet above 
 the anal level. The small, soft rubber Wales tube is used in order 
 to avoid injury to the anal mucosa when introduced, thus avoiding 
 irritation in this location, which interferes with subsequent manip- 
 ulations. The fluid should be heated to 100° F. Cold or hot 
 solutions are not well borne by the rectal mucosa, and the enema 
 is likely to be immediately exj^elled if its temperature is not 
 watched. 
 
 The formulae mentioned above will meet the indications in 
 almost any case. The conception held by the writer with respect 
 to the food value of certain so-called beef extracts is not shared by 
 all observers. For this reason, a number of formula? are added 
 with the view of meeting the inclination of readers who take an 
 opposite view. The formulae are taken verbatim from Tattle s 
 work on the " Rectum and Pelvic Colon." 
 
 BiegYs formula: 
 
 Milk 250 c.c; 
 
 Eggs 2 to 3 ; 
 
 Salt 2 to 3 pinches; 
 
 Eed wine 30 grammes. 
 
 Catillous formula: 
 
 Beef peptone (saturated solution) . 5.0 grammes; 
 
 Water 125 grammes; 
 
 Bicarbonate of soda 30 centigr. ; 
 
 Laudanum 4 drops. 
 
 Tournier : 
 
 Salted bouillon 140 to 150 grammes; 
 
 Yolk of egg 2 ; 
 
 Wine 20 to 40 grammes ; 
 
 Sydenham's laudanum .... 4 to 8 drops. 
 
296 FEEDING AFTER OPERATION 
 
 Tournier : 
 
 Milk 140 grammes ; 
 
 Yolk of egg 2 ; 
 
 Sugar 10 grammes ; 
 
 Laudanum 4 to 8 drops. 
 
 Tournier : 
 
 Bouillon 140 grammes ; 
 
 Yolk of egg 6 ; 
 
 Wine 20 grammes ; 
 
 Salt 2 teaspoonfuls. 
 
 Tournier : 
 
 Water • • • 150 grammes ; 
 
 Dry peptone 10 grammes ; 
 
 Yolk of egg 1 ; 
 
 Glucose 20 grammes ; 
 
 Sydenham's laudanum 4 drops. 
 
 Professor Jaccoud's formula : 
 
 Bouillon 250 grammes ; 
 
 "Wine 150 grammes ; 
 
 Yolk of egg 2 
 
 Dry peptone 4 to 20 grammes. 
 
 Lathier employs : 
 
 Dry peptone 3 teaspoonfuls: 
 
 Yolk of egg 1 ', 
 
 Milk • 125 grammes ; 
 
 Tincture of opium 5 drops ; 
 
 Starch-powder 5 grammes. 
 
 Adamkicivicz recommends : 
 
 Dry peptone 100 grammes , 
 
 Flour 300 grammes ; 
 
 OH 90 grammes ; 
 
 Salt 30 grammes ; 
 
 Bouillon 1,000 grammes. 
 
 In several injections. 
 
RECTAL FEEDING 297 
 
 Fleiner : 
 
 Bouillon 200 grammes ; 
 
 White wine 50 grammes. 
 
 Singer uses : 
 
 Milk 125 grammes ; 
 
 Wine 125 grammes; 
 
 Yolk of egg 1 ; 
 
 Salt 2 grammes ; 
 
 Witt's dry peptone 1 teaspoonf ul ; 
 
 Glucose 2 grammes. 
 
 Schlesinger employs : 
 
 Milk 200 grammes ; 
 
 Eggs 
 
 9 
 
 Wine 15 grammes ; 
 
 Eice flour 6 grammes ; 
 
 Salt 2 pinches. 
 
 Ratjen uses: 
 
 Milk 250 grammes ; 
 
 Yolk of egg 2 ; 
 
 Salt 1 pinch ; 
 
 Bed wine ., 15 grammes; 
 
 Starch 15 grammes. 
 
 It will be noticed that some writers add a small amount of 
 opium to the mixture. This has some advantages in cases when 
 prolonged rectal feeding is necessary. The small amount of 
 opium contained in each enema does not have a noticeable con- 
 stitutional effect upon the patient, being intended only to soothe 
 the irritated mucosa. On the other hand, the presence in the 
 fluid of an opiate lessens the rapidity with which the nutritive 
 constituents are absorbed. The mucosa does not functionate as well 
 when the opium is used as it does without it. A certain amount 
 of discretion will have to be exercised in this connection. At 
 times copious lavage of the lower gut through a Kemp return 
 tube will cleanse very thoroughly the mucosa, which, when rested 
 for six hours, will again take up its function and permit of the 
 resumption of this avenue of nutrition. 
 
CHAPTEE XV 
 CARE OF WOUNDS AFTER OPERATIONS 
 
 Time of changing dressings — Preparation for change of dressings — Exposing 
 the wound — Removal of stitches — Cleansing and drainage of infected 
 wounds. 
 
 The primary dressing of operative wounds has already been 
 described and its rationale discussed. With the application of 
 the retention bandage, the office of the surgeon ceases in a large 
 number of instances, and the subsequent care of the wound 
 evolves upon the practitioner. This has led to more annoying 
 complications as regards the relationship the practitioner bears 
 to the patient than, perhaps, any other phase of the treatment of 
 operative cases. For instance, the occurrence of stitch abscess 
 ten or twelve days after the operation is frequently regarded as 
 the outcome of a factor for which the practitioner is held respon- 
 sible. That this is a faulty conclusion has already been shown. 
 However, it is probable that infection of the wound may take 
 place subsequent to the operation, as the result of faulty technie. 
 
 It is also true that at the end of several days after the opera- 
 tion the process of repair has advanced sufficiently far to make 
 infection exceedingly unlikely, and that ordinary precautions 
 will avoid this contingency. The more remote the first disturb- 
 ance of the surroundings of the wound is from the time of opera- 
 tion the less liable is infection to occur, and this argues for the 
 avoidance of early interference with wounds as long as there is 
 no direct indication to the contrary. This assumption is borne 
 out by experience, and if the general trend be that of conservatism 
 and patience rather than meddlesome enthusiasm, the interests of 
 all are best conserved. 
 
 The surgeon is warned that a heated denunciation of the prac- 
 titioner's lack of skill in the after-care of the wound is objec- 
 tionable, and more so as the infection may easily have been the 
 
 298 
 
TIME OF CHANGE OF DRESSINGS 299 
 
 result of some occurrence at the time of the operation, and the 
 practitioner be in no wise responsible for it. Frequently, the re- 
 sult of unavoidable infection of the woujjid is that the practitioner 
 and the surgeon devote considerable time and effort in useless 
 attempts to fix the responsibility of a late skin infection upon each 
 other, when, as a matter of fact, neither may be responsible. 
 Certain it is that this possibility should cause both to avoid dis- 
 play of annoyance for the benefit of the family and friends. 
 
 The after-care of operative wounds varies with whether 
 drainage has been employed. Clean wounds in which no drain- 
 age has been used will heal without change of dressing, and the 
 latter need not be removed until the tenth day in order to remove 
 the sutures. If the suture material used in the skin is catgut, 
 the dressing need not be removed for this purpose, but should be 
 changed in order to permit of cleansing of the parts contiguous 
 to the wound which have been covered by the protective dressing 
 and where secretions have accumulated. Indeed, in cases where 
 an elaborate protective dressing has been applied, the outer 
 dressings may be changed on the fourth or fifth day, but the 
 portion of dressing, immediately contiguous to the wound need 
 not be and, indeed, is best not disturbed at this time. 
 
 Frequently the patient will complain of itching and irrita- 
 tion in the skin beneath the dressings, and if the bandage or 
 binder be released, the skin sponged with alcohol and warm 
 water, and a clean outer dressing applied, the comfort given the 
 patient will be found exceedingly desirable. As has already been 
 stated, non-absorable suture material is less likely to be compli- 
 cated with stitch abscesses than the absorbable variety, and re- 
 quires removal at the end of ten days. It is to be remembered 
 that the removal of stitches disturbs the repair process which has 
 taken place in the line of the buried portion of the suture, and 
 this trauma, slight as it is, makes again a field which is suscep- 
 tible of infection, though, of course, this is not as likely to oc- 
 cur as obtains during the operation itself. 
 
 TIME OF CHANGE OF DRESSINGS 
 
 The indications for removal of the dressings in wounds 
 which have not been drained are expressed in the temperature 
 
300 CARE OF WOUNDS AFTER OPERATIONS 
 
 and pulse rate. Indeed, in the usual symptoms of inflamma- 
 tion. This does not mean that rise of temperature or increase of 
 pulse rate at the end of forty-eight hours after an operation calls 
 for change of dressings. Indeed, this may he due to a number 
 of causes, but if the temperature and increased pulse rate persist 
 into the third or the fourth day, and are not accounted for by other 
 causes, the dressings should be removed and search made with the 
 view of disclosing local conditions which account for the dis- 
 turbed metabolism. 
 
 In these instances infection of the wound will, no doubt, be 
 manifest, and the release of one or more of the sutures will give 
 opportunity for the discharge of the inflammatory exudate, and 
 in the vast majority of instances this measure will afford relief 
 of the symptoms, and the only setback to meet will be the fact 
 that healing by granulation will take place instead of primary 
 union. 
 
 When the wound is dressed for the purpose of removing 
 stitches which are no longer of service, or with the view of dis- 
 covering and treating infection, the technic of the procedure is 
 the same. All the material which comes in contact with the 
 wound and its immediate surroundings should be sterile. This 
 is, of course, more imperative when the protective dressing is 
 disturbed soon after the operation than if the ten days spoken of 
 above have been allowed to elapse. However, the precautions 
 should be just as rigidly enforced in the latter instance. 
 
 As the change of dressing usually takes place when the pa- 
 tient is in bed, either in the hospital ward or room, provision 
 should be made for transportation of sterile material. In hos- 
 pital practice this is quite a matter of routine and, indeed, in 
 private practice the preparation of dressings, as already de- 
 scribed, renders the problem quite simple. Whatever the selec- 
 tion of the surgeon may be as to asepsis or antisepsis with regard 
 to operating-room technic, there can be no doubt that the latter 
 is the more advisable when the dressing is changed. 
 
 PREPARATION FOR CHANGE OF DRESSING 
 
 The prolonged preparation of the hands necessary to cleanse 
 the skin would entail considerable hardship upon the attendant. 
 
PREPARATION FOR CHANGE OF DRESSING 301 
 
 Indeed, if it were necessary to go through the same elaborate 
 mechanical and chemical cleansing of the hands necessary to 
 achieve the purpose each time a case were dressed, the attendant 
 would not have much skin left. When dressing cases, the rubber 
 gloves fill an exceedingly useful purpose, and a pair of sterile 
 gloves should be prepared for the attendant for each case. As 
 there is no violent manipulation attendant upon changing the 
 dressing, gloves are not frequently perforated during the dress- 
 ing, and the question of economy is not so important a factor. 
 A convenient method of handling gloves is to have each pair 
 wrapped in a towel together with a small quantity of talcum 
 powder in a small envelope, which are readily sterilized in the 
 steam sterilizer. The gloves can be readily transported in this 
 way, and when about to be used, the nurse opens the package 
 and the attendant dusts his hands with the powder and slips into 
 the left glove, being careful not to touch any portion of the glove 
 except the gauntlet, which is, of course, not allowed to come in 
 contact with the wound or its surroundings. The right glove 
 may now be lifted with the fingers of the left gloved hand, 
 and as these are sterile, the manipulation need not be limited 
 to the gauntlet. If the glove on the left hand is not properly 
 adjusted by the first act, it may be manipulated into place by 
 the right, as now only sterile surfaces come in contact with each 
 other. 
 
 The attendant does not remove the outer dressings, but has 
 the nurse cut the bandages or loosen the binder, as the case may 
 be, and remove the combination dressing. 
 
 For purposes of illustration, a description of the technic of 
 dressing a wound is given in connection with a wound of the 
 thigh, but is to be regarded as applicable to all portions of the 
 body. 
 
 For the purpose the nurse should prepare : 
 
 Six sterile towels. 
 
 Basin with wipes in carbolic acid 1 in 100. 
 
 Pus basin. 
 
 Kelly pad. 
 
 Bandage scissors. 
 
 Tray with sterile scissors for cutting dressings. 
 
302 CARE OF WOUNDS AFTER OPERATIONS 
 
 Thumb forceps, plain. 
 
 Scissors for cutting stitches. 
 
 Dressing forceps. 
 
 Director. 
 
 Glass nozzle for irrigator tube. 
 
 Package of four-by-four sponges. 
 
 Package of two-by-two sponges. 
 
 Irrigator containing solution of biehlorid 1 in 1,000. 
 
 Hydrogen peroxid. 
 
 Same dressings as used at operation. 
 
 EXPOSING THE WOUND 
 
 The thigh is exposed together with its encasing dressing, and 
 the outer bandage and the dressings down to the last piece of 
 gauze, which is usually found adherent to the wound, are re- 
 moved. The parts immediately contiguous to the wound are pro- 
 tected with sterile towels (Fig. 216), in order to obviate con- 
 tamination of any of the instruments, sponges, etc., which may 
 come in contact with these parts. It is wise to slip a Kelly pad 
 under the dependent portion of the part in order to catch fluids 
 which are used in the dressing. However, unless irrigation or 
 copious lavage is necessary, a simple pad of absorbent cotton or a 
 few towels folded upon themselves and placed at the dependant 
 part will suffice for the purpose. 
 
 A gauze or cotton " tupfer " is now removed from the basin 
 containing the carbolic solution (1 in 100), and the fluid allowed 
 to drip over the portion of gauze corresponding to the area of 
 the wound. The latter is usually clearly indicated by the stain 
 from the secretions of the wound (Fig. 216). This moistens the 
 gauze and permits of its more easy removal. However, in some 
 instances the dry crust consisting of blood and antiseptic powder 
 is rather tenacious, and the measure indicated is not effective. 
 In these instances force should not be used, but a glass syringe is 
 filled with hydrogen peroxid and the latter injected under the 
 edge of the adherent gauze. The effervescence which occurs as 
 the outcome of the contact of the secretions and the peroxid of 
 hydrogen will usually gently lift the gauze from the wound with- 
 out giving any pain to the patient. If necessary the injection 
 
EXPOSING THE WOUND 303 
 
 may be several times repeated if the first application Joes not 
 suffice. 
 
 The habit of forcibly tearing the dressings from wounds is to 
 be deprecated, not alone on the ground that unnecessary pain is 
 inflicted, but because the trauma, slight as it is, to the edges of 
 the wound favors late infection and delay in repair. 
 
 After the last piece of gauze has been removed the wound 
 
 Fig. ,216. — Gauze in Contact with Wound. 
 
 and surrounding skin is cleansed with the carbolic acid or corro- 
 sive sublimate solution, using for the purpose the gauze wipes 
 or tabs of cotton. Care should be exercised in this connection 
 not to wipe the wound with a sponge which has been used for 
 cleansing of the surrounding skin or vice versa, i.e., after the 
 wound has been wiped the sponge is thrown aside and a fresh one 
 used. This also applies to sponges used on the neighboring skin. 
 The rationale of this precaution is obvious. Too frequently will 
 the interne or nurse swab the skin and then apply the soiled 
 sponge to the wound. This is a fair way to introduce infection 
 into the wound. 
 
 If the quantity of secretion be large, the cleansing of the parts 
 may be supplemented by irrigation with corrosive sublimate solu- 
 tion. However, it is best not to employ this measure relying more 
 upon the former method. 
 
304 
 
 CARE OF WOUNDS AFTER OPERATIONS 
 
 REMOVAL OF THE STITCHES 
 
 This simple measure may be performed in a manner which 
 will stand in a causative relationship to late superficial infec- 
 tion. If the wound be clean, 
 the next step is to remove the 
 stitches with the minimum of 
 annoyance to the patient, and 
 with the view of preventing in- 
 fection. Commonly the stitch is 
 lifted by the end of the suture 
 near the knot, scissors are slipped under the stitch, and after its 
 division the thumb forceps are used to remove the stitch. This 
 method of procedure is painful and somewhat awe-inspiring to 
 
 Fig. 217. — Angular Probe-pointed 
 Scissors for Ready Removal of 
 Stitches from Wounds. 
 
 Fig. 218. — Removing Suture from Wound with Probe-pointed Angular 
 
 Scissors. 
 
 the patient, despite the frequent admonitions of bystanders " not 
 to look." The writer employs for the purpose a probe-pointed 
 scissors (Fig. 217), the lower blade of which is slipped under 
 the portion of the suture distal from the knot (Fig. 218). This 
 makes but little tension on the suture, especially if the lower 
 blade of the scissors is slightly depressed into the skin, as shown 
 in Fig. 218. The little manipulation is accomplished with one 
 
CLEANSING AND DRAINAGE OF INFECTED WOUNDS 305 
 
 hand and the suture is cut. The knot is now seized with the 
 thumb forceps and the suture is withdrawn. It must be borne 
 in mind that the portion of the suture lying on the skin is likely 
 to be the habitat of bacteria, and this should not be dragged 
 through the suture bed, but the division of the suture should take 
 place near its point, of egress, as shown in the illustration. The 
 measure is, of course, repeated for each stitch. If a continuous 
 suture is employed, each crossing of the suture material is sepa- 
 rately divided, taking the same precaution to avoid dragging of 
 the superimposed part of the suture through the suture holes. 
 
 CLEANSING AND DRAINAGE OF INFECTED WOUNDS 
 
 If the wound be infected, it will show itself in redness and 
 puffiness, most marked at the site of the sutures. 
 
 Fig. 219. 
 
 -Director Introduced into Wound in Search of Infective 
 Secretions. 
 
 In these instances it is wise to leave in situ as many sutures 
 as is feasible, to obviate wide separation of the lips of the wound, 
 especially as infection usually manifests itself upon the fourth 
 or fifth day after the operation, and repair at this time is not 
 sufficiently advanced to permit of their removal. A single su- 
 ture is now released in the manner described, and a director in- 
 troduced into the wound (Fig. 219) with the view of disclosing 
 
306 CARE OF WOUNDS AFTER OPERATIONS 
 
 the site of suppuration in order that only such sutures be re- 
 moved to liberate infective material and yet maintain apposition 
 of the divided structures. Usually the most dependent suture is 
 removed at first to facilitate subsequent drainage. This argues 
 for the employment of interrupted sutures in the skin, and that 
 they should be of material which will withstand rapid absorp- 
 tion and manipulation. If the infection be located in this way, 
 the upper suture may now be removed and the wound irrigated 
 with a solution of corrosive sublimate 1 in 1,000, using a conical 
 
 Fig. 220. — Method of Cleansing an Infected Wound. 
 
 pointed glass nozzle connected with an irrigator. The glass 
 nozzle is introduced into the upper end of the wound, and the 
 lower end is gently held apart with slender forceps to facilitate 
 discharge of the fluid and to prevent undue distention pressure 
 upon the wound, which might separate it unnecessarily (Fig. 
 220). The injection of peroxid of hydrogen into the wound is 
 objectionable at this time for the same reason. It may, how- 
 ever, be effectually employed when repair in the portion of the 
 wound between the two exit holes has advanced farther. After 
 the infective secretions have been entirely removed and the solu- 
 
CLEANSING AND DRAINAGE OF INFECTED WOUNDS 307 
 
 tion appears clear at the dependant side, the irrigation is discon- 
 tinued and the residual solution gently expressed. A probe 
 armed with a small layer of cotton soaked with iodin may now 
 be introduced the entire length of the wound with the view of 
 destroying bacteria. This measure has been found exceedingly 
 effectual at the hands of the writer. The smarting sensation ex- 
 perienced by the patient is a minor consideration and disap- 
 pears in a few moments. The attendant is warned that the 
 iodin will, when coming in contact with gauze, convert the 
 
 Fig. 221. — Dressing Forceps Introduced Through Wound. Gauze seized 
 preparatory to introduction. 
 
 starch in the gauze into the blue iodid of starch and may lead 
 
 to the faulty notion that the wound is infected with the pyo- 
 
 cyaneus bacillus. Drainage is now established. This may be 
 
 accomplished in the manner already described under the head 
 
 of drainage or, as is better, a dressing forceps is passed from end 
 
 to end (Fig. 221) through the wound and a piece of gauze pulled 
 
 through (Fig. 222). The diameter of the gauze depends, of 
 
 course, upon the size of the wound. It should not be sufficiently 
 
 bulky to cause pressure which would interfere with capillarity. 
 
 If the gauze be moistened before introduction with carbolic acid 
 22 
 
308 
 
 CARE OF WOUNDS AFTER OPERATIONS 
 
 solution its introduction will be facilitated and final capillarity 
 enhanced. 
 
 Infected wounds should be dressed every twenty-four hours, 
 irrespective of systematic indications. As strongly as non-in- 
 terference is advocated for non-infected wounds the proper cleans- 
 ing of infected wounds is equally strongly insisted upon. The 
 drain should, at the second dressing, be shortened. This is ac- 
 complished by cutting off the portion protruding from the upper 
 end of the wound and withdrawing the gauze through the lower 
 
 Fig. 222. — Gauze Drainage in situ. 
 
 opening. The object of cutting off the protruding upper end is 
 to prevent the portion of the drain which has been in contact 
 with the skin from being dragged through the wound. 
 
 The wound is now cleansed, as stated above, and if the quan- 
 tity of infective secretion be small, a shorter drain is introduced 
 into the lower opening, which latter is replaced by a shorter 
 piece of drain at each dressing until the discharge ceases. This 
 rarely requires more than ten days. The upper opening may, if 
 there be undue gaping be held in apposition with sterile adhesive 
 plaster. The lower opening is treated in the same way after the 
 drain has been permanently removed. 
 
CLEANSING AND DRAINAGE OF INFECTED WOUNDS 309 
 
 These measures are applicable in eases of moderate infection 
 of the superficial wound. In instances where infection of the 
 deeper tissues occurs with cellulitis, the measures need be some- 
 what more radical. In these cases all the superficial sutures 
 should be removed and the site of infection directly attacked. 
 
 The patient will probably require narcosis, though in some 
 cases the instillation of a one per cent, cocain solution will con- 
 trol the pain sufficiently to permit of the necessary manipulations. 
 Alter the wound and surrounding parts have been cleansed in 
 the manner just stated, the superficial sutures are removed and 
 the deeper layer searched in the same manner, with the director, 
 as described above. Here, again, it may not be necessary to re- 
 move all the sutures, and if some may be left in situ, repair will 
 be conserved. The upper and lower stitches may be removed and 
 
 Fig. 223. — Infected Wound Packed with Gauze and Sutures Placed. 
 
 the deep wound cleansed with the antiseptic fluid. A drain is 
 passed beneath the suture line, as described above, the ends of 
 which are permitted to protrude well beyond the limits of the 
 wound. 
 
 The superficial wound is now loosely packed with iodoform 
 gauze. The packing should not make pressure, but should be 
 
310 CARE OF WOUNDS AFTER OPERATIONS 
 
 allowed to comfortably fill the wound cavity. As infection may 
 be controlled by these measures, provision should at this time be 
 made for coaptation of the edges of the wound when infection 
 has been arrested. For the purpose, interrupted silk-worm gut 
 sutures are introduced and left loose, being held at their distal 
 ends with a serre-fine. Fig. 223 shows a wound packed and the 
 sutures held by a forceps. 
 
 The protruding portion of gauze is intended to facilitate re- 
 moval of the packing. At the next dressing this is seized with 
 dressing forceps, and after the gauze packing has been thoroughly 
 saturated with the cleansing solution, it is gently removed by 
 twisting it upon itself. Hydrogen peroxid may be used for the 
 purpose as the avenue of egress for the bubbling mixture of 
 blood, and the peroxid is ample under these conditons. 
 
 When the infection is controlled, the edges of the wound are 
 held in apposition by tying the sutures in the usual manner, 
 leaving, however, the upper and lower corners of the wound 
 slightly open, with the view of making any necessary cleansing 
 more readily accomplished. This measure saves much time in 
 ultimate repair and prevents an unnecessary degree of scarring. 
 Indeed, it not infrequently happens that the infection subsides 
 at the end of three or four days as the outcome of the drainage 
 and light packing, and the early approximation of the edges of 
 the wound makes possible an ultimate result not greatly at vari- 
 ance with that obtained with primary union. 
 
CHAPTER XVI 
 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 Operations on the scalp: Preparation of the narcotist — Preparation of the 
 scalp — Care of wounds. 
 
 Operations on the cranium : Kroenlein construction — Care of wounds of cranial 
 bones. 
 
 Operations involving cranial contents: Bone necrosis — Secondary hemorrhage 
 — Retention of cerebrospinal fluid — Edema and softening of the brain 
 substance — Discharge of cerebrospinal fluid — Brain prolapse — The retain- 
 ing bandage — Mastoid operations — Intracranial neurectomy. 
 
 OPERATIONS ON THE SCALP 
 
 PREPARATION OF NARCOTIST 
 
 Asepsis during operations on the head is not readily obtained 
 and calls for especial precautions. The presence of the narcotist 
 immediately contiguous to the operative field, the secretions from 
 mouth and nose, the occasional discharge of vomitus, all contribute 
 to the factors which enhance the difficulties in this connection. 
 
 It is a good rule to have narcosis produced by one assistant, 
 while a second prepares for the narcosis during the operation. 
 The patient is narcotized in the ante-room by the first assistant 
 after the usual preliminary preparation of the operative field has 
 been made and is then transported to the operating room and 
 placed on the table. 
 
 The non-sterile attendant carefully removes the superficial re- 
 taining bandage holding the protective dressing in place without 
 coming in contact with the subjacent gauze and the narcotizer, 
 who has prepared himself in the usual manner (Fig. 85) and 
 who wears a sterile gown, cap, mask and gloves, takes charge of 
 the narcosis, using a sterile cone or mask for the purpose. 
 
 The operation may then proceed with the element of infec- 
 tion, as far as the narcotist is concerned, eliminated. The care 
 
 311 
 
312 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 of the nose and mouth in operations in their field is taken up 
 under a separate head. 
 
 Vomiting during the operation may be controlled by judicious 
 administration of the narcotic. This suggests that novices should 
 obtain their education in this connection on cases other than those 
 involving operations on the head. 
 
 PREPARATION OF SCALP 
 
 The preparation for operations on the scalp cranium, and con- 
 tents of the cranium, does not differ as regards local steps. As 
 a rule, the entire scalp should be shaved. In cases requiring sur- 
 gical interference of magnitude this is a minor consideration. 
 However, in cases which involve only the removal of benign 
 growths, such as a sebaceous cyst, removal of the entire hair is 
 perhaps unwarranted. Especially is this true if the patient be 
 a woman. 
 
 In these instances the following technic will be found ser- 
 viceable and, no doubt, justifiable. The portion of scalp to be 
 attacked, together with a space surrounding it an inch in breadth, 
 is shaved and the' entire scalp thoroughly anointed with olive oil 
 or white vaseline. This is done the evening before the operation, 
 the object being softening of the dried sebaceous secretion with 
 which the scalp is always more or less covered. An hour before 
 the operation the scalp is thoroughly shampooed with an alkaline 
 green soap, the alkali being intended to saponify the greasy mix- 
 ture of the application and the softened sebum. 
 
 The resultant lather is freely lavaged with sterile water. Cor- 
 rosive sublimate solution should not be employed for this pur- 
 pose, as the alkali in the soap may precipitate the mercury, which, 
 though not particularly objectionable, had best be avoided. The 
 corrosive sublimate solution may be used for its cleansing effect 
 after the soap has been removed by lavage with sterile water. 
 
 The hair should now be dried with a sterile towel and braided 
 (in women) in such a way as to direct it away from the field 
 of operation. A dressing of fluffed sterile gauze may now be ap- 
 plied to the head. Immediately before proceeding with the opera- 
 tion the dressing is removed and the denuded area painted with 
 tincture of iodin. This latter step takes place after narcosis is 
 established, or in the event of local anesthesia, after the patient 
 
OPERATIONS ON THE SCALP 
 
 313 
 
 has been conveniently postured and before apjolication of the local 
 anesthetic is made. 
 
 In order to isolate with certainty the operative field, a goodly 
 sized square of gauze composed of several layers of this material 
 is prepared. About six layers of gauze are used, between the 
 center layers of which a sheet of elastic rubber is placed. An 
 opening a little larger than the dimensions of the operative field, 
 but not quite as large as the denuded area, is cut into the gauze 
 protector, and this is fastened near the margins of the hair by 
 means of sutures of very fine silk introduced with a slender needle 
 (Fig. 224). 
 
 Fig. 224. — Method op Isolating Portion of Scalp by Sterile Gauze 
 
 Protector. 
 
 It is quite impossible to place sterile towels in contact with 
 the hair, and prevent their dislodgmcnt during the surgical 
 manipulation, and the gauze fastened in the manner stated ef- 
 fectually isolates the field, rendering the introduction of infec- 
 tious material from the contiguous surfaces quite unlikely. The 
 elastic rubber sheeting prevents soiling of the hair with blood, se- 
 cretions, and cleansing fluids used during the operation. 
 
314 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 The object may be attained by fastening small towels around 
 the operation field in the form of a hollow square, the crossings 
 of which are held fast to the scalp by means of small clamps spe- 
 cially constructed with sharp biting ends. This, while quite useful, 
 is not as effective a measure as the one stated above. The sutures 
 holding the protector are not removed until the operative wound 
 is protected by the first layers of the dressing. 
 
 The points of contact of the edge of the opening in the pro- 
 tector may be sealed with collodion to obviate trickling of the 
 cleansing solutions, etc., beneath the protector. 
 
 Wounds of the scalp heal very readily and do not become in- 
 fected with frequency. Both these characteristics are explained 
 on the ground that the scalp is very vascular and that the presence 
 of glandular elements in large number conserves the process of 
 repair. Fine silk-worm gut or horsehair are the suture materials 
 of choice in this class of cases. 
 
 CARE OF WOUNDS 
 
 Drainage of wounds of the scalp is not usually necessary. If, 
 however, the subaponeurotic space has been invaded and the sur- 
 geon be not reasonably certain of the asepsis during the operation, 
 a small drain consisting of horsehair or silk-worm gut (page 193, 
 Fig. 147) may be introduced and left in situ for several days. 
 If infection occurs and the purulent material gains access to 
 the subaponeurotic space, drainage of the wound itself will not 
 suffice in all instances. The infection is exceedingly likely to in- 
 vade the loose connective tissue beneath the galea and cause an 
 edematous infiltration of the entire scalp. 
 
 The edematous infiltrate puffs up the entire surface of the 
 cranium and, indeed, invades the upper eyelids. Patients afflicted 
 in this way suffer considerable pain, and, indeed, if the periosteum 
 be infected, present the picture of an alarming condition. The 
 severe pain is due to pressure upon the periosteum, which is ex- 
 ceedingly sensitive. The constitutional symptoms are quite sug- 
 gestive of a deep erysipelas. 
 
 When this occurs the wound should be opened at once, care- 
 fully and thoroughly cleansed with a solution of corrosive sub- 
 limate 1 in 2,000, and lightly packed with iodoform gauze. If 
 the subaponeurotic cellulitis go on to suppuration, drainage open- 
 
OPERATIONS ON THE SCALP 
 
 315 
 
 ings must be made over either one or both eyebrows, as is indi- 
 cated by the magnitude of the infection, and the infected space 
 washed through from the wound (Fig. 225). If the infection 
 does not then subside and 
 the " bogginess " extends 
 backward, an additional 
 drainage opening should be 
 made over the external oc- 
 cipital protuberance. For 
 the purpose tube drainage 
 (page 189, Fig. 143) is the 
 most serviceable, as fre- 
 quent through-and-through 
 iavage may be necessary to 
 obtain thorough cleansing 
 of the infected area. The 
 surgeon is admonished not 
 to err on the side of timid- 
 ity in these cases, for the 
 reason that, should a sup- 
 purative periostitis occur, it 
 is not a long step to inva- 
 sion of the emissaries of 
 Santorini, sinus phlebitis, 
 and possibly abscess of the 
 brain. 
 
 The rubber drainage 
 tube should be of rather 
 firm rubber, to avoid its 
 collapse from pressure of the tense aponeurosis. The rubber tube 
 drainage found in the market is too light for the purpose, and it 
 will be found expedient to use an appropriately sized soft rubber 
 catheter for the purpose. 
 
 An infection of the skin alone does not call for these severe 
 measures, as the skin is quite firmly attached to the tissues, and 
 the simple packing of the wound will suffice the indications. 
 
 The tubes should not be permitted to remain in the anterior 
 portion of the scalp any longer than necessary. If the drainage 
 openings are maintained for a long time, objectionable scarring 
 
 Fig. 225. — Rubber Tube Drainage of 
 Subaponeurotic Space of Scalp. 
 
316 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 occurs. However, the possibility of an unfavorable cosmetic out- 
 come must not act as a deterent with respect to radicalism in this 
 connection, for the reasons stated. 
 
 In clean cases the sutures may be left in situ for five days, 
 when they should be removed. 
 
 OPERATIONS ON THE CRANIUM 
 
 Operations on the cranium beyond those undertaken for the 
 repair of trauma comprise resection of diseased areas and inva- 
 sion of the bone to provide an avenue of approach to the cranial 
 contents. The technic of the two classes of cases differs in the 
 essential respect, that in the cases where the bone is sectioned for 
 relief of disease in this situation the bone is removed, while in the 
 last-mentioned class of cases the bone is saved and replaced after 
 the operation is completed. Consideration of the treatment of 
 fracture of the skull does not belong here, though the after-treat- 
 ment of wounds in this connection is essentially similar to that 
 of bone trauma for the relief of disease. 
 
 When the cranial bones or the contents of the cranium are 
 to be subjected to operative attack, the preparation of the scalp is, 
 in a general way, similar to that described under the head of minor 
 operations in this situation. The entire scalp is shaved, however, 
 and the cleansing is performed as stated. In those cases in which 
 the brain is to be made the object of manipulations, the landmarks 
 are designated upon the shaven scalp (Fig. 226) with the nitrate 
 of silver stick. The scalp may be cleansed again just before pro- 
 ceeding with the operation without eradication of the guides. 
 
 I 
 KROENLEIN CONSTRUCTION 
 
 The illustration shows the situation of the fissure of Rolando 
 and that of Sylvius according to the Kroenlein construction. In 
 instances in which the surgeon operates without previously see- 
 ing the case, the physician in charge is expected to locate these 
 two fissures in the manner stated before narcosis is induced. As 
 a matter of fact, this should be done in all instances, and the 
 patient thus escapes unnecessary prolongation of the narcosis. The 
 physician in charge should acquaint himself with the method of 
 
OPERATIONS ON THE CRANIUM 
 
 317 
 
 arriving at these locations and proceed patiently twenty-four hours 
 before the operation to mark out the necessary guides. 
 
 The following description is quoted from Krause, " Surgery 
 of the Brain " : 
 
 Localization is most readily accomplished when the situations of 
 the fissures of Rolando and Sylvius are determined. The simplest 
 
 Fig. 226. — Fissure of Sylvius and Rolando Outlined with Nitrate of Silver. 
 
 (Krause.) 
 
 method of arriving at a conclusion in this regard is the Kroenlein 
 construction, which is taken from his own illustration and shown in 
 Fig. 227. 
 
 In order to rapidly locate these two lines Kroenlein employs a 
 craniometer made for himself by the instrument makers, Hanhart & 
 Ziegler, of Zurich. It is my practice to delineate these lines on the 
 shaved scalp twenty-four hours before the operation with the nitrate 
 of silver stick (Fig. 226). 
 
318 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 The following additional lines are outlined on the scalp : 
 
 1. The base line (the German horizontal line) is in accord with 
 the Frankfurt agreement, drawn from the lower rim of the orbital 
 cavity, backward through the highest point of the external auditory 
 meatus. 
 
 
 
 
 
 r 
 
 
 
 P/ 
 
 
 
 R 
 
 
 
 s 
 
 tinea horiz. supra-orbitalis 
 
 (Superior horizontal) |\ 
 
 fie? 
 
 MS*** 
 
 B 
 
 
 K' 
 
 Linea horiz. orienlo-nrhitalis 
 
 (German horizontal) 
 
 
 
 
 M 
 
 Fig. 227. — Kroenlein Construction for Locating the Central Sulcus, and the 
 Fissure of Sylvius on the Surface. K, Division of fissure of Sylvius; S, Pos- 
 terior end of fissure of Sylvius; R, Lower end of central culcus; P, Upper end of 
 central sulcus. 
 
OPERATIONS ON THE CRANIUM 319 
 
 2. The upper horizontal line parallels the first on a line with the 
 upper edge of the orbital cavity. 
 
 3. The front vertical (Z) line runs vertically between the first 
 and second through the center of the zygomatic arch. 
 
 4. The middle vertical line (A) crosses the center of the articular 
 knob of the inferior maxilla. 
 
 5. The posterior-vertical line (M) crosses the posterior edge of 
 the mastoid processes. 
 
 The linea Rolandi (EP) connects the intersection of the front 
 vertical and the upper horizontal (K) lines at a point where the pos- 
 terior vertical meets the median line (P). 
 
 The linea Sylvii (KS) halves the angle (Pkk) ; this is prolonged 
 backward to the posterior vertical line. Further elucidation may be 
 obtained from Fig. 227. 
 
 Kroenlein bases his work on the observations of A. Froriep, whose 
 construction in general is figured with respect to various forms of 
 skulls, taking into account short, high or long low forms of heads. 
 In the first class of cases Froriep thinks the brain is crowded toward 
 the forehead and would indicate that the fissure of Bolando lies far- 
 ther forward. (Frontipetal type.) In the latter class the brain 
 appears to make a turn upon its horizontal axis and its posterior is 
 crowded backward, constituting a displacement backward of the entire 
 brain, thus causing the central sulcus to lie more obliquely backward. 
 (Occipitopetal type.) The same respective displacements of all 
 convolution and fissures occur in the same proportion. "The more 
 marked," says Froriep, "the length of the posterior segment of the 
 skull is and the more the external occipital protuberance lies toward 
 the horizontal or beneath it, the more certain may the occipitopetal 
 type with a corresponding position of the brain be taken into account. 
 Per contra the frontipetal type is to be expected when the audito- 
 occipital distance is short and the posterior segment of the skull is 
 high." 
 
 Figures 228 and 229 represent the two types as described by Fro- 
 riep, though the differences are quite strongly drawn. The squares 
 surrounding the sketch correspond to the long diameter and the height 
 at the ear line of the skull. The inferior edge of the orbital cavity 
 is indicated on the audi to-orbital line, as is also the location of the 
 auditory meatus. The dotted line running upward at the latter situa- 
 tion makes quite apparent the differences in frontipetal or occipito- 
 petal types of brains. The averaging of a number of measurements 
 would indicate that the most frequent variation in position of the 
 
320 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 brain is that of rotation on its transverse axis combined with dis- 
 placement downward and backward. 
 
 For these types Froriep emphasizes that " the total length of the 
 skull, rather than the longitudino-transverse index, indicates the con- 
 ditions. If the total length is beyond a certain dimension the occipi- 
 topetal type presents and per contra, if this be below a certain meas- 
 urement, the frontipetal type obtains. Although the importance of 
 increased vertical diameter is not to be disregarded, neither the brachy- 
 
 Fig. 228. — Example of Frontipetal Type of Brain. (Krause.) 1, Sulcus cen- 
 tralis; 2, Point of division of Fissure Sylvii (Sylvian Point); 3, Sulcus centralis; 
 4, Fissure of Sylvius (Upper end); 5, Fissure parieto-occipitalis (Lateral end); 
 6, Rim of orbit ; 7, External auditory canal ; 8, Prot. Occip. Ext. ; 9, German 
 Horizontal line. 
 
 cephalic nor dolichocephalic heads- need necessarily present the fronti- 
 petal or occipitopetal types of brain position." These represen- 
 tations of Froriep are of importance to the surgeon, giving us the 
 relative values of each type upon which to base a method of action. 
 
 Beyond the various types of skulls other deviations from standard 
 are to be considered, such as race, sex and age. To avoid encumber- 
 ing elucidation of the problem I proceed at once to a discussion of the 
 most important considerations in connection with the convolutions 
 and fissures of the brain. 
 
 1. The sulcus central is (fissure of Rolando) generally takes a 
 course in which there are two kneelike bends; its situation, therefore, 
 is only determinable on the calvarium at its upper and lower termina- 
 
OPERATIONS ON THE CRANIUM 
 
 321 
 
 tions. The former is Located by dividing in one-half the distance 
 between the root of the nose (naison) and the external occipital pro- 
 tuberance (inion) and measuring backward from this 2 cm. {Thane, 
 1 cm.) Broca employs for the purpose in addition to the naison, 
 which corresponds to where the nasal suture reaches the frontal bone, 
 the ophryon, which is located at the middle of the glabella. Measur- 
 ing backward from the ophryon in the median line the upper end of 
 the central fissure is located 53/100 behind the former. (E. Masse 
 and Woolingham.) The lower end of the fissure corresponds in the 
 
 Fig. 229. — Example of Occipito Petaler Type or Brain. (Krause.) 1, Sulcus 
 centralis; 2, Point of division of Fissure Sylvii (Sylvian Point); 3, Sulcus cen- 
 tralis; 4, Fissure of Sylvius (Upper end); 5, Fissure parieto-occipitalis (Lateral 
 end); 6, Rim of orbit; 7, External auditary canal; 8, Prot. Occip. Ext.; 
 9, German Horizontal line. 
 
 adult to a point determined by dropping a vertical line through the 
 preauricular depression between the tragus and the articular head of 
 the inferior maxilla on the upper edge of the zygoma, and measuring 
 upward on this line 5 to 6 cm. from the upper edge of the external 
 auditory meatus. In children the foot of the fissure is located 15 
 mm. below the middle of a line drawn vertically from the external 
 auditory meatus to the sagittal line. This line, together with the 
 fissure, forms an angle of 67 degrees. (Hare.) 
 
 The central fissure lies in the middle of the anterior third of the 
 parietal bone; its lower two-thirds runs nearly parallel to the coronal 
 suture, while the upper one-third deviates sharply backward. The 
 position it occupies is at its lower end 30, at the upper 40 to 50 mm. 
 
322 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 from the coronal suture. In women the distances are 27 to 45 mm., 
 and in children 11 to 33 mm. respectively. (Poirier.) 
 
 As the -gyri centralis anterior and posterior in the adult measure 
 at their middle 18 to 22 mm. in breadth, determination of the situa- 
 tion of the central fissure locates the situation of the precentral and 
 postcentral convolutions. 
 
 2. The Fissure of Sylvius runs with moderate ascending obliquity 
 from Brocas' pterion, which latter is located near the posterior end 
 of the sphenoparietal suture (anterior vertical line 4 to 4% cm. above 
 the zygoma), to the middle of the lower portion of the parietal tubercle, 
 though it does not in all instances reach quite to the latter point. 
 As the fissure varies in development, and with regard to its upper 
 terminal end also varies considerably as to its course, the designa- 
 tion just stated is somewhat unreliable. In the frontipetal type 
 Froriep found the upper end of the fissure more toward the anterior 
 lower portion of the parietal tubercle, and in the occipitopetal type 
 more toward its posterior aspect. In children during the first two 
 years of life the squamous bone is quite small, and the parietal 
 bone reaches to or extends below the first temporal sulcus. In these 
 instances the fissure of Sylvius is covered entirely by the parietal 
 bone. 
 
 The fissure divides into three branches, ramus, anterior horizon- 
 talis, ramus anterior ascendens and ramus posterior horizontalis. The 
 latter represents as the main branch the greater part of the fissure. 
 The origin of the two anterior branches corresponds to the punctual 
 Sylvii {Sylvian point of the English), which is located at the pterion. 
 The ramus anterior ascendens lies vertically to the ramus posterior 
 horizontalis ; the ramus anterior horizontalis runs from the pterion 
 beneath the sphenoparietal suture with reliable persistence in an ante- 
 rior direction. 
 
 3. The three frontal convolutions lie with their posterior ends 
 in contact with the precentral convolution, i. e., about 22 mm. from 
 the central fissure. The first begins 1 cm. from the median line, taking 
 the longitudinal sinus into account. The second is located with its 
 middle (in children, Fere) under the center of the frontal eminence, 
 while in the adult this point corresponds to the first frontal fissure 
 or to the border between the inner and outer two-thirds of the second 
 frontal convolutions (Poirier). The third is situated about the rami 
 anterior horizontalis and ascendens of the fissure of Sylvius. 
 
 4. The three lateral temporal convolutions occupy the space at 
 the side of the brain between the fissure of Sylvius and the temporal 
 border. The latter in the average corresponds to a line 5 mm. above 
 
OPERATIONS ON THE CRANIUM 323 
 
 the upper edge of the external auditory meatus, that is, in this situa- 
 tion, very near the level of the upper border of the zygoma, and at 
 its middle to the incisura semilunaris of the lower jaw, where the 
 lowest point of the temporal lobe is usually found (A. Froriep), 
 though it may dip down to opposite the lower edge of the zygoma. 
 
 The first temporal convolution measures at its center about 15 
 mm. in breadth, and is bounded below by the first temporal fissure, 
 which is, because it runs parallel to the fissure of Sylvius, at times 
 called the fissura parallela. The second, which is rarely strongly 
 apparent, lies about in the middle between the first fissure and the 
 temporal border line. 
 
 The anterior two-thirds- of the first and second temporal convolu- 
 tions are covered by the squamous portion of the temporal bone, the 
 extreme front ends by the greater wing of the sphenoid. The anterior 
 portion of the third (and fourth) temporal convolution may be reached 
 from the anterior part of the inferior temporal fossa, which is formed 
 by the greater wing of the sphenoid bone. 
 
 All three lateral temporal convolutions end at their posterior 
 aspects in the gyrus angularis and supra marginalis, both of which 
 are most largely formed by the parietal lobes. 
 
 5. The location of the gyrus supramarginalis corresponds to the 
 situation of the tuberosity of the parietal bone {Hushe), and winds 
 around the posterior end of the ramus posterior horizontalis of the 
 fissure of Sylvius. 
 
 6. The gyrus angularis winds around the posterior upper end of 
 the first temporal fissure. Its location is determined upon the un- 
 opened skull in its relationship to the tuberosity of the parietal bone 
 lying a little behind and above it, i. e., about 3 cm. behind the gyrus 
 supramarginalis. (Poirier. ) 
 
 7. The sulcus parietalis (intraparietal -fissure) consists of two 
 divisions; its ascending branch connects with the retrocentral fissure, 
 and lies about 20 mm. behind the central fissure. (Waldeyer.) The 
 longer horizontal branch runs close to the upper portion of the tuber- 
 cle of the parietal bone, 45 mm. lateral to the median line, and when 
 it reaches to opposite the lambda it approaches to within 33 mm. of 
 the latter. (Thane.) 
 
 8. The parieto-occipital fissure, in the occipitopetal type of 
 skull, lies with its upper end immediately above the lambda (top of 
 the squamous portion of the occipital bone) or corresponds exactly 
 to this point, and in the frontipetal type and in young children, 
 1 cm. higher up and 2 cm. lateral from the horizontal line. The 
 lambda is, in the adult, located 6 to 7 cm. above the external occipital 
 
 23 
 
324 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 protuberance (inion), and 8 to 10 cm. behind the upper end of the 
 Rolandic fissure. 
 
 Prolongation of the lines KS and KK, of the Kroenlein construc- 
 tion to the sagittal line, leaves a space between it and the median line ; 
 if this be divided into three parts the parieto-occipital fissure will be 
 found to correspond to about the junction of the middle and upper 
 thirds. 
 
 A knowledge of the course of the fissures of Rolando and Sylvius 
 reveals the location of the central convolutions, the operculum, the 
 temporal lobe and also the seat of the frontal and parietal lobes of 
 the cerebrum. As the external occipital protuberance is palpable in 
 all skulls, the location of the occipital lobe is also readily recognized. 
 
 9. The cerebellum, with its hemispheres, lies in contact with the 
 squamous portion of the occipital bone, the posterior third of the mas- 
 toid process of the temporal bone, and rests with its inferior surface 
 upon the foramen magnum. Upward it reaches to the linea nucha 
 superior, which corresponds to the lower edge of the transverse sinus. 
 " The white substance of the vermis runs on a quite horizontal line 
 to the confluent sinus." (Waldeyer.) 
 
 10. The large basal ganglia. As I have not made any observa- 
 tions and have had no experience in this connection, I quote Waldeyer 
 verbatim : " My investigations substantiate on the whole those of 
 Fere and Dana, but to be exact the three localization levels of these 
 authors should be supplemented by three additional ones. According 
 to Dana a frontal level 18 mm. behind the fronto-zygomatic suture 
 corresponds to the anterior end of the corpus striatum, a second at 
 the posterior border of the base of the mastoid process or the upper 
 end of the fissure of Rolando corresponds to posterior knee of the 
 corpus striatum or posterior border of the thalmus. A horizonal level 
 45 mm. below the vertex of the cranium skirts the upper surface of the 
 striatum. I add to this that the lower border of the cerebral gan- 
 glionic mass corresponds to the naison-horizontal line, its lateral di- 
 mensions lying between the middle level and the lateral ventricle. 
 
 The anterior horn of the latter, however, lies (according to 
 Poirier) at the forehead, 6 to 7 cm. from the scalp, the posterior and 
 inferior horns 4 cm. Tillaux states with truth that the basal gan- 
 glia, in toto, are situated above the external auditory meatus and that 
 this opening corresponds about to their middle. 
 
 Between the levels mentioned the island of Reil is situated, for 
 the exact localization of which additional guides are necessary. G. D. 
 Thane locates the pole of the island at the punctum Sylrii. A point 
 on the linea Sylvii 35 mm. behind this indicates the posterior end of 
 
PuNCT. ROLflNOICUM SUP. 
 
 BREGMA 
 
 Lambda — 4L/ 
 
 Nasion 
 
 Jnion 
 
 Fig. 230. — Location of the Insula and Lateral Ventricle. Island of Reil. 
 The Punctum Sylvii designates the pole of the island, its posterior end lies on 
 the linea Sylvii 35 mm. behind this point. The shaded outline of the island 
 acts as a guide to the basal ganglia, which extend only slightly beyond it, about to 
 the outer border of the main portion of the lateral ventricle. The lateral ventricle 
 is outlined by a dotted line, its three horns (anterior, posterior and inferior) are also 
 indicated in the same way. The fissure of Rolando and Sylvius is indicated with 
 broken lines. Reid's base line (horizontal line of the skull) is the Frankfurter 
 Linie of the German anthropologists. It begins at the lowest point of the inferior 
 edge of the orbital cavity and crosses at the highest point of the upper edge of the 
 external auditory meatus. (Krause.) 
 
 325 
 
326 OPERATIONS OX THE SCALP, SKULL AND BRAIN 
 
 the island, and the anterior end lies 15 mm. in front of the punctum 
 Sylvii. The upper horder runs from behind in a curve through the 
 upper end of the ramus ascendens anterior sylvii to the anterior upper 
 end, the lower from the posterior end to a point 15 mm. forward from 
 the punetum Sylvii on the linea zygomatico-lambdoidea, the anterior 
 border being outlined by the union of the two anterior end points 
 mentioned. (Fig. 230, Krause.) 
 
 For the purpose, the scalp is shaved and cleansed in the man- 
 ner stated above. The physician supplies himself with a diagram 
 of the necessary measurements, and after placing the patient in 
 a comfortable position proceeds to indicate the fissures mentioned. 
 This is the more accurately done by the physician in charge of 
 the case, who has had the patient under observation for some time 
 and has had ample opportunity to arrive at a conclusion as to 
 what particular type of skull formation is being dealt with. The 
 outlines of the fissure are marked with the ordinary nitrate of 
 silver stick, which is moistened with water when the demarcation 
 is being made. The scalp should not be moistened and the silver 
 pencil then applied, for the reason that the excess of water will 
 cause the silver solution to " run," streaking the contiguous skin 
 and giving rise to confusion as to the exact location of the fissures, 
 at the time of the operation. Especially is this to be borne in 
 mind, since faulty streaking does not become apparent until 
 several hours after application of the silver stick, the silver salt 
 not becoming black until oxidized. 
 
 The illustration (Fig. 226) shows only the Sylvian and Bo- 
 landic fissures outlined, and, indeed, these are the two most im- 
 portant guides necessary to cranial operations. However, addi- 
 tional fissures and sulci may be outlined in cases which involve 
 invasion of other than the motor areas, in the same way. 
 
 CARE OF WOUNDS OF CRANIAL BONES 
 
 Resection of the cranial bones either for removal of diseased 
 bone or for the purpose of attacking the cranial contents is in- 
 variably followed by drainage, the drainage agent being modified 
 in accord with the character of the process for which relief is 
 undertaken. As a rule, textile fabric drainage will be found the 
 most useful. Tuberculosis of cranial bones, suppurative osteo- 
 
OPERATIONS OX THE CRANIUM 327 
 
 myelitis, osteitis, etc., when attacked surgically, are always fol- 
 lowed by drainage. 
 
 The removal of gumma, osteosarcoma and aneurism of the 
 diploe do not present urgent indications for the employment of 
 drainage. However, when there is much trauma to the bone, and 
 if the sectioning of the bone be attended with considerable oozing 
 of blood, provision should be made for egress of secretions by the 
 introduction of silk-worm gut or horsehair drainage. The exudate 
 following operations of this sort will accumulate in the subdural 
 space if this precaution be not taken, and in some instances is 
 sufficiently great in quantity to cause cerebral pressure and its 
 attendant symptoms. 
 
 The drainage need not be maintained for more than from three 
 to five days, and will not interfere very much with a favorable 
 ultimate outcome as far as the wound is concerned. Indeed, it 
 may be said that drainage should be employed in all cases involv- 
 ing invasion of the cranial cavitv. 
 
 Infected wounds of the scalp and cranial bones should be 
 dressed every forty-eight hours. The protective dressing should 
 consist of wet gauze, the gauze being saturated with a solution of 
 corrosive sublimate 1 in 2,000. It conserves drainage to fluff the 
 gauze (Fig. 188, page 223). Capillarity is enhanced and clean- 
 liness conserved in this way. The gauze may be covered with 
 rubber tissue or oiled silk to maintain, as long as possible, the 
 moisture, and prevent soiling of the bedclothes from contact with 
 the wet dressing. Prolonged application of carbolic acid solutions 
 may cause gangrene, and this agent should not be used for the 
 purpose. Cleansing of the wound at each sitting should be made, 
 with ample provision for free discharge of the cleansing agent. 
 Hydrogen peroxid especially calls for precautions in this regard. 
 
 It is easy to see how the bubbling peroxid of hydrogen might 
 convey infective material into heretofore uninvaded areas if care 
 be not exercised to provide for its ready egress. This is most 
 important in connection with wounds involving the aponeurosis, 
 and especially so if the bone and dura mater have been sectioned. 
 When the latter has been opened, the entrance of infective sub- 
 stances between it and the pia may lead to exceedingly dangerous 
 complications, the infection extending into the meshes of the 
 arachnoid to the pia and to the brain cranial contents. 
 
328 OPERATIONS OX THE SCALP, SKULL AND BRAIN 
 
 OPERATIONS INVOLVING CRANIAL CONTENTS 
 
 Operations involving invasion of the cerebral membranes and 
 tbe cranial contents present certain problems, the outcome of com- 
 plication, which do not have the same import in other portions 
 of the body. 
 
 During all operations upon the brain care must be exercised to 
 avoid undue pressure upon the thorax and abdomen which might 
 interfere with respiration. The top of the table should be arranged 
 to allow of change of position on its transverse axis, so as to make 
 it feasible to raise the head of the patient if venous bleeding be exces- 
 sive (V. Bergmann) or to lover the same in the event of syncope. 
 The operating room should be warm (24°-28° C). Beyond this I 
 lay the patient upon warm pads at the temperature of the body, and 
 wrap the entire body in woolen blankets. 
 
 For operations on the cerebrum, the patient is postured with 
 the shoulders and thorax raised to a little less than 45 degrees. If 
 the posterior portion of the head rests on the pad, i. e., when the 
 anterior portion of the skull is being invaded, the portion of the table 
 upon which the pelvis rests is lowered a little while tbe upper body 
 is caused to rise obliquely. This position is very secure. In operating 
 on the side or posterior aspect of the head it is best to posture the 
 patient on his side and allow the head to extend beyond the edge of 
 the table. In all instances an assistant holds the head firmly with the 
 fingers apposed to the jaw and cheeks. 
 
 When opening the posterior cranial fossa the patient may be placed 
 on the sound side in such a manner as to bring the shoulder on a level 
 with the edge of the table, a posture which makes readily approachable 
 the area of operation. The head is held by an assistant, or, better still, 
 may rest on the head supporter. In the case of fat persons or those 
 who have short necks, this posture does not give sufficient room, and 
 I employ it, as a rule, only for the first step of the trephining, although 
 I have removed tumors of the acusticus on two occasions with the 
 patient in this position. 
 
 As a rule the operator finds it convenient to be seated when invad- 
 ing the cerebellum. The head of the table is lowered slightly; head 
 and shoulders are permitted to extend somewhat beyond the back sup- 
 port, so as to permit of ready approach beneath the posterior occipital 
 protuberance. The assistant holding the head turns it sidewise or 
 bends it forward, as the necessities demand. An assistant is detailed 
 
OPERATIONS INVOLVING CRANIAL CONTENTS 329 
 
 to watch the pulse and respiration. The regions of the medulla oblon- 
 gata, with the centers of respiration and that of the heart, are likely 
 to be disturbed, indeed, twice I was compelled to interrupt the opera- 
 tion for from ten to fifteen minutes to permit of reestablishment of 
 function in this connection. The patient reacted very nicely; how- 
 ever, had the pulse and respiration not been closely observed a fatal 
 issue on the table would no doubt have been the outcome. (Krause.) 
 
 In instances where operation is undertaken for relief of in- 
 fectious processes within the skull, dura, and brain, drainage is 
 maintained for a long time, indeed, until all evidence of infec- 
 tion has disappeared. It is best to err on the side of conservatism 
 in this connection and prolongation of the drainage, to this end, 
 is not to be regarded as over caution. 
 
 The more modern and most generally employed method of 
 approach to the contents of the cranial cavity involves saving of 
 the bone, unless the intracranial affliction involves by extension the 
 bone itself. In these instances, as obtains with tuberculosis, 
 gumma, and malignant disease, the bone must be sacrificed. 
 
 In operations involving the cranial contents where infection 
 does not exist, drainage of the superficial wound is usually es- 
 tablished and left in situ for four or five days. By this time the 
 question of infection will be quite settled, and if none has appeared, 
 the drainage agent may be removed. If the cavity in the brain 
 tissue resulting from removal of a diseased process has also been 
 packed with gauze, this, too, should be removed at the same sitting. 
 A smaller portion of gauze may now be placed in the brain cavity 
 through the wound of egress of the two drains removed, and this 
 will act as a drain for both the deep and superficial areas. 
 
 It is to be remembered that the trauma to the bone consequent 
 to osteoplastic resection may cause superficial necrosis of the edges 
 of the flap or the opposite edge of the bone. The inferior angle 
 of the bone may, therefore, be kept open for a time after the 
 drains have been removed, with the view of encouraging discharge 
 of the detritis through this avenue. This is accomplished by plac- 
 ing a small horsehair or silk-worm gut drain into the point of exit 
 of the gauze drains. As a rule, gauze drainage in clean cases need 
 not be maintained for more than ten days after the operation. 
 
 The posture of patients after operations on the cranium, its 
 coverings, and contents, after the shock has disappeared, should 
 
330 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 contemplate lessening of the quantity of blood in that region and 
 gravitation of the cerebrospinal fluid away from the ventricles. 
 The head of the bed should, therefore, be raised. However, if 
 the operation has been done with the view to facilitating discharge 
 of the fluid in order to lessen intracranial pressure, as obtains in 
 the decompression operations intended for the relief of hydro- 
 cephalus internus, the discharge of fluid is enhanced by lowering 
 the head of the patient. Discharge of cerebrospinal fluid calls for 
 additional precautions. The quantity discharged in twenty-four 
 hours is at times amazingly large, and the fluid saturates the dress- 
 ings in a few hours. Under these circumstances, it is difficult to 
 maintain asepsis. Close attention to detail has succeeded in pre- 
 venting infection for several months in a certain number of in- 
 stances, but this outcome was attained only as the result of pains- 
 taking effort. The general condition of the patient depends much 
 upon whether the discharge of cerebrospinal fluid is free or not. 
 This applies, of course, to cases in which the cause of increase 
 of intracranial pressure has not been removed at the operation. 
 Cessation of the flow is usually attended with restlessness, head- 
 ache, paralysis, and subconsciousness, in the order mentioned. In 
 these instances inspection will probably reveal interference with 
 drainage. 
 
 The establishment of permanent drainage is not properly dis- 
 cussed here. During the care of postoperative cerebral prolapse, 
 when pressure is being made to reduce the protrusion, return to the 
 normal is facilitated by permitting the patient to assume the sit- 
 ting posture if there is no distinct indication to the contrary. In- 
 deed, if the general condition of the patient permits, the pressure, 
 as described farther on, should be made while the patient is sit- 
 ting. As a rule, drainage of the cranial wound is made from its 
 most dependent portion, and the posture of the patient should take 
 cognizance of this with regard to both the supine and sitting 
 positions. 
 
 Patients who have been subjected to operative attack in this 
 region of the body are frequently subconscious or entirely insen- 
 sible. Especial care must, therefore, be exercised with respect to 
 the excretions. Involuntary discharge of feces and urine must 
 be balanced by scrupulous attention to cleanliness, and the bed 
 linen should be frequently changed. Again, when sensation is 
 
OPERATIONS INVOLVING CRANIAL CONTENTS 331 
 
 impaired as the outcome of central lesions, bed sores are likely 
 to occur, and it is a wise plan to place these patients upon a water 
 bed immediately after the operation, and the attendant must be 
 admonished to frequently change the posture of the patient and 
 to sponge the skin often with alcohol to obviate pressure necrosis 
 and its consequences. 
 
 The diet does not differ in these cases from that usually em- 
 ployed in postoperative care. It may, however, be said that al- 
 cohol is probably best omitted for obvious reasons. The character 
 of dressings applied to the scalp does not differ from that described 
 in connection with the care of wounds generally. 
 
 In instances of operations on the cranium which involve in- 
 vasion of the brain the problem is somewhat different. Contact 
 of antiseptic gauze with the wound itself should be avoided in 
 clean cases. However, the fact, as already stated, that large quan- 
 tities of cerebrospinal fluid are discharged from wounds of this 
 sort, and that infection may thus gain access to the site of surgical 
 trauma, suggests that the outer layer of gauze would be well satu- 
 rated with some antiseptic. For the purpose 5 per cent, iodoform 
 gauze answers very well, though its use is somewhat objectionable 
 on the score of its offensive odor. Gauze soaked in corrosive sub- 
 limate may be used. However, a certain capillarity exists in both 
 directions, and prolonged contact of corrosive sublimate solution 
 with the skin causes dermatitis. It is best to use the corrosive 
 sublimate gauze dry and change it sufficiently frequently to ob- 
 viate its penetration to the wound surface. This will vary in 
 accord with the amount of cerebrospinal fluid discharged. It is 
 probable that a change of the outer dressing twice daily will suf- 
 fice the contingencies. 
 
 When the operative procedure is divided into two stages, as is 
 frequently the case in large neoplasms of the brain, the sutures 
 temporarily holding the parts in position should be removed on 
 the fourth day following the operation, with the view of prevent- 
 ing the occurrence of small necrotic areas at the site of the sutures 
 which favor local infection. Infection in the superficial wound 
 would necessitate postponement of the final measure of relief until 
 it has been controlled, an occurrence which might be objectionable, 
 should urgent symptoms suddenly develop in the case calling for 
 immediate invasion of the brain tissue. 
 
332 OPERATIONS ON THE SCALP SKULL AND BRAIN 
 
 BONE NECROSIS 
 
 With respect to bone necrosis following operations on the skull, 
 Krause says: 
 
 If separation of the periosteum is avoided necrosis of the bone 
 rarely occurs in aseptic cases. Bone necrosis is very likely to occur 
 if the periosteum is widely separated at the edges of the flap, and espe- 
 cially is it liable to occur in purulent processes. In the latter cases 
 the cavity is tamponed and this causes interference with nutrition in 
 the bone. Owing to the consistence and thickness of the cranial 
 vault demarcation and separation of necrotic bone areas is a pro- 
 longed process, and this together with carious degeneration of the 
 edges of the bone sections may be maintained for months before ulti- 
 mate healing takes place. No general rule as to whether removal of 
 the diseased bone is indicated may be given the reader for guidance. 
 
 Early in my experience I had two cases in which extensive necrosis 
 of bone occurred. Both cases were operated upon for removal of the 
 ganglion of Gasser by my own osteoplastic flap method at the tem- 
 poral region. The one case was one of one-sided resection of the 
 ganglion, the osteoplastic temporal flap being fashioned with the cir- 
 cular saw. (August 23, 1895.) The patient had been subjected to 
 peripheral trifacial resection at which time a certain degree of hemo- 
 philia was discovered. Owing to the severe and persistent bleeding 
 at the time of the intracranial neurectomy the operation lasted three 
 hours. The prolonged hemostatic manipulations subjected the flap 
 to considerable trauma and the periosteum was largely separated from 
 the bone. Replacement of the flap was nevertheless made. The other 
 case (the second attempt of the kind made by myself in 1892), that 
 of a man, aged sixty-two, the intracranial resection of the second branch 
 of the nerve required chiseling of the bone. The operation was per- 
 formed on both sides at the same time, and owing to the enfeebled 
 general condition of the patient the second wound was tamponed for 
 five days before resection of the ganglion was undertaken. The con- 
 sequent prolonged interference with nutrition resulted in necrosis. 
 
 In these two cases the bone necrosis was not accompanied by fever. 
 The process expressed itself in an edematous swelling of the skin 
 flap and adjacent tissues together with puffiness of the lower eyelid. 
 On the tenth day the wound was opened and the bone flap removed. 
 The excised bone showed a thin layer of fibrinous pus on its inner sur- 
 face. The scalp flap was replaced and sutured, and drainage intro- 
 duced into the two lower angles of the wound. A small amount of 
 
OPERATIONS INVOLVING CRANIAL CONTENTS 333 
 
 purulent discharge accompanied the healing, which latter was achieved 
 without rise of temperature. 
 
 Exfoliation of small portions from the edges of the hone flap 
 occurred in two other cases under my observation. In neither case 
 was interference called for. The necrotic bone was eliminated in the 
 form of fluid discbarge. The process was exceedingly protracted, the 
 fistula? remaining patent for eight and ten months respectively. To 
 prevent occurrences of this sort the edges of the bone flap which have 
 been denuded of periosteum should be removed with the biting 
 forceps. 
 
 SECONDARY HEMORRHAGE 
 
 The occurrence of moderate bleeding following operations 
 upon the brain is attended with quite radical modification of the 
 clinical picture, and if not relieved may lead to a fatal outcome. 
 This may be illustrated by quoting a case of the sort from Krause. 
 The patient, a merchant aged twenty-three, who presented the 
 symptoms of cerebellar tumor, was subjected to osteoplastic re- 
 section of the skull. Krause relates the following: 
 
 After opening the posterior cranial fossa a cyst was incised, and 
 the cavity tamponed with vioform gauze. At the end of five days the 
 tampon and the drain was removed at which time no fluid secretion 
 was discharged. During the few days following the operation the 
 marked symptoms of. cerebral compression had disappeared and the 
 less manifest symptoms had much improved ; however, four days later 
 the evidence of cerebral compression again appeared. When the dress- 
 ing was removed a large quantity of clear fluid poured from the lower 
 right angle of the wound. The osteoplastic flap manifested definite 
 pulsation. Despite this fact, the compression symptoms did not 
 diminish, the temperature rose in the evening to 39.5 and 40.0. 
 There was no rigidity of the neck, but dysphagia and subconscious- 
 ness rapidly developed. For these reasons I felt justified in opening 
 two days later (eleven days after incising the cyst) the entire wound. 
 Clear fluid dripped constantly from the lower left corner of the wound, 
 and the osteoplastic flap, which had quite advanced toward repair, 
 pulsated visibly. While the skin was being shaved and cleansed with 
 ether a rather forcible stream of clear fluid bubbled out of a grayish 
 granulating area located at the center of the wound (about 20 cm. 
 in quantity). However, T regarded it as proper to expose the entire 
 operation field in view of the patient's menacing general condition. 
 The osteoplastic flap was rapidly turned down with the closed scissors. 
 
334 OPERATIONS OX THE SCALP, SKULL AND BRAIN 
 
 The exposed cerebellum appeared normal, its surface was smooth 
 and shining and of the same color as at the previous operation. 
 There was no swelling, softening, necrosis or pus present. The only 
 abnormality presented on the surface of the left cerebellar lobe in the 
 form of a slightly jDrotruding area the size of the distal phalanx of 
 the thumb which was dark blue in color and corresponded to the site 
 of the cyst opened at the previous sitting. The incision into the 
 cerebellum had quite healed but was now bluntly separated, exposing 
 a cavity the size of a plum which Avas tensely filled with coagulated 
 blood. This was gently expressed and the cavity tamponed with vio- 
 form gauze. The osteoplastic flap was sutured into its original posi- 
 tion. The following day the more marked symptoms of compression 
 disappeared. The tampon was removed on the fourth day, and two 
 days later the sutures were removed. 
 
 The disturbance was evidently due to the fact that after the tam- 
 pon had been removed (five days after the operation) the cerebellar 
 wound became glued together, and bleeding occurred from the not yet 
 obliterated vessels in the cyst wall which distended the cavity. The 
 coagulum, acting like a tumor and together with the retained fluid, 
 provoked the symptoms of compression. After the second operation 
 recovery went on to completion without interruption which was still 
 maintained at the end of a year and a half. 
 
 In two cases of cortical excision for Jachsonian epilepsy it was 
 necessary to reopen the operation wound because of blood and fluid 
 collections which produced menacing compression symptoms. The 
 first case was that of a man. aged thirty years, who was subjected to 
 cortical excision on October 15, 1902, after locating the primary spasm 
 area witli the farad ic battery in the forearm, hand and face centers. 
 The operation did not make any serious impression on the patient's 
 general condition. The pulse was regular, quite full and strong (80). 
 The immediate course was favorable, the drain and gauze strip being 
 removed on the fourth day and the sutures three days later. The tem- 
 perature reached 37.8 at the end of thirty hours, and fluctuated in the 
 neighborhood of 37.0 until the eighth day. when it rose to 38.7 degrees. 
 The evening of the day of operation the pulse rose to 128 but slowly 
 dropped to 92. Simultaneously with the increase of temperature the 
 pulse rose again to 128. There was no evidence of meningitis, and the 
 wound was healed except for the drainage openings. 
 
 The patient became subconscious and complained of bladder tenes- 
 mus. Badiating pains in the thigh developed and the entire right 
 leg was markedly weaker than it had been during the latter few days. 
 The muscles of the thigh were contracted. The evidence of irritation 
 
OPERATIONS INVOLVING CRANIAL CONTENTS 335 
 
 pointed to a focus in the leg center. On October 23d, under chloro- 
 form narcosis, I opened the entire wound, which required the knife 
 for the purpose, owing to the firm union already established, and 
 turned aside the osteoplastic and dural flaps. We found a brownish 
 red firmly coagulated clot lying on the surface of the brain at the 
 upper portion of the exposed field by the side of which clear fluid 
 oozed out. When this was removed the corresponding surface of the 
 brain glistened, but was slightly infiltrated with bloody exudate. A 
 few strips of iodoform gauze were laid on the involved area and the 
 dural and bone flaps replaced after a small drain had been introduced. 
 The next day the temperature fell to 37.9 degrees, and the following 
 day to 37 degrees. The pulse dropped to 104. Eestlessness and the 
 other symptoms disappeared. Eepair of the wound occurred without 
 further complications. The tamponade was renewed with sterile 
 gauze every three days and continued for fourteen days (until Novem- 
 ber 7th), at which time the bone was pushed into the space in the 
 skull. As hernia cerebri did not develop the bone healed into place 
 without disturbing the normal outline of the skull. On December 
 29th the patient was discharged. 
 
 RETENTION OF CEREBROSPINAL FLUID 
 
 The influence of retained cerebrospinal fluid is a complication 
 arising subsequent to surgical attack upon the brain, which leads to 
 much the same train of symptoms related in Krause's case of sec- 
 ondary hemorrhage. The inference is when symptoms of this sort 
 occur that either the drainage has been interfered with, or that 
 drainage was indicated in cases where it was not employed. This 
 condition of affairs is most likely to occur in connection with the 
 postoperative picture following cases in which the intracranial 
 pressure has for a long time been abnormally high, and relief 
 immediately following the operation is, in a measure, due to 
 relief of tension. 
 
 However, the fact that the retension of cerebrospinal fluid 
 may give rise to symptoms wdien there has not been an abnormally 
 high intracranial pressure is illustrated in the history of the case 
 here submitted, which was subjected to trephining for relief from 
 epilepsy. 
 
 The patient, a feeble boy, aged twelve years, had quite overcome the 
 effects of excision of the hand center. The temperature had risen 
 once, on the evening of the day of the operation, to 38.5, the pulse to 
 
336 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 136. On the second day the record showed temperature 37.5, pulse, 
 96. Despite this the patient at this time became restless and vomited 
 persistently, although he had quickly recovered from the effects of 
 chloroform after the first 0|)eration. There was no interference with 
 the movements of the head, and indeed, he showed no symptoms of 
 meningitis. His appearance was unfavorable and the general con- 
 dition so enfeebled that he did not retain the smallest nutritive enema. 
 As the conditions continued to grow more menacing and endangered 
 life, I lifted, on the third day after the operation (October 27, 1907), 
 the large osteoplastic flap (60-80 mm.) and the dural flap (50-78 mm.) 
 emptying out a small quantity of coagulum and a large amount of 
 cerebrospinal fluid. After the introduction of vioform gauze the 
 dura and superficial flap were replaced without suture. The next day 
 the patient retained a soft boiled egg and four rectal injections of 100 
 cm. each. The color of the face improved and was no longer green- 
 ish yellow, as it had been the day before. Improvement continued 
 with slight fluctuations. On October 30th the flaps were again lifted 
 and the gauze removed. At the site of the cortical excision a single 
 strip of gauze was introduced which was removed on November 2d. 
 The dressing continued to be saturated with cerebrospinal fluid until 
 November 16th. The flap was not sutured, but nevertheless healed 
 in -place on the level with the contiguous skull without any residual 
 bulging. On November 29th the boy was discharged, in perfect phys- 
 ical and mental health. Six months later the patient reported in 
 perfect health. 
 
 EDEMA AND SOFTENING OF THE BRAIN SUBSTANCE 
 
 Edema and softening of the brain substance may occur, even 
 in aspetic cases, in the region of the operative field. 
 
 These changes are, as regards intensity, primarily dependent upon 
 the extent of surgical trauma. If the operation be restricted to sim- 
 ple cortical excision for Jaclesonian epilepsy, the more or less extensive 
 paralysis immediately following the operation disappears at the end 
 of a few days. The characteristic disturbances dependent upon re- 
 moval of a certain motor center, however, remain. If traumatic 
 degeneration develop in the contiguous brain tissue additional paraly- 
 sis appear, which are dependent upon involvement of adjacent foci. 
 The process is not necessarily accompanied by systematic manifesta- 
 tions. The symptoms of edema and softening appear usually, if 
 at all (which is not frequently the case), about a week following the 
 operation, and disappear in a short time. 
 
OPERATIONS INVOLVING CRANIAL CONTENTS 337 
 
 Following removal of tumors the process is likely to be quite ex- 
 tensive, the outcome of severe trauma to the brain substance. The 
 cause of these encephalitic, edematous softening processes as they may 
 be designated, may be explained as follows. The growth of the tumor 
 has exercised a harmful pressure upon the invaded brain tissue, the 
 extirpation has necessitated division of blood vessels which also has 
 robbed the surrounding parts of nutrition. Division of nerve fibers 
 always provokes edematous saturation and swelling in the region of 
 the trauma, as has been observed in the peripheral nervous system. 
 All these factors aided, perhaps, by' small hemorrhages cause a condi- 
 tion of softening, which, in the majority of cases of aseptic operations, 
 is limited to the immediate neighborhood of the operative field and 
 does no great harm. On the other hand the process may extend and 
 lead to a fatal outcome, as shown in the following instance. 
 
 The patient, a laborer, aged forty-four, was subjected to operation 
 March 15, 1904. I removed a cortical glioma from the lower portion 
 of the anterior central convolution after deligating the approaching 
 veins, exercising an area 35-39 mm. in diameter and 20 mm. in depth. 
 The wound in the brain was covered with vioform gauze, over which 
 the dural flap was laid. The osteoplastic flap was replaced and held 
 with sutures except for a small area. 
 
 The dressing was changed on March 21st. The wound was 
 healthy and the gauze strips were removed. The general condition 
 of the patient was satisfactory. On March 29th the scar was normal, 
 but a pulsating prolapse the size of a walnut protruded from the ante- 
 rior inferior angle of the incision. The patient stated that on this 
 day the movements of the right leg were less certain and weaker than 
 immediately after the operation. On April 12th the prolapse 
 appeared considerably flatter. The general condition remained good. 
 Appetite and intestinal functions were normal, however, the patient 
 complained of intermittent headache. From the 29th of March, on 
 the right lower extremity showed paretic symptoms. On April 4th 
 clonic spasm of the quadriceps appeared. The asphasic disturbances 
 which had followed immediately after the operation became more 
 marked, though the psychic functions remained normal. The condi- 
 tions in the trephine wound continued to improve. On April 20th 
 the still decreasing prolapse showed signs of dermatisation and by 
 April 26th the hernia had receded to the level of the surrounding skin. 
 
 However, the general condition of the patient became worse, 
 vomiting occurred once. In the next few days the vomiting increased 
 and the paralysis increased, though no spasm occurred. Beyond the 
 headache no symptoms of brain pressure developed. Choked disk 
 
338 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 did not appear. After the 29 th of April the patient did not speak 
 except to answer questions ; urine and feces were passed involuntarily. 
 The next day the general condition was slightly better. From May 
 1st on matters took on a worse form, the left side of the body became 
 paralyzed and deglutition became difficult. Up to this time the pulse 
 remained below 76 and the temperature normal. May 2d the pulse 
 was 98 in the morning and 110 in the evening, respiration 28 to 30. 
 Death supervened on the morning of May 3d after paralytic and bron- 
 chopneumonic symptoms appeared. Vomiting and convulsions did 
 not recur. 
 
 Autopsy showed the surface of the brain richly covered with thick 
 veins which quite effectually obscured the fissures. The sagittal end 
 of the left fissure of Eolando corresponded to a point 1 cm. in front 
 of the posterior pole of the left cerebral hemisphere, which latter 
 measured, from its anterior to its posterior aspects, 19 cm. The fis- 
 
 frontalp-ol 
 
 Occijtitai/iel 
 
 Fig. 231. — Area of Cerebral Softening. (Krause.) 
 
 sure of Rolando met at the point designated the longitudinal fissure. 
 Two and a half centimeters inferior to this point the anterior central 
 convolution presented a defect which corresponded to the site of opera- 
 tion (Fig. 231). The contiguous convolutions were slightly tinged 
 
OPERATIONS INVOLVING CRANIAL CONTENTS 
 
 339 
 
 with yellow. The irregular anterior border of the defect encroached 
 upon the frontal convolutions. Frontal section disclosed beyond the 
 defect mentioned the fact that the greater part of the left cerebral 
 hemisphere was infiltrated with dark red and black hemorrhages 
 (Fig. 232), which extended toward the median line to near the longitu- 
 dinal fissure and downward to the level of the fissure of Sylvius, in- 
 volving, however, only the white substance. The gray matter was not 
 invaded, the crux was not involved, and the process had extended 
 between the cerebral peduncles and the optic thalma, leaving the basal 
 ganglia unaffected. 
 
 r 
 
 X.' 
 
 Fig. 232. — Area of Cerebral Softening. (Krause.) 
 
 It was evident that the bleeding had begun beneath the fissure of 
 Rolando and extended throughout the entire left hemisphere, involv- 
 ing an area of 11 cm. Judging from the anatomical and microscopical 
 findings death had been caused by hemorrhage and softening. 
 
 In some instances a fortunate discharge of degenerated brain sub- 
 stance occurs and the threatening symptoms disappear. This is illus- 
 trated by the following case : A woman, aged thirty-seven, had been 
 subjected to removal of a fibrosarcoma, the size of a mandarin, from 
 the left island of Reil. At the end of twelve days following the enu- 
 cleation, a quite complete paralysis of the opposite arm occurred, 
 which was followed by paresis of the lower portion of the face and 
 24 
 
340 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 muscular weakness of the leg a few days later. The aphasia which 
 had improved after the operation became again manifest, speech dis- 
 appearing entirely. The involvement of motor centers contiguous to the 
 site of removal of the tumor justified the belief that the cause of the 
 paralysis was either an edema or softening of the respective foci in 
 the central region. In addition, the patient showed some evidence 
 of irritation, headache, pain in the wound, and increased pulse rate 
 (100). Though the temperature did not rise sharply the remissions 
 were more marked than had previously obtained. The consciousness 
 was dull, though this cleared up in a few clays. The paralysis, how- 
 ever, remained for several weeks and gradually cleared up entirely 
 while speech returned but slowly. During this time the drainage 
 opening discharged at first large quantities of serous secretion together 
 with disintegrated particles of brain substance, which gradually les- 
 sened in amount. 
 
 This observation would seem to teach that a policy of non-inter- 
 ference together with close espionage of the manifestations is justifi- 
 able. Every attack upon the brain, indeed, the comparatively simple 
 reoi3ening of the osteoplastic wound involves additional trauma to 
 and pressure upon the brain substance, which may cause softening. 
 On the other hand the discharge of disintegrated brain substance was 
 manifestly of benefit in this case. Much experience and some good 
 fortune are requisite to enable the observer to determine what is best 
 in a given case. 
 
 This sort of superficial necrosis of brain substance contiguous to 
 tumors has been but rarely encountered by the writer. They are not 
 of importance, and will be discharged spontaneously provided the 
 avenue of egress be of sufficient dimensions. A secondary operation 
 may, however, be requisite if the necrosis occur beneath a healed tre- 
 phine opening, and the process have not created a mode of egress at 
 some distant part. In the case just mentioned the trephine wound 
 had healed except for a small opening at the lower anterior angle of 
 the wound, where the end of the gauze tampon had emerged. At this 
 place a fistula remained, which did not heal despite the cessation of 
 the discharge of brain substance and a small thin drainage tube was 
 inserted. Eemoval of the drainage tube was followed in a few hours 
 by clonic contraction of the muscles of the opposite side of the face 
 and hand and forearm. At the same time the patient who. up to this 
 time, had been entirely free from symptoms, became restless and com- 
 plained of headache, which originated from the site of the trephine 
 opening. When the drain was re-inserted a few drops of thin fluid pus 
 were discharged, and the symptoms promptly disappeared. As the con- 
 
OPERATIONS INVOLVING CRANIAL CONTENTS 341 
 
 ditions did not improve, and each attempt at discontinuance of the 
 drainage was followed by recurrence of the symptoms stated, it was 
 concluded that a necrosis existed in the direction of the drainage which 
 was located obliquely backward and upward under the bone flap. The 
 drain entered the area to iy 2 cm. from its point of exit at the anterior 
 border of the wound. 
 
 Several weeks after extirpating the tumor I exposed the bone in the 
 direction of the drain with an oblique incision, and made an opening 
 in the corresponding portion of the bone flap with the burr the size 
 of a silver quarter of a dollar. The bone was normal in appearance. 
 The opening exposed at once the grayish red brain, which was covered 
 Avith blood vessels of the arachnoid and pia. (The dura had been 
 removed at the time of the operation of extirpation.) Immediately 
 below and beside this normal brain area a surface the size of a finger 
 nail and of bluish yellow color presented, which was evidently a thin 
 layer of necrotic brain tissue. The sound introduced through the 
 drainage opening reached this spot. The necrotic area was excised, 
 using the sound as a guide, and the latter pushed through making a 
 counter opening for drainage at the posterior aspect of the original 
 trephine wound. There was no exudate present. Introduction of a 
 drain behind and tamponade with vioform gauze of the wound ended 
 the operation which healed by granulation in a few weeks. 
 
 It is evident that the spontaneous discharge of brain substance had 
 not resulted in removal of all of the necrotic area. The trephine 
 wound had healed posteriorly and the resisting osteoplastic flap pre- 
 vented complete separation and discharge of the dead tissue. The 
 fistula, which was 5 cm. long, was too narrow for the purpose, and 
 only after a free avenue of approach had been made behind did the 
 latter heal. If the technic employed would not have accomplished 
 the desired end, it would have been necessary to split the bony roof of 
 the fistulous tract with the Giglia saw or excise a narrow strip with 
 the Dahlgren forceps. 
 
 DISCHARGE OF CEREBROSPINAL FLUID 
 
 Cerebrospinal fluid constantly trickles from the surface of brain 
 prolapse in considerable quantity and especially so from the site of the 
 wound in the brain itself, saturating the dressings quite rapidly. Tn 
 one case of exploratory incision into the motor zone, which disclosed 
 a tumor of inoperable dimensions, the subsequent discharge of cerebro- 
 spinal fluid was so large in quantity as to arouse the suspicion that 
 the lateral ventricle had been invaded. The autopsy performed sev- 
 eral months later proved the contrary. 
 
342 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 At times the amount of cerebrospinal fluid discharge bears a rela- 
 tionship to the size of the hernia. I have observed variations in this 
 connection in two instances of trephining for removal of neoplasms 
 which proved inoperable. If the discharge of fluid was free the hernia 
 became perceptibly smaller and less tense. This always occurred 
 when large quantities of clear fluid had been thrown off for several 
 consecutive days. As the lateral ventricle had not been opened in 
 either instance it seems fair to assume that at these times the edema 
 had been relieved by the discharge of fluid. 
 
 (The outflow of cerebrospinal fluid may not occur even if large 
 openings be made in the dura, if there be no increase of intracranial 
 pressure at the time of the operation. In any event the loss of cerebro- 
 spinal fluid ceases very soon if the wound is sutured. For this reason 
 immediate repair of the wound is desirable. Under these conditions the 
 dressing remains dry and need not be changed until healing takes place. 
 
 The loss of considerable quantities of cerebrospinal fluid influences 
 to some extent the condition of the patient. Patients complain of 
 headache, especially marked at the posterior aspect of the cranium, 
 feel weak, are apt to hold the neck rigid, though no other symptoms 
 of meningeal irritation appear. Considerable rise of temperature 
 frequently accompanies the symptoms just related. When the dis- 
 charge of fluid lessens in quantity the symptoms promptly disappear. 
 I have also observed these manifestations (minus rise of temperature), 
 in some cases after extirpation of the ganglion of Gasser, when the 
 dura has been torn while separating the upper surface of the ganglion 
 because of firm adherence to the former. In these instances the brain 
 itself is not invaded and the contention with regard to the influence of 
 loss of cerebrospinal fluid is better proved than in operations on the 
 brain. 
 
 On the other hand, the well-being of the patient depends upon 
 maintaining the outflow of cerebrospinal fluid as shown in cases oper- 
 ated upon for hydrocephalus. In these cases arrest of the outflow 
 gives rise to headache and other disturbances. In this connection I 
 may state that considerable rise of temperature occurs when the dress- 
 ing becomes dry. 
 
 If for any reason infection occurs, the trephine wound must be at 
 once freely opened. The entire diseased brain area must be exposed 
 in order to determine the necessity for incising the brain, enlarging 
 the opening in the bone or of splitting the dura. All dead spaces 
 should be lightly packed with sterile iodoform gauze and drainage 
 strips introduced. The wound should be kept open until healthy 
 granulations ajjpear. (Krause.) 
 
OPERATIONS INVOLVING CRANIAL CONTENTS 
 
 343 
 
 BRAIN PROLAPSE 
 
 Sacrifice of the bone, when the pia mater is sectioned at the 
 same time, usually means cerebral prolapse, as a postoperative 
 complication. The size and persistence of prolapse depend upon 
 whether the operative measure has relieved the intracranial pres- 
 sure, though at times cerebral extrusion occurs when the pressure 
 is not above the normal. Indeed, prolapse may occur when the 
 bone has not been sacrificed, as is shown in the case depicted here 
 (Figs. 233-234). 
 
 * ■■ ll 
 
 .., ^m 
 
 . '■'' 'Is 
 1 | 
 
 *■ 
 
 Ilk 
 
 |HB| Jr JJHBH«| 
 
 
 
 J0 
 
 fm 
 
 Fig. 
 
 233. — Cerebral Prolapse Following Osteo-plastic Resection of the 
 Skull for Abscess of the Brain. 
 
 These illustrations were taken from a case of subcortical ab- 
 scess of the motor region situated beneath the arm and leg centers. 
 The hernia forced the osteoplastic flap upward and displaced it 
 downward as shown in the illustration (Fig. 234). The denuded 
 area of bone is the portion fashioned into a flap at the time of the 
 operation. The bone, which was separated from the skin and 
 
344 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 periosteal flap by the progressive growth of the protrusion, ne- 
 crosed and was removed. 
 
 The illustrations show the condition of affairs six weeks after 
 the operation. A large portion of the extrusion sloughed, and 
 separation of the necrotic tissue was effected by patiently remov- 
 ing separated portions at each dressing. The procedure indulged 
 
 Fig. 234. — Same as Fig. 233. Showing Bone Flap Elevated by Protrusion of 
 
 Prolapse. 
 
 in in this instance may be regarded as indicative of what is gen- 
 erally to be done in these cases. 
 
 ~No attempt was made to cut away the prolapse. As Krause 
 says, " each trauma to the cortex of the brain, in situations which 
 possess important functions, is attended with paralysis, and should 
 be avoided when feasible." 
 
 When the extrusion is cut away it reappears promptly, and 
 each application of the cautery or escharotic is followed by new 
 protrusion. 
 
 The prolapse is but sparsely supplied with nourishment, and 
 after a time spontaneous sloughing takes place to a considerable 
 extent. During this time the wound must be kept as clean as is 
 
OPERATIONS INVOLVING CRANIAL CONTENTS 
 
 345 
 
 feasible, and ample drainage provided for. The dressings should 
 be changed twice daily and sloughing areas removed with thumb 
 forceps or by the gentle use of the curet. Bleeding may be con- 
 trolled by gauze sponge pressure. Nature will do much in these 
 cases if given reasonable aid. The reestablishment of the balance 
 of pressure is also of assistance in ultimate repair. When the 
 sloughing has ceased and healthy granulations cover the mass, a 
 surprising reduction in size of the prolapse will be found to have 
 taken place. 
 
 The hair should not be permitted to grow to the extent shown 
 in the accompanying illustrations. On the other hand, during the 
 time that the sloughing is going on it is not wise to subject the 
 patient to the annoyance of keeping the scalp shaved all the time. 
 Once a week or at ten-day intervals will suffice. When the wound 
 
 Fig. 235. — Adhesive Plaster Strips and Gauze Tapes for Pressure on Cere- 
 bral Prolapse. 
 
 surface is clean, the scalp may be kept shaved in order to permit of 
 the application of pressure. This may be attained by applying 
 
 However, patients complain 
 
 a firm bandage over the dressings 
 
346 
 
 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 of the tightness of the bandage at the base of the dressing, and 
 the presence of the gauze renders pressure on the protrusion itself 
 less effective than is desirable. 
 
 Pressure is effectually attained by fastening strips of ad- 
 hesive plaster to the contiguous scalp, at the central ends of which 
 rather broad tapes are attached (Fig. 235). A flat, thick pad of 
 gauze is now placed upon the prolapse and the tapes tied over this, 
 
 Fig. 236. — Gauze Pad Applied to Cerebral, Prolapse. 
 Tying Gauze Strips in Place. 
 
 Pressure Made by 
 
 making the required amount of pressure (Fig. 236). The degree 
 of pressure may be standardized by the behavior of the case, never 
 being sufficiently great to cause discomfort nor to give rise to symp- 
 toms of cerebral pressure. On the whole, it may be said that 
 operative attempts at repair should not be made until three months 
 after the original operation unless the behavior of the case be mani- 
 festly so favorable as to warrant earlier interference. Nature, 
 time, and patience will do much in this class of cases. Undue haste 
 may do harm. 
 
 At times a cerebral prolapse becomes dermatized, the protru- 
 
OPERATIONS INVOLVING CRANIAL CONTENTS 
 
 347 
 
 sion being still considerably elevated above the skull level. This, 
 of course, obtains when the bone has been sacrificed. The protru- 
 sion is then called a hernia cerebri, in contradistinction to prolapse, 
 which latter term should be applied to protrusions of brain not 
 covered by any tissue. 
 
 Fig. 237 shows a case of moderate hernia cerebri following 
 
 Fig. 237. — Cerebral, Hernia Following Resection of the Skull. 
 
 (Krause.) 
 
 osteoplastic resection of the skull for enucleation of a cerebral 
 tubercular form. This is a fair sample of the ultimate outcome in 
 this class of cases, though in a certain number of cases no deforma- 
 tion of the cranial outline persists. If the patient feels any dis- 
 comfort or apprehension at the presence of the hernia, it may be 
 protected by the wearing of a truss, though this will only rarely 
 be found necessary. 
 
348 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 THE RETAINING BANDAGE 
 
 Following operations on the scalp, cranium, and contents, the 
 retaining bandage is applied in the form of a cap made up of prop- 
 erly adjusted roller bandages. Covering of the entire skull with 
 the dressing is cumbersome, and when the operation has been lim- 
 ited to removal of growths of the scalp, the dressing for the first 
 twelve hours following may consist of a liberal amount of gauze 
 held in place with the roller bandage. However, the oozing of 
 secretions will have ceased by this time, and the wound may now 
 be sealed with a mixture of iodoform and collodion, a half dram 
 
 Fig. 238. — Single Roller Bandage of the Head. Beginning in the median line 
 the surgeon lays each succeeding turn of the bandage a little further to the right or 
 left. (Foote.) 
 
 to the ounce, or aristol may be substituted for the iodoform if the 
 odor of the latter is offensive. 
 
 The ether holding the guncotton in solution evaporates and 
 leaves the latter, holding the antiseptic confined in its meshes, in 
 contact with the wound. The application holds the stitches firmly 
 
OPERATIONS INVOLVING CRANIAL CONTENTS 
 
 349 
 
 enmeshed, and may be left in this way for six days without inter- 
 ference. Remembering that the guncotton is soluble in ether, it is 
 only necessary to apply the latter to the surface, and the mixture 
 of collodion, antiseptic powder, and a small amount of bloody 
 secretion is readily removed, permitting of withdrawal of the 
 sutures without causing pain to the patient. When the stitches 
 have been removed, the wound may be again coated with the 
 collodion-iodoform or collodion-aristol mixture, and the ultimate 
 repair will take place beneath this protection without further 
 attention. 
 
 When the operation is of greater magnitude, the dressing is 
 held in place with roller bandages which cover the entire skull. A 
 two-inch bandage is used for the purpose. The single roller may 
 be employed and is applied in the manner shown in Figs. 238 
 
 Fig. 239. 
 
 -Single Roller Bandage of the Head Completed. 
 (Foote.) 
 
 and 239. The double roller is best used where it is desirable to 
 make pressure on the wound, especially in making compression 
 following invasion of the bone. The mode of application of the 
 
350 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 latter form of bandage is shown in Figs. 240 and 241. Frequently 
 patients who have been subjected to operations on the cranium 
 and its contents are, as already stated, exceedingly restless. The 
 continuous tossing about is likely to loosen the bandage, with un- 
 desirable results. In these instances it is well to supplement the 
 
 Fig. 240. — Double Roller Bandage of the Head. Each circular turn of the nar- 
 rower bandage fixes the reverse of the wider one on the forehead and on the occi- 
 put. (Foote.) 
 
 cap dressing with an " anchor bandage " applied in the way shown 
 in Fig. 242, which may be applied over the retaining single or 
 double roller bandage. 
 
 Patients suffering from cerebral irritation frequently pick at 
 the dressings. It is not always wise to administer opiates in these 
 cases, at least not in sufficient quantity to produce unconsciousness, 
 on the ground that the symptomatology of the postoperative period 
 is masked by so doing. It is not uncommon to see patients in- 
 sinuate the fingers beneath the edges of the roller bandage and 
 gradually loosen the strips, ultimately tearing aside the entire 
 dressing. In these instances a cap made of unbleached muslin 
 
Fig. 241. — Double Roller Head Bandage Completed. (Foote.) 
 
 Fig. 242. — Figure of Eight Bandage of the Head, Showing Anchoring. (Foote.) 
 351 
 
352 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 may be applied to the head and fastened firmly beneath the occiput 
 with tape (Fig. 243). The smooth surface of the cap makes it 
 
 Fig. 243. — Skull Cap for Delirious Patients Following Operations 
 on the Head. 
 
 difficult for the patient to grasp the dressing and prevents loosen- 
 ing when the head is tossed about npon the pillow. 
 
 MASTOID OPERATIONS 
 
 THE SIMPLE OPERATION 
 
 The preparation of patients to be subjected to operations npon 
 the mastoid cells and contiguous tissues does not materially differ 
 from that in operations in other situations. It is to be remem- 
 bered that the invasion of the mastoid cells is usually undertaken 
 for the relief of suppurative inflammations, which suggests that 
 
OPEPATIONS INVOLVING CRANIAL CONTENTS 353 
 
 the technic of the operative procedure should aim at antisepsis 
 rather than asepsis. The care of the wound is very similar to that 
 which obtains in infected wounds in other portions of the body. 
 The wound at the end of the operation is lightly packed with iodo- 
 form gauze. The packing should be made in such a way as to 
 avoid undue pressure upon the tissues. Firm pressure for twenty- 
 four hours may be necessary if there be much oozing of blood at 
 the close of the operative procedure. If the tamponade be firmly 
 introduced for this reason, it should be removed carefully at the 
 end of twenty-four hours and a new tamponade of the same mate- 
 rial introduced. 
 
 In this situation, as in all others, the object of the tamponade 
 is to furnish a substance which will readily absorb the exudate 
 and prevent the accumulation of offensive substances in the wound. 
 Firm tamponade prevents the growth of granulations, interferes 
 with the nutrition of the part, and it is no exaggeration to state 
 that the patient would, no doubt, be better off if the wound were 
 not packed at all. If the operation be the so-called simple mastoid 
 operation the tamponade need not be disturbed for five or six days. 
 The indications for earlier change of the tamponade are excessive 
 soiling of the dressing with secretion, pain, fever, or an offensive 
 odor (Kopetzhy). If the outer dressing be saturated with secre- 
 tion, this may be changed and the dressing immediately contiguous 
 to the wound be left undisturbed, unless one or more of the indi- 
 cations mentioned be present. 
 
 When the dressing is ultimately changed the iodoform gauze 
 is loosened with peroxid of hydrogen and carefully removed with 
 the view of obviating undue trauma to the newly formed granu- 
 lation tissue. 
 
 The general surgical principle of keeping a wound free from 
 foreign substances should be conserved here, too. The gauze tam- 
 ponade should become progressively less bulky, and when the 
 granulations reach the skin surface be omitted entirely. Disregard 
 of this rule will cause the existence of an offensive condition of 
 affairs lasting over a long period of time and, in the opinion of 
 the writer, is frequently responsible for the unfavorable cosmetic 
 effect which so often follows mastoid operations. It is suggested 
 that the ear specialist apply general surgical rules to the class of 
 cases w T ith which he comes in contact. 
 
354 OPERATIONS OX THE SCALP, SKULL AND BRAIN 
 
 The after-treatment of cases treated without tamponade. After 
 the wound is thoroughly cleansed, the cavity is insufflated with 
 boric acid powder. KopetzTcy uses aristol for the purpose, but 
 places a small gauze drain into the meatal orifice. He reports 
 good results from the measure. The advantage of this procedure 
 is that the changes of dressing are quite devoid of pain, also that 
 granulation is not retarded. 
 
 In cases where epidermization is tardy and no local impediment 
 to its advancement is to be found, Bondy obtains good results from the 
 local application of concentrated etherial solution of picric acid (1.0- 
 10.0). The mixture is applied after the parts are thoroughly cleansed. 
 Its disadvantage lies in the intense pain caused by the application. 
 This, however, ceases as soon as the ether has evaporated. To hasten 
 evaporation, air is blown into the wound. This treatment is adminis- 
 tered every second day. and during the intervals the wound is kept 
 dry by insufflations of boracic acid or clermatol. 
 
 When this plan is adopted the wound secretions rapidly lessen in 
 amount, and exuberant granulations disappear, while the wound sur- 
 face rapidly becomes covered by epithelium. 
 
 In a certain number of cases, after thoroughly cleansing the wound 
 cavity, we have been very successful in checking exuberant granula- 
 tions \yj applying orthochlorphenol, followed by absolute alcohol ; but 
 in the majority of our cases we simply change the soiled for a clean 
 dressing, and kept the wound surface dry. This has yielded good 
 results. Very often, after epidermatization has taken place on one 
 section of the wound cavity, destruction of the newly formed epidermis 
 takes place, clue to the action of the wound secretions from other parts 
 of the cavity. To prevent this, the recommendation of Briihl, 
 namely, to cover the newly formed epithelium with zinc ointment, 
 deserves mention. We have used lanolin with excellent effect for 
 similar purposes. 
 
 Dermatitis of the meatal orifice or surrounding tissue, often results 
 from faulty asepsis, but occasionally this condition is due to the action 
 of the secretions. Eegarding dermatitis, the deleterious effects of 
 iodin should be remembered. "We dispense with iodoform after the 
 first dressing, substituting either plain gauze or boracic acid, or aristol 
 insufflations. In children, we entirely dispense with the use of iodo- 
 form gauze. 
 
 Our own procedure in the local after-treatment of these operations 
 is extremely simple. We check any tendency to exuberant granula- 
 tions by any of the above-named measures; we change the dressings 
 
OPERATIONS INVOLVING CRANIAL CONTENTS 355 
 
 every second da}', and unless the secretions are excessive, we wipe the 
 cavit} r clean with dry or moist wipes — moistened in normal salt solu- 
 tion. The tamponade after the second week is very light; usually 
 in cases progressing satisfactorily we content ourselves with placing 
 a strip of plain gauze in the meatal orifice, and extending it to the 
 antral opening. Previous to the introduction of this tampon, aristol 
 is insufflated. 
 
 When the secretions are excessive, we instill hydrogen peroxid, 
 and follow this with 95 per cent, alcohol. This usually gives satis- 
 factory results. Where granulations are indolent, general systematic 
 treatment, an outdoor life, and nutritious diet are indicated, together 
 Math the local application of Peru and castor oil in equal parts. One 
 or two applications of the latter are usually sufficient to stimulate 
 indolent granulations. (Kopetzhy.) 
 
 THE RADICAL OPERATION 
 
 When the radical operation has been performed the introduc- 
 tion of gauze is limited to a single gauze strip, which is intended 
 for drainage. The introduction of firm packing interferes with 
 the intent. The dressing is left undisturbed for a week. Indeed, 
 the wound is treated in all respects similar to that applied to 
 aseptic cases, except that the drain is employed. The stitches are 
 removed at the first dressing. The dressing is, of course, removed 
 if during the healing process there are any manifestations of ac- 
 cidental infection, in which event the wound is treated as are 
 infected wounds in other situations. 
 
 RESULTS OF AFTER-TREATMENT 
 
 The length of time required for healing is different in every case. 
 It is manifestly unfair to compare the results obtained from a pro- 
 cedure which in itself is the same, but which is employed to cure dif- 
 ferent diseases in the temporal bone. In general, the best results 
 are obtained in from six to eight weeks. Many cases are under treat- 
 ment for months, and some for years, before final recovery can be 
 pronounced. This is especially the case in under-nourished children 
 and in adults debilitated from general disease, and it is an especial 
 feature of tuberculous mastoiditis. The average duration of the after- 
 treatment is between three and four months. (Kopetzlcij.) 
 
 25 
 
356 OPERATIONS ON THE SCALP, SKULL AND BRAIN 
 
 INTRACRANIAL NEURECTOMY 
 
 Intracranial neurectomy, i.e., removal of the ganglion of Gasser 
 involves much the same problem as regards preparation of the 
 field of operation and the local after-treatment as obtains with 
 the problem of section of the skull for other purposes. These 
 considerations have been so largely entered into under operations 
 on the brain as not to need repetition here. However, it is per- 
 haps proper to state in this connection that the bone is quite fre- 
 quently sacrificed in approaching the ganglion, though the osteo- 
 plastic resection is also made in a not inconsiderable number of 
 cases. The former technic is less likely to be followed by super- 
 ficial necrosis of bone than the latter. However, some necrosis 
 of the bone does occur in either instance. The evidences of its 
 presence and the care given the wound until exfoliation takes place 
 are already described, being in all regards similar to those follow- 
 ing opening of the cranium for other purposes. 
 
 Of course the operation is not undertaken for infection, and 
 if tamponade is made, it is with the intent of controlling bleeding. 
 This argues for removal of the tampon at the end of forty-eight 
 hours sequential to the operation. A small drain of silk-worm 
 gut should, however, be introduced into the wound at this sitting, 
 with the view of furnishing an avenue of egress for the secretions 
 attendant upon wound repair, and possibly to allow of discharge 
 of disintegrated bone tissue. The fact that patients who are sub- 
 jected to intracranial neurectomy have suffered violent pain for 
 extended periods of time, permits of the assumption that anodynes 
 have been more or less employed to afford relief. Probably a 
 considerable number of persons afflicted with trifacial neuralgia 
 are more or less habitues in this regard. This must be taken into 
 consideration immediately after the operation and no radical ef- 
 fort made to correct the habit immediately after the ganglion has 
 been removed. This question has been taken up under a general 
 head (page 30). 
 
 In the after-treatment, the care of the eye on the side where 
 the ganglion has been removed calls for special precautions. The 
 injury to the sympathetic nerve fibers while the ganglion is being 
 resected disturbs the nutrition of the eyeball, and the loss of sensa- 
 tion results in the accumulation of foreign particles upon the eye 
 
OPERATIONS INVOLVING CRANIAL CONTENTS 357 
 
 which otherwise would be dislodged by winking. This is obviated 
 by suturing the eyelids over the eyeball for four or five days 
 following the operation. 
 
 During this time the eyeball should be washed off by syringing 
 a saturated solution of boracic acid beneath the eyelids at frequent 
 intervals. This should be done every four or five hours and the 
 solution should be warm. Later than this a shield should be worn 
 over the eye, and cleanliness observed for a long period of time. 
 It would appear that, until the nutritive changes are balanced by 
 nature, care in maintaining nutrition of the body has a tendency 
 to prevent the sloughing of the cornea, due to alteration in this 
 respect, the outcome of injury to vasomotor nerves. 
 
 Patients who have been subjected to intracranial neurectomy 
 should be fed as largely as is consistent with the other indications 
 manifest after operations of magnitude. More especially is this 
 true in view of the fact that, as a rule, considerable modification 
 of general nutrition will, in all probability, have already taken 
 place, the outcome of the protracted suffering from the neuralgia. 
 
CHAPTER XVII 
 
 OPERATIONS ON THE FACE 
 
 Rhinoplasty — Osteoplastic rhinoplasty — Harelip and cleft palate — Miscel- 
 laneous operations in mouth. 
 
 The sources of infection in operations on the face, other than 
 those which obtain from causes necessitating the operation, are 
 the hair and the nasal and the oral secretions. The hair of the 
 scalp should be treated in much the same manner as for the re- 
 moval of benign growths from the scalp. The scalp is anointed, 
 the day before the operation, with olive oil or vaseline and sham- 
 pooed very thoroughly with tincture of green soap for a few hours 
 
 before the operation. The 
 hair is then wrapped in a 
 sterile towel. If the opera- 
 tion contemplates attack of the 
 parts contiguous to the hairy 
 scalp, the towel may be moist- 
 ened with a solution of cor- 
 rosive sublimate 1 in 2,000. 
 The method of application of 
 
 Fig. 244. Applying Aseptic Cap. First Step. (Gerster.) 
 358 
 
OPERATIONS ON THE FACE 
 
 359 
 
 the towel is shown in Figs 244 and 245. 
 
 Fig. 
 
 Fig. 245.- 
 
 -Applying Aseptic Cap. 
 (Gerster.) 
 
 Second Step. 
 
 246 shows the 
 towel retained in place with a sterile gauze bandage. 
 
 In men the face should be shaved a few hours before the opera- 
 tion. It is best to 
 have a barber do this, 
 as the nicking of the 
 skin consequent upon 
 unskilled manipula- 
 tions of the razor is 
 conducive to infec- 
 tion and causes un- 
 necessary annoyance 
 to the patient. Oper- 
 ations upon the fore- 
 head, eyes, and 
 cheeks above the level 
 
 of the nostrils do not call for special precautions in after-treat- 
 ment. The mode of applying the retaining dressing in this class 
 of cases is shown in Fig. 247. 
 
 Following operations involving the forehead and the eyelids, 
 
 and, indeed, a small 
 area of the cheek, the 
 bandage is applied as 
 shown in Fig. 248. 
 This form of bandage 
 is used in instances in 
 which there is not 
 much trauma at the 
 time of the operation, 
 such as removal of a 
 superficial sebaceous 
 
 
 
 IfcllL^ 
 
 p.-;--'-. 
 
 PK^*^SHJ Wtr?.: .'•• ■" ' J f f ~ 
 
 
 .:.. . vm&m* 
 
 \ X^xh. $UF^ ~ r ' 'l^fci^^W! 
 
 Fig. 
 
 246. — Aseptic Cap, Held 
 Sterile Gauze Bandage. 
 
 in Place with 
 
 {Gerster.) 
 
 cyst or a 
 moid cyst 
 region of 
 brow. 
 
 small der- 
 from the 
 the eye- 
 
 The operations need not be followed by the elaborate dressing 
 shown in Fig. 247. Each alternate turn is crossed in the manner 
 shown in the illustration, and a pin is ultimately made to pene- 
 trate all the layers of bandage at the site of crossing. The ban- 
 
360 
 
 OPERATIONS ON THE FACE 
 
 Fig. 247. — Dressing for Wounds of Face 
 Above Nostrils. (Gerster.) 
 
 dage should be made of one 
 and a half inch material. 
 Gauze is used for the pur- 
 pose because it is more pli- 
 able than linen and will con- 
 form more readily to the 
 irregular outline of the parts. 
 Wounds of the face heal 
 rapidly, the outcome of the 
 vascularity of the part, and, 
 perhaps, also because of the 
 presence in large quantity of 
 glandular elements in this 
 situation, resembling, in 
 these regards, the scalp. 
 The suture material best em- 
 ployed in this portion of the 
 body is horsehair or fine 
 
 Fig. 248. — Bandaging Upper Portion of One Side of Face. (Foote.) 
 
OPERATIONS ON THE FACE 361 
 
 silk-worm gut. The subcuticular suture is followed more fre- 
 quently by suppuration than the usual interrupted suture. This 
 is perhaps due to the trauma to a large number of glandular ele- 
 ments of the skin, which are the habitat of bacteria as far as their 
 ducts are concerned, and the needle, passing through them later- 
 ally, liberates the bacteria, permitting of invasion of the surround- 
 ing tissue. 
 
 A fine silk-worm gut threaded upon a slender Ilagedorn needle, 
 introduced in the interrupted method and tied just sufficiently 
 tight to hold the tissues in apposition without strangulation, will 
 produce desirable results. The sutures should not be permitted to 
 remain in situ longer than six days, when they should be carefully 
 removed, using slender scissors for the purpose and avoiding un- 
 necessary trauma to the surrounding skin surfaces. The needle 
 holes will then disappear very rapidly. The wound may then be 
 sealed with collodion iodoform or collodion aristol, and the ultimate 
 repair takes place under this seal. 
 
 For some unknown reason, erysipelas is more frequently a 
 complication of wounds of the face than obtains in other situations 
 of the body. This occurrence need not be regarded as portentious 
 of unfavorable cosmetic outcome. Recovery from the erysipelas 
 is usually followed by a complete restitution to the normal, and the 
 fact that it has occurred need not be considered a reason for per- 
 mitting the sutures to remain in situ any longer. 
 
 When facial erysipelas occurs as a postoperative complication, 
 the sutures may be removed in the usual way, and the infected 
 surface, together with the wound, covered with a 25 per cent, 
 solution of ichthyol in collodion, and the constitutional treatment 
 is carried out as usual. 
 
 Asepsis has made this occurrence quite rare, yet it does occur, 
 and a meddlesome policy, the result of apprehension with respect 
 to the wound, is to be deprecated. The writer has seen quite 
 satisfactory ultimate cosmetic results follow the method of pro- 
 cedure here indicated. Of course, if suppuration occurs either 
 from pyogenic infection or is due to the streptococcus of Fehleisen 
 together with a pus organism, the wound is treated by opening of 
 a portion of the wound, drainage, and light packing as indicated 
 above (page 305). 
 
 A sharp rise of temperature with moderate acceleration of 
 
362 OPERATIONS ON THE FACE 
 
 pulse rate and little or no pain usually means facial erysipelas. 
 A moderate rise of temperature, sharp increase in pulse rate, with 
 pain and throbbing, would indicate pus infection. The former 
 permits of conservatism and abstinence from interference with 
 respect to the effort at immediate union, the latter calls for libera- 
 tion of secretions, loosening of sutures, and drainage. 
 
 Operations on the face involving areas which are liable to be 
 contaminated with nasal or oral secretions call for special precau- 
 tions, both with respect to preparation and after-treatment. It is 
 quite impossible to render sterile the secretions from mucous mem- 
 branes. However, the number of pyogenic organisms present 
 may be reduced to a minimum, and the tissues may be relied upon 
 to resist their invasion if present in small number. 
 
 For several days before the operation the mouth and nasal 
 cavities are frequently lavaged with listerine or a similar prepara- 
 tion. In the mouth listerine may be used undiluted as a wash, 
 and this followed by gargling with large quantities of the agent 
 diluted to one-third of listerine and two-thirds of sterile water. 
 This acts most largely mechanically, though some chemical effect 
 is produced by the agent. It is necessary to use large quantities 
 of .the fluid with the view of diluting and perhaps exhausting the 
 virulence of bacteria. The teeth should be thoroughly cleansed, 
 preferably by a dentist, several days before the contemplated 
 operation, and the brush used frequently until that time. Cor- 
 rosive sublimate and carbolic acid solutions are not safe agents 
 to use in this situation. 
 
 The nose is douched with the same solution, though pure lis- 
 terine used in this way is advised against as being too irritating. 
 Care should be taken in lavaging the nasal cavities to permit of 
 easy egress of the cleansing solution. If this precaution be not 
 taken, the middle ear may be invaded by way of the Eustachian 
 tube, and unpleasant complications in this situation may develop 
 as the result. A convenient and comparatively safe method of 
 lavage of the nasal cavities is to introduce from the mouth, be- 
 hind the soft palate, a suitably curved nozzle fitted to the barrel 
 of a syringe (Fig. 249), which washes the nasal cavities from 
 behind, and the cleansing fluid flows unobstructedly from the an- 
 terior nares. 
 
 If the secretion in the nose is crusted, a saturated solution of 
 
OPERATIONS ON THE FACE 363 
 
 sodium bicarbonate, warmed to the body temperature aud intro- 
 duced as described, will be found quite effective in removing the 
 incrustations. The comparatively clean mucosa may now be 
 freely lavaged with additional cleansing fluid, such as boric 
 acid, listerine 1 in 3, or the like, using the same syringe for the 
 purpose. 
 
 Immediately before the operation, the mucosa of the nose may 
 be painted with a solution of adrenalin 1 in 3,000, which arrests 
 the secretion for a time, and, indeed, for the twenty-four hours 
 following the operation the mucosa may be kept contracted in this 
 way, effectually limiting the mucous secretions. 
 
 Fig. 249. — Syringe for Cleansing Naso-pharynx. 
 
 This measure is not so effective in the mouth, as the salivary 
 secretions come from glands remote from the local influence of the 
 adrenalin. However, the salivary secretion may be lessened by 
 the administration of a small close of atropin (1-120 gr.), and 
 the secretion from the mucosa itself controlled with the adrena- 
 lin solution. Attention to what appears like minor considera- 
 tions of this sort may determine the question of postoperative 
 infection. 
 
 The salivary secretion is probably sterile as it emerges from 
 the ducts of the salivary glands, and is later contaminated as it 
 mingles with the mucous from the lining membrane of the mouth. 
 If the mucosa be kept clean, the saliva need not be regarded as of 
 menacing import in this connection. It is also probable that but 
 little saliva from the salivary glands themselves is secreted at 
 other times than during mastication. A diet which does not call 
 for the exercise of this function is a logical indulgence. 
 
 The sterilization of articles of diet is taken up under sepa- 
 rate head (page 430). In this connection it is proper to state that 
 whatever efficiency, as regards nutritive value, food loses as the 
 outcome of sterilization need not be considered as an important 
 factor when used for a short period of time. The introduction of 
 
564 
 
 OPERATIONS ON THE FACE 
 
 food through the mouth by means of sterile apparatus of prehen- 
 sion should, of course, be assiduously practiced in all cases where 
 the organs concerned in deglutition are 
 subjected to operative attack (page 
 430). 
 
 The dressing of operative wounds 
 contiguous to the nose and mouth is 
 held in place with some difficulty. For 
 the purpose it is necessary to apply 
 an elaborate protection, which, though, 
 cumbersome, and likely to pro- 
 voke some rebellion on the part 
 of the patient, should, never- 
 theless, be applied. 
 
 A combination of head 
 cap, jaw bandage, and neck 
 dressing, covered with rubber 
 tissue, elastic rubber sheeting, 
 or oiled silk to obviate satura- 
 tion from without with ar- 
 ticles of diet and secretions, 
 
 as shown in Fig. 250, may be Fig. 250. — Dressing foe Face and Neck 
 , , „. .,, . Operation. The arm sling is omitted 
 
 employed. lhe illustration if neck is not invaded. (Gerster.) 
 
 shows, also, the arm sling and 
 
 axillary dressing. The latter, of course, are not added unless the 
 neck has been subjected to operation at the same time, and may 
 be omitted in face cases. 
 
 RHINOPLASTY 
 
 Rhinoplasty should be preceded by cleansing of the nasal cavi- 
 ties described above. The after-treatment relates to prevention of 
 tension and avoidance of infection during healing. Patients op- 
 erated upon for correction of deformity in this situation will be 
 found exceedingly tractable and easily managed, provided, of 
 course, the operation be undertaken when the patient is sufficiently 
 advanced in life to contribute to the effort of the surgeon with in- 
 telligent cooperation. If the operation be made under local an- 
 esthesia, the posture of the patient immediately subsequent to the 
 
RHINOPLASTY 365 
 
 operation is easily indicated and maintained. When, however, 
 narcosis has been employed, the patient must of necessity be 
 placed in the dorsal decubitus for several hours until conscious- 
 ness returns. 
 
 Most persons who have been subjected to narcosis vomit. 
 The vomitus oozes through the nose and is likely to contaminate 
 the field of operation. Cases of this sort should be watched by 
 an efficient assistant, who, by careful attention to detail, removes 
 the vomitus from the region of the wound. When the vomiting 
 has ceased, the wound should be redressed, the nasal and oral 
 cavities thoroughly cleansed, and a fresh protective dressing ap- 
 plied. 
 
 In a considerable number of cases drainage tubes are placed 
 into the nostrils with a view of promptly removing contaminating 
 discharges from the area of operation. These are liable to be dis- 
 placed during vomiting, and should be replaced with sterile tubes 
 when this contingency arises. 
 
 After operations on the nose the sitting posture should be 
 maintained as soon as feasible for the purpose of facilitating 
 drainage. The quantity of nasal secretions is increased by the 
 presence of drainage material. If it be regarded necessary to 
 employ drainage tubes, an attendant should very frequently 
 cleanse the surface contiguous to the point of egress of these 
 agents. 
 
 During the waking hours the patient may be furnished with 
 a hand mirror and a basin of corrosive sublimate solution (1- 
 3,000). Small gauze sponges are placed in the corrosive sub- 
 limate, which the patient removes at frequent intervals and wipes 
 away the secretion. During the sleeping hours an attendant 
 should be available for this purpose. 
 
 The tubes are removed every twelve hours and replaced with 
 sterile ones. Tube drainage should not be maintained for longer 
 than three days for fear of pressure necrosis. Packing of the 
 nostrils for a protracted period of time should be avoided. In- 
 fection of the accessory sinuses and cavities may be the outcome 
 of firm packing permitted to remain in situ. Empyema of the 
 antrum of Tlighmore, and infection of the ethmoid and sphenoid 
 sinus may result if these precautions are disregarded. 
 
 In addition to this, the nasal cavities are gently lavaged from 
 
366 OPERATIONS OX THE FACE 
 
 behind with the syringe shown in Fig. 219, using a mildly anti- 
 septic solution for the purpose (potassium permanganate 1 in 
 1,000). Tension upon the sutures is relieved by immobilizing 
 the contiguous soft parts with adhesive plaster strips. These 
 should be gently removed daily and replaced with new ones. For 
 this purpose it is well to remember that rubber is soluble in ether, 
 and the plaster strips may be removed by the application of this 
 agent, thus avoiding unnecessary trauma to the wound and an- 
 noyance to the patient, which accompany the forcible removal of 
 the plaster. 
 
 The surroundings of these patients should be quiet with the 
 view of avoiding the muscular effort attendant upon conversa- 
 tion and laughter. 
 
 The postoperative diet need not be sterile in this class of 
 cases. However, as mastication calls for the use of muscles which 
 are attached to the field of operation, the diet should consist of 
 liquids taken through a tube or by means of the feeding cup for 
 several days after the operation. 
 
 The patient should be encouraged to sleep in the sitting post- 
 ure, a position easily maintained by means of the bed-rest. 
 
 It will be found advantageous to give attention to detail, the 
 neglect of which may determine the outcome. 
 
 OSTEOPLASTIC RHINOPLASTY 
 
 Osteoplastic rhinoplasty, such as the Koenig method, demands 
 patience in after-treatment. The bone flap may not unite pri- 
 marily, and, indeed, a portion of it may necrose. This does not 
 mean that a favorable outcome need be despaired of. A portion 
 of the flap, if it retain its vitality and become fixed in place, will 
 result frequently in a good cosmetic result, though at the time of 
 the healing process it looks anything but indicative of this out- 
 come. 
 
 In these cases the wound must be kept clean and the disin- 
 tegrated bone tissue gently removed. Forcible manipulation of 
 the parts at this time interferes with nutrition and should be 
 avoided. The use of strong antiseptic solution in this connection 
 is unwise. A mild solution of potassium permanganate (1 in 
 1,000) may be used. Exuberant granulations should be treated 
 
HARELIP AND CLEFT PALATE 367 
 
 with the nitrate of silver stick. Care should be exercised in ap- 
 plying the silver to avoid trauma to the white epithelial edge of 
 the wound. When a sinus persists, the pouting excrescent granu- 
 lation which frequently extrudes from the opening should be cut 
 away with fine scissors curved on the flat, and the bleeding surface 
 lightly touched with the caustic stick. The application of tinc- 
 ture of iodin into the sinus by means of a small cotton pledget 
 wound about the end of a slender probe will stimulate granula- 
 tions and destroy pyogenic organisms. The application may be 
 repeated every three or four days for several sittings. 
 
 Hydrogen peroxid should not be introduced into the nasal 
 cavities ; the effervescence may force infective material into the 
 accessory sinuses and the antrum. The essential factors in the 
 after-treatment of wounds in this situation are frequent cleansing 
 of the field with large quantities of mildly antiseptic solutions, 
 drainage, avoidance of meddlesome manipulations, and immobili- 
 zation of the apposed wound surfaces. 
 
 Resection of one or both superior maxilla?, invasion of the an- 
 trum of Higlimore, and accessory sinuses, such as the ethmoid, 
 sphenoid and frontal sinuses, demand practically the same after- 
 treatment described with rhinoplasty. The fact that attack upon 
 these parts involves invasion of the mouth, demands that this 
 cavity be given the same preparation described under the gen- 
 eral preparation for operations on the face. The administration 
 of sterile diet is essential in these cases. The reader is referred 
 to the discussion of this problem on page 430, et seq. 
 
 HARELIP AND CLEFT PALATE 
 
 Harelip and cleft palate cases are prepared for operation in 
 the same way as the cases discussed above. However, the pre- 
 cautions with respect to subsequent cleanliness and the avoidance 
 of unnecessary disturbance to the field contiguous to the wound is 
 especially emphasized at this time. The impracticability of ap- 
 plying a protective dressing which is efficient in these cases ren- 
 ders them difficult to manage. 
 
 In harelip cases Gerster advises against the application of a 
 cumbersome dressing and simply dusts the wound with iodoform 
 powder. This forms a paste when mixed with blood and secre- 
 
368 OPERATIONS ON THE FACE 
 
 tions, which, upon drying, makes an efficient protection to the 
 wound. Gerster also deprecates the employment of strips of ad- 
 hesive plaster intended to overcome tension. He regards their 
 presence, in infants, as irritating, causing the little patient to cry 
 and tear asunder the sutures. 
 
 In adults this does, of course, not obtain, and a small square of 
 iodoform gauze may be placed in contact with the skin wound and 
 held in place with plaster strips. The dressing must be changed 
 twice daily for the first three days. Thereafter a daily change 
 of dressing will suffice. Harelip pins should not be permitted to 
 remain in situ longer than seven days. At this time union in the 
 wound will have taken place, and the ulceration consequent upon 
 the presence of the pins will not have progressed sufficiently to 
 interfere with favorable ultimate cosmetic outcome. The apposi- 
 tion sutures may be removed at the same time. If catgut has been 
 employed for the latter purpose it will have undergone absorption 
 by this time. However, when it is borne in mind how much less 
 trauma attends upon the employment of very fine silk-worm gut 
 or horsehair, the use of catgut in this class of cases may be re- 
 garded as objectionable. 
 
 - In cleft palate it is, of course, impossible to apply the pro- 
 tective dressing. Especial care should, for this reason, be given 
 to the preparation of the mouth. The care of the teeth and the 
 thorough cleansing of the mouth with a solution of potassium 
 permanganate (1 in 1,000), frequently applied, should be indulged 
 in for several days before the operation. Hydrogen peroxid may 
 be used for the purpose, as the effervescence in the mouth is not 
 objectionable. 
 
 Articles of diet should be introduced by means of a sterile tube. 
 The food, which should be in liquid form, is sucked up through 
 the tube. However, in cases of harelip this effort makes demand 
 upon the muscles of the lips, and this is objectionable. In infants 
 it is wise to administer food through a catheter passed through 
 the nose, for two days following the operation. 
 
 Adults can be instructed to achieve the object without using 
 the lips. It will be found quite feasible to introduce the food into 
 the pharynx by manipulating the tongue against the palate and 
 holding the lips still. A sterile feeding cup answers the purpose 
 very well. The liquid is allowed to run into the mouth and is 
 
MISCELLANEOUS OPERATIONS IN MOUTH 369 
 
 readily swallowed without any effort upon part of the lips. In 
 this class of cases it is quite justifiable to administer atropin with 
 the view of lessening salivary secretion. The digestive function 
 of the saliva may well be dispensed with for the postoperative 
 period, and the diet may be restricted to articles which do not con- 
 tain large quantities of carbohydrates. The small quantity of 
 sugar contained in milk will be taken care of by the digestive secre- 
 tions in the intestinal canal, without the unimportant aid given by 
 the saliva. 
 
 After operations for cleft palate the sutures may remain in 
 place until the tenth day if no contraindication present. The ques- 
 tion of cosmetic effect, with respect to the stitch holes, does not 
 come into consideration in this situation. Especially is it wise 
 to keep the sutures in place for ten days or two weeks if the opera- 
 tion has comprehended invasion of the bone. 
 
 For the purpose of holding the bone in place, silver wire is 
 frequently used. This may be permitted to remain in situ for 
 several weeks without untoward manifestations arising, provided 
 a reasonable degree of attention be shown cleanliness. 
 
 Attention to detail, painstaking observation of the aseptic and 
 antiseptic methods of care of wounds, and sterilization of articles 
 of diet, are necessary to success in this class of cases. 
 
 MISCELLANEOUS OPERATIONS IN MOUTH 
 
 Removal of a part of or the entire tongue, resection of the oral 
 mucosa, excision of the inferior maxilla, and, indeed, other opera- 
 tions of greater or lesser magnitude which involve communication 
 of the wound surface with the mouth, call for the exercise of the 
 directions just offered. Intrabuccal removal of the tongue for 
 malignant disease is rarely limited to this step. The general 
 rule, that contiguous lymph glands should be removed at the 
 same time, frequently permits of the maintenance of dependent 
 drainage through the wound in the neck. This renders keeping 
 the mouth wound clean a comparatively easy matter. Drainage 
 in this way should be maintained until the mouth wound is quite 
 healed. 
 
 Resection of the tissues in the mouth for gumma, tuberculosis, 
 and benign neoplasms, such as racemose angiomata, do not com- 
 
370 
 
 OPERATIONS ON THE FACE 
 
 preliend opening of the neck in all instances. In these cases the 
 mouth is kept clean with some difficulty. However, persistent 
 
 cleansing, together with the precau- 
 tions mentioned, will obviate infec- 
 tion in the majority of instances. 
 
 It is true that the maceration 
 of soft parts consequent upon the 
 liberal use of solutions interferes 
 with healing, and that wounds 
 which are kept dry will unite pri- 
 marily in a short time. However, 
 the situation of the wound and the 
 contingencies to which it is exposed 
 modify the technic of postoperative 
 care in this situation. 
 
 For the purpose of cleansing the 
 mouth, the introduction of the dis- 
 infecting solution is best accom- 
 plished with the Janet-Frank syr- 
 inge, armed with a soft rubber tube 
 slipped over the metal terminal of 
 the instrument to avoid trauma to 
 the tissues. (Fig. 251.) If lavage 
 be made by means of a glass which 
 the patient rests against the lips, 
 the contact of the fluid with the 
 skin before it gains access to the 
 wound should be avoided. This is, 
 of course, a minor factor, yet if it 
 be true, as frequently stated in this 
 work, that infection is a question 
 of dosage, each avoidable dilution 
 of the germicidal quality of a 
 cleansing solution should be avoid- 
 ed. When cleansing the mouth the 
 patient is placed in the sitting posture, with the head bent forward 
 and the mouth held wide open. An assistant, or the patient, holds 
 a goodly-sized basin beneath the chin, and the surgeon, who is 
 seated on a low stool beside the patient, injects the cleansing solu- 
 
 Fig. 251. — Janet-Frank Syringe 
 Armed with Soft Rubber 
 Tube for Cleansing Mouth 
 after Operation. 
 
MISCELLANEOUS OPERATIONS IN MOUTH 
 
 371 
 
 tion from below (Fig. 252). The solution is thus permitted to 
 flow over the wound surface and is readily discharged, thus avoid- 
 ing forcing of secretions back into the pharynx. The necessary 
 amount of pressure is easily regulated. 
 
 A fountain syringe hung two feet above the level of the 
 patient's mouth will answer the purpose very well. In this event, 
 a number of glass nozzles are kept constantly submerged in a jar 
 filled with carbolic acid solution, and a new nozzle is used at each 
 
 Fig. 252. — Cleansing Patient's Mouth after Operation. 
 
 sitting. The advantage possessed by the syringe is that the so- 
 lution is less apt to become contaminated, as the hands come in 
 contact only with portions of the instrument not closely applied 
 to the wound. Between times the syringe is kept immersed in an 
 antiseptic solution. 
 
 Shreds of necrosed tissue are carefully removed with thumb 
 forceps. If a necrosed shred should be somewhat firmly attached 
 its separation may at times be achieved by a slightly more forcible 
 
 projection of hydrogen peroxid against the point of attachment. 
 26 
 
372 OPERATIONS ON THE FACE 
 
 After thorough cleansing, the wound surface may be lightly dusted 
 with iodoform powdei\ The offensive odor of this agent is very 
 disagreeable to patients. However, it is fair to say that noth- 
 ing will take its place, and its disagreeable qualities had best be 
 borne. 
 
 Iodoform poisoning is quite likely to occur when the agent 
 is used in the mouth, for obvious reasons. Bismuth cakes and is 
 not very effective. The use of corrosive sublimate solutions should 
 be avoided. 
 
CHAPTER XVIII 
 
 OPERATIONS ON THE NECK 
 
 Torticollis — Tuberculosis of cervical lymph glands — Operatians on larynx and 
 trachea : intubation of larynx ; tracheotomy ; laryngectomy ; thyroidect- 
 omy ; exothyreopexy ; drainage and packing of cysts of the thyroid ; 
 esophagotomy. 
 
 The preparation of the surface of the neck for operative attack 
 does not differ in any essential regard from that which obtains in 
 other situations. The preliminary care of the upper air passages 
 preceding attack upon the larynx and trachea is quite similar to 
 that employed in pre- 
 paring cases for opera- 
 tions involving the nose 
 and mouth (page 362). 
 The same conditions 
 obtain .with respect to 
 operations upon the 
 esophagus. The ques- 
 tion of diet is taken up 
 under discussion of gas- 
 trointestinal surgery. 
 
 TORTICOLLIS 
 
 The subcutaneous 
 division of the sterno- 
 mastoid has been quite 
 abandoned since the ad- 
 vent of asepsis. After 
 suture of the muscle by 
 the open method, the 
 
 Wound Of approach is FlG ' 253 ;-Leet Torticollis Showing Method 
 1 L or 1' ixing Head in the Over-corrected 
 
 closed with silk-WOrm Position after Operation. (Whitman.) 
 
 373 
 
374 
 
 OPERATIONS ON THE NECK 
 
 gut sutures and the neck im- 
 mobilized in the over-corrected 
 position (Fig. 253), using a 
 stiff bandage of starch or plas- 
 ter-of-Paris for the purpose. 
 The immobilization is main- 
 
 Fig. 255. — GHssoji's Sling for 
 Applying Counter Ex- 
 tension to the Shoulder 
 after Operation for Tor- 
 ticollis, (von Bergmann.) 
 
 Fig. 254. — Manipulation of Xeck and 
 Massage of Muscles after Oper- 
 ation for Torticollis, (von Berg- 
 mann.) 
 
 tained for fourteen days, when the 
 dressing is removed and the stitches, if 
 the j be of nonabsorbable material, re- 
 moved. If the catgut has been used the 
 sutures will have been absorbed by this 
 time. 
 
 The after-treatment consists of mas- 
 sage and passive motion destined to 
 overcome the malposition of the cer- 
 vical vertebra?. If this be not assidu- 
 ously carried out, the deformity is 
 liable to recur, or, at least, complete 
 correction will not be attained. The 
 method of massaging the neck muscles 
 and correction of the deformity is 
 shown in Fig. 25-i. The symmetrical 
 development of the muscles of the neck 
 and shoulder is conserved by the use of 
 a Glisson sling and counterweight held 
 in the hand. The opposite hand grasps 
 the handle of the pulley rope, and 
 the patient raises himself upward by 
 his own muscular efforts (Fig. 255). 
 
TUBERCULOSIS OF CERVICAL LYMPH GLANDS 375 
 
 These manipulations must be carried on for a long period of time 
 (months). In addition, the patient should be encouraged to in- 
 dulge in exercises designed to correct the deformity, such as sys- 
 tematic class exercises in a gymnasium or training in a military 
 school, where his pride and a desire to do as well as his comrades 
 will stimulate him to an erect carriage with the eyes directed 
 ahead. Rowing, boxing, fencing, and wrestling should be dis- 
 couraged until the deformity is quite overcome, on the ground 
 that the muscles previously overdeveloped might be strengthened 
 beyond the affected ones. The parent or friend can be easily 
 taught the proper kind of manipulations to employ. Patients 
 should not be permitted to carry out the after-treatment them- 
 selves. The stimulating effect of companionship and extrinsic in* 
 terest will do much to obviate neglect of the orders given. 
 
 TUBERCULOSIS OF CERVICAL LYMPH GLANDS 
 
 The preparation of the field of operation for removal of tuber- 
 culous lymph glands varies somewhat, depending upon whether 
 mixed infection, periadenitis, abscess and consequent sinuses exist. 
 In the simple, uncomplicated cases no special precautionary prep- 
 aration need be made, except that after the skin has been sectioned 
 it would seem logical that antiseptic solutions be used for lavage 
 of the deep wound. For the purpose, a solution of corrosive sub- 
 limate 1 in 2,000, liberally flowed over the field at frequent in- 
 tervals, is a useful measure. The wound is smeared with iodoform 
 powder and drainage established. The drainage material found 
 serviceable in this connection is silk-worm gut (Fig. 147), or at 
 times when there is a reasonable certainty that primary union will 
 be attained the catgut drain (Fig. 149) may be inserted. The 
 latter has the advantage that it need not be removed, and the 
 dressing need not be changed for eight or ten days following the 
 operation, at which time the sutures may also be removed. In 
 cases complicated by sinuses and mixed infection, the operative 
 field should be cleansed in the usual way and the skin anointed 
 with a 20 per cent, oleate of mercury, twice daily, for several days 
 before the operation. In other regards preparation of the opera- 
 tive field is the same as obtains in uncomplicated cases. 
 
 This method of prepa ration, together with excision of the 
 
376 OPERATIONS ON THE NECK 
 
 sinuses, and especial care with regard to the exercise of antisepsis, 
 have resulted in primary union in several instances at the hands 
 of the writer. 
 
 Drainage is, of course, established in this latter class of cases, 
 and the silk-worm gut or gauze drainage material employed. The 
 wound is dressed at the end of forty-eight hours and cleansed with 
 corrosive sublimate solution 1 in 2,000. The drain is removed 
 at this time and a smaller one inserted. Drainage may be dis- 
 pensed with' at the end of another forty-eight hours if there be no 
 indication to the contrary. Cleansing of the wound by the forcible 
 injection of hydrogen peroxid is especially dangerous in this situa- 
 tion, as the deep fascial spaces communicate with the mediastinum 
 and the two pleural cavities. • 
 
 The effervescence consequent to the use of this agent may force 
 fluids into these cavities. This applies also to the cleansing of 
 superficial wounds of the neck. The forcible injection of cleansing 
 fluids beneath the platysma may force its way beneath this muscle 
 to below the clavicle and down upon the anterior aspect of the 
 chest, where secondary infective foci have been known to develop 
 as the result. This is to be borne in mind with respect to early 
 drainage of suppurative inflammations in the neck, which, if per- 
 mitted to proliferate to a considerable extent, will follow the paths 
 indicated. 
 
 The constitutional after-treatment in these cases should be 
 directed toward the resumption of nutrition as soon as feasible. 
 As soon as postoperative vomiting and shock have been obviated, 
 the feeding by mouth may be cautiously begun. The writer 
 administers rectal feeding at the end of twelve hours if the 
 vomiting persist. The liability to infection is lessened by main- 
 taining the general tone. This is more essential in this class 
 of cases than obtains in patients not afflicted with an exhausting 
 disease. 
 
 When it is borne in mind that lung infection is a frequent, 
 and bone infection a not rare, coexisting condition in these cases, 
 the rationale of the proposition becomes apparent. The operation 
 itself is exceedingly exhausting because of the more or less severe 
 hemorrhage consequent to the attack of a region so largely sup- 
 plied 'with blood-vessels. If to this be added a period of post- 
 operative starvation, the liability to a sudden exacerbation of 
 
TUBERCULOSIS OF CERVICAL LYMPH GLANDS 
 
 377 
 
 latent tuberculous processes in other situations in the body becomes 
 a menace of considerable magnitude. 
 
 The patient should be set up in bed the day following the 
 operation and the bed wheeled into the open air. The former con- 
 serves drainage, the latter stimulates the desire for food, aside 
 from whatever therapeutic effect the inhalation of fresh air may 
 have. As soon as the digestive functions are reestablished, the 
 generally accepted method of feeding in tuberculosis should be 
 employed. 
 
 These cases for some reason frequently have tonsillitis follow- 
 ing the operation. This is 
 painful and interferes 
 with the taking of nour- 
 ishment. The writer finds 
 it useful to permit the pa- 
 tient to take cracked ice 
 at frequent intervals, and 
 in addition gives sodium 
 salieyl, gr. x, every two 
 hours for six doses, with 
 apparent benefit. As a 
 routine measure creosote 
 is given during the period 
 of convalescence. 
 
 When extensive resec- 
 tion of the tissues of the 
 neck up to the forman 
 jugularis and down to the 
 subclavian has been made, 
 the dressing is applied in 
 the manner shown in Fig. 
 256. Loss of sensation, 
 the result of the division 
 
 of sensory nerves, is a common sequel to this operation. Division 
 of the auricularis magnus paralyzes sensation in the external ear. 
 This, however, usually returns after several weeks, the function 
 being taken up by filaments from the fifth cranial nerve. The 
 loss of sensation in the skin of the neck is a small matter, and fre- 
 quently is not noticed by the patient. Division of the spinal ac- 
 
 Fig. 256. — Dressing for Extensive Opera- 
 tion on the Neck. (Gerster.) 
 
378 OPERATIONS ON THE NECK 
 
 cessory causes limitation of motion in the sternomastoid muscle. 
 This is at times distressing. Division of the cervicofacial para- 
 lyzes the angle of the mouth. This is only permanent in a small 
 percentage of cases. These facts are mentioned in this connection 
 with the view of obviating unnecessary concern to the patient. The 
 removal of neoplasms from the neck does not call for special prep- 
 aration nor after-treatment other than obtains in clean wounds in 
 other situations. The general principles are to be applied here 
 as previously discussed. 
 
 Immediately after the operation, and while the patient is still 
 partially narcotized, care should be taken to protect the protective 
 dressing from soiling with expectoration and vomitus. For this 
 purpose the attendant covers the dressing with a towel firmly 
 pinned about the neck and replaces it with a clean one as fre- 
 quently as necessary. W nen t ne nea( i is tossed about on the pil- 
 low the upper edge of the protective dressing is likely to be dis- 
 lodged, leaving a space between it and the skin. Foreign material 
 is quite liable to find its way under the dressing and come in 
 contact with the wound, if this obtain, unless the precaution men- 
 tioned is observed. 
 
 OPERATIONS ON THE LARYNX AND TRACHEA 
 
 The preparation of patients about to be subjected to opera- 
 tive invasion of the air passages through the neck involves much 
 the same preparatory steps, as described under operations on the 
 mouth (page 362). If the epiglottis is not removed the admin- 
 istration of articles of diet subsequent to the operation need not 
 be especially considered. In complete laryngectomy, including 
 removal of the epiglottis, it is best to administer sterile food, on 
 the ground that the tongue will not sufficiently protect the wound 
 surface from the entrance of foreign substances. 
 
 INTUBATION OF THE LARYNX 
 
 The treatment following intubation of the larynx relates 
 chiefly to the administration of food. When food gains access 
 to the larynx, coughing is provoked and the tube is expelled. This 
 is, perhaps, the greatest objection to employment of intubation. 
 
OPERATIONS ON THE LARYNX AND TRACHEA 
 
 379 
 
 O'Dwyer recommends placing the patient in the horizontal posi- 
 tion with the head hanging over the edge of the table or at- 
 tendant's knee, and feeding semisolid food with a spoon. The 
 position is shown in Fig. 257. The passage of a soft catheter 
 
 Fig. 257. — Method of Feeding Infant after Intubation. 
 
 through the nose or by the mouth into the esophagus is use- 
 ful, but the strangulation and gagging frequently dislodge the 
 tube from the larynx when the latter methods are attempted. 
 The fact that the laryngeal tube may be expelled at any time 
 calls for immediate availability of a skilled attendant to rein- 
 troduce it. 
 
 If a string has been left attached to the tube, the patient's 
 hands should be confined in such a way as to prevent its acci- 
 dental withdrawal. The tube should be changed at the end of 
 twenty-four to forty-eight hours. If dyspnea does not recur it 
 
380 
 
 OPERATIONS ON THE NECK 
 
 need not be reintroduced. However, it will usually be necessary 
 to maintain the intubation for three or four days. 
 
 The tube should not be left in situ any longer than is absolutely 
 necessary, to obviate pressure necrosis. While the use of anti- 
 toxin for the relief of diphtheria has made less frequent the neces- 
 sity for intubation, it is probably true that a case requiring in- 
 tubation will give obstruction symptoms for three days, even 
 though antitoxin be given. This is to be borne in mind in ar- 
 riving at a conclusion as to when the tube may be permanently 
 removed. 
 
 TRACHEOTOMY 
 
 The care of the patient subjected to tracheotomy is the same 
 whether the operation involves the high, low, or intermediate 
 method, and, indeed, whether the operation be done for the pur- 
 pose of relieving dyspnea or 
 as a preliminary step to 
 surgical invasion of the 
 pharynx, larynx, etc. The 
 tube most generally em- 
 ployed is the one known as 
 the Luer tube (Fig. 258), 
 which is a double one per- 
 mitting of removal of the 
 inner cannula for the pur- 
 pose of cleansing it. The 
 shield is furnished with two 
 slits which permit of the at- 
 tachment of tapes, by means 
 of which the cannula is held 
 in place. Fig. 259 shows the means of holding the apparatus in 
 place, and also shows the position the patient should be placed in 
 after the operation is completed. Tracheotomy done for relief of 
 obstructive inflammation requires assiduous attention to the de- 
 tails of after-treatment. The number and character of inspira- 
 tory efforts are the guide as to efficiency of the measure of relief. 
 The lumen of the cannula must be kept free at all times, and an 
 attendant must be constantly on watch in order to correct any fal- 
 lacy in this regard. 
 
 Fig. 258. — Liter's Double Tracheal, Can- 
 nula, (von Bergmann.) 
 
OPERATIONS ON THE LARYNX AND TRACHEA 381 
 
 When evidence of obstruction occurs the inner cannula is im- 
 mediately removed and cleansed by means of wet sterile gauze, 
 pushed through it with a bent probe. If the dyspnea is not re- 
 lieved by this means, the outer tube must be removed, cleansed, 
 and reinserted. The latter measure is rarely necessary. How- 
 
 Fig. 259. — Tracheotomy Tube in Place, and Position of Patient 
 after Tracheotomy, (von Bergmann.) 
 
 ever, it does at times occur that dried secretions accumulate over 
 the end of the outer tube, and these must be removed to free the 
 cannula. 
 
 One of the causes of unfavorable outcome following trache- 
 otomy is due to the absence of the normal amount of moisture 
 contributed to the inspired air in its passage over the mucosa of 
 nose, mouth, and pharynx. Moist air is an important means of 
 preventing the drying of secretions in the cannula. For the pur- 
 pose, the bed is covered with a hood and the bedclothes covered 
 with waterproof material. A croup kettle is located near the 
 bed with the nozzle led beneath the hood. Various medicinal 
 agents have been added to the water, which become vaporized 
 when the mixture boils and are supposed to contribute to the 
 beneficial effect of the moist air. It is probable that the latter 
 is the important consideration, though there is no objection to 
 
382 OPERATIONS ON THE NECK 
 
 the addition of medicinal agents, provided that some non-irritat- 
 ing substance be used. 
 
 If obstruction occur after the inner tube has been removed, a 
 soft catheter may be introduced through the inner tube and suc- 
 tion made with a syringe. This measure should not be employed 
 as a routine, but only in the event of the failure of the removal 
 of the inner tube to relieve the obstruction. 
 
 The entire apparatus should not be removed if avoidable for 
 three days following its introduction, i.e., until a distinct tract 
 has been formed in the wound. Reintroduction at an earlier 
 period may be attended with unsurmountable difficulties. In any 
 event, the patient must be postured in the same way as for trache- 
 otomy, and the edges of the tracheal wound held open with hooks. 
 If, for the reasons stated, the tube must be removed before a tract 
 has been formed, the same precautions must be taken. 
 
 When changing the tracheotomy tube no time must be lost 
 before the second one is introduced, as the tracheal wound con- 
 tracts very rapidly. For the purpose it is wise to introduce into 
 the wound at once a suitably sized rubber catheter and slip the 
 new tube into place over it. Ultimate decannulement should be 
 performed when the air passes freely through the larynx. The 
 average period when this can be done in cases of diphtheria is 
 from the sixth to the tenth day. When the tracheotomy has been 
 done as accessory to operations involving 
 the upper air passages, a shorter period of 
 time may be allowed to elapse. 
 
 Cannulas which have openings in them 
 are best used for this reason. This per- 
 mits of removal of the inner tube and its 
 replacement with an inner tube furnished 
 with an obturator. Fig. 260 shows a tube 
 which has been used by v. Brans for years. 
 
 Fig. 260. — Cannula Used j j 
 
 for Convalescents The inner tube is not pervious and reaches 
 after Tracheotomy, c^e^at beyond the outer one. This al- 
 
 {von Bergmann.) 
 
 lows the air to pass without difficulty, and 
 should the patient develop obstruction, it can readily be removed 
 and the pervious inner tube substituted. If the patient sleeps 
 quietly for two nights with the impervious tube in situ, the per- 
 manent decannulement may be made. 
 
OPERATIONS ON THE LARYNX AND TRACHEA 383 
 
 When the tube is permanently removed, the wound usually 
 closes in a few days. While the tube is in situ the skin contigu- 
 ous to the wound should be kept covered with 5 per cent, sterile 
 iodoform in vaselin to prevent excoriation and eczema, due to the 
 presence of secretions. 
 
 Following tracheotomy for removal of foreign body, the 
 elaborate after-treatment is regarded as unnecessary. In some 
 cases the tube is not introduced and the tracheal wound closed 
 with suture and the superficial wound drained. However, it is 
 recommended that if the tube be used, provision for moistening 
 the inspired air be made. It is a small matter, and may obviate 
 disagreeable if not dangerous complications. The use of a gauze 
 apron moistened with water and placed over the tracheotomy tube 
 opening is a procrastination, as it cannot fill the purpose. Em- 
 physema of the soft parts of the neck occurs when the tube is 
 dislodged from the trachea by coughing or as the result of un- 
 skillful manipulations on part of the attendant. The condition 
 itself is not serious, but may necessitate the secondary introduc- 
 tion of a longer tube which reaches beyond the tissues swollen by 
 the presence of air. This, of course, is likely to occur only be- 
 fore a canal has been formed by the tube, and argues for not 
 changing the tube for the first few days following the operation. 
 
 Pressure necrosis from the tube is a common complication. 
 A properly fitting tube tends to prevent this complication. When 
 ulceration occurs the mucus expelled from the tube is streaked 
 with blood. This should be regarded as evidence that the tube is 
 not appropriate for the case, and a proper one should be speedily 
 substituted. 
 
 After permanent decannulement the care of the wound is a 
 simple matter. The dressing is changed every other day until 
 healing takes place. At times a sinus leading to a necrosed area 
 of tracheal cartilage persists for a considerable period of time, 
 but this usually heals without interference. The healing may be 
 hastened by painting the sinus wall with tincture of iodin every 
 second day for several sittings. 
 
 LARYNGECTOMY 
 
 The high mortality rate following laryngectomy has been due 
 to infection, the result of the invasion of the stump of the trachea 
 
384 
 
 OPERATIONS OX THE NECK 
 
 by saliva and mucous secretions from the mouth and pharynx, 
 which are, of course, more or less infected with bacteria. The in- 
 fection extends to the lung, and a so-called deglutition or aspira- 
 tion broncho-pneumonia carries off the patient. While the modi- 
 fication of technic recently employed, which involves isolation 
 of the respiratory tract by fastening the stump of the trachea to 
 the skin, has quite eliminated this element of danger, septic cellu- 
 litis in the deep tissues of the neck, with extension to the medi- 
 astinal and pleural cavities, still remains as a menacing compli- 
 cation during the postoperative period. 
 
 When the tracheal stump is fastened to the skin by suture and 
 furnished with a suitable cannula (Fig. 261) the care of the pa- 
 tient is in all respects 
 similar to that de- 
 scribed under trache- 
 otomy, as far as modi- 
 fication of the inspired 
 air is concerned (page 
 381 et seq.) As far 
 as the infective com- 
 plications are con- 
 cerned, Bryant sug- 
 gests that the patient 
 be taught to swallow 
 
 while in the Trendel- 
 enburg position before 
 the operation is begun. 
 Patients afflicted with 
 disease calling for so 
 radical a measure as 
 complete laryngec- 
 
 Fig. 261. — Perier Cannula Used after Laryn- 
 gectomy, {von Bergmann.) 
 
 tomy will be found 
 willing to undergo the discomfort incumbent upon this training. 
 During this time the mouth and pharynx are frequently cleansed, 
 as already described (page 362). 
 
 The wound is usually only partially closed when the extent of 
 the disease has necessitated removal of the epiglottis and the mu- 
 cosa, rendering suture of the tracheal stump to the latter mem- 
 brane impracticable. In the former class of cases the danger of 
 
OPERATIONS ON THE LARYNX AND TRACHEA 385 
 
 infection is obviously greater than obtains in the latter. Imme- 
 diatedly after the operation the wound is packed with gauze, the 
 patient is placed in a position with the head dependent, to facili- 
 tate drainage, and the attendant frequently cleanses the mouth in 
 the manner described under operations in the latter situation. 
 
 Rectal feeding every sixth hour and saline enema every third 
 hour are employed. The gauze packing is changed twice or three 
 times daily. This latter step causes much discomfort if clumsily 
 executed, and the anticipation of the impending distress has an 
 exceedingly depressing influence upon the patient's general con- 
 dition. The suggestions already stated with regard to light pack- 
 ing and gentle removal of the gauze should be adopted. It is not 
 amiss to soak the gauze in sterile potassium permanganate and 
 change the packing before the moisture is sufficiently absorbed to 
 permit of agglutination to the surfaces of the wound. If, because 
 of excessive secretion, lavage of the wound surfaces is indicated, 
 the patient's head is still farther lowered and the cleansing is made 
 by introducing gently into the lower portion of the wound a sterile 
 soft catheter connected with a syringe. The apparatus shown in 
 Fig. 251 will be found serviceable for the purpose. The patient 
 holds the mouth over a basin and the fluid enters from below and 
 runs out above between the lips. If vomiting has occurred im- 
 mediately following the operation, the gauze should be removed 
 as soon as the vomiting ceases and lavage made in the manner 
 indicated. "When gastric alimentation is begun, sterile food is 
 administered by means of a sterile catheter passed into the 
 esophagus. 
 
 Following the third day after the operation the patient should 
 attempt to swallow small quan- 
 tities of sterile water. Moderate 
 pressure with the fingers against 
 the outer surface of the neck will 
 facilitate the effort, and, indeed, 
 the training the patient has had 
 in swallowing wdiile in the Tren- 
 delenburg posture will be found 
 to have been of value. 
 
 As regards the wearing of an „ ... „ . , . 
 
 Fig. 262. — Gussenbaiier s Artificial 
 
 artificial larynx, suturing in situ Larynx. (Bryant.) 
 
386 
 
 OPERATIONS ON THE NECK 
 
 of the trachea to the mucosa of the epiglottis, of course, does not 
 call for any apparatus, phonation being accomplished with the 
 tongue and lips. When the stump of the trachea is not fastened to 
 the skin, Gussenbauer s artificial larynx (Fig. 262) will he found 
 serviceable. This apparatus may form the basis of one which, 
 no doubt, will need some modification in construction to suit the 
 
 Fig. 263. — Gluck's Phonation Apparatus in Place. 1, Cup with Valve; 2, Voice. 
 
 {von Bergmann.) 
 
 individual case. When the stump of the trachea has been fastened 
 to the skin, a measure now quite universally employed, the ap- 
 paratus of Gliick (Fig. 263) has given satisfactory results. The 
 illustration explains itself. It may, however, be stated that only 
 a limited number of patients find the use of an artificial speaking- 
 apparatus of service. It is probable that an apparatus such as 
 
OPERATIONS ON THE LARYNX AND TRACHEA 387 
 
 Gluck's will be found the least objectionable. The other forms 
 of apparatus expose the patient to the entrances of pharyngeal 
 secretions into the air passage, a danger from which a valvular 
 attachment to the upper segment of the tube does not give security. 
 No effort should be made to introduce an apparatus until the wound 
 is quite healed, which requires between five and six weeks. 
 
 The posture maintained by the patient with the head lowered 
 should be insisted upon for at least five days following the opera- 
 tion. During the healing process the gauze packing will be found 
 to be slowly dislodged by the granulation tissue, and ultimately 
 only a small drain need be inserted into the lower portion of the 
 wound. This latter may be discontinued as soon as it is evident 
 that the deep wound is healed. Unnecessary prolongation of the 
 packing will cause the maintenance of a fistula, which may not 
 close for months. 
 
 Patients should be guarded against the entrance of dust into 
 the trachea when convalescence has been established. The wear- 
 ing of a gauze apron, held in place by tapes, will be found service- 
 able for the purpose. 
 
 THYROIDECTOMY 
 
 After either partial or complete thyroidectomy the persistent 
 oozing of blood usually requires tamponade of the wound for two 
 or three days following the operation. This is, of course, not 
 necessary in all cases, and, indeed, the wound may in some in- 
 stances be closed and dependent drainage made, which may be 
 removed in two days, if no evidence of infection develops. When 
 tamponade has been made the pressure upon the recurrent laryn- 
 geal nerve, the phrenic, the pneumogastric nerves, and the trachea 
 must be considered in connection with symptoms, the result of the 
 presence of the gauze. It is never necessary to make sufficient 
 pressure to produce modification of respiration from pressure on 
 the trachea, but heart symptoms and aphonia or hoarseness may 
 be produced, which might be regarded as the result of injury to 
 nerve fibers, which, as a matter of fact, soon clear up when the 
 tamponade is removed. Tamponade for the purpose of arresting 
 bleeding need not be left in situ longer than forty-eight hours, and 
 the tampon (preferably, for the purpose, the Mickulicz tampon 
 should be used) may then be removed. 
 27 
 
388 OPERATIONS ON THE NECK 
 
 At times a hematoma forms if the packing has been omitted, 
 which gives rise to pressure symptoms, though these disappear 
 when the blood clots are expressed or dislodged with a saline irriga- 
 tion or the same solution introduced through the drainage opening 
 by means of a syringe. At times a kinking of the atrophied 
 trachea, which latter condition is the result of prolonged pressure 
 on the trachea, causes severe dyspnea. This is corrected by ex- 
 tending forcibly the head and maintaining it persistently in that 
 position. 
 
 Dyspnea following thyroidectomy has been caused by the ac- 
 cumulation of saliva in the upper segment of the pharynx due to 
 paralysis of the esophagus. However, this condition of affairs 
 is exceedingly rare and may be obviated by lowering the head of 
 the bed, allowing thus of discharge of the saliva and its expulsion 
 from the mouth either by gravity or as the result of voluntary 
 ex23ectoration. 
 
 The rise of temperature following removal of the thyroid gland 
 is not necessarily ascribable to infection nor, indeed, to absorp- 
 tion of ferments. In almost all cases of thyroidectomy a sharp 
 pyrexia follows the operation. This disturbance of metabolism 
 has been attributed to absorption of portions of glandular elements 
 coming in contact with a large surface of tissue subjected to trauma, 
 and is clinically differentiated from the rise of temperature due 
 to infection, inasmuch as the latter (infection) is accompanied by 
 the concomitant symptoms due to the infection, such as increase of 
 pulse rate and the local symptoms of inflammation, pain, etc., 
 while the pyrexia due to absorption of glandular elements is a soli- 
 tary symptom not accompanied by the clinical picture, the out- 
 come of the invasion of bacteria. 
 
 Pneumonia occurs as a part of sepsis, but is also due to paralysis 
 of the larynx due to injury or pressure on the recurrent laryngeal 
 nerve. In the latter instance, the pneumonia may be regarded as 
 an aspiration pneumonia and belongs to the class of lung inflam- 
 mations following tracheotomy. Hoarseness or aphonia following 
 thyroidectomy is an indication for employment of the precautions 
 with regard to the inspiration of moist air, described under the 
 head of tracheotomy (page 381), and removal of packing or the 
 blood clots of a hematoma at as early a period as is consistent with 
 the other symptoms. If infection of the wound occurs, the care 
 
OPERATIONS ON THE LARYNX AND TRACHEA 389 
 
 and treatment of the wound is in all respects similar to that which 
 obtains in other situations of the body. It is well to reiterate iu 
 this connection that early drainage of the infected area is especially 
 indicated here because of the danger of rapid invasion of the 
 mediastinum and pleural cavities (page 376). 
 
 Tetany and chronic myxedema have been considered as two dis- 
 tinct afflictions following thyroidectomy and due to removal of the 
 gland. At this time they are regarded as degrees of the same 
 condition. 
 
 Acute myxedema is now quite rare, as experience has taught 
 that it may be prevented by leaving behind a portion of the gland 
 or an accessory gland. The symptoms of this condition appear 
 either immediately after the operation or may develop several days 
 later (up to the tenth day). Prodromal symptoms, such as re- 
 stricted motion or rigidity of the muscles of the extremities, occur. 
 Clivostelc's sign — that of a fulminating contraction of the face 
 following a tap over the facial nerve — or Trousseau s sign — that 
 of a spasmodic contracture of the muscles of an extremity follow- 
 ing pressure upon one of the main arteries or nerves supplying 
 the limb — together with the occurrence of the stiffness of the 
 muscles mentioned, may make the diagnosis easy. 
 
 As the affliction develops, the entire body becomes progressively 
 tetanic. There is little, if any, disturbance of temperature during 
 the attacks and the sensorium remains clear. The prognosis of 
 this condition is exceedingly unfavorable. It is worthy of note 
 that the intensity of the postoperative manifestations in this re- 
 gard bears a direct proportion to the amount of gland tissue left 
 in situ. 
 
 Chronic Postoperative Myxedema is manifested by diminished 
 mental activity and edematous swelling of the skin. For com- 
 plete description of the symptomatology, the reader is referred 
 to works on the principles of surgery. In this connection it is 
 proper to state that the clinical picture is the result of the ab- 
 sence or destruction of normal thyroid tissue, a deviation from 
 the original intent of this work justified by the fact that it is 
 this which presents the most important indication for postopera- 
 tive treatment. 
 
 Treatment of Tetany and Cachexia after Thyroidectomy.— As 
 already stated, the fact that, as a rule, the symptoms mentioned 
 
390 OPERATIONS ON THE NECK 
 
 do not occur when a portion of the gland is left behind points the 
 way with respect to treatment. It must be borne in mind that 
 the residual amount of glandular tissue may not suffice to fur- 
 nish the necessary elements to the processes of metabolism, and, 
 again, the character of the diseased process for which thyroid- 
 ectomy is undertaken may preclude leaving any of its tissue be- 
 hind, and, again, it is not impossible that the changes in the 
 gland may be such that the portion left behind does not func- 
 tionate sufficiently for the purpose. 
 
 It may be stated that the introduction of thyroid tissue into 
 the system obviates the occurrence of unfavorable manifestations. 
 The injection method, while effective, should only be employed 
 when the prodromic symptoms of tetany described above are 
 elicited, and the introduction by mouth of desiccated thyroid 
 extract, now obtainable in the market, should be used in all cases 
 whether symptoms arise or not. To summarize, inject extract of 
 thyroid if the entire gland has been removed and there be the 
 slightest indications of tetany. Give desiccated extract of thyroid 
 in all cases. When the acute symptoms of myxedematous tetany 
 subside, discontinue the injections and give the preparation by 
 the mouth. In all cases begin treatment as soon after the opera- 
 tion as possible, and maintain it for a long period of time. 
 
 If, by reason of the urgency of the indications, thyroid ex- 
 tract is introduced by injection, a long needle and roomy syringe 
 barrel should be used. The illustration shows an instrument 
 
 which is serviceable for 
 the purpose (Fig. 264). 
 The injection is prefer- 
 
 Fig. 264.— Record Syringe, Barrel of Ground ably made into the glll- 
 
 Glass with Metal Plunger and Long teal muscle The thv- 
 Needle; Useful for Deep Muscular In- . 
 
 jectioxs. r01 d extract is mixed 
 
 with sterile water, 
 using about five grains of the desiccated extract in a half dram 
 of water; this is sucked up into the barrel, and the needle is in- 
 troduced into the buttock before the connection is made. The 
 protruding portion is watched for hemorrhage, the absence of 
 which indicates that a vein has not been entered. The barrel is 
 now connected to the needle, and the injection slowly made. The 
 skin should be first wiped off with denatured alcohol. Local re- 
 
OPERATIONS ON THE LARYNX AND TRACHEA 391 
 
 action does not occur if these instructions are followed. The in- 
 jection may be repeated at six-hour intervals until the patient is 
 in condition to take the preparation by mouth. Tablets of five 
 grains each are taken after meals. The dosage varies with the in- 
 dications, being increased, if necessary, to fifteen grains three 
 times daily. This dose may give rise to cardiac disturbances 
 (tachycardia), demanding reduction in the size of the dose. The 
 treatment must be carried on for years unless a regeneration of 
 the portion of gland left behind becomes commensurate with the 
 demands of metabolism. Interruption of the treatment is invari- 
 ably attended with return of symptoms, which promptly disap- 
 pear upon renewal of the administration, unless the conditions 
 just mentioned obtain. 
 
 It is generally regarded wise to limit the amount of meat 
 taken by the patient. This should involve no special hardship, 
 and while its rationale is not clearly apparent, the precaution is 
 advised on general principles. 
 
 EXOTHYROPEXY 
 
 Exothyropexy {Jaubolay, Poncet, Berard) is not generally 
 employed. It consists of delivering the thyroid out of the super- 
 ficial wound and permitting it to strangulate. The after-treat- 
 ment does not differ from that of thyroidectomy except that the 
 temperature symptoms are more marked, and that, for obvious 
 reasons, infection is more liable to obtain. The exposed goiter 
 must be dressed every day. The first few days after the opera- 
 tion the gland discharges copious amounts of clear fluid (goiter 
 sweats). This necessitates more frequent changing of dressings. 
 The method is not regarded as a desirable one. 
 
 DRAINAGE AND PACKING OF CYSTS OF THE THYROID 
 
 Drainage and packing of cysts of the thyroid are practiced 
 when the neoplasm makes pressure. The measure is used upon 
 elderly persons in whom the radical excision is contraindicated. 
 
 Simple drainage does not often achieve obliteration of the 
 sac. The drainage material is left in situ until forced out by the 
 proliferating scar tissue. 
 
 Packing more frequently achieves the purpose. The packing 
 
392 OPERATIONS OX THE NECK 
 
 is changed every second day. Care must be taken to obviate the 
 occurrence of infection. The cavity may be syringed out with a 
 mild solution of iodin, a few drops to the pint of water, with 
 the view of stimulating repair and preventing infection. At 
 longer intervals the cavity may be painted with the pure tincture 
 of iodin, though this had best be done after considerable con- 
 traction of the cyst cavity has taken place. The injection of 
 hydrogen peroxid is permissible, with the view of facilitating re- 
 moval of the gauze tamponade, as the cyst does not communicate 
 with the deep fascial spaces of the neck. If the cyst extends to be- 
 hind the sternum, care should be exercised with respect to the ac- 
 cumulation of cleansing fluids in its dependent portion, as forc- 
 ible tamponade may rupture the cyst wall and distribute the 
 contents into the mediastinum. Especially should this be guarded 
 against if suppuration occurs. In the latter instance the cyst 
 should be emptied by suction with a syringe connected to a soft 
 rubber catheter, which is introduced through the wound. There- 
 after gauze wick drainage should be introduced well to the bottom 
 of the poststernal cavity, and the end of the drain should be per- 
 mitted to escape beside the tamponade occupying the rest of the 
 cavity. Entire obliteration may ultimately be obtained in this 
 way. When total excision of thyroid cysts has been accomplished 
 the after-treatment does not differ in any essential regard from 
 that described under thyroidectomy. 
 
 ESOPHAGOTOMY 
 
 Cervical esophagotomy does not call for special local prepara- 
 tion. The fact that the manipulations are carried on contiguous to 
 the apparatus employed for narcosis suggests that provision should 
 be made for sterile narcosis (page 311). The administration of 
 sterile diet, while indicated, is probably not applicable, as the 
 operation is usually undertaken to overcome obstruction, a con- 
 dition which, of course, precludes the introduction of food. 
 Rectal alimentation should be maintained until just before nar- 
 cosis is begun. The last enema may contain stimulants which 
 are designed to combat shock. The usual preparations for the 
 hypodermic administration of stimulants should be made, espe- 
 cially as the exhaustion due to lack of proper nourishment pre- 
 disposes to collapse. Thirst is a marked symptom of esophageal 
 
OPERATIONS ON THE LARYNX AND TRACHEA 393 
 
 obstruction. A high saline enema given soon after the operation 
 will tend to overcome this distressing manifestation. Introduc- 
 tion of food with the stomach tube may be begun forty-eight hours 
 after the operation, though care must be taken to sterilize the 
 tube and to introduce it with gentleness, especially if an effort 
 has been made to obtain primary union in the esophageal wound. 
 The introduction of food into the stomach should not be begun 
 until a reasonable certainty exists that the postoperative vomiting 
 has ceased. It is obvious that soiling of the wound surfaces with 
 the contents of the stomach is objectionable. 
 
 The care of the wound after esophagotomy varies slightly with 
 regard to whether the esophageal wound has been closed by su- 
 ture or not. It is probable that complete closure of the wound is 
 unwise. Contamination during the operation may be avoided, 
 but, as already stated, the vomited matter which is almost invari- 
 ably discharged after an operation is likely to infect the wound. 
 In some instances the wound in the esophagus is closed and the 
 wound in the neck freely drained. In either case cleansing of 
 the wound should be practiced at the end of the postoperative 
 vomiting, with the view of lessening the chances of infection. 
 
 If the esophageal wound has been left open this step would 
 seem very necessary, which, indeed, is the case. However, on 
 the other hand, the fact that the wound is open will permit of 
 more satisfactory cleansing, and the attendant has more assur- 
 ance that infective material is not so likely to burrow in the deep 
 fascial spaces. It is a good rule in surgery to provide for free 
 access to surfaces which are liable to infection or are to be sub- 
 jected to manipulations. If the esophageal wound has been 
 closed, the presence of minute portions of material which may 
 have leaked into the surrounding tissues may escape notice and a 
 fallacious complacency be engendered which may lead to unfa- 
 vorable results. It is also well to bear in mind that saliva is more 
 or less continuously passed down the esophagus, and this con- 
 stitutes an element of danger in the respect mentioned. In order 
 to lessen the infective character of the saliva, frequent liberal 
 lavage of the mouth with boric acid or similar solution should 
 be made. The patient will regard the latter measure as a very 
 satisfying one, as thirst, if not relieved by it, is less distressing 
 because of it. 
 
394 OPERATIONS ON THE NECK 
 
 The initial dressing should not remain in situ more than 
 twenty-four hours, even though vomiting does not occur, and, 
 indeed, cleansing of the wound should be done twice daily for four 
 days after the operation, reeding with liquid food may be car- 
 ried out at each dressing, and all foreign matter removed from 
 the wound immediately thereafter. The liquid food should be 
 sterile (page 430), for obvious reasons. 
 
 The wound in the esophagus heals usually in ten days. The 
 administration of solid food should not be begun until there be 
 reasonable assurance that the esophageal wound is closed. 
 
CHAPTER XIX 
 
 OPERATIONS ON THE THORAX 
 
 Excision of the Breast — Thoracotomy — Thoracoplasty — Decortication of the 
 Lung — Resection of Large Surfaces of the Thoracic Wall — The Deformity. 
 
 EXCISION OF THE BREAST 
 
 The special local preparation for excision of the breast relates 
 to shaving the axilla and thoroughly cleansing of the skin of the 
 thorax, neck and arm of the patient- 
 Excision of the breast for malignant disease contemplates re- 
 moval of tissues, including the lymphatics concerned in draining 
 the mammary gland, a procedure involving invasion of large 
 areas of tissue, a factor which calls for especial care in the ob- 
 servance of antiseptic precautions before, during, and after the 
 operative procedure. As hemorrhage is likely to be severe dur- 
 ing the operation, a liberal number of gauze sponges and a large 
 number of towels should be available. 
 
 When the excision is followed by complete closure of the 
 wound the local after-treatment does not differ from that em- 
 ployed elsewhere, except that retention sutures (page 215), Figs. 
 179 to 184) are frequently introduced. 
 
 Drainage from the dependent portion of the wound, which 
 corresponds to the lower part of the axillary flap, is also intro- 
 duced in the majority of cases, the withdrawal of which is gov- 
 erned by the same rules applied elsewhere (page 186). In this 
 situation the oozing of blood may obstruct the drainage tube, and 
 while the dressing should not be unnecessarily disturbed, it should 
 be changed at the end of twenty-four hours if there has been much 
 oozing immediately subsequent to the operation, with the view of 
 removing the tube and reestablishing its patency when it may be 
 again introduced, or better still a fresh tube may be inserted in 
 its place. The wound may then be redressed and the subsequent 
 
 395 
 
396 
 
 OPERATIONS ON THE THORAX 
 
 changes of dressings be governed as to frequency by the indica- 
 tions, as already stated. After radical excision for malignant 
 disease of the breast, the wound presents the appearance shown 
 in Fig. 265. The drainage tube is seen to emerge from an in- 
 cision made at the dependent portion of the subcutaneous wound, 
 through the latissimus dorsi muscle. The retention sutures held 
 by buttons are also shown. If, however, it has been impossible 
 
 Fig. 265. — Appearance of Wound after Excision of Breast. (Gerster.) 
 
 to bring into apposition the edges of the wound because of the 
 involvement of large surface of skin, a portion of the wound is 
 left to heal by granulation. This calls for slightly different 
 measures in the after-treatment. 
 
 It is believed by some observers that malignant disease recurs 
 more frequently after operations when the ultimate repair is at- 
 tended with healing by granulation and suppuration than obtains 
 if primary union follows the operation. A discussion of the cell- 
 ular activity consequent to the formation of granulation tissue 
 does not belong here. It is mentioned, however, to emphasize the 
 need of preventing infection in the care of wounds which heal by 
 granulation. The surface not covered by skin is lightly packed 
 with iodoform gauze, and this is changed at intervals of forty- 
 eight hours. Each dressing is made under strict aseptic precau- 
 
EXCISION OF THE BREAST 
 
 397 
 
 tions, the field being surrounded with sterile towels and the at- 
 tendant prepares the hands and instruments in the usual manner. 
 When the granulations have reached the skin level, the treatment 
 of the wound should not be left to the patient, but the precau- 
 tionary measures mentioned must be persisted in until the wound 
 is entirely closed. The healing process will be conserved by 
 strapping the wound with adhesive plaster, which is affixed in 
 such a manner as to draw the edges of the raw surface together. 
 The adhesive strips should not cover the entire surface of the 
 wound, but should leave sufficient space on either side to permit 
 of drainage. 
 
 The Dressing. — A liberal amount of fluffed gauze should be 
 placed next the wound (Fig. 188) to absorb the discharges, 
 which in these cases, as already stated, is likely to be consider- 
 able in quantity. The method of holding the protective dressing 
 in place varies at the hands of the operator. The immobilization 
 of the arm contiguous to the operation conserves repair and re- 
 laxes tension. On 
 the other hand, this 
 method of bandag- 
 ing causes disuse, 
 atrophy, and par- 
 tial, more or less 
 persistent ankylosis 
 of the shoulder 
 joint and favors 
 cicatricial contrac- 
 tion, which ulti- 
 mately limits the 
 amount of motion 
 in the limb. 
 
 For this reason 
 it is best not to 
 attempt a display 
 of the art of band- 
 
 aging, but to re- 
 tain the protective 
 dressing with a 
 
 sort of "cui- 
 
 Fig. 266. — Cuirass to Hold Dressings in Place after 
 Removal of Breast, (von Bergmann.) 
 
398 OPERATIONS ON THE THORAX 
 
 rass," which permits of free motion of the limb. The kind of 
 retention dressing which is of great service in this connection 
 is shown in Fig. 266. It will be seen that the retention appara- 
 tus covers entirely the field of operation including the subcla- 
 vian triangle, which latter is frequently invaded in operations 
 of this sort. It also covers the insertion of the major pectoral 
 muscle and at the same time allows of free motion of the arm. 
 In addition to this, the " demi-waist " is fastened behind and 
 presents a smooth surface in front, a factor which contributes to 
 its serviceability to a not inconsiderable degree. This demi-waist 
 is readily made by a seamstress or an adroit nurse, and is con- 
 structed of unbleached muslin. It is best furnished with tapes 
 set closely together, which are attached behind and permit of 
 some elasticity with regard to adjustment. Safety pins are apt 
 to exert uncomfortable pressure when the patient is in the supine 
 position. 
 
 During the postoperative period it is well to encourage the 
 patient to use the arm as much as is consistent with comfort, 
 though no such effort before the sixth day should be encouraged. 
 After this time passive motion while the wound is exposed should 
 be made, and later, at the beginning of the tenth or twelfth day, 
 the patient should begin making muscular efforts. 
 
 If the postoperative course is uncomplicated, the drainage 
 may be permanently removed on the fourth day after the opera- 
 tion. The retention sutures should be taken out on the seventh 
 day, and the apposition sutures removed on the tenth day. If 
 infection has occurred, the retention sutures are left in situ and 
 the apposition sutures removed as the indications arise, remov- 
 ing those which interfere with thorough lavage and cleansing of 
 the wound. The retention suture may remain in place for four- 
 teen days when infection has occurred, with the view of obviat- 
 ing gaping of the wound surfaces. 
 
 The treatment of an infected case does not vary from that of 
 those cases which did not permit of complete closure of the wound 
 at the time of the operation. Radicalism with regard to free in- 
 cision and dependent drainage should be observed. The attend- 
 ant need hardly fear on the side of the latter proposition. It is 
 to be borne in mind that a large surface of the body has been sub- 
 jected to trauma, and that a considerable area of wound surface 
 
THORACOTOMY 399 
 
 is in a condition to present an avenue of absorption for the prod- 
 ucts of infection, and that systemic invasion is exceedingly liable 
 to occur. For this reason the admonitions just presented are 
 submitted. 
 
 THORACOTOMY 
 
 The special preparation for thoracotomy should take cogni- 
 zance of the fact that narcotics have a depressing influence upon 
 respiration, and that the oxygenation of the circulating fluid is 
 already seriously embarrassed because of the condition for which 
 thoracotomy is undertaken. The attendant should have a tank 
 of oxygen close at hand and be prepared to make artificial respi- 
 ration. For the latter purpose the Fell-O'Dwyer apparatus, as 
 modified by Fell, will be found useful. (Described on page 409 
 et seq.) Embarrassing complications may be avoided if this ap- 
 paratus be at hand. 
 
 The patient should be postured in such a manner as to allow 
 of free expansion of the sound side of the thorax. The narcosis 
 should be limited to as short a period of time as possible, and all 
 preparation for operating should be made, with the view of ob- 
 viating delay. 
 
 Simple incision of the intercostal space for drainage of the 
 pleural cavities does not permit of the ready removal of fibrinous 
 exudates, nor does it allow of prolonged maintenance of drain- 
 age, for the reason that as the chest wall contracts an over-riding 
 of the ribs contiguous to the incision and closure of the wound is 
 likely to occur. However, the measure is employed in children 
 and feeble persons, and with care in the after-treatment the wound 
 may be kept sufficiently patent to achieve sufficient relief to, per- 
 haps, permit of more radical measures at a later period. 
 
 After the incision has been made, an ordinary large-sized 
 metal tracheotomy tube (Fig. 258) is introduced into the pleural 
 cavity and fastened with tapes about the chest. The tube may 
 be cut off at its intrathoracic end to suit the purpose. Care 
 should be taken to see that the plate guard of the tube lies flat 
 upon the thorax. A rubber tube may be passed through the metal 
 one for purposes of drainage or suction. The metal tube should 
 be removed only at long intervals if at all, as the ribs will en- 
 croach upon the space at once when it is withdrawn. The after- 
 
400 
 
 OPERATIONS ON THE THORAX 
 
 treatment following this method of drainage is in all respects 
 similar to that employed following resection of a rib. Fig. 267 
 shows the tracheotomy tube in situ held by tapes. 
 
 Fig. 267. — Method of Drainage of Pleural Cavity after Simple Thoracotomy. 
 
 Excision* of part of a rib permits of more liberal drainage 
 and removal of fibrinous exudate. After discharge of the con- 
 tents of the pleural cavity, tnbe drainage is introduced and 
 
 the distal ends of 
 the wound closed 
 by suture. Silk- 
 worm gut sutures 
 are most commonly 
 employed for the 
 purpose, for reasons 
 already indicated 
 with regard to in- 
 fected wounds. 
 When the operation 
 is finished, the wound presents the appearance shown in Fig. 
 268. 
 
 The dressing should consist of a large quantity of antiseptic 
 gauze, preferably fluffed (Fig. 188), as this form of dressing- 
 enhances absorption of the discharges. The dressing should be 
 changed every day for several weeks, and may then be changed 
 
 Fig. 268. — Wound with Drainage Tubes after 
 Thoracotomy. {Bryant.) 
 
THORACOTOMY 
 
 401 
 
 every forty-eight hours. Care must be exercised in manipulat- 
 ing the drainage tubes, that they do not slip into the pleural 
 cavity, and in each instance the safety pin should be affixed, as 
 shown in the illustration, to prevent this accident between dress- 
 ings. 
 
 The after-treatment of thoracotomy for purulent pleural in- 
 flammation is a long and tedious procedure. Favorable outcome 
 is only to be expected as the result of patient application of meas- 
 ures of relief. Drainage should be maintained until the dis- 
 charge ceases, or at least until only a serous exudate small 
 in quantity persists, which is the result of the presence of the 
 tube. Too early interruption of the drainage will result in clo- 
 sure of the superficial opening and reaccumulation of the 
 exudate. When the tube is removed, it is best to place into 
 the opening several strands of silk-worm gut (Fig. 147), which 
 may be gradually lessened in number until final healing takes 
 place. 
 
 Aspiration with drainage following thoracotomy promotes ex- 
 pansion of the lung and obliteration of the empyemic cavity. 
 J. D. Bryant has devised an apparatus for this purpose which 
 
 Fig. 269. — Bryant's Aspiration Apparatus. A, Hollow rubber 
 cushion; B, Distended rubber bag; C, Stopcock; D, Glass 
 observation tube. 
 
 has proven of singular service in cases under the observation of 
 the writer. The apparatus (Fig. 269) is described in the lan- 
 guage of its inventor. 
 
402 OPERATIONS ON THE THORAX 
 
 The end of the tube projecting beneath the cushion (a) is passed 
 into the empyemic cavity the proper distance, and the cushion (a) 
 is placed in contact with the wall of the thorax in such a manner as 
 
 Fig. 270. — Aspiration of Pleural Cavity. A, The glass observa- 
 tion tube, showing suction force applied by syringe. {Bryant.) 
 
 to command equally the area surrounding the opening into the pleural 
 cavity. The nozzle of an ordinary syringe is then inserted into the 
 distal end of the tube (Fig. 270), the liquid withdrawn, followed 
 
 Fig. 271. — Aspiration of Pleural Cavity. A, Segment of glass tube. Cavity 
 aspirated and stop-cock closed to prevent admission of air. (Bryant.) 
 
THORACOTOMY 
 
 403 
 
 finally by sufficient exhaustion of air to cause the rubber cushion to 
 fit closely enough to the chest wall to prevent the passage of air beneath 
 it into the pleural cavity. The stop-cock is then closed (Fig. 271), 
 the syringe removed, and the nozzle of the rubber bag (Fig. 271), while 
 fully collapsed, is inserted firmly into the open end of the tube (Fig. 
 272), the stop-cock reversed, thus establishing aspiration, which is 
 
 Fig. 272.- — Aspiration of Pleural, Cavity. The Collapsed Rubber Bag At- 
 tached and Stop-cock Opened. A, Glass observation tube; the apparatus in 
 action. (Bryant.) 
 
 maintained so long as the bag is expanding. The chest is then dressed 
 and the apparatus duly fastened into place as indicated in Fig. 273. 
 The patient can go about comfortably with the apparatus in action 
 without attracting special attention. When the bag is nearly dis- 
 tended, the stop-cock should be closed, the bag cleansed, again col- 
 lapsed, reapplied and the stop-cock opened. 
 
 If brisk and forcible aspiration by the syringe be made, the tube 
 will collapse (Fig. 270), and often the discharge will be tinged with 
 blood, which can be noted through the glass segment of the tube. 
 Continuous and mild aspiration is safer and quite as effective as the 
 vigorous, in the vast majority of instances. Tbe degree of distention 
 of the bag should be frequently observed in order that it may be 
 removed, cleansed, and reapplied without interruption of aspiration. 
 Adhesive plaster applied to the chest around the opening aids in the 
 exclusion of air. Absorbent cotton, thoroughly wet with boric-acid 
 28 
 
404 
 
 OPERATIONS ON THE THORAX 
 
 solution, or rubber tissue hinders the passage of air beneath the 
 cushion. It is very important in this connection to remember that 
 the cotton, or any small movable body, may be drawn into the chest 
 unless care be exercised. Should this happen it can be removed quite 
 readily in most instances by moving around in the cavity the inner 
 end of the tube while making suction on the outer with the syringe. 
 
 In the cases to which aspiration has been applied it acted effi- 
 ciently and promptly, and was easily managed by the patient. 
 
 It seems to the writer that practicable aspiration offers the oppor- 
 
 Fig. 273. — Aspiration of Pleural Cavity. A, Glass observation tube. The dress- 
 ing applied; apparatus held in place by safety pins while in action. (Bryant.) 
 
 tunity of prompter cure in excision cases, and not impossibly may 
 render needless the more serious methods of practice by obviating the 
 conditions that prompt their use. Much contention has arisen in 
 the past regarding its feasibility. The writer notes with regret the 
 seemingly strenuous tenor of these contentions. Cases complicated 
 with gangrene of the lung and abundant fibrinous deposits are cer- 
 tainly unsuited for the immediate use of aspiration treatment. 
 Eepeated experience with the simple portable apparatus devised by the 
 author since the writing of the preceding clause has not in any degree 
 lessened his belief in its efficiency, in suitable cases. On the contrary, 
 the rapidity with which, in nearly every instance, the size of an 
 empyemic cavity has been reduced by this simple method of aspira- 
 tion emphasizes its worth in limiting the often tedious course of this 
 affection in a most decided manner. Xow we, in nearly every instance, 
 
THORACOTOMY 405 
 
 introduce the tube into the cavity as soon after resection or simple 
 incision as will permit of the tissues being sufficiently tightly drawn 
 around it with adhesive strips to prevent the entrance of air from with- 
 out. Sometimes over these adhesive strips, aseptic absorbent cotton, 
 wet with boric-acid solution, is packed and confined in place with ad- 
 hesive strips, before air can be excluded, when suction is applied. In 
 such cases care must be taken to prevent air from forcing fragments 
 of cotton into the cavity. The apparatus has proven decidedly effi- 
 cient in those cases from which fibrin had been removed or in which 
 not enough was present to obstruct the tube ; also, in which the walls of 
 a small cavity or of a sinus were not obstructed from suction. The hol- 
 low rubber cushion (Fig. 269, a) is not so secure as the use of adhe- 
 sive strips. In many instances a glass chamber has been substituted 
 for the glass tube (a) and the fluids collected therein as they were 
 withdrawn by the rubber bag. In two instances the tube was inserted 
 through a cannula deposited between the ribs by means of a fitting 
 trocar, the cannula being removed as soon as the tube was in place. 
 In those instances the tissues pinched the tube closely, especially when 
 suction was applied, and easily excluded the admission of air. The 
 influence of force of aspiration on the dimension of a cavity is best 
 appreciated by occasional measurement through the agency of water, 
 introduced into it with the body always in the same posture. Both 
 antiseptic and aseptic flushings are employed when indicated. 
 
 By the apparatus one can determine the presence of minute lung 
 perforations, as then a vacuum is not maintained. 
 
 Dr. Bryant informs the writer that he has quite abandoned 
 the use of the rubber cushion in these cases, as it is difficult to 
 obtain symmetrical application of the rubber to the chest wall be- 
 cause of the irregularity of the outline of the latter. In most 
 cases he introduces the intrathoracic portion of the tube, packs 
 the wound and surrounding tissues with absorbent cotton, and 
 seals the surface with collodion. This measure is very effective 
 and may be substituted for the rubber cushion if the latter be 
 found defective in the regard mentioned. Also, it will not be 
 always convenient to obtain the rubber cushion at short notice, 
 and the measure just discussed may be employed until an espe- 
 cially constructed cushion is made, which should, of course, be 
 fitted with the view of obviating the objection mentioned. If 
 a special cushion be made for each case its use should be found 
 effectual for the purpose. The objection, on the other hand, to 
 
406 OPERATIONS ON THE THORAX 
 
 the cotton and collodion seal is that it is removed with difficulty 
 when the wound is to be cleansed. In this connection the at- 
 tendant is asked to bear in mind that ether will dissolve the mix- 
 ture, and its removal will be much aided by its use. 
 
 It should also be borne in mind that the most dependent por- 
 tion of the pleural sac is posteriorly and inferiorly, and that 
 thoractomy is never, if ever, done at this aspect of the chest wall. 
 Thorough emptying of the empyemic cavity is never achieved 
 except as the outcome of suction, and when the dressing is 
 changed, whether the aspiration apparatus has been employed or 
 not, a rubber tube of sufficient length to reach the bottom of the 
 cavity should be introduced and the contents removed by suction. 
 When flushing is employed, the lavage should be made with ample 
 provision for* return flow, in order to obviate respiratory disturb- 
 ance from pressure of the cleansing fluid on the lung. 
 
 The cleansing fluid should have a temperature of 105° F., 
 and be introduced with the precautions mentioned. For the pur- 
 pose Thiersch' s solution or a normal saline solution, giving due 
 attention to sterility of the agent, may be used. Solutions of 
 corrosive sublimate or carbolic acid should never be employed 
 except in chronic inflammatory conditions which have been freely 
 exposed by thoracoplasty (page 407). 
 
 After the return fluid is clear the irrigation is suspended, the 
 cavity is completely emptied by suction, and the aspiration ap- 
 paratus reapplied. It is preferable to have the patient in the 
 supine position during the lavage. However, when suction is 
 made for the purpose of completely emptying the pleural sac, 
 the patient may be sat up in order to cause gravitation of the 
 fluid contents to the most dependent portion of the cavity and 
 thus permit of its complete removal. During the latter act due 
 care should be exercised to obviate syncope, as lavage of the 
 pleural cavity is not infrequently attended by considerable shock 
 to the patient. Under no circumstances should hydrogen peroxid 
 be used in this class of cases, for obvious reasons. 
 
 THORACOPLASTY 
 
 The resection of a greater or lesser amount of contiguous ribs, 
 with the view of giving relief of chronic inflammatory conditions 
 
THORACOPLASTY 407 
 
 of the pleura, does not necessarily involve the use of the agents 
 to obviate interference with respiration, as is the case in opera- 
 tions for more acute processes. This is, perhaps, due to the 
 fact that rarely, indeed, is the entire pleural sac involved, and, 
 as a rule, compensatory dilatation of the opposite air cells 
 has produced a certain respiratory balance. It is wise, how- 
 ever, to be prepared for the emergencies in even this class of cases 
 (page 399). 
 
 After completion of the resection the wound, as a rule, is left 
 open and the residual cavity packed with iodoform gauze. The 
 gauze is removed at the end of twenty-four hours and the cavity 
 lightly packed, this procedure being repeated every second day 
 until obliteration of the cavity takes place. As in these cases 
 there is ample provision for egress of cleansing agents, hydrogen 
 peroxid may be used for the purpose, and, indeed, its employ- 
 ment is advised, with the view of loosening the gauze which, in 
 some instances, becomes adherent to the pleura. The cavity may 
 be irrigated with either corrosive sublimate (1-5,000) or carbolic 
 acid 1 in 200 solution. In those cases in which the pleura is 
 much thickened the surface of the cavity may be painted with 
 tincture of iodin with the view of giving rise to moderate in- 
 flammation and to stimulate the deposit of scar tissue. This may 
 be repeated every' four days. 
 
 As expansion of the lung in these cases is not to be expected, 
 and obliteration of the cavity is achieved as the outcome of col- 
 lapse of the chest wall, the latter should be encouraged by strap- 
 ping the chest with moderate pressure. The irrigation of the 
 cavity should be done with large quantities of solution, the tem- 
 perature of which should be about 105° F. The employment of 
 warm solutions has a tendency to obviate the shock attendant 
 upon manipulations in this situation. As the cleansing is made 
 every two days, or possibly oftener, the repeated manipulations 
 are likely to exhaust the patient. A Kelly pad (Fig. 13, page 
 49) may be slipped under the patient and the surrounding sur- 
 face of the body protected with blankets, and, indeed, the tech- 
 nic of the procedure should be designed to obviate, as much as 
 possible, discomfort and annoyance to the patient. As soon as it 
 is feasible, the patient should be placed in the open air and the 
 over feeding begun. This is exceedingly important, as not a 
 
408 OPERATIONS ON THE THORAX 
 
 small number of those afflicted with chronic inflammatory con- 
 ditions of the pleura are tuberculous. 
 
 As soon as convalescence is established breathing exercises 
 and gymnastics should be indulged in. The tendency toward 
 lordosis may be in a measure overcome by the employment of 
 these measures. The application of apparatus designed to cor- 
 rect deformity of the spine must be postponed until the wound 
 is healed. On the whole, the wearing of apparatus to overcome 
 spinal deformity in these cases is of little service unless supple- 
 mented by rational gymnastics. 
 
 DECORTICATION OF THE LUNG 
 
 Decortication of the lung and removal of the parietal pleura 
 limiting the empyemic cavity calls for the same preparation as 
 obtains with the procedures just discussed. As, however, re- 
 moval of the pyogenic membrane contemplates expansion of the 
 lung and closure of the wound in the chest wall, the after-treat- 
 ment differs, inasmuch as simple drainage is introduced and the 
 measures designed to promote expansion of the lung are assidu- 
 ously practiced early in the postoperative care. Packing is, of 
 course, omitted. The measure has not been sufficiently tested 
 to permit of a conclusion with regard to its practicability. 
 
 RESECTION OF LARGE SURFACES OF THE THORACIC 
 
 WALL 
 
 Resection of large surfaces of the thoracic wall and invasion 
 of the pleural cavities for disease in these situations, other than 
 inflammatory conditions of the pleural sac, differ with regard to 
 the problem presented inasmuch as in the latter class of cases the 
 lung is already collapsed or displaced to an extent commensurate 
 with the extent of the affliction, while in the former class of cases 
 the lung is still in contact with the thoracic wall, and invasion of 
 the pleural sac or lung produces a sudden collapse of the lung, 
 and death from embarrassment of the respiratory function is 
 likely to occur. The deformity following attack of the thoracic 
 wall for disease of the pleura is the result of collapse of the chest 
 wall. In instances in which the thoracic wall is opened for the 
 
RESECTION OF LARGE SURFACES OF THORACIC WALL 409 
 
 relief of disease of the lung itself, healing takes place without 
 marked deformity. Fig. 274 shows a case in which extensive 
 resection of the chest wall was made for gangrene of the lung. 
 It will be seen that there is no collapse of the chest wall and that 
 no spinal deformity has occurred. This applies with equal force 
 to surgical invasion of the lung tissue itself. Certain diseases of 
 
 Fig. 274. — Appearance of Chest Following Extensive Resection 
 of Ribs, Including Clavicle for Gangrene of the Lung. 
 (von Bergmann.) 
 
 the lung are regarded as amenable to surgical treatment, and the 
 attendant is expected to have in readiness apparatus which will 
 obviate the danger of collapse of the lung. 
 
 The following description is taken from a communication to 
 Dr. J. D. Bryant from the originator of the apparatus, Fell 
 (Fig. 275), who has improved the original apparatus in the 
 following way : 
 
 The apparatus which I have used and found so efficient in cases 
 
410 
 
 OPERATIONS ON THE THORAX 
 
 of forced respiration (Fig. 276) consists of a bellows (a), the size 
 of which has been determined by my experience. It is operated as 
 follows : Three movements for inspiration and three for expiration. 
 
 Fig. 275. — The Fcll-O'Dwyer Apparatus in Action, Showing the Bellows, As- 
 sorted Sizes or Intubation Cones, and the Conductor. An intubation cone of 
 suitable size is pressed into the larynx so as to prevent the escape of air between it 
 and the laryngeal wall. The bifurcated arrangement of the conductor regulates 
 the amount of air introduced by means of the thumb acting as a valve at the point 
 of escape. (Bryant.) 
 
 This will produce eighteen or twenty respirations per minute when 
 worked at a convenient rate of speed. The attempt to operate it so 
 that a single movement represents an inspiration would almost cer- 
 
RESECTION OF LARGE SURFACES OF THORACIC WALL 411 
 
 tainly defeat the purpose for which the apparatus is intended. The 
 anesthetic can be administered by placing a sponge or gauze, prop- 
 erly saturated with the anesthetic, over or in proximity to the open- 
 
 Fig. 276. — Forced Respiration, Fell's Improved Apparatus. A, Bellows; B, Air 
 valve; C, Face mask. (Bryant.) 
 
 ing through which the air enters the bellows. A simple arrangement, 
 constructed on the principle of the chemist's wash bottle, by means 
 of which oxygen can be made to pass through a tube into the air valve, 
 thence with the anesthetic into the lungs, can be attached. This 
 device, along with that for mingling oxygen 
 with the inspired air, makes a complete outfit 
 for the purpose. Next to the bellows is the air 
 valve (b) with which it is arranged to act. The 
 operator presses down the piston of the valve 
 a full stroke during three movements of the 
 bellows, thus causing inspiration by permitting 
 the air saturated with the anesthetic to enter 
 the lungs through any one of the selected 
 channels, i.e., the face mask (c), the intuba- 
 tion cone (Fig. 275), or the tracheotomy tube 
 (Fig. 277). The piston is then released until 
 three movements of the bellows are made, 
 which permits expiration to occur. Before the 
 operation is begun the mask should be snugly 
 
 fitted to the face to prevent any uncertainty in this respect. If, 
 during inspiration, it does not fit so that the cheeks may bulge 
 
 Fig. 277. — The Tra- 
 cheotomy Tube and 
 Rings Used in 
 Forced Artificial, 
 Respiration, Fell's 
 Method. (Bryant.) 
 
412 OPERATIONS ON THE THORAX 
 
 without air escaping by the side of the mask, its action cannot be 
 attained. Frequently a pad or folded handkerchief placed over the 
 bridge of the nose will secure a tight fit. If an intubation tube be 
 employed, a rubber tube from the air valve can be connected with the 
 former and good inflation can be secured, provided that the end of 
 the tube is of proper size to fit the trachea. My best results in long- 
 continued respiration have been secured by means of tracheotomy and 
 the occluding of the trachea with a suitably sized ring screwed to the 
 end of the tracheotomy tube (Fig. 277). But for operative work on 
 the thorax, the other methods appear to be better suited. The size 
 of the bellows and the manner of its operation should be suited to the 
 requirements of individual cases, i. e., one movement for inspiration 
 and one for expiration in a child, two movements for inspiration and 
 three for expiration in a youth, and three for inspiration and the same 
 for expiration in an adult will usually suffice. 
 
 Various cabinets have been devised for the purpose, one of 
 which has been extensively used by Mikulicz. These appara- 
 tuses are cumbersome and difficult to manage. Their employ- 
 ment in well-equipped hospitals is found of use. Under ordi- 
 nary conditions the Fell apparatus will be found to quite meet 
 the indications. It is advised that in all operations contemplat- 
 ing invasion of the pleura and lung and, indeed, the medias- 
 tinum, this apparatus be available, and that it be employed in 
 the class of cases alluded to above. With regard to the invasion 
 of the mediastinum, indeed, in sectioning the sternum this ap- 
 paratus should be available, as the relationship of the pleural 
 cavities to the mediastinum is so atypical as to, in almost all in- 
 stances, render their puncture exceedingly liable. Quite invari- 
 ably surgical wounds of the pleural sacs and lungs are treated by 
 the open method. In a few instances, such as decortication of 
 the lung and parietal pleura, and in the rare instances where 
 malignant disease of these parts is attacked, the operation is fol- 
 lowed by closure of the wound in the thoracic wall and establish- 
 ment of drainage. The admonitions with regard to the postopera- 
 tive care of these cases, as stated above, should be assiduously 
 regarded. The attendant should, for obvious reasons, be pre- 
 pared to overcome shock. Accidental infection should be care- 
 fully guarded against during the postoperative care of the wound, 
 as the pleural sacs are large lymph spaces from which absorption 
 
THE DEFORMITY 
 
 413 
 
 of infective material readily takes place. The infective process 
 calling for surgical interference has, in many instances, already 
 been taken care of by the tissue changes attendant upon the in- 
 flammatory process. The surgical trauma is quite likely to open 
 additional avenues for the entrance of infection, and the newly 
 introduced infection may be of a character which the resistance 
 of the patient may not be sufficient to combat. 
 
 It is a not uncommon error for practitioners to regard the 
 fact that empyema is an infective process as making asepsis or 
 antisepsis an unnecessary indulgence. The writer warns against 
 action in accord with this belief, on the grounds stated. 
 
 THE DEFORMITY 
 
 The deformity following resection of the thoracic wall has al- 
 ready been alluded 
 
 to. 
 
 Fig. 278 shows 
 
 a not uncommon ul- 
 timate o u t c o m e . 
 This may be, to a 
 considerable extent, 
 prevented by gym- 
 nastics. The patient 
 should be instructed 
 to take breathing 
 exercises and to un- 
 dergo exercises with 
 pulleys designed to 
 obviate the spinal 
 curvature. The ex- 
 ercises should not be 
 sufficiently arduous 
 to involve dyspnea, 
 though increase in 
 the number of respi- 
 rations is beneficial. 
 If the p a t i e n t be 
 compelled to earn his 
 livelihood while 
 
 Fig. 278. 
 
 -Deformity Following Extensive Resec- 
 tion of Rius. (von Berc/mann.) 
 
414 OPERATIONS ON THE THORAX 
 
 seated at a machine or desk, the chair he occupies should be fitted 
 with a slanting seat, so arranged as to carry the curve of the spine 
 toward the afflicted side. Women should be encouraged to wear 
 corsets which do not take the place of muscular effort. If, for 
 cosmetic reasons, the patient be found intractable in this connec- 
 tion, a few hours a day should be occupied without the presence 
 
 Fig. 279. — Retraction of Flap Following Thoracoplasty, (von Bergmann.) 
 
 of the corest. In all cases the general tone of the patient should 
 be brought to as high a level as is feasible by attention to diet, the 
 administration of tonics, creosote and fat emulsions. The admin- 
 istration of iodin seems to be of benefit. A mixture of syrup of 
 the iodid of iron in an emulsion of the mixed fats has proven of 
 apparent benefit. The causative factor which produced the con- 
 dition calling for operative relief is, of course, the most determin- 
 ing prognostic element. However, even in tuberculous processes, 
 a favorable ultimate outcome will not infrequently prove sequen- 
 tial to painstaking attention to details in the after-treatment. 
 
THE DEFORMITY 415 
 
 Following thoracoplasty by the flap method the cavity left 
 beneath the flap, not having any osseous wall, contracts and bulges 
 with deep respiration or coughing. This has been regarded as 
 the outcome of distention or collapse of the lung (Figs. 279 and 
 280). 
 
 Fig. 280. — Bulging of Flap Following Thoracoplasty, (von Bergmann.) 
 
 The entrance and expulsion of air is, however, not the causa- 
 tive factor in this regard. The bulging may be produced by 
 keeping the glottis open and making pressure upon the abdominal 
 wall in an upward direction. 
 
 The phenomenon need not be regarded as rendering exercise 
 of the respiratory function dangerous. During muscular exer- 
 tion the patient may best be protected from unnecessary strain 
 upon the weakened thoracic wall by wearing a firm pad over the 
 site of the thoracotomy. The retraction of the flap is, perhaps, 
 of minor importance, and it is probable that if any unfavorable 
 outcome is to be apprehended, it is from the bulging. The pre- 
 caution mentioned has a tendency to obviate these contingencies. 
 
CHAPTER XX 
 OPERATIONS ON THE SPINAL COLUMN 
 
 Laminectomy — Tuberculosis osteomyelitis of the spine. 
 
 LAMINECTOMY 
 
 Laminectomy, or perhaps more properly stated, resection of 
 the vertebral arches, for the purpose of attacking the spinal canal 
 does not call for especial preparatory measures beyond those given 
 in connection with operations in other situations. Host afflic- 
 tions of the spinal cord calling for operative intervention are at- 
 tended with certain trophic changes in the portions of the body 
 located below the seat of disease, and special measures in after- 
 treatment must be carried out to obviate determining complica- 
 tions. The trophic changes spoken of have, too, an influence in 
 the character of the healing process in the wound, and drainage 
 is usually made of wounds in this situation. Immediately after 
 the patient is operated upon, he should be placed on a water bed. 
 It is, of course, quite impossible to obviate absolutely all press- 
 ure on the v\-omi(l. but this should be aimed ,at, and the patient 
 postured on the side as soon and as long as is possible. For the 
 purpose the attendant must, during the period of semi-conscious- 
 ness immediately following the operation, be watc-hful and pa- 
 tient, and not leave the patient until intelligent cooperation may 
 be expected. The patient will, no doubt, be willing enough to 
 carry out instructions designed to obviate pressure upon the 
 wound, but as operations on the spinal cord are usually performed 
 at a time when paralysis exists, he may not be in a position to 
 do so. 
 
 A lateral position should not be maintained for more than 
 three hours, and the patient should then be rolled carefully over 
 and so lifted as to avoid trauma to the wound. Each morning 
 the patient should be bathed with tepid water and sponged with 
 
 416 
 
LAMINECTOMY 417 
 
 alcohol. The occurrence of bed sores is a very likely complica- 
 tion following the operation, and this should be avoided. It is 
 to be borne in mind that alcohol does not act specifically as a 
 preventative of bed sores, and the attendant must not be content 
 with simply sopping the alcohol on the skin. Alcohol simply 
 cleanses and perhaps stimulates nutrition in the skin. The most 
 effective preventative of bed sores is frequent change of posture, 
 assiduous attention to cleanliness, and gentle massage of the skin. 
 The tendency to contractures and posture deformities must be 
 combated by passive motion of all the limbs, especially the lower 
 ones. Immobilization of the limbs with the view of preventing 
 deformity is unwise as ankyloses which are very obstinate are 
 likely to occur. The bladder demands special care. As a rule, 
 afflictions of the spinal cord are attended with paralysis of the 
 bladder. This results in overdistention and overflow, the urine 
 dribbling constantly into the bed. These patients are reported 
 to the attendant as incontinent, and unless investigation is made, 
 the bladder is left filled and the urine undergoes decomposition, 
 causing cystitis. The bladder mucosa becomes severely in- 
 flammed and in some instances sloughs from pressure. The re- 
 sult is that fetid urine is discharged, which soaks the bedclothes, 
 and the patient is left lying in the putrid pool at times for hours. 
 Catheterization of the bladder in these cases should be done every 
 six hours following the operation and twice daily after the third 
 day following the operation. Special precautions should be taken 
 to prevent infection of the bladder or urethra during the manip- 
 ulations, as they must, most likely, be carried on for a long pe- 
 riod of time. Infection would make the catheterization a diffi- 
 cult problem. 
 
 In some instances, when the bladder is unable to hold any 
 urine whatever, it is best to introduce the " mushroom " reten- 
 tion catheter (Fig. 354). The bladder should not be irrigated 
 unless infection occurs. However, it is not probable that cystitis 
 will be avoided when the retention catheter is employed ; so in 
 these instances lavage of the bladder, once daily with a mild so- 
 lution of potassium permanganate (1 in 1,000), should be prac- 
 ticed. For the purpose no undue force should be employed in 
 injecting the fluid, and no more than six ounces of fluid pro- 
 jected into the bladder at one time, when it is immediately al- 
 
418 OPERATIONS ON THE SPINAL COLUMN 
 
 lowed to run out. In these cases no residual cleansing fluid is 
 permitted to remain in the bladder. The mushroom catheter 
 should be removed at the end of twenty-four hours, and the 
 urethra cleansed by the Janet-Chetwood method (page 584"). Ure- 
 thritis and its complications may be avoided in this way. An- 
 other retention catheter is introduced and the one removed is 
 sterilized and kept submerged in sterile water until it, in turn, 
 is introduced at the next sitting. The distal end of the catheter 
 is connected, by means of a glass tube, with a long rubber tube, 
 which is led into a bottle partially filled with a solution of car- 
 bolic acid 1 in 100. The bottle is affixed to the side of the bed. 
 
 This measure is far more satisfactory than placing a recep- 
 tacle between the patient's legs to receive the end of the catheter. 
 These receptacles will be upset and the bed soiled, and, again, 
 the posture of the patient is much more readily varied if the 
 measure suggested is employed. Incontinence of feces is a much 
 more difficult problem than that of urine. The character of the 
 food should be such as not to produce liquid stools, and a daily 
 saline enema should be given. The latter cleanses the lower 
 bowel, and in this way the leakage of feces may be. in a measure, 
 controlled. The administration of cathartics should be avoided, 
 and if constipation alternate with diarrhea, the saline irrigation 
 will be found to serve the purpose in each instance. The anus 
 should be cleansed with tepid water applied with cotton to avoid 
 the irritation produced by the usual materials employed for the 
 purpose. 
 
 It will be seen that the execution of the measures here sug- 
 gested will demand almost continuous attention to the patient. 
 This is true, and, indeed, it is suggested that operative attack 
 upon the spinal cord should not be undertaken unless the condi- 
 tions can be made to conform to the necessities. Celiotomy and, 
 indeed, many other major operations do not always demand spe- 
 cially skilled after care, though, indeed, this should be obtained 
 when feasible. With operations on the spinal cord, the proposi- 
 tion is constantly and invariably a complicated one, and they 
 should not be undertaken except in well-appointed quarters. 
 
 The care of the wound following laminectomy is quite similar 
 to that following operations in other portions of the body. As 
 already stated, the nutritive changes in the soft parts, the out- 
 
LAMINECTOMY 419 
 
 come of injury to the trophic centers in the cord, renders primary 
 union in the wound quite unlikely. In any event, free drainage 
 should be established. If the subdural space has been invaded, 
 free discharge of cerebrospinal fluid occurs, and this must not 
 be permitted to soil the dressing for any considerable period of 
 time. In this event the dressing should be changed twice daily 
 or more frequently if necessary, the number of changes of dress- 
 ing in the day being regulated by the amount of discharge of 
 fluid. As stated in connection with the discharge of cerebro- 
 spinal fluid following invasion of the brain and its membranes, 
 it is best to protect the wound with an antiseptic protector. For 
 the purpose the layer of gauze remote from the wound may be 
 of the kind impregnated with corrosive sublimate, iodoform, vio- 
 form, etc. The layer of gauze nearest the wound should not be 
 medicated for fear that dermatitis may occur as the result. The 
 skin in this situation is, indeed, most likely to develop inflamma- 
 tion for the reasons stated above. 
 
 Textile fabric drainage in the form of the " cigarette drain " 
 (Fig. 154) is perhaps the most useful agent for the purpose, 
 though silk-worm gut (Fig. 147) may suffice in some instances. 
 The wound is best held in apposition by silk-worm gut sutures, 
 for the reasons already frequently discussed in this work. 
 
 Laminectomy for fracture of the vertebras contemplates re- 
 moval of the offending fragments of bone. Necrosis of bone does 
 not frequently follow the operation, as the vertebra? are amply 
 supplied with blood. However, it does occur, and the complica- 
 tion must be borne in mind with the view of determining the time 
 when the drainage agent may be permanently removed. The 
 necrosis is likely to be only superficial, but will, nevertheless, 
 give rise to a rather brisk reactionary inflammation if opportu- 
 nity for free egress be not made. In this class of cases it is, 
 therefore, best to maintain drainage for two weeks following the 
 operation, and the sutures may be left in situ for the same period 
 of time. The textile fabric drain, if employed, may be removed 
 on the fifth day following the operation, and for the remaining 
 portion of the two weeks mentioned silk-worm gut drainage may 
 be used. If at the end of this period of time there be no evidence 
 of dead bone, the drain may be removed. If, however, the dis- 
 charge from the drainage wound take on the characteristic 
 29 
 
420 OPERATIONS ON THE SPINAL COLUMN 
 
 " prime-juice " character, indicative of dead bone, the drainage 
 must be maintained until the discharge takes on the character- 
 istics of clear serum, when the drain may be removed. 
 
 TUBERCULOUS OSTEOMYELITIS OF THE SPINE 
 
 Tuberculous osteomyelitis of the spine is subjected to sur- 
 gical attack when so-called cold abscess forms, or when a puru- 
 lent infection is superadded to the tuberculous process. The 
 operation consists usually of simple drainage of the abscess cavity, 
 though in some instances free incision and packing of the wound 
 is employed. It is, perhaps, permissible to stretch the scope of 
 this book sufficiently to state that the latter method of relief is 
 the wiser. Simple incision and drainage, the valvular approach, 
 and similar measures of relief are all procrastination. No patho- 
 logical process is benefited by anything so much as by its radical 
 removal. If this be feasible it should always be done. 
 
 Cold abscess usually points at the space of Petit, though al- 
 most any portion of the back may be the site of its local manifes- 
 tation in a certain small percentage of cases. After the abscess 
 has been freely incised and its walls curetted, the cavity is packed 
 with iodoform gauze in the manner shown in Fig. 223. This 
 packing is left in situ for forty-eight hours, when it is removed 
 in the manner already described in connection with the treatment 
 of infected wounds. 
 
 It must be remembered that tuberculous osteomyelitis of the 
 spine has its primary focus almost invariably in the body of the 
 vertebrae, and that an attempt to obtain communication with the 
 seat of the bone infection should be made. For the purpose a 
 strip of the gauze packing should be carried well down toward 
 the body of the vertebra?, with the view of supplying an avenue 
 of escape for the necrosed bone and inflammatory discharges. 
 After the wound takes on a healthy appearance, the spine should 
 be immobilized in a plaster-of-Paris jacket and a window cut in 
 it corresponding to the site and area of the wound. As the dis- 
 charge from the wound is liable to find its way between the skin 
 and the plaster cast, the wound must be dressed every day and the 
 edges of the plaster cast contiguous to the wound protected with 
 oil silk. 
 
TUBERCULOUS OSTEOMYELITIS OF THE SPINE 421 
 
 As soon as the spine is immobilized, the patient is permitted 
 to go about or at least is wheeled into the open air in a chair. 
 !No attempt should, however, be made to send the patient to re- 
 mote health resorts unless he be attended by some one skilled in 
 the care of the wound. An added infection, suppurative in char- 
 acter, is exceedingly undesirable at this time, for obvious reasons. 
 The usual dietary treatment used in tuberculosis must be em- 
 ployed, and this begun as soon after the operation as is feasible. 
 Prompt immobilization of the spine, as indicated, will tend to 
 obviate the distressing deformity which is so largely the sequel 
 of this affliction. 
 
 As tuberculosis of bone is quite constantly an expression of 
 tuberculosis elsewhere, an attempt should be made to locate the 
 port of entrance of the infection, and this should be subjected to 
 appropriate treatment. 
 
 Above all cases of this sort must not be confined to bed any 
 longer than is absolutely necessary Immobilization of the spine 
 is quite feasible very soon after the operation, the window used 
 for the local treatment of the wound being in no wise an inter- 
 ference in this connection. 
 
 If it be necessary to cut away considerable areas of the jacket 
 with the view of obtaining the necessary amount of room for 
 proper care of the wound, the jacket may be reinforced at its 
 lateral sides by burying strips of galvanized steel in the layers of 
 the plaster-of-Paris bandages. 
 
CHAPTEE XXI 
 
 OPERATIONS ON THE ABDOMEN 
 
 Celiotomy — Special preparation of the gastrointestinal canal — Sterile diet — 
 Drainage — Closure of abdominal wound — Drainage of superficial wound — 
 The protective dressing — After-treatment following celiotomy. 
 
 CELIOTOMY 
 
 Celiotomy is at the present time so frequently performed that 
 a few additional remarks with regard to the special preparation 
 of patients about to be subjected to surgical invasion of the peri- 
 toneal sac seem justified. It is true that recent investigations 
 tend to prove that the peritoneum is not as vulnerable with re- 
 spect to infection as was formerly believed, and this is ascribed 
 to the fact that this membrane represents a lymph space and con- 
 sequently is regarded, in the light of the function of the lym- 
 phatic system, as capable of causing certain modification in the 
 constituents of pyogenic material which renders toxic effects less 
 liable so far as the blood is concerned. It must be remembered, 
 however, that a too great complacency in this connection is a 
 dangerous viewpoint to take regarding the problem, and one 
 which is to be deprecated. 
 
 It is, indeed, true that purulent collections which have been 
 in contact with restricted areas of the peritoneum for a consid- 
 erable period of time will not, upon liberation and contact with 
 contiguous portions of the peritoneum, give rise to additional in- 
 fection. Yet there is no means of ascertaining at the time of the 
 operation whether the infectiousness of the process has been ex- 
 hausted or whether sufficient virulence is still present which, 
 when the new field of invasion presents, may develop a seriously 
 menacing inflammation. Clinically it not seldom happens that 
 the invasion of the female pelvis for relief of pyosalpinx of long- 
 standing, which involves soiling of the peritoneum with pus, is 
 
 422 
 
CELIOTOMY 423 
 
 followed by an acute septic peritonitis and death under condi- 
 tions which makes infection from without during the operative 
 procedure exceedingly improbable, and must be ascribed to that 
 contamination from the suppurative process which had been lo- 
 cally confined and mechanically walled off by adhesive peritonitis 
 when brought in contact with heretofore uninfected areas. 
 
 The accidental introduction of infection, while objectionable 
 in all portions of the body, is not as frequently followed by se- 
 vere symptoms, death, and serious sequels as obtains in the peri- 
 toneal sac. The rules laid down above should be carefully fol- 
 lowed with the view of avoiding these contingencies. Celiotomy 
 made with the view of invading the lumen of the gastrointestinal 
 tract calls for additional preparation, which will be presently 
 taken up. In this connection it is proper to state that invasion 
 of the lumen of the gut means contamination of the operative 
 field to a greater or lesser degree in all instances. A slight 
 amount of infective invasion will be taken care of by the natural 
 resistance of the peritoneum. The technic of asepsis should, 
 therefore, be directed toward limiting the infective possibilities 
 to the unavoidable amount, and for this reason each step of the 
 preparation for operation should be subjected to painstaking di- 
 rectorate to this end. The situation may be illustrated by the fact 
 that an appendectomy, which involves but a meager solution of 
 continuity of the gut, is more liable to be followed by infection 
 than a hysterectomy for a large fibroid tumor. Clinical experi- 
 ence will be found to bear out this statement. Practitioners who 
 remove tumors from the abdomen in country practice and con- 
 tend that infection does not complicate their cases should bear 
 in mind that their results are not so favorable in cases when the 
 gut is opened. The contention that asepsis need not be so as- 
 siduously employed in the country, on the ground that septic 
 bacteria do not exist largely in less closely populated districts, 
 can, of course, not include in this belief the Communis coli, which 
 is the normal resident of the gastrointestinal canal even in the 
 arctic regions, where sterility as regards infective bacteria is quite 
 commonly found to exist. 
 
 In a general way, it may be said that celiotomy should not be 
 made without forty-eight hours' preparation of the patient, if 
 this be consistent with the indications. Invasion of the gastro- 
 
424 OPERATIONS ON THE ABDOMEN 
 
 intestinal canal should be preceded by preparation extending 
 over four days if the conditions warrant this delay. Observance 
 of these admonitions will be found to conserve most the best in- 
 terests of the patient as regards immediate and ultimate outcome 
 of surgical intervention in this situation. 
 
 The primary incision, which sections the skin and muscle to- 
 gether with their fascial inclosures, should be made with instru- 
 ments which are then discarded and replaced by fresh ones. For 
 this purpose the knife and scissors should be duplicated. Ample 
 provision should be made for gauze packing, and a large number 
 of abdominal pads (Fig. 23, page TO) should be provided. 
 These — the pads — should be counted and their number recorded 
 for comparison before the abdominal wound is closed, to prevent 
 the accidental retention of a pad in the abdomen, an occurrence 
 which, unfortunately, is not uncommon. The same rule should 
 be applied to instruments, especially artery forceps, all of which 
 should be accounted for before the peritoneal sac is sutured, in 
 accord with the original tabulation recorded before the opera- 
 tion. A copious saline lavage should be provided for, and the 
 paraphernalia necessary to its employment be at hand (page 114, 
 et seq.). 
 
 The local preparation of the patient should receive especial 
 attention, and when the patient is postured on the operating 
 table, the body should be placed in such relationship to the 
 mechanism of the table as to permit of change of posture, such 
 as the Trendelenburg position, without disturbance of the sterile 
 surroundings contiguous to the operative field, a contingency 
 which is liable to cause exasperating delay in the operative pro- 
 cedure. As operations involving the abdominal cavity are fre- 
 quently attended with shock of more or less intensity, ample pro- 
 vision should be made to meet its occurrence (page 227). 
 
 SPECIAL PREPARATION OF THE GASTROINTESTINAL 
 
 CANAL 
 
 The special preparation of the gastrointestinal canal together 
 with the month and pharynx contemplates achieving comparative 
 sterility of the canal. The treatment of the mouth and pharynx 
 has already been stated (page 362), and need not be repeated 
 
SPECIAL PREPARATION OF GASTROINTESTINAL CANAL 425 
 
 here. The portion of the text devoted to the question of diet and 
 cleansing of the gastrointestinal canal, and the discussion of its 
 rationale, is taken from Moynilian, whose masterly summary of 
 the situation may be regarded as standard in accordance with the 
 present condition of the sciences. 
 
 Sterility of the digestive tract in its entirety is probably not 
 attainable. The aim is to reduce the number of bacteria in it. 
 The newborn enters the world with a sterile digestive tract, a fact 
 Billroth first called attention to. Contamination with bacteria 
 occurs a few hours after birth. Moynilian regards the question 
 of the bacteriology of the alimentary tract as sorely in need of 
 elucidation. He states: 
 
 The exact origin of the Bacillus coll, which is the constant inhabi- 
 tant of the intestinal canal in man, has never been satisfactorily deter- 
 mined, but there can be little doubt that the infection takes place 
 through the mouth, and that the vehicle is the food. It is to Esclierich 
 that we owe a recognition of the fact that the Bacillus coli is the char- 
 acteristic organism of the human intestine, and that it remains an 
 unvarying inhabitant throughout life. 
 
 A bacterial invasion of the intestinal canal is not essential to the 
 life or health of the individual. Experimental work, which has been 
 amply confirmed, has shown that life may be sustained in young 
 animals whose food, and whose surroundings are sterile. Nuttall and 
 Thierfelder obtained a guinea pig from its mother by Cesarean sec- 
 tion, and placed it at once in a sterile chamber, supplied with sterile 
 air, and fed it upon sterilized foods. At the end of eight days the 
 animal, which was thriving, was killed and its intestinal contents found 
 to be sterile. Levin investigated the bacterial conditions in the intes- 
 tinal canals of animals, bears, seals, etc., in Spitzbergen, and found 
 that, as a rule, the contents of the bowel was sterile. In the arctic 
 regions, of course, there is a great scarcity of organisms both in the 
 air and in water. 
 
 Within the first few hours of life the intestinal contents cease to 
 be sterile ; organisms can always be found. Of these organisms two 
 varieties are described — the permanent and the transient. The per- 
 manent variety in man is the Bacillus coli, the transient includes any 
 that are introduced into the intestinal canal by the food. It is obvious, 
 if any organism whatever be introduced deliberately into the stomach 
 with the food, it will remain for a shorter or longer time an inhabitant 
 of the alimentary canal. But, as Gillespie and Miller have shown, 
 
426 
 
 OPERATIONS ON THE ABDOMEN 
 
 when the bacteria are introduced in this way, there is a steady decrease 
 in their numbers as digestion proceeds and in proportion to the increase 
 in the acidity of the gastric contents. According to Miller, at the end 
 of nine hours the stomach contains no organisms. In the duodenum 
 the number of organisms is small ; but, the further down in the intes- 
 tine is the material from which the examination is made, the more 
 numerous are the organisms, until the ileocecal valve is reached. In 
 the large intestine the bacteria are again few in number. Gilbert and 
 
 Jlo.afjerTns 
 per Tny- 
 100,000 
 
 Stomach. Duodenum.. Jejurm^n, Ileum, L.amelntesbuu! 
 
 Fig. 281. — Gilbert and Domenici's Diagram Showixg the Relative Ntjmber of 
 Bacteria P.resext ix the Coxtexts of Differext Parts of the Allmextary 
 Tract. The dogs were killed three hours after a meal of bread and meat. Ex- 
 amination of the intestinal contents at this stage of digestion showed an abundance 
 of organisms in the stomach, a pronounced diminution in number at the duodenum, 
 followed by a gradual rise to the ileocecal valve, where bacteria flourish in the 
 greatest luxuriance. When the large intestine is reached there is a marked falling 
 off in number, with a slight rise proportionate to the distance from the cecum. 
 {Harvey dishing.) From Moynihan. 
 
 Domenici have presented diagrammatically the average bacterial viru- 
 lence of the alimentary canal of dogs. (Fig. 281.) 
 
 Harvey Cusliing has investigated the conditions in cases of intes- 
 tinal fistula. In a case of jejunal fistula a glass of milk could be 
 entirely recovered within a few minutes of its ingestion, with its bac- 
 teriological features practically unchanged. The importance of the 
 physical characters of the food is, therefore, considerable. If the in- 
 gesta be fluid they are passed rapidly onward into the duodenum 
 and are but little, if at all. altered by transit through the stomach. 
 If the food be solid, it will remain, perhaps for hours, in the stomach, 
 subject throughout this time to the action of the gastric juice, and 
 when passed into the duodenum it will have the number of bacteria 
 greatly reduced. Maefadyen, quoted by Cusliing, has shown that the 
 bacillus of anthrax, an organism easily killed by the gastric juice, 
 cannot be recovered by the intestine when taken after a full meal, but 
 
SPECIAL PREPARATION OF GASTROINTESTINAL CANAL 427 
 
 when administered with a large amount of liquid on an empty stomach, 
 its recovery from the lower bowel is easy. In one of dishing' 's cases, 
 the Bacillus prodigiosus, an organism especially susceptible to the 
 action of gastric juice, could be easily recovered from a jejunal fistula 
 after its ingestion with inoculated milk. 
 
 When the stomach has emptied itself of food, either fluid or solid, 
 the mucous membrane is sterile; the small amount of material that 
 can be scraped from the mucous surface contains no organisms. Mar- 
 fan and Bernard have shown that the same applied to the intestine; 
 that when any part of the intestine has emptied itself of its contents, 
 it becomes amicrobic. In cases of artificial anus in man, the distal 
 loop of the bowel, so long as it remains empty, is always found to be 
 sterile. If from any reason the stomach is unable to empty itself 
 satisfactorily, leaving always some food stagnant, the natural amicrob- 
 ism can never be attained. Cashing writes : " It is, I believe, depend- 
 ent only upon interference with the stomach's power completely to 
 expel its contents that the bacterial life may persist in its lumen. The 
 same principle holds true for the duodenum, and it is not improbable 
 that a similar amicrobic state following digestion, with a canal com- 
 pletely free from food and the accompanying bacteria, may be brought 
 about as far down as a condition of emptiness may be reached through 
 fasting." In a dog that had been starved for several days, the upper 
 part of the intestine was found sterile. The accompanying diagram 
 
 100,000 
 $0,000 
 10,000 
 70,000 
 60,000 
 50,000 
 40.000 
 30.019 
 10,000 
 10,000 
 
 a 
 
 Stomach. Huodenum Jejunum. Ileum. Cecum. 
 
 Rectum. 
 
 Fig. 282. — Harvey Cushing's Diagram Showing the Relative Number or Micro- 
 organisms at Different Levels of a Dog's Intestine After Prolonged 
 Fast. (Moynihan.) 
 
 (Fig. 282) which Gushing gives may be contrasted with that of Gil- 
 bert (Fig. 281). It will be seen that all that portion of the intestine 
 which can be rendered empty is by this means alone rendered sterile, 
 also. Conversely, in cases of acute or chronic intestinal obstruction 
 where the bowel has been unable to empty itself for days or for weeks, 
 
428 OPERATIONS ON THE ABDOMEN 
 
 the intestinal contents are teeming with bacterial life. The Bacillus 
 coli and streptococci are found in great numbers, and their virulence 
 is extreme. 
 
 The conclusions which may be stated are as follows : 
 
 1. The stomach contains, immediately after a meal, a number of 
 microorganisms of different varieties, according to the nature of the 
 food administered. 
 
 2. If the food is given in liquid form, it is rapidly passed onward 
 into the intestine, and the bacterial forms are but slightly, if at all, 
 affected. 
 
 3. If food is given in solid form, it remains longer in the stomach, 
 and the number of bacteria contained therein undergoes a steady 
 diminution until digestion is complete. The empty stomach is then 
 amicrobic. 
 
 4. The duodenum is often sterile; the number and virulence of 
 bacteria of the intestine increase in proportion to the distance from 
 the duodenum, and attain their maximum at the ileocecal valve. 
 
 5. The Bacillus coli communis is the characteristic organism of the 
 human intestine ; it is never absent after the first few days of life. 
 
 6. The stomach and the upper part of the jejunum can be rendered 
 sterile by administering only sterilized foods and by attention to the 
 toilet of the mouth. In dogs, starvation for a few days leaves the 
 upper part of the intestine empty and sterile. 
 
 7. The stomach and intestine, when their contents have been dis- 
 charged and they are empty, are sterile. If the emptying is prevented 
 by obstruction at the pylorus, or in the intestine, the contents, dammed 
 up behind the block, contain organisms whose number and whose viru- 
 lence are greatly increased. 
 
 The importance of these facts from the surgical point of view is 
 that they show what is to be expected in cases of perforation of the 
 stomach or intestine, and they demonstrate the possibility of rendering 
 sterile, for purposes of operation, the stomach and upper part of the 
 intestinal canal. For example, when peritonitis results from a per- 
 foration high up in the intestine, the offending microorganism is 
 generally a streptococcus; when the perforation is low down in the 
 intestine, the Bacillus coli is the most abundant or the only organism. 
 
 It is to Dr. Harvey Cusliing, of Baltimore, that we are indebted 
 for calling the attention of surgeons to the possibility of rendering the 
 stomach and intestine sterile as a preparatory measure to operations. 
 He wrote, in a very able paper from which I have freely quoted (vol. 
 IX, Johns Hopkins Hospital Reports) : 
 
 The procedure which we have employed is simple and mainly con- 
 
SPECIAL PREPARATION OF GASTROINTESTINAL CANAL 429 
 
 sists in an attempt to render amicrobic all ingesta. The mouth is 
 rinsed with an antiseptic solution and the teeth are carefully brushed 
 at intervals of a few hours, and with especial care before and after 
 feeding. The stomach, if any chronic catarrh exists and microorgan- 
 isms in number are found present after a test meal, is washed out care- 
 fully morning and evening. Food is taken in small amounts and at 
 comparatively frequent intervals, from clean or, preferably, sterile 
 vessels, and consists of boiled water, sterilized milk, beef tea, albumin 
 water, and similar liquids. Patients with chronic gastritis have been 
 seen to gain weight under this regime. Preliminary to the operation 
 for from six to ten hours nothing is given by mouth, rectal feeding 
 being instituted if necessary. 
 
 Many drugs have been given in the hope that by their aid the intes- 
 tinal contents could be rendered sterile. Among such are /3-naphthol, 
 salol, iodoform, and actol, to mention only a few. All have proven 
 useless. Eecently Adolph Hoffmann (Mittheilungen a. d. Grenz- 
 gebiet. 1906. Bd. 15 Heft 5. P. 596) has recorded a series of observa- 
 tions made upon the intestinal contents recovered from fistuhe, 
 colotomy openings, and enterostomy openings after the administration 
 of isoform. This drug is administered in powder or in capsules, or 
 in both together, the dose being 3 grammes, given in quantities of y 2 
 gramme, within a period of two to twenty-four hours. The effect was 
 remarkable and constant. The number of colonies that could be cul- 
 tivated from the discharge was enormously reduced in all cases. The 
 rapidity with which the effect upon the contents was produced 
 depended upon the part of the alimentary canal from which cultures 
 were taken. In cases of pyloric disease the effect upon the stomach 
 contents was noticed in a few minutes if the drug was administered 
 in powder. Isoform is supplied in powder and in capsules, hardened 
 and unhardened — the latter dissolve in about an hour and a half in 
 the stomach, setting free the drug; the former pass into the intestine, 
 where they are dissolved in a variable and often uncertain time. In 
 the intestine an undoubted effect is produced in thirty hours from 
 the administration of the dose. Though 3 grammes is the usual 
 dose, as much as 7 to 8 grammes have been given to the adult male 
 without producing distress. The symptoms which come from an ex- 
 cessive dose, or from too frequently repeated doses, are loss of appe- 
 tite, vomiting, and a feeling of sickness. 
 
 Acetozone' dissolved in sterile water is a useful agent in this 
 connection. About seven and a half grains are added to a half 
 pint of hot water, and to this a half pint of cold sterile water is 
 
430 OPERATIONS ON THE ABDOMEN 
 
 added. The patient sips this in place of pure water as a beverage 
 between feedings. The greatest field of usefulness of the agent 
 is as a preparatory measure in operations on the stomach. The 
 writer uses it preliminary to gastroenterostomy. 
 
 STERILE DIET 
 
 The administration of sterile diet in hospital practice is not 
 attended with special hardship, as, of course, the means of sterili- 
 zation of the articles of diet and the containers is an easy matter. 
 In private practice the problem presents some practical difficul- 
 
 Fig. 283. — Vessel for Administration of Sterile Fluids. 
 
 ties. Of course, chemical sterilization of the vessels used in pre- 
 hension is impossible, because the antiseptics are not proper ar- 
 ticles of food. Sterilization of the vessels mentioned must be 
 attained by heat. For the purpose white enameled receptacles 
 may be used, which are boiled. A gas stove with two burners 
 should be placed in the patient's immediate environment, one of 
 which furnishes heat to the large metal boiler in which the re- 
 ceptacles are sterilized by boiling for twenty minutes, and the 
 other cooks the food. Dry baking will, of course, not sterilize 
 the food, and as liquid food is to be partaken of for the four days 
 preceding the operation, this outfit will be found to serve the pur- 
 pose. 
 
 Contamination of the vessels is liable when being used for 
 transporting the nourishment from the boiling utensil to the pa- 
 tient's mouth. To avoid this, small vessels with handles should 
 be used, and at no time need the hand come in contact with the 
 portion of the vessel which must not be contaminated. Fig. 283 
 
STERILE DIET 
 
 431 
 
 shows a vessel which has been found of use in this connection, 
 which will be found in most households or is, at least, obtainable 
 in housefurnishing stores. Several of these vessels may be at 
 hand at a time. 
 
 After the sterilization by boiling is completed, the handle of 
 the vessel is grasped with a sponge holder and so manipulated as 
 to be accessible to the hand of the attendant. This had best be 
 done after the water has sufficiently cooled to make manual con- 
 tact possible. It is unwise to expect the attendant to sterilize the 
 hands each time a feeding takes place. Again, if the patient him- 
 self is enabled to handle the vessel from which the food is taken, 
 the rate of administration of the food is under his own control, 
 which is desirable. The food should be cooked and, of course, 
 at the same time sterilized in a vessel which will permit of the 
 liquid being poured into the feeding vessel without contamina- 
 tion. Vessels which have handles are exceedingly convenient for 
 
 Fig. 284. — Arrangement for Sterilizing Food. 
 
 the purpose (Fig. 284). It should be borne in mind that albu- 
 min is coagulated by heat, and that the nutritive constituents of 
 the basis of broths is not present in liquid extracts. There is no 
 objection to the administration of particles of macerated beef 
 which has been subjected to sterilizing heat, for the reason stated, 
 
432 OPERATIONS OX THE ABDOMEN 
 
 and, too, because the presence in the stomach of firmly coagu- 
 lated albuminoids ■ stimulates secretion of gastric juice, as has 
 been experimentally proven in many instances. If, as Cushing 
 says, a normal secretion of gastric juice contributes much to the 
 sterility of the gastrointestinal canal, the use of this prepara- 
 tion is advisable. The method of preparation consists of macer- 
 ating fresh, lean beef in a mangier, mixing it with cold water, 
 and, after adding seasoning, boiling for twenty minutes. The 
 result is a mushy mess which is readily swallowed without masti- 
 cation and is quite palatable. Indeed, the mess can be forced 
 through the stomach tube immediately after gastric lavage by a 
 syringe (Fig. 251) when, for any reason, the latter is system- 
 atically employed as a preliminary step to operation. The ad- 
 ministration of the mixture may be done once daily as supple- 
 mentary to the pure liquid diet. Milk is, of course, readily 
 sterilized by boiling, but the coating of the fat globules with the 
 coagulated albumin renders it of less service as a food, more espe- 
 cially as the digestion of fats takes place in the small intestines. 
 However, this should not act as a deterrent to its judicious use. 
 For the purpose, milk with a portion of the cream removed had 
 best be used for the day before the operation. The additional 
 hardship to the digestive tract several days before the operation 
 may be regarded as counterbalancing the objection stated. Car- 
 bohydrates in the form of grain gruels may be sterilized and 
 given to within twenty-four hours before the operation. The fact 
 that carbohydrates leave considerable residue in the intestinal 
 canal after extraction of the nutritive constituent by the circula- 
 tion explains the rationale of this advice. 
 
 The use of table service, spoons, etc., had best be dispensed 
 with, and the patient is ordered to partake of nourishment di- 
 rectly from the vessel into which the food has been poured. Boil- 
 ing of the food in the same vessel from which it is administered 
 is not desirable, as its upper, outer portion is subjected only to 
 dry heat, and is not as certainly sterilized as when boiled in the 
 manner stated. "Water is, of course, readily made sterile, and 
 may be administered in the same way as sterile food. It will be 
 found, however, that but little water will be partaken of during 
 the administration of liquid food. Indeed, the aim of the latter 
 may be to obviate the necessity of its use. 
 
DRAINAGE 433 
 
 DRAINAGE 
 
 Drainage after abdominal operations has been so extensively 
 discussed in the recent literature that protracted treatment of the 
 subject in this connection is quite out of place. 
 
 Yates, quoted by Moynihan, says " drainage of the general 
 peritoneal cavity is physically and physiologically impossible." 
 This is no doubt true. It is to be remembered, however, that this 
 does not dismiss the subject of drainage after abdominal opera- 
 tions, as the terse statement above might lead one to believe. 
 There are many instances in which the abdomen is opened in 
 which drainage is distinctly indicated, but these instances are 
 limited to the class of cases when egress is made possible by fur- 
 nishing an avenue of escape of inflammatory exudates which are 
 situated immediately contiguous to the wound of entrance, i.e., 
 to the drainage opening. For instance, a large peritoneal ab- 
 scess complicating pyosalpinx has for its walls a thickened pyo- 
 genic membrane which it is impossible to remove at the time of 
 the operation. Drainage under these circumstances is essential 
 to recovery, despite the fact that the pyosalpinx itself may have 
 been removed at the time of the operation. A pericecal abscess 
 complicating suppurative appendicitis, with sloughing of the 
 cecum contiguous ■ to the inflamed appendix, will almost surely 
 be followed by a fecal fistula. Here, certainly, is an indication 
 for drainage, but here, again, the problem is not that of drain- 
 age of the general peritoneal cavity. The statement of Yates is 
 not damaged in the least by the equal truth of the examples of- 
 fered, yet a casual perusal of it might lead to an erroneous con- 
 clusion. The special indications for drainage in a given class of 
 cases will be taken up under their especial heads. Yates also 
 states " peritoneal drainage must be local, and unless there is 
 something to be gained by rendering an area extraperitoneal, or 
 by making such an area a safe path of least resistance leading 
 outside the body, there is, aside from hemastasis no justification 
 for its use," which is another way of saying what has been of- 
 fered above. Yet, this later statement is at the first glance so at 
 variance with the one first quoted as to perhaps lead to confusion, 
 which an attempt has been made here to efface. 
 
 The question of drainage is, of course, determined at the time 
 
434 OPERATIONS ON THE ABDOMEN 
 
 of the operation. Its removal is frequently a question which the 
 general practitioner has to determine as to how soon the drain 
 may be removed. Nor, indeed, is this question always easy to 
 decide. Hernia follows celiotomy most frequently when drain- 
 age has been employed, yet it is wiser to run the risk of this com- 
 plication than to permit of the reaccumulation of septic secre- 
 tions, the result of too early removal of the drainage agent. The 
 question is also taken up in connection with a given class of cases 
 in this regard. However, it may be proper to state here that, as 
 far as the danger of invasion of the contiguous peritoneum is con- 
 cerned, this is obviated in twenty-four hours following the opera- 
 tion. The wound of egress, through the abdominal wall, need not 
 be artificially kept open for more than four days, at which time 
 the septic secretion will be found to have made an avenue of escape 
 for itself along the path of the drain, and the secretion needs there- 
 after be simply guided toward the periphery by strands of silk- 
 worm gut, which are gradually reduced in number until the dis- 
 charge ceases. Postural efforts at drainage are indicated in the 
 class of cases mentioned, though they are of doubtful value when 
 general peritonitis exists, i.e., a local collection of pus will drain 
 better if the patient be postured in such a manner as to make the 
 seat of affliction the most dependent portion of the body. A hard 
 and fast rule in this regard is objectionable, as, for instance, in 
 cases where the suppurative process is low down in the pelvis 
 and abdominal drainage is made, the sitting posture is contrain- 
 dicated for obvious reasons. The drainage material employed in 
 this situation is governed by the. same rules as obtain in other 
 portions of the body (page 186). 
 
 It is the writer's practice to employ drainage in accord with 
 the statements made above. A perhaps common source of error 
 with respect to the efficiency of drainage and its bearing on the 
 outcome with respect to recovery, is the fact that no doubt the 
 prognosis of general, or at least widely spread, septic peritonitis 
 depends largely upon the character of the causative infection. An 
 observer may be led to regard the measure as effective in a series 
 of cases of this sort, in which the infection did not possess great 
 virulence, and the reverse may be the case if a series of cases of 
 great virulence come under observation during a short period of 
 time. 
 
CLOSURE OF THE ABDOMINAL WOUND 435 
 
 CLOSURE OF THE ABDOMINAL WOUND 
 
 Closure of the abdominal wound is universally made by " tier 
 suture." The suture material employed for apposition of the 
 deep layers of the abdominal wall should consist of absorbable 
 suture material. The suggestion with regard to the use of thick 
 catgut in deep wounds, taken up under the general head of suture 
 material (page 85), should be borne in mind. Deep infection in 
 this situation, though comparatively rare, does at times occur, 
 and if the wound need be opened with the view of draining the 
 pus, ventral hernia is likely to occur. For the purpose of closing 
 the peritoneum, ]STo. 1 plain catgut; for the muscle, ]STo. 2 chromi- 
 cized gut ; for the rectus sheath, ISTo. 1 plain gut are the sizes ad- 
 vised. The skin is best closed with iron-dyed silk-worm gut, the 
 reasons for which have already been stated (page 97). The ra- 
 tionale of using plain catgut of small diameter in the rectus 
 sheath, is that this membrane is but sparsely supplied with blood 
 and consequently does not readily absorb the suture material. 
 The presence of chromicized gut for a prolonged period of time 
 favors infection and, indeed, it not infrequently happens that on 
 the tenth day or later, following the operation, separation of a 
 slough of the sheath necessitates opening of the wound. The at- 
 tendant is warned that the employment of a continuous suture in 
 the rectus sheath which is tightly drawn and comprehends fre- 
 quent puncture of its substance is a menace in this connection 
 from strangulation of the edges of the sheath of the muscle. The 
 rectus sheath should be closed with sutures which are placed only 
 sufficiently closely together to hold gently the edges of the wound 
 in apposition. In no portion of the body is the fallacious notion 
 that firm apposition of wound surfaces is essential to healing 
 more objectionable than in closure of an abdominal wound. 
 Union by primary intention is exceedingly desirable in this situ- 
 ation. Aside from the dangers involved as regards postoperative 
 hernia, as stated, the patient, who would probably have been able 
 to leave the bed in two weeks or less following abdominal section, 
 is confined to bed for several additional weeks while the healing 
 by granulation takes place. 
 
 30 
 
436 OPERATIONS ON THE ABDOMEN 
 
 DRAINAGE OF THE SUPERFICIAL WOUND 
 
 Drainage of the superficial wound after celiotomy has been 
 quite discarded, unless, of course, in the event of the presence of 
 the conditions in which drainage is introduced into the abdominal 
 cavity, when the drain entering the peritoneum also answers the 
 purpose for the superficial wound. Most surgeons entirely close 
 the superficial wound in clean cases. It is, however, rational to 
 make somewhat elastic this proposition. Given a fat abdomen 
 sectioned and the edges of the wound subjected to prolonged 
 trauma, the outcome of hauling and mauling with retractors, or 
 the operator's hands, superficial necrosis of the subcutaneous fat 
 is very likely to occur and, as nature attempts to throw the for- 
 eign material off, a purulent secretion accumulates beneath the 
 skin, which it becomes necessary to liberate by opening a more 
 or less extensive portion of the skin wound. Again, a fat ab- 
 dominal wound will ooze a peculiar oily material from the sub- 
 cutaneous tissues, which undergoes much the same alteration 
 stated above. This secretion is not arrested by the usual hemo- 
 static measures ; indeed, efforts made in this direction involve a 
 degree of trauma to the tissues which, of itself, favors necrosis. 
 In these cases a small drain, placed contiguous to the rectus 
 sheath and immediately beneath the layer of subcutaneous fat 
 and brought out at the inferior angle of the wound, will permit 
 of egress of the offending material and favor primary union. The 
 skin plays no part in retention of the abdominal contents, and the 
 slight delay in union caused by the presence of the drain need not 
 be regarded as a disturbing factor of determining import. The 
 drain may consist of strands of chromic catgut or silk-worm gut, 
 and is removed on the third day following the operation. At this 
 time the gauze contiguous to the wound will be found quite satu- 
 rated with a glairy secretion, slightly stained with blood which 
 has been given an opportunity to escape from the wound by em- 
 ployment of the superficial drainage. 
 
 THE PROTECTIVE DRESSING 
 
 The protective dressing consists of two layers of folded gauze 
 (Fig. 187), which is applied immediately contiguous to the 
 
THE PROTECTIVE DRESSING 
 
 437 
 
 wound, as shown in Fig. 187. This is supplemented by fluffed 
 gauze (Fig. 188), the latter being applied in large quantity if 
 drainage has been introduced into the peritoneum. The fluffed 
 gauze is covered with "combined dressing" (Fig. 190), and the 
 entire dressing held in place with strips of adhesive plaster. For 
 the purpose the strips are, in some instances, carried across the 
 dressing in one piece and extend to well on the flanks. 
 
 This has the advantage of making firm, equable pressure upon 
 
 Fig. 285. — Abdominal Dressing Held in Place With Adhesive 
 Strips and Tapes, Allowing of Change of Gauze Pad With- 
 out Removal of Adhesive Plaster. 
 
 the abdomen, which is desirable for the first twelve hours follow- 
 ing the operation. However, at the end of this time distention of 
 the gut almost invariably occurs, and the pressure becomes ex- 
 
438 
 
 OPERATIONS ON THE ABDOMEN 
 
 ceedingly distressing to the patient. The strips may then be 
 loosened, a step which calls for considerable disturbance. In 
 most instances it is the wisest to fasten the adhesive plaster strips 
 to either flank and unite them by means of tapes over the dress- 
 ing (Fig. 285). It will be seen that it requires only untying of 
 the tapes to effect the purpose. Whatever pressure need be made 
 upon the abdomen can readily be attained by means of the 
 
 Fig. 286. — Many Tailed Abdominal Binder in situ. 
 
 Sculletus (Fig. 286) binder, and this can be loosened with 
 a minimum of disturbance to the patient when the indication 
 arises. 
 
 In the absence of the Scultetus bandage, a binder similar to 
 that used after confinement may be used (Fig. 287), which will 
 serve quite well the purpose. Two perineal straps should be used, 
 
THE AFTER-TREATMENT FOLLOWING CELIOTOMY 439 
 
 as this bandage is 
 more likely to slip up- 
 ward as the result of 
 the patient's move- 
 ments. 
 
 THE AFTER-TREAT- 
 MENT FOLLOWING 
 CELIOTOMY 
 
 The after-treatment 
 following celiotomy 
 involves no particular 
 modification with re- 
 gard to shock and 
 narcosis precautions 
 
 (page 154). As SOOn Fig. 287. — Retaining Bandage after Celiotomy. 
 
 as these two elements {Bryant.) 
 
 have been eliminated, 
 
 the posture of the patient depends upon the affliction for which the 
 
 section has been made. After operations upon the stomach and 
 
 following some on the gall-bladder, the sitting posture will be 
 
 found to best conserve the patient's comfort and the intent of the 
 
 operative procedure. 
 
 Postoperative vomiting has been made the text of extensive 
 discussion above (page 272, et seq.). Following celiotomy this 
 symptom takes on additional import, and attention is called to 
 the necessity of avoiding its occurrence, or at least contributing 
 to its arrest as soon as possible. Some surgeons wash out the pa- 
 tient's stomach while he is still on the operating table and before 
 narcosis is recovered from. The measure has no objections dis- 
 cernible to the writer and, indeed, may obviate distressing symp- 
 toms. Whatever conception may be had of the measure regarding 
 its routine employment after operations in general, it is a de- 
 sirable indulgence following celiotomy performed for conditions 
 which of themselves are accompanied by vomiting. In the pres- 
 ence of peritonitis or intestinal obstruction, the measure should 
 always be employed. The fact that the patient is still narcotized 
 eliminates, as far as this particular lavage is concerned, the dis- 
 
440 
 
 OPERATIONS ON THE ABDOMEN 
 
 tressing retching and vomiting attendant upon gastric lavage 
 made during consciousness. With the patient still narcotized, 
 copious, prolonged, and thorough lavage of the stomach may be 
 made without bringing any strain upon the wound, which latter 
 is so objectionable when the measure is employed during the post- 
 operative period following celiotomy. At the end of the lavage 
 no residual cleansing fluid should be permitted to remain in the 
 stomach, for fear of contributing to the dilatation of this organ, 
 which may occur as a postoperative complication. Acute dilata- 
 
 Fig. 288. — Acute Dilatation of the Stomach Following Abdominal Section. 
 
 (Campbell Thomson.) 
 
 tion of the stomach sequential to celiotomy is a more frequent 
 occurrence than obtains after operations involving other portions 
 of the body. The problem has been quite extensively taken up 
 above (page 271, et seq.). Allusion is made to it in this connec- 
 tion for the reason stated with regard to frequency. Fig. 288 
 shows a specimen of dilated stomach. The illustration is placed 
 contiguous to this portion of the discussion to emphasize the 
 subject. 
 
THE AFTER-TREATMENT FOLLOWING CELIOTOMY 
 
 441 
 
 It is not improbable that routine lavage of the stomach fol- 
 lowing celiotomy, especially if the gastro-intestinal tract has been 
 invaded, is of service in preventing acute dilatation of this organ. 
 
 After the patient is returned to bed and postured, as stated 
 above, in the way to meet the indications, he is not disturbed until 
 narcosis is recovered from. Patients who have been subjected to 
 extensive operations or those which have involved loss of large 
 quantities of blood, are likely to be very restless. Of course, the 
 shock treatment is then instituted at once, which implies close 
 attendance. However, if restlessness follows from irritation of 
 nerve centers due to the previous alcoholic habits of the patient, 
 or as the outcome of the subconsciousness between narcosis and 
 mental clearness, it may be necessary to restrain the patient with 
 the view of avoiding damage to the wound, displacement of the 
 protective dressing, or, indeed, to prevent the patient from doing 
 himself harm. For the purpose it is best to have in attendance 
 a cool-headed nurse. Failing in this, the sheet may be fastened 
 over the patient in such a way as to prevent motion of the body, 
 and the upper limbs fastened to the sides of the bed by padding 
 the wrists with cotton batting and applying a bandage over this, 
 
 Fig. 289. — Method of Restraining Patient after Operation. 
 
 which is tied to the side-bar of the bed (Fig. 289). The restraint 
 should be removed as soon as quiet obtains. The treatment of 
 shock has been fully discussed above (page 233). As soon as con- 
 
442 OPERATIONS ON THE ABDOMEN 
 
 sciousness returns and the vomiting is a not marked symptom, 
 the introduction of particles of ice into the mouth is permitted. 
 This should be done by an attendant, and the patient not allowed 
 to undergo the exertion necessary to self-administration. The 
 use of ice may be alternated by teaspoonfuls of hot water given 
 at frequent intervals, an indulgence which will help relieve thirst 
 and is less often attended by vomiting than the former. It is well 
 to remember that deglutition requires six seconds from the lips 
 to the stomach, and that a small dose of hot water trickles very 
 slowly along the esophagus and is not apt to contribute an im- 
 portant factor to the causation of dilatation of the stomach. 
 
 Thirst, which is the most constantly distressing symptom fol- 
 lowing celiotomy, may be relieved by the rectal administration of 
 saline water (page 283). 
 
 As a routine, the writer orders a saline enema given in cases 
 following celiotomy of 500 c.c. of a normal salt solution placed in 
 the rectum every six hours. The first injection is made soon after 
 the patient is in bed. This is not intended to relieve shock. If 
 the latter be a factor in the case, the treatment is carried out as 
 stated (page 233). It would seem that the measure controls 
 thirst to some extent. The quantity of saline solution injected 
 should never be sufficient to cause the lower bowel to rebel and 
 expel it. Of course, larger quantities are most generally tolerated 
 in this situation. However, this is probably only so when the 
 tube is inserted high up into the bowel, a procedure which should 
 be reserved for especial indications. 
 
 If vomiting persist after celiotomy, attempts at the administra- 
 tion of food by the mouth had best be entirely abandoned and 
 rectal alimentation (page 291) given exclusively until vomiting 
 ceases. Vomiting persisting into the second twenty-four hours 
 following the operation should arouse suspicion of nephritis. If 
 this be found to be the case, the usual treatment directed toward 
 using the vicarious channels of elimination, i.e., the skin and 
 bowel, should be vigorously employed. 
 
 Nephritis following celiotomy occurs as the result of adminis- 
 tration of ether and perhaps, too, owing to the congested condition 
 of the splanchnic area from shock. It is not of necessity a seri- 
 ously menacing condition if recognized early and made the sub- 
 ject of therapeutic attack. The administration of morphia in 
 
THE AFTER-TREATMENT FOLLOWING CELIOTOMY 443 
 
 considerable quantity during the nephritis is contraindicated, 
 though it must be borne in mind that, if pain be a factor in the 
 case, its use may not be avoidable, and the attendant must use 
 his best judgment in the individual case as to the dosage. It will 
 be found difficult to withhold the drug entirely in some instances. 
 
 The quantity of urine excreted after celiotomy is usually 
 small as the result of vomiting and the fact that the taking of 
 food has been abstained from for several hours before the opera- 
 tion, together with the loss of blood attendant upon the surgical 
 manipulations. If no fluid is introduced into the circulation soon 
 after the operation the convoluted tubes of the kidney, theoretic- 
 ally, at least, should be engorged with solid excretory constitu- 
 ents. This condition of affairs, while not readily conceived of as 
 of determining influence upon nephritis, . is sufficiently objection- 
 able to warrant attempts at furnishing the blood with fluid. At 
 the end of twenty-four hours considerable quantities of fluid 
 should be given by the mouth, provided vomiting has ceased. 
 
 Retention of urine after celiotomy is a common occurrence. 
 Catheterization should not, however, be indiscriminately em- 
 ployed. The nurse is instructed to cause the patient to attempt 
 to pass spontaneously the urine at the end of six hours following 
 return to the bed. If the effort be unsuccessful, an attempt should 
 be made every two hours and a total of twelve hours be allowed 
 to elapse before the catheter is used. A record of the total quan- 
 tity of urine excreted in twenty-four hours should be kept, with 
 the view of standardizing the quantity of fluids administered. 
 The patient's sensations with regard to the necessity for fluid is 
 not always a reliable guide in this connection, as the administra- 
 tion of ojnates may impair the sensorium. The catheterization 
 must, of course, be executed under aseptic precautions. The 
 catheter should be sterilized by boiling and kept in a vessel sub- 
 merged in mild carbolic acid solution, in a convenient place. The 
 meatus and contiguous parts should be gently wiped with a sterile 
 gauze sponge, soaked with the same solution before the catheter 
 is introduced. A chemical examination of the urine should be 
 made every twenty-four hours for several days following the 
 operation. 
 
 The administration of opiates may be stated as objectionable in 
 principle, but necessary in a certain number of cases. The ob- 
 
444 OPERATIONS ON THE ABDOMEN 
 
 jections are that they paralyze peristalsis, which favors the forma- 
 tion of adhesions, that they lessen secretions and excretions, of 
 which the latter is the most important factor, and that they mask 
 symptoms which are indicative of complications. On the other 
 hand, arrest of peristalsis is not objectionable for twenty-four 
 hours after invasion of the lumen of the digestive tract, as it is 
 easy to see that a wiggling gut will not heal as certainly as one 
 which is immobilized. This is a principle with regard to repair 
 of all tissues in all parts of the body. Again, pain which is suffi- 
 ciently severe to cause restlessness and interfere with the exercise 
 of the necessary after-treatment is best controlled, even if the ob- 
 jectionable features of the opiate have to be taken into account. 
 Opiates are more readily avoided in cases which do not involve 
 much intra-abdominal manipulation, i.e., a ventral uterine fixa- 
 tion will not be followed by severe pain and an opiate need not 
 be given. However, if there has been much trauma to the ab- 
 dominal organs, pain may be a disturbing factor, and the use of 
 an opiate be unavoidable. 
 
 Catharsis after celiotomy is employed early if the lumen of the 
 digestive tract has not been invaded. Theoretically stimulation 
 of peristalsis should tend to prevent the formation of adhesions. 
 It must be remembered that the bowel has been quite thoroughly 
 cleansed while the patient was being prepared for the operation, 
 and that, aside from the fact that the intestinal canal is to be re- 
 garded as an important eliminative organ, catharsis is not urgently 
 indicated. However, it is not improbable that a certain amount 
 of decomposition of the intestinal contents takes place after celi- 
 otomy, the outcome of a relative intestinal paresis, and this re- 
 sults in the formation of gases which distend the gut and give rise 
 to distress. It is the practice of the writer to administer in these 
 cases one-tenth of a grain of calomel every half hour for twelve 
 doses beginning the second day following the operation. When 
 twelve doses have been given, three hours are allowed to elapse, 
 and then a saturated solution of magnesium sulphate is given in 
 doses of one drachm, for eight hours, unless catharsis is provoked 
 before the entire half ounce of magnesium sulphate is adminis- 
 tered. (Magnesium sulphate solutions saturate at 50 per cent.) 
 In this event the administration of the magnesium sulphate is 
 stopped when a movement of the bowels occurs. If no discharge 
 
THE AFTER-TREATMENT FOLLOWING CELIOTOMY 445 
 
 of feces occurs after the entire half ounce of magnesium sulphate 
 is taken, two hours are allowed to elapse and an enema of hot 
 water is given. 
 
 Tympanitis after celiotomy is a common occurrence. It will 
 he found that the measure stated above will have a tendency to 
 control this occurrence. It is generally regarded as the outcome 
 of intestinal paresis due to handling of the gut. It, of course, fol- 
 lows most frequently after abdominal operations involving the 
 lumen of the gut itself, but does occur quite commonly when or- 
 gans other than the gut are attacked. Especially is this true if 
 it has been necessary to pack off large areas of the abdominal 
 cavity with gauze, which packing is left in situ for a long period 
 of time. Perhaps the most important causative factor in these 
 cases is intestinal paresis, and treatment directed toward relief 
 should contemplate correction of this condition of affairs. As 
 already stated, the food administered immediately subsequent to 
 celiotomy is of such a character as to involve little justification 
 for the belief that it may be regarded as a determining factor in 
 the problem. When distention occurs alimentation by the mouth 
 should be restricted to water given in small closes and stimulation 
 administered hypodermically or by rectum, if the indications for 
 the same be presented. Strychnia in doses of one-thirtieth of a 
 grain given under the skin at intervals of two or three hours, if 
 not really of service as regards the relief from shock, serves the 
 purpose of stimulating intestinal peristalsis. Doses of eserin of 
 one-thirtieth of a grain, or, indeed, of one-fifteenth of a grain ad- 
 ministered every two hours is a most effective agent in this con- 
 nection, stimulating peristalsis and contraction of blood-vessels, 
 thus aiding in raising blood pressure. If the distention be in the 
 colon the introduction of a rectal tube of large caliber will afford 
 considerable relief in a number of instances. 
 
 Atropin has been largely employed for the purpose, given in 
 doses as high as one-tenth and even one-fifth of a grain. The 
 writer has seen instances when this agent appears to have been 
 successful in stimulating intestinal peristalsis, where oilier reme- 
 dies have failed. It should, of course, not be expected to replace 
 the mechanical means mentioned, but may be employed supple- 
 mentary to them. It will probably be necessary to tie the patient 
 down in bed after a maximum dose has been given, as delirium 
 
446 OPERATIONS ON THE ABDOMEN 
 
 of maniacal quality is likely to occur. The atropin is adminis- 
 tered hypodermically. The doses may be repeated in three hours. 
 The writer has never felt justified in the administration of a 
 third dose. It is, of course, to be borne in mind that the condi- 
 tions present a desperately dangerous clinical aspect, and a meas- 
 ure which, under ordinary circumstances, is regarded as unjusti- 
 fiable may become warranted under the circumstances. The ap- 
 plication of turpentine stupes to the abdomen would seem to be 
 of little service, for obvious reasons. The heat which the appli- 
 cation develops may be of service in a general way, but this can 
 be attained by other means which do not expose the patient to the 
 irritating local effect which attends the application of turpentine 
 to the skin. The retention bandage should be loosened at once 
 and the question of acute dilatation of the stomach borne in mind. 
 If relief is not quite promptly afforded, the stomach should be 
 washed out. The special reasons for the latter measure have al- 
 ready been taken up. 
 
 The administration of agents designed to " settle the stomach " 
 and remove gas is to be deprecated. The intestinal tract is in no 
 condition to accept additional labor. The indication is clear, i.e., 
 to stimulate peristalsis and to remove by mechanical means the 
 gas. Lavage of the colon with saline solution if ample provision 
 for egress of the fluid is made is justifiable, as it may stimulate 
 contraction of the gut. Distention of the gut, the outcome of in- 
 testinal paresis, is differentiated from that caused by peritonitis 
 by the absence of the signs of inflammation attendant upon the 
 latter. The differential diagnosis will decide quite definitely the 
 question of reopening the wound, which question may arise in 
 connection with inflammatory processes of the peritoneum follow- 
 ing celiotomy. If the intestinal paresis be due to handling of the 
 gut, an additional trauma will only add to the condition pre- 
 sented. 
 
 The administration of solid food following celiotomy should 
 not be begun until there has been a normal evening temperature 
 for three days. In cases which run an uncomplicated course the 
 lighter articles of diet, such as chicken, squab, and broiled meat, 
 may be given on the fifth day. A free evacuation of the bowels 
 should precede the return to usual articles of diet. In cases in 
 which the digestive tract has been invaded, solid food should not 
 
THE AFTER-TREATMENT FOLLOWING CELIOTOMY 447 
 
 be given for ten days after the operation, despite the immediate 
 favorable behavior of the case. Sufficient fluid or light diet may 
 be given to sustain the general tone of the patient to obviate any 
 hardship in this regard. In a general way, it may be said that 
 less error will arise, if the precautions be carefully followed than 
 if a policy of complacency be indulged in. 
 
 The time of leaving the bed in cases where the abdomen has 
 been opened for any purpose should not be less than ten days fol- 
 lowing the operation. Much has been written in the current liter- 
 ature with respect to the early arising of patients after celiotomy. 
 Some observers strap the abdomen very firmly after celiotomy 
 with strips of adhesive plaster and permit the patient to get out 
 of bed twenty-four or forty-eight hours after the operation. Re- 
 membrance of the complications which are likely to follow in- 
 vasion of the abdominal cavity should be sufficient argument to 
 show the fallacy of this procedure. It may be said quite em- 
 phatically that no repair of tissue is enhanced by motility, and 
 that immobilization of parts subjected to trauma is an almost in- 
 dispensable adjunct to repair, a lesson in nature one might well 
 learn from the lower animals. In addition to this, the histology 
 of the repair of tissue which has been sectioned will teach the 
 rationale of the writer's contention. Any condition requiring in- 
 vasion of the abdominal cavity is worth the hardship of quiet in 
 bed for ten days to two weeks following the operation. Those 
 conditions which would seem to permit of disregard of this rule 
 probably did not require operative interference. In no case, in- 
 cluding interval intermuscular appendectomy, should a patient 
 subjected to celiotomy be permitted to assume the erect position 
 for ten days following the section. And in all cases where the 
 rectus is sectioned two weeks in bed should be the rule. Much 
 unnecessary distress and, indeed, much adverse criticism of the 
 science of surgery will be obviated if this is a common practice. 
 
 If primary union does not occur and the abdominal wound 
 heal by granulation, the patient should be kept in the recumbent 
 or semi-recumbent position until firm union of the muscular layer 
 of the abdomen is attained. This requires several weeks in some 
 instances. As soon, however, as the muscles are healed the pa- 
 tient may be permitted to leave the bed, even though complete 
 cicatrization of the skin has not taken place. This is justified by 
 
448 
 
 OPERATIONS ON THE ABDOMEN 
 
 the fact that the skin plays no part in retention of the abdominal 
 contents. 
 
 When the patient is permitted to sit up or walk about, the ab- 
 domen should be firmly supported with an abdominal binder 
 which is applied while the patient is still in the recumbent posi- 
 tion, and the binder should be fastened from below upward. The 
 
 Fig. 290. — Granulating Wound Ready for Secondary Suturing. 
 
 wearing of belts and corsets following celiotomy is taken up under 
 a separate head (page 475). 
 
 The removal of sutures after celiotomy depends upon the ques- 
 tion of drainage and infection. In cases in which the wound has 
 been closed up entirely, the sutures are left in situ until the tenth 
 day. Of course, when catgut has been used, the sutures need not 
 Be removed unless the portion of the suture material buried be- 
 neath the skin is not absorbed at the end of the ten days. The use 
 
THE AFTER-TREATMENT FOLLOWING CELIOTOMY 449 
 
 of catgut in the skin is, as already stated, inadvisable and, indeed, 
 but little employed. The silk-worm gut sutures are removed on 
 the tenth day, provided there be no indication for their earlier 
 removal. In many instances it will be found possible to leave en- 
 tirely undisturbed the celiotomy wound until the time for remov- 
 ing the sutures arrives. The method of removal of sutures is al- 
 ready described (page 304, et seq.). If there be infection of the 
 superficial wound, it should be treated in the manner already de- 
 scribed with respect to other situations of the body (page 305). 
 If infection of the superficial wound occurs after celiotomy, 
 
 Fig. 291. — Granulating Celiotomy Wound Approximated with Adhesive Plas- 
 ter Strips. Rubber Tissue Drain in situ. 
 
 healing by granulation is an exceedingly tedious process, requir- 
 ing change of dressings every forty-eight hours for several weeks. 
 The scar following healing by granulation in this situation is of 
 minor import in the male, but in certain cases the female patient 
 objects strongly to the destruction of a certain cosmetic effect pro- 
 duced by a marred abdomen. In these instances the wound should 
 be treated by cleansing and light packing until it is clean, and 
 it may then be quite approximated by deep silk-worm gut su- 
 tures, which do not entirely approximate the lower angle of the 
 wound. Fig. 290 shows a wound which cleaned up after three 
 
450 OPERATIONS ON THE ABDOMEN 
 
 weeks of care, and now presents a condition favorable to second- 
 ary approximation. 
 
 The patient at times objects to narcosis and, indeed, to the in- 
 jection of cocain solution. The latter is efficient for the purpose, 
 the injection of a 1 per cent, cocain solution along the edges of the 
 wound being quite devoid of pain. However, in some instances the 
 manipulation is strongly objected to. In these cases the wound 
 may, when the purulent discharge has quite ceased, be approxi- 
 mated with adhesive plaster, as shown in Fig. 291, care being 
 taken to give room for egress of serum at the lower portion of the 
 wound. ISTeglect of the latter precaution at times gives rise to an 
 annoying dermatitis in the vicinity of the wound. Wounds which 
 have been secondarily approximated in the manner stated at times 
 heal with astonishing rapidity, and the residual scar is not of 
 much greater breadth than obtains after primary union. The 
 amount of time saved the patient by the little procedure is also 
 a factor to be taken into consideration. 
 
CHAPTEE XXII 
 
 OPERATIONS ON THE ABDOMEN (Continued) 
 
 PEEITONITIS FOLLOWING CELIOTOMY 
 
 Prevention of peritonitis : Flushing of the peritoneum — Treatment of peritonitis : 
 The Murphy Treatment. 
 
 PREVENTION OF PERITONITIS 
 
 Consideration of the preparation of patients for celiotomy who 
 are afflicted with intra-abdominal conditions which render the oc- 
 currence of postoperative diffuse suppurative peritonitis a likely 
 complication, brings up the question of prophylactic measures be- 
 yond those involved in the operative technic. As a general rule, 
 it may be said that the accidental introduction of infection into 
 the peritoneal sac, as the outcome of the surgical manipulations, 
 per se, is avoidable by close application to the rules of asepsis, 
 and special measures, such as are about to be discussed, need not 
 be considered in cases which are operated upon for the relief of 
 non-infective processes. Indeed, it would seem that whatever ex- 
 perimental data is available in this regard, is of such a nature as 
 to place the routine employment of systemic preparation with the 
 view of lessening the probability of postoperative peritonitis in 
 an objectionable light. 
 
 However, given a case of acute suppurative pyosalpingitis, 
 acute suppurative cholecystitis or acute appendicitis with little or 
 no evidence of peritoneal involvement and yet evidence of the pres- 
 ence of a virulent infective process in the situations mentioned, 
 for the relief of which transperitoneal approach is to be made, it 
 may be justifiable to make an effort to prepare more thoroughly 
 the tissues for the contingencies involved in peritoneal infection. 
 If invasion of the digestive tract is contemplated, the measure to 
 31 451 
 
452 PERITONITIS FOLLOWING CELIOTOMY 
 
 be discussed should also be taken into consideration in those cases 
 where an operation of magnitude is to be undertaken, such as par- 
 tial resection of the stomach, resection of large portions of the in- 
 testine, or for the relief of intestinal obstruction, where adequate 
 preparation in other regards is not feasible because of the urgency 
 of the indications for operation. The disease itself, that of acute 
 suppurative peritonitis, is a universally fatal affliction, though, 
 indeed, many factors are to be considered in a given case, such as 
 the character of the infection, etc., before a definite conclusion as 
 to prognosis in a given case can be justly offered. The measures 
 about to be discussed are not by any means in a position to be 
 definitely offered as advisably used in any given class of cases. 
 However, it would seem wise to suggest that they be given serious 
 consideration in the class of cases alluded to. 
 
 Much experimentation has been carried on with the view of 
 lessening the danger of postoperative peritonitis following ab- 
 dominal section. It has been observed that the injection of vari- 
 ous albumoses into rabbits produced at first a hypoleukocytosis and 
 later a hyperleukocytosis. When animals thus injected were in- 
 fected with various bacteria during hypoleukocytosis they died, 
 but if the injection of pathogenic organisms was made during 
 hyperleukocytosis, sufficient resistance was maintained to make re- 
 covery possible. The bactericidal value of normal blood was al- 
 ways greatest during increased leukocytosis. These favorable con- 
 ditions were produced as the result of the injection of nucleins 
 into the blood and, indeed, an increase of leukocytosis follows the 
 ingestion of nucleins by mouth. 
 
 Mickulicz states : 
 
 The question arises whether artificial hyperleukocytosis may not 
 be of value in practice as a prophylactic. According to the experiments 
 of Loewy and Richter, or Jakob and Hahn, one cannot exclude the 
 possibility that, by a partly anticipated mobilization of great masses 
 of leukocytes, the latter may overcome the bacteria which had obtained 
 entrance in the first instance in relatively small masses with greater 
 ease, than if the leukocytes delay their attack in force, until the number 
 and virulence of the bacteria in the tissues have markedly increased. 
 
 Experimentation carried on by Miyake under the directorate 
 of Mikulicz seems to prove that the injection of nuclein in ani- 
 
PREVENTION OF PERITONITIS 453 
 
 mals prior to the fertilization of the peritoneal cavity by organ- 
 isms had an undoubted effect in lessening the occurrence of peri- 
 tonitis. These experiments are summarized as 
 
 Consisting in performing a laparotomy and forcing through an 
 opening in the stomach or intestine as much of their contents as could 
 be obtained from the immediate neighborhood of the incision. Of 
 five control animals which had not been previously prepared, four 
 died from peritonitis between five and sixteen hours after the opera- 
 tion. The fifth became extremely ill but finally recovered, but the 
 amount of intestinal contents which was transferred to the perito- 
 neum was less in this case than in the others. Ten animals were 
 prepared. These recovered without exception. The preparation con- 
 sisted of three intraperitoneal injections of nucleic acid, two injections 
 of neutralized nucleic acid. In each case laparotomy was performed 
 seven hours after the injection. These experiments are such as to 
 excite our interest in the highest degree, for by subcutaneous injection 
 of nucleic acid, it was possible to raise the resistance of the peritoneum 
 to such an extent that even a considerable quantity of intestinal con- 
 tents could be placed in the peritoneal cavity without causing 
 damage, whilst without previous treatment an acute, rapidly fatal 
 peritonitis followed almost without exception. This opens out a new 
 field for the surgeon in preventing postoperative peritonitis. 
 
 With regard to the application of the results of these experi- 
 ments Mikulicz states : 
 
 The number of my experiments is not sufficient to permit me to 
 form a definite judgment upon these points and to give an unguarded 
 reply. We cannot, in the case of man, as we do in that of the lower 
 animals when introducing infective material into the abdominal 
 cavity, give a certain multiple of the minimum lethal dose in order 
 to see how far a preventive treatment has succeeded. We set all our 
 apparatus in action, in spite of preventive inoculation, to reduce in- 
 fection to a minimum. Since this method fortunately succeeds in 
 the majority of cases, even without preventive inoculation, in guard- 
 ing the patients from a fatal peritonitis, a small number of satisfac- 
 tory results do not prove much ; but, on the other hand, one or two 
 unsatisfactory results most certainly cannot condemn the method, for 
 this method gives not absolute certainty like a specific immunization, 
 but only increases the natural resistance, and this may, in certain 
 circumstances, even when increased thirty-fold, nevertheless be insuf- 
 
454 PERITONITIS FOLLOWING CELISTOMY 
 
 ficient. I have, however, the impression that the eases hitherto treated 
 have given more favorable results, not only in the number of cases 
 recovered, but. also, in the progress of the individual cases, than the 
 analogous cases of earlier date where the operation was performed 
 without this preparation. In 10 cases of resection of the stomach for 
 carcinoma, 9 recovered, 6 of them without the slightest complication. 
 The progress was marked by a smoothness that was quite exceptional 
 before the treatment was adopted. Two cases which presented excep- 
 tional difficulty in the removal of the carcinoma did, undoubtedly, 
 within twenty-four hours develop peritonitis, with a pulse up to 160, 
 which according to our usual experience, foretold the most dismal 
 prognosis. The patients fortunately survived the peritonitis. In 
 the ninth case which recovered, the progress was disturbed from the 
 fourth day by bronchopneumonia. The tenth case died; after seven 
 days of uninterrupted progress, he developed pneumonia, to which 
 he succumbed three weeks after the operation. Of the remaining 
 operations, I should like to refer to 22 cases of gastroenterostomy 
 and enteroanastomosis, 12 of which were for carcinoma. Of these 
 cases, 19 recovered and 3 died. In all 3 cases death was most cer- 
 tainly not due to peritonitis, but in 1 case to perforation of an ulcerat- 
 ing carcinoma of the stomach two weeks after the operation; in an- 
 other case, to continued hemorrhage from a carcinoma of the stomach 
 sixteen days after operation; and in the third, to peritonitis arising 
 from a tuberculous granuloma in the intestine four weeks after opera- 
 tion. Of 6 cases of resection of the intestine at one operation, 4 
 recovered and 2 died. In one case death occurred from collapse on 
 the second day after a very prolonged operation of double resection 
 for carcinoma ; in the other case, where the injury was a bullet wound, 
 death took place on the tenth clay from hemorrhage from the vena 
 cava. In neither of the cases was there any peritonitis. One case 
 of opening the stomach and stretching the cardiac orifice, performed 
 on account of spasm, recovered. So also did 6 cases of operation on 
 the bile duct, 7 other operations upon abdominal organs without open- 
 ing the intestinal tract, and 3 extra-abdominal operations. The last 
 to be mentioned are 2 cases of nephrectomy, which were treated before 
 the operation with nucleic acid. In both cases, in order to remove 
 the suppurating kidney, the peritoneum had to be widely opened. 
 One case recovered, the other died twelve days after the operation 
 from hemorrhage from the renal artery. In this case, too, there was 
 no peritonitis. We therefore have 45 laparotomies in which the ab- 
 dominal cavity was exposed to infection by the contents of the stomach 
 or intestines or bv some other infectious secretion; 38 of these cases 
 
FLUSHING OF THE PERITONEUM 455 
 
 recovered, and in none of the 7 fatal results was peritonitis the cause 
 of death. 
 
 Mikulicz has finally settled upon injecting 50 c.c. of neutral- 
 ized nucleic acid, 2 per cent., twelve hours hefore the operation. 
 
 FLUSHING OF THE PERITONEUM 
 
 Flushing of the peritoneum with large quantities of saline 
 solution and permitting a moderate amount to remain in situ 
 after completion of the intra-abdominal operation is a practice 
 quite largely employed by surgeons. It is probable that the re- 
 sistance of the peritoneum to infection is increased by this means. 
 It is wise to omit the measure, in the presence of considerable 
 quantities of purulent secretion not widely distributed, for fear 
 of spreading mechanically the infection. The most rational field 
 of usefulness of the measure would seem to be in cases where the 
 peritoneum has been subjected to considerable trauma for the re- 
 lief of non-infective afflictions, such as carcinoma of the uterus or 
 other neoplasms in this situation. The solution should have a 
 temperature of 110° F., and be poured into the wound by means 
 of a pitcher. About 500 c.c. of the solution is comfortably taken 
 care of by the peritoneum in twelve hours. 
 
 The writer usually employs flushing after hysterectomy or 
 transperitoneal nephrectomy, but omits it when the intestinal 
 canal has been opened either with the view of relieving affliction 
 or accidentally while operating upon contiguous organs. When- 
 ever hemorrhage has been a factor in the procedure, the flushing 
 is maintained until the solution returns clear, and then 500 c.c. 
 of the fluid is left in situ. Under these conditions employment of 
 the measure seems advisable. Peritonitis, of course, does not fre- 
 quently follow this class of cases, and a standard as to its efficiency 
 with respect to obviating its occurrence is not possible. 
 
 Kader uses an antistreptococcic serum with the view of im- 
 munizing the patient against peritonitis. While the measure has 
 not proven of value as yet, it comprehends a field of endeavor 
 which is along the lines leading to successful results in other con- 
 nections, and for this reason reference to the matter should not be 
 omitted in a work of this kind, if for no other reason than to 
 stimulate investigation in this direction. 
 
456 PERITONITIS FOLLOWING CELIOTOMY 
 
 TREATMENT OF PERITONITIS 
 
 The occurrence of peritonitis is heralded by persistence of 
 pain after the lapse of twenty-four hours following the operation. 
 Its occurrence must be differentiated from the distress and disten- 
 tion, the result of intestinal paralysis. This subject has already 
 been taken up. The condition of the vomit should be scrutinized. 
 The occurrence of blood, more or less altered, in the vomit arouses 
 suspicion of peritonitis, though it may indicate acute dilatation 
 of the stomach. In the latter instance it appears early ; the writer 
 has seen small flecks of dark blood in the vomit, as the patient was 
 being transported from the operating table. The patient had been 
 subjected to celiotomy for hysterectomy, and infection before the 
 operation was readily excluded. Within twenty-four hours an 
 acute dilatation of the stomach supervened, though fortunately 
 the patient made an excellent ultimate recovery, after appropriate 
 measures of relief had been employed. It may be proper to re- 
 gard a prognosis based on the appearance of so small a quantity 
 of blood in the vomitus, as stated, a trifle pessimistic. However, 
 liberal gastric lavage should be employed in cases where even a 
 minute quantity of blood appears in the vomit after celiotomy, 
 and, indeed, also if there be any doubt as to the conditions in this 
 regard. The subsequent behavior of the case showed that infection 
 had not occurred, and the wound healed by primary union. The 
 contention that " black vomit " following celiotomy is fatal is true 
 enough when it is the outcome of sepsis, but if it be due to acute 
 dilatation of the stomach, recovery is not to be despaired of. 
 
 A discussion of the symptomatology of peritonitis does not be- 
 long here. However, it may be proper to state that the classical 
 symptoms of inflammation as taught in school are the index in this 
 situation as they are elsewhere in the body. As soon as the indi- 
 cations of peritonitis are manifest, an attempt should be made to 
 empty the gut. The persistence of vomiting makes the adminis- 
 tration of medicinal agents directed to this end quite impractic- 
 able. Calomel in small doses is, perhaps, most likely to be of 
 service in this connection. High enemata, to which a few drops 
 of turpentine have been added, are the means most likely to serve 
 the purpose. If an expulsion of flatus and some feces attend the 
 
TREATMENT OF PERITONITIS 457 
 
 measure, the prognosis may be regarded as more favorable. The 
 administration of eserin, atropin, and lavage of the stomach, as 
 already indicated in connection with intestinal paresis, are meas- 
 ures of service. Reopening of the abdomen for the purpose of 
 cleansing and draining the peritoneum, is a measure of doubtful 
 utility. The shock of the first operation, the exhaustion attending 
 the peritonitis, and the fact that additional trauma to the peri- 
 toneum and the necessary handling of the gut will all enhance the 
 intestinal paralysis, would seem to lead to the conclusion that the 
 measure is not properly to be expected to afford relief. However, 
 this may be said, if the general condition of the patient warrants 
 the attempt, if cyanosis, and venous stasis are not dominatingly 
 established, the opening of the abdomen, at the lower median por- 
 tion, and the introduction of hot saline solution may be justified. 
 
 THE MURPHY TREATMENT 
 
 The Murphy treatment has recently come much into vogue. 
 Gilliam states the cardinal features of the Murphy treatment as 
 " the Fowler position, pelvic drainage, and continuous drop-by- 
 drop instillation into the rectum of a saline solution." 
 
 Gilliam states: 
 
 1. Drainage of the germ impregnated fluids into the pelvis, where 
 absorption is least active, and away from the diaphragm, where 
 absorption is most active, thus tending to diminish systemic infec- 
 tion. This is accomplished by means of the Fowler position. 
 
 2. Drainage of the pelvis to prevent stasis and accumulation of 
 the peccant matters, which is in furtherance of the same object. The 
 drainage is effected through tubes usually introduced through a supra- 
 pubic incision to the bottom of the pelvis, though on occasions the 
 drainage may be affected through the vault of the vagina. 
 
 3. Surcharging the lymphatics with a saline solution to prevent 
 their taking up and conveying into the general circulation the poison- 
 ous products of the pathogenic germs themselves. This is effected by 
 rectal installation. 
 
 It is claimed that the saline infusion into the rectum is carried 
 by antiperistalsis the full length of the large intestine, and in this 
 way the area of absorbing surface is prodigiously increased. Xow, 
 inasmuch as the large bowel possesses both an absorbent and excretory 
 
458 PERITONITIS FOLLOWING CELIOTOMY 
 
 function, I am of the opinion that the saline infusion serves a double 
 purpose by creating both an endosmotic and exosmotic current, where- 
 by the vascular channels are filled, on the one hand, with innocuous 
 saline solution, and the excretory products, including the poisonous 
 matters, are, on the other hand, swept into the bowel, to be carried 
 away with the excretions. I have seen cases in which a diarrheal 
 discharge of distinctly fecal character went hand in hand with evi- 
 dence of absorption of the saline infusion and a gradual subsidence 
 of septic manifestations. 
 
 Gilliam quotes from a communication sent him by Murphy: 
 
 In the last five years' work in general septic peritonitis, we have 
 had forty-seven cases of perforative, diffuse, general peritonitis oper- 
 ated in the active stage, with but two deaths, and neither of these from 
 peritonitis. The treatment after the operation in these cases con- 
 sisted in placing and retaining the patient in the semi-sitting (Fowler) 
 position (35 to -15°) for three or four days, administering large 
 quantities of saline solution by rectum, from six to fifteen quarts in 
 twenty-four hours; the saline must be allowed to seep in, the tube 
 remaining constantly in position. ISTo water is given by the mouth, 
 as the stomach never absorbs it direct, and under these conditions it 
 does not readily transmit it to the intestine for absorption. Mild 
 catharsis should be induced with small closes of calomel, beginning 
 eight hours after operation. During the transportation of cases of 
 general suppurative peritonitis to the hospital, and during the opera- 
 tion the patients should be kept in a semi-sitting position. Use ordi- 
 nary vaginal douche tips with three openings, so that the water can 
 flow into one and the gas come out of the other. A single opening 
 tip will not permit the gas to bubble back into the can, and th£ passing 
 of gas is important. The can should be elevated from four to six 
 inches above the anal level. The tube can be strapped permanently 
 to the body (the thigh) of the patient with adhesive plaster, and the 
 nurse should be carefully instructed to watch closely and not allow 
 more than one and a half pints of saline solution to flow in from 
 forty minutes to one hour. The speed of the flow must not be con- 
 trolled by forceps on the tube, but by elevation, or depression, of the 
 can. A hot water bag should be used to keep the solution warm. 
 (The can is replenished every two hours.) There is no irritation of 
 the rectum and the tube is not taken out for days, the time varying 
 in different patients and depending on the virulence of the infection. 
 Through the drain, the tension of the pus is kept low. With the 
 
TREATMENT OF PERITONITIS 
 
 459 
 
 saline irrigation, these patients have increased urination and increased 
 perspiration when the blood pressure is restored. 
 
 Gilliam employs for the purpose of maintaining the Fowler 
 position an adjustable chair, which is not unlike the so-called 
 steamer chair used by travelers, which he describes as 
 
 Consisting of a canvas body rest or hammock, supported by a 
 wooden frame work, and as its name implies, it is capable of being 
 thrown into various positions ranging from the upright to, or near 
 the horizontal. It is provided with a leg rest which is also capable 
 of being raised or lowered. Incidentally, it is light in construction 
 and can be folded into a small compass for easy transportation. 
 
 Fig. 292 shows a patient postured as described with the irri- 
 gation can placed in about the proper relationship to the anal level. 
 The purpose can be achieved by raising the head of the bed or by 
 
 Fig. 292. — Patient in the Fowler Position Being Given the Murphy Instil- 
 lation into Rectum. 
 
 placing a bed rest beneath the patient's body at an angle of 35° 
 to 45°. It will be found expedient to place the patient's buttocks 
 on a goodly sized rubber ring, to obliterate the acute angle which 
 the tube forms to the position of the body. The latter may kink 
 
460 PERITONITIS FOLLOWING CELIOTOMY 
 
 the tube. A return flow is, of course, not provided for, for obvious 
 reasons. Undue exertion on part of the patient is to be avoided 
 for the reason that drainage of the abdomen favors sequential ven- 
 tral hernia. 
 
 The class of cases in which drainage is efficient is those in 
 which purulent peritonitis already exists, and here dependent 
 drainage may accomplish the purpose in contradistinction to those 
 cases in which drainage is introduced as a prophylactic measure, 
 with the view of preventing infection. This phase of the subject 
 has already been discussed. 
 
 The tube drainage should be removed as soon as the discharge 
 of purulent secretions ceases. This is usually feasible on the third 
 or fourth day. If improvement in the general conditions occurs 
 at the end of twenty-four hours, rectal alimentation may be made 
 for one injection and the irrigation interrupted for three hours. 
 The introduction of nutritive elements by mouth will be found to 
 be quite impossible during the time that the indications for con- 
 tinuous instillation exist. As soon, however, as the stomach toler- 
 ates liquids gastric alimentation, under the precautions stated, 
 should be begun. 
 
 When peritonitis follows celiotomy the patient should not be 
 permitted to leave the bed until convalescence has been well estab- 
 lished. 
 
CHAPTEE XXIII 
 
 OPERATIONS ON THE ABDOMEN {Continued) 
 
 COMPLICATIONS IN CELIOTOMY 
 
 Lung complications — Parotitis — Hematemesis — Phlebitis and thrombosis — Adhe- 
 sions following celiotomy — Abdominal belts and supporters. 
 
 LUNG COMPLICATIONS 
 
 Pathological processes in the lungs follow celiotomy more fre- 
 quently than operations in other situations of the body. The ad- 
 vent of asepsis has lessened the number of instances in which these 
 complications occur, but there is still a preponderance of lung dis- 
 ease following celiotomy as compared to other operations. Pneu- 
 monia, pleurisy, bronchitis, pulmonary edema, embolic infarcts, 
 and abscess of the lung are the processes most commonly encoun- 
 tered. They may follow simple or severe operations. 
 
 The belief that the afflictions were due to chilling of the lung 
 tissue by ether was abandoned when the same complications 
 occurred subsequent to operations made under local anesthesia. 
 Moynihan says: 
 
 It is well known that for a few days after any abdominal opera- 
 tion, the wound may feel stiff and sore, though it is not actually pain- 
 ful. The taking of a deep breath or the act of coughing causes a 
 sudden " stitch " in the wound, and the patient feels as though a free 
 effort at coughing would tear the wound edges apart. 
 
 It was suggested then that immobilization of the abdominal 
 muscles, in the unconscious protection of the wound area by the 
 patient, resulted in an accumulation of the bronchial secretions 
 in the lung. A deep breath was not taken; the breathing remained 
 thoracic in type, and the air passages were not cleared in the act 
 of coughing. The lung then became irritated and waterlogged by 
 
 461 
 
462 COMPLICATIONS IN CELIOTOMY 
 
 retained secretions. In favor of this suggestion is the fact that 
 all forms of chest involvement are more frequent after operations 
 performed in the upper abdomen. 
 
 A factor which is, without question, one of great importance is 
 the chilling of the patient before, during and after the operation. 
 
 The precautions necessary in this connection are already taken 
 up (page 162). 
 
 Moynihan further states : 
 
 In some cases I feel sure that the cause of the lung implication 
 is to be found in the inhalation of septic matter. This septic matter 
 may come from the patient's own mouth, or it is conceivable that a 
 dirty inhaler may be responsible for it. Of the necessity for cleanli- 
 ness in both these directions there is no further need to speak. 
 
 In some cases the pneumonia has been proven to be due to embo- 
 lism, the septic emboli being derived from the operation area. In 
 operations upon the stomach or intestine in particular, thrombosis 
 of veins may result from unduly rough handling or from infection of 
 the wounds. Neatness and a certain dainty fastidiousness and the 
 utmost cleanliness in all operations are things to be cultivated. 
 
 There can be little doubt, I think, that in some cases the long 
 continuance of the Trendelenburg position in pelvic operations is 
 productive of harm. The viscera are pressed against the diaphragm, 
 whose freedom of action is thereby limited. There is a congestion of 
 the lungs as a result of the gravitation of blood to the dependent 
 parts. It is my custom to perform the early and late steps of any 
 pelvic operation with the patient in the usual horizontal. As soon 
 as the Trendelenburg position is necessary, the table is altered by the 
 anesthetist in a moment ; as soon as the pelvic part of the operation is 
 completed, the table is again made horizontal. The patient, there- 
 fore, remains the briefest possible time in this constrained position. 
 
 It has become a general custom, more especially among resident 
 officers, to give intravenous saline injections to all patients who are 
 suffering in any serious degree from shock. The custom has much 
 to recommend it, but I am strongly disposed to think that it is not 
 seldom provocative of harm, for, in some cases, when large quantities 
 of fluid are injected, an acute edema of the lung, with copious frothy 
 expectoration, occurs. On postmortem examination of such cases, 
 it can be seen that there is an acute edema of both lungs, the lungs, 
 in fact, are waterlogged. Saline infusions are remedies we cannot 
 afford to do without, but a little more discretion than seems generally 
 
LUNG COMPLICATIONS 463 
 
 customary should be exercised in their administration. Above all, it 
 should be seen that the fluid injected is of proper temperature, that 
 no air is allowed to get into the vein, and that the quantity injected 
 does not exceed three pints. As much as five or six pints has been 
 frequently given, but I do not think that as much benefit results from 
 one large injection as from two smaller ones given with an interval 
 of twelve or twenty-four hours. 
 
 Professor Mikulicz orders all his patients, after abdominal opera- 
 tions, to breathe deeply for a few minutes two or three times daily, 
 in the belief that the tendency to stagnation in the lung bases is thereby 
 relieved and broncho-pneumonia prevented. 
 
 From the foregoing discussion it will be realized that, though the 
 possible causes or influences giving rise to the lung complications after 
 abdominal operations are many, it is not to any one of them that para- 
 mount importance can* be attached. The surgeon's part, therefore, 
 must be to safeguard his patient by all means in his power from all 
 these harmful influences, and he will find that by so doing the risk 
 of the occurrence of these most serious disasters will be greatly les- 
 sened, if not entirely abolished. 
 
 The treatment of the lung complications following abdominal 
 operations does not differ from that which is observed in the cases 
 ordinarily seen. I have come to place much reliance upon the fre- 
 quent use of the steam inhaler with or without tincture of benzoin 
 or other stimulants. The patient always expresses himself as much 
 relieved, and a copious expectoration generally results from each use 
 of the inhaler. A mixture containing digitalis, vinum ipecacuanha, 
 and carbonate of ammonia generally gives relief. 
 
 Bibergeil in 3,909 operations in Korte's clinic found that 
 pneumonia followed in 135 of the collected cases, and presented 
 in 10 instances the croupous or lobar, in 98 the lobular, and in 
 the remaining 27 the hypostatic form. Other complications, such 
 as pulmonary embolism and abscess, bronchitis, pleurisy, and em- 
 pyema, occurred in 147 other cases. With regard to pneumonia, 
 Bibergeil found that this complication of abdominal surgery was 
 in no wise influenced by the condition of the wound. Of the 10 
 cases of the septic lobar pneumonia type, in 8 the wound was 
 aseptic and septic only in two. He states that : 
 
 A careful study of the collected cases has led to rejection of the 
 views that this complication may be due to infection by way of 
 the lymphatics, and to such causes as exposure to cold of the 
 
464 COMPLICATIONS IN CELIOTOMY 
 
 surface of the body or of the peritoneal cavity to abdominal irrigation, 
 and to direct action of the anesthetic. The lobular form, or broncho- 
 pneumonia, which is most frequently met with after laparotomy, is 
 regarded as being usually the result of autoinfection, due to the aspi- 
 ration of secretions from the mouth and pharynx, whilst the patient 
 is under full influence of an anesthetic. 
 
 It is pointed out that the interference with free breathing and 
 expectoration, resulting from pain at the seat of the operation 
 and impeded movements of the incised abdominal wall, must favor 
 very much the development of lung disease after laparotomy, 
 while the resistance to the inflammatory attack is in many cases 
 much impaired in consequence of the enfeebled condition of the 
 patient. In concluding, the author recommends, as suitable pro- 
 phylactic measures, thorough cleansing of the" mouth and throat 
 and irrigation of the stomach before the operation; a cautious 
 administration of the anesthetic, the patient's face being turned 
 to one side to permit a free external flow of oral secretion; pre- 
 vention of chilling of the surface of the abdomen during and 
 after the operation ; the application of thick and warm com- 
 presses to the wound, and avoidance of tight bandaging ; frequent 
 change of the patient's position in bed during the after-treatment, 
 and as speedy a release from the recumbent posture as the state 
 of the wound will allow. 
 
 The fact, as already stated, that lung complications follow 
 abdominal section when local anesthesia is employed, suggests 
 that some of the causative factors are due to the factors which 
 Bibergeil enumerates. It must not be forgotten, however, that 
 septic emboli do locate in the lung which may have their origin 
 in the field of operation, and no local evidence of sepsis in the 
 postoperative course of the case be manifested. This is readily 
 understood, from a physiological viewpoint, when the arrange- 
 ment of the abdominal circulation is borne in mind. Indeed, 
 abscess of the lung and empyema pleuritica has frequently fol- 
 lowed abdominal section when the abdominal wound did not in- 
 dicate septic infection. Indeed, the same condition, i.e., abscess 
 of the brain and fatal meningitis, has occurred under the same 
 conditions. Pneumonia and pleurisy complicating abdominal sec- 
 tion are both more liable to be followed by empyema than the or- 
 dinary type of both these diseases. 
 
PAROTITIS 465 
 
 If all the precautions mentioned be carried out, many factors 
 which may properly he regarded as causative to lung complica- 
 tions following celiotomy will be eliminated. The attendant is 
 warned, however, against eliminating the question of chilling the 
 patient before, during, or after the operation. Complacency in 
 this regard, the outcome of the assumption that mechanical fac- 
 tors play the most important role in causation, is to be depre- 
 cated. So it is with respect to change of posture in the so-called 
 hypostatic pneumonia. The hypostasis is most likely to occur 
 in old and enfeebled persons, and, while it is true that the re- 
 cumbent position favors gravitation of fluids to the bases of the 
 lungs, it is also true that the sitting posture is not without danger 
 to the patient's heart under the same conditions. The upper por- 
 tion of the body should be cautiously elevated, under careful 
 espionage of rate and character of pulse, and when marked al- 
 teration in these regards becomes manifest, the recumbent posi- 
 tion is to be again attained. Under no circumstances is the pa- 
 tient to be permitted to assume the upright position as the result 
 of muscular effort. In some instances the lateral positions, varied 
 as to the side turned upon, would seem to be a rational indulgence. 
 This, too, should be done by the attendant and not be the result 
 of exertion on part of the patient. 
 
 PAROTITIS 
 
 Parotitis, that is an acute inflammation of one or both parotid 
 glands, is another occurrence quite common following abdominal 
 section. In 1887, Stephen Paget collected the records of 101 
 cases and investigated their causes. He found that in 10 cases 
 parotitis arose after disease or injury of the urinary tract; 18 
 cases, parotitis arose after disease or injury of the alimentary 
 tract; 23 cases, parotitis arose after disease or injury of the ab- 
 dominal wall, peritoneum or pelvic cellular tissue; 50 cases, 
 parotitis arose after disease or temporary derangement of the 
 generative organs. 
 
 It has been believed that the preponderance of cases following 
 abdominal section for disease of the genital organs was due to 
 the fact that the opening of the abdominal cavity for pelvic dis- 
 ease was more frequently undertaken than for other intra-ab- 
 
466 COMPLICATIONS IN CELIOTOMY 
 
 dominal afflictions. Also, that heretofore the custom was not to 
 supply water to the system following celiotomy, and that the dry, 
 parched condition of the mouth favored inflammation of these 
 glands. It is worthy of note, however, that surgical attack of 
 the female generative apparatus is followed quite frequently by 
 tonsillitis, even now, when copious amounts of fluid are intro- 
 duced into the system after celiotomy. It is also true that ton- 
 sillitis frequently occurs in the newly married. It would seem 
 that, as far as the generative organs is concerned, there is a 
 peculiar relationship between them and the tonsillar and parotid 
 tissue, one which is not readily explained. 
 
 The significance of the subject lies in the confusion the oc- 
 currence of complications of this sort give rise to, with regard to 
 standardizing the systemic symptomatology with respect to wound 
 complications. The acceleration of pulse rate, and increase of 
 temperature coincident to the complications mentioned, arousing 
 suspicion of other more directly sequential conditions. 
 
 The occurrence of parotitis, secondary to celiotomy, has been 
 ascribed to several causes. It was at first regarded as a primary 
 mumps, unfil the marked difference with respect to the tendency 
 to suppuration in the secondary form became accepted as justi- 
 fying a different conclusion. The pyemic or embolic theory was 
 the one to first receive general approval. Before the advent of 
 aseptic repair of wounds, this conclusion seemed rational enough, 
 but latterly, as the condition obtained in the course of nonseptic 
 wound repair, the theory was discarded. Indeed, in those in- 
 stances in which infection of the celiotomy wound did occur, 
 there was frequently no evidence of thrombosis which would 
 justify the belief that the suppurative parotitis was embolic. Of 
 course pyemic parotitis does occur in the course of sepsis, but 
 then develops as a part of pyemic processes in other situations. 
 
 Bucknall states: 
 
 More recently the question of embolic origin has been definitely 
 proven to be incorrect, for it has been shown by microscopical examina- 
 tion that the conditions present are different in secondary parotitis 
 and in parotitis of pyemic origin. In the former instance, the process 
 of inflammation begins around the ducts in the centers of the lobules 
 and, moreover, many lobules are simultaneously affected. In the 
 latter (pyemic type), the inflammation begins around the arteries 
 
PAROTITIS 467 
 
 which run in the perilobular tissue and the inflamed mass is a single 
 one, involving the area of gland tissue supplied by the particular 
 vessel which has been blocked by the septic clot. 
 
 Paget leans toward the sympathetic theory already alluded 
 to, on the ground of the peculiar relationship between the organs 
 of generation and the parotid gland. Moynihan does not regard 
 this relationship as of determining import, believing the process 
 in the glands as always infective and extending from the mouth. 
 This view is strongly supported by Ilanau and Pilliet. 
 
 Buchnall presents this view as follows : 
 
 They found on microscopical examination of sections of the paro- 
 tid (1) that the ducts were choked with debris containing micro- 
 organisms; and (2) that the inflammatory processes present invariably 
 
 Fig. 293. — Parotitis. Infected Ducts and Adjacent Central Parts of Lobule 
 Breaking Down to Form Abscess Cavities. (Rupert Bucknall.) 
 
 began around the ducts in the center of each lobule, and only spread 
 later to the periphery of the lobule and the perilobular connective 
 tissue in which the blood vessels are situated. They concluded, there- 
 fore, that secondary parotitis could not be of embolic origin, or else 
 the inflammation would have originated around the vessels, and that 
 32 
 
468 
 
 COMPLICATIONS IN CELIOTOMY 
 
 the fact that inflammation hegan simultaneously in the centers of 
 many lohules at once, pointed to an ascending infection of the ducts 
 as the real source of the affection, — a conclusion which was further 
 borne out by the actual presence of microorganisms in the ducts them- 
 selves in such cases. 
 
 Additional evidence of different kinds has been subsequently 
 brought forward in support of this view. 
 
 Microscopical sections serve to show that in all cases of secondary 
 parotitis, the disease pursues the following course: (a) The ducts 
 become blocked with debris (Fig. 293). (b) Inflammation first be- 
 gins in the center of each lobule around the ducts, and at a point 
 farthest away from the vessels (Fig. 294). (c) Many lobules are 
 
 Fig. 294. — Parotitis. Gland Tissue Destroyed and Replaced by Inflammatory 
 Products, Which are Breaking Down to Form Abcess Cavities, Vessels not 
 Thrombosed or Specially Inflamed. {Rupert Bucknall.) 
 
 simultaneously affected; they each become centrally necrosed and 
 then finally, by extension, they fuse to form a multilocular abscess. 
 (Fig. 295.) 
 
 Bacteriological examination, first carried out by Girode, has served 
 to prove: (a) That several different kinds of organisms may give rise 
 to secondary parotitis, the commonest being the staphylococcus, the 
 next frequent the pneumococcus, and after that the pneumobacillus, 
 the typhoid bacillus, and the streptococcus, in order of frequency. 
 
PAROTITIS 469 
 
 (b) That on taking cultivations from the gland itself, the pus con- 
 tained in it, the orifice of Stensons duct, and the oral cavity respec- 
 tively, the organisms found at each spot are invariably identical in 
 each individual case, a fact which supports the conclusion that the 
 infection of the gland spreads from the mouth via the duct, (c) 
 
 Fig. 295. — Parotitis.' Showing Multilocular Abcesses in Ducts and General 
 Cell, Infiltration of Lobules. (Rupert Bucknall.) 
 
 That the organism giving rise to secondary parotitis is by no means 
 invariably the same as that giving rise to the primary disease, during 
 the course of which the attack of parotitis has arisen. Thus, in the 
 cases complicating pneumonia, the organism causing parotitis may 
 be the pneumococcus or the staphylococcus; in typhoid fever, it may 
 occasionally be the typhoid bacillus, but it is much more commonly 
 the staphylococcus or pneumococcus. In embolic parotitic due to 
 pyemia, on the other hand, the organism in the parotid is invariably 
 identical with that giving rise to the primary disease and the abscesses 
 in other parts of the body. 
 
 The treatment of parotitis does not differ from that of acute 
 inflammatory processes elsewhere in the body. The discussion 
 related above argues for cleanliness of the mouth prior to opera- 
 tion (page 362). 
 
470 COMPLICATIONS IN CELIOTOMY 
 
 HEMATEMESIS 
 
 Hematemesis following celiotomy and its significance has 
 been made the subject of extensive discussion under postopera- 
 tive vomiting and acute dilatation of the stomach. A repetition 
 of this would be out of place. The reader is referred to these 
 portions of the work for guidance. 
 
 PHLEBITIS AND THROMBOSIS 
 
 Phlebitis and thrombosis are not infrequent occurrences, com- 
 plicating abdominal section, though, indeed, they are almost 
 usually sequential to operations on the pelvic organs, especially 
 hysterectomy, but have also occurred following attack upon the 
 other abdominal organs, including the stomach and gall-bladder. 
 
 In the vast majority of cases the phlebitis occurs first, and 
 the formation of the thrombus is secondary to it. However, in 
 some instances, especially where there is an impoverished condi- 
 tion of the blood, the so-called "marasmic thrombosis " of Bill- 
 roth occurs, which the latter attributes to increase of the coagu- 
 lability of the blood, due to an increase in the proportion of cal- 
 cium salts. 
 
 The phlebitis is due, almost always, to infection, though it 
 does also occur when the wound runs an aseptic course. It will 
 be noticed, however, that even though the wound itself presents 
 at no time evidence of inflammation, the so-called reactionary 
 temperature, on the second day following the operation reaches 
 101-J° F. The notion that infection is the causative factor in 
 phlebitis is not absolutely accepted by all surgeons. The fact that 
 it occurs most frequently after hysterectomy, during which, of 
 course, an infective area is invaded, would argue for the accu- 
 racy of the infection theory. Phlebitis has also occurred after 
 interval appendectomy, but it must be remembered that the veins 
 of the mesoapj^endix are intimately connected with the contigu- 
 ous large venous trunks, and that an infection not of sufficient 
 virulence to manifest itself at the port of entrance, may still find 
 the conditions for a favorable culture medium in a contiguous 
 vein. 
 
 The saphenous and femoral veins on the left side are the ones 
 
PHLEBITIS AND THROMBOSIS 471 
 
 most frequently involved. W. W. Keen regards the fact that the 
 left common iliac vein passes under the right common iliac ar- 
 tery, as a possible indirect cause of the preponderance of cases 
 of infection of the veins on the left side. Though this explanation 
 is not easy to accept, it may be said that there is a certain causa- 
 tive relationship possible. Summarizing the subject of venous 
 thrombosis and phlebitis, Moynihan says: 
 
 Thrombosis occurs most frequently following abdominal operations 
 upon the lower part of the abdomen. . It is estimated to happen in 2 
 per cent, of all cases ; it is first noticed about two weeks after the opera- 
 tion; it is more apt to afflict patients who are debilitated by long ill- 
 ness, or whose condition is poor as a result of frequent hemorrhages; 
 it is found in great preponderance upon the left side, where it affects 
 the saphenous and femoral veins. As a causative factor, sepsis can 
 rarely be excluded. Phlebitis precedes the thrombosis as a rule. 
 
 Cordier has collected records of 232 cases. He gives the fol- 
 lowing table, which shows the number of cases following various 
 operations : 
 
 Nephorraphy 9 
 
 Appendectomy — mostly so-called aseptic cases 27 
 
 Cholecystotomy 4 
 
 Oophorectomy (cystic, scirrhotic, etc.) 16 
 
 Hysterectomy, fibroids, so-called aseptic cases 69 
 
 Vaginal operations, character not stated 8 
 
 Alexander's operation 3 
 
 Hernia 4 
 
 Pyosalpinx 7 
 
 Pelvic operations not specified 9 
 
 Abdominal and pelvic operations not specified.... 56 
 
 Ectopic pregnancy 4 
 
 Vaginal hysterectomy for cancer 9 
 
 Suspension of uterus 7 
 
 Splenectopy 1 
 
 SPECIAL FEATURES 
 
 In 213 cases, left saphenous or femoral veins affected. 
 
 In 8 cases, both left and right veins affected. 
 
 In 11 cases, right veins alone affected. 
 
 In 182 cases, proximal part of vein first affected. 
 
472 COMPLICATIONS IN CELIOTOMY 
 
 In 36 cases, distal part of vein first affected. 
 In 14 cases, portion of vein affected not mentioned. 
 In 166 cases, sepsis was not present at time of operation. 
 In 56 cases, no mention of sepsis or asepsis was made. 
 In 10 cases, there was pus present at time of operation. 
 In the great majority of cases the first symptoms appeared from 
 the 19th to the 15th day. 
 
 In 6 cases, pleuritic and lung complications. 
 In 3 cases, sudden death occurred. 
 
 Cordier describes the clinical course as follows: 
 
 The usual onset of this condition is marked by a gradually increas- 
 ing pain along some portion of the long saphenous vein, usually the 
 left, and most frequently just below the saphenous opening in the fascia 
 lata. This pain may extend along the whole course of the vein and, 
 as a rule, does follow the vessel below the knee. An elevation of 
 temperature of from 2° to 3° is noticed, and a proportionately in- 
 creased pulse-rate is also observed. The pain in the limb is increased 
 by moving the limb or by permitting it to remain in a dependent posi- 
 tion, and is partially relieved by elevating the leg and thigh. On 
 examining, in many cases, there will be noticed a redness along the 
 course of the inflamed vein or veins. If seen early, no perceptible 
 swelling of the limb will be noticed, but within a few days, if the case 
 is a severe one, the whole limb will be swollen, but more particularly 
 the calf of the leg. This swelling is uniform, and free from discolora- 
 tions or redness; in fact, the surface is blanched. Pressure along the 
 course of the vein elicits tenderness, and in the calf of the leg the 
 tenderness is found all over the posterior surface. The vein is hard- 
 ened and rolls under the finger like a tendon, in many cases. Pres- 
 sure, if continued for several minutes, may produce pitting, but not 
 so well marked as in dropsical afflictions. Except along the course 
 of the superficial portion of the vein, which may feel unnaturally 
 warm, there is a death-like temperature of the surface to the examin- 
 ing hand. 
 
 The patient should at once, immediately upon recognition of 
 the affliction, be warned of the serious outcome which may attend 
 disturbance of the limb. The affected limb should be elevated on 
 several pillows, and warm applications, of boracic acid, lead, and 
 opium wash or simple water be made. The limb may be incased 
 in a many-tailed bandage, and thus the applications may be 
 
ADHESIONS FOLLOWING CELIOTOMY 473 
 
 made to the sides and front of the limb without disturbing it. 
 Heat in some form will be found soothing and agreeable to the 
 patient. If the phlebitis begin sufficiently far down in the course 
 of the vein, the Bier passive hyperemia should be tried. The 
 writer has found this treatment of apparent service in cases 
 which permitted of the constriction being placed above the seat 
 of inflammation. 
 
 Cellulitis suppuration and abscess rarely occur, and must be 
 met in the usual way when they become manifest. In some in- 
 stances it would seem advisable to cut down on the vein near the 
 saphenous opening, deligate it and remove the thrombus. This 
 latter measure has been found of signal service in a number of 
 cases observed by the writer. 
 
 The precautions with regard to keeping the limb quiet must 
 be assiduously observed for several weeks, until there is a reason- 
 able assurance that the process has subsided. Disregard of these 
 precautions has in no small number of instances resulted in dis- 
 lodgment of the thrombus, and embolic invasion of the lung and 
 heart with sudden death. 
 
 The intravenous injection of collargol has proven useful at 
 the hands of some observers. Its employment would seem justi- 
 fied, if the phlebitis constantly recur after apparent subsidence 
 of the primary .attack. Its use must be carefully executed, and 
 this under aseptic precautions, together with careful observance 
 of the rules laid down with respect to intravenous medication. 
 
 ADHESIONS FOLLOWING CELIOTOMY 
 
 Adhesions following celiotomy are quite unavoidable. They, 
 of course, do not always occur to a considerable extent following 
 celiotomy undertaken for non-infective processes. However, 
 they do occur in a certain number of cases of this sort, and may 
 be regarded as inevitable consequential occurrences subsequent 
 to operations where peritoneal inflammation exists, or is provoked 
 as the outcome of surgical trauma. 
 
 The avoidance of prolonged drainage and unnecessary manip- 
 ulations within the abdomen during the operative procedure may 
 be regarded as determining factors with respect to causation. 
 
 It may be said that the introduction into the abdomen of vari- 
 
474 COMPLICATIONS IN CELIOTOMY 
 
 ous mechanical substances with the view of obviating the occur- 
 rence of adhesions has not been attended by favorable results in 
 this connection. The administration of cathartics, and leaving a 
 certain amount of saline solution in the peritoneal sac, are meas- 
 ures which theoretically should be of some benefit. So is it with 
 regard to the administration of atropin and eserin. 
 
 A discussion of the consequences of the formation of adhe- 
 sions in the peritoneum and the organs it covers does not belong 
 here. It is, however, proper to state that mechanical obstruction 
 of the gut follows in a certain number of cases which have been 
 subjected to intraperitoneal surgical trauma, and that the ob- 
 struction is most likely to follow cases in which the lumen of the 
 gastrointestinal tract has been invaded. The symptomatology is 
 that of intestinal obstruction and, as a rule, does not present it- 
 self until weeks after the operation. When the patient has over- 
 come the intestinal paresis and there has been an interval of from 
 several days to weeks of intestinal patency, as shown by the free 
 evacuation of feces and gas, and then symptoms of intestinal ob- 
 struction develop, the case may quite properly be regarded as one 
 of mechanical obstruction due to adhesions. 
 
 The measures of relief justified when the obstruction is due 
 to intestinal paresis, which involve stimulation of the gut, should 
 be avoided and the case at once subjected to celiotomy, destined 
 to remove or obviate the cause of obstruction. This postoperative 
 complication is most distressing, calling, as it does, for a second- 
 ary major operation in a case already subjected to severe meas- 
 ures. It is, however, urged that the attendant do not permit these 
 considerations to stand in a causative relationship to delay in the 
 attempt to obviate the difficulty. 
 
 It would seem that massage of the abdomen as soon as con- 
 valescence is established, should have a tendency to obviate the 
 formation of adhesions, or at least to aid in stretching those al- 
 ready formed, thus, from a theoretical viewpoint, possibly avoid- 
 ing obstruction by kinking. It is, of course, quite impracticable 
 to conclude as to the value of the massage. However, as persons 
 who have been subjected to celiotomy are apt to be in poor gen- 
 eral condition following the operation, employment of abdomi- 
 nal massage may be justified on the ground of the general benefit 
 as regards tone of the gut, which follows its judicious use. A 
 
ABDOMINAL BELTS AND SUPPORTERS 475 
 
 patient who has been subjected to celiotomy most always relaxes 
 the abdominal muscles when in the upright position, bringing 
 the thorax nearer the pelvis in an effort to relieve the tension on 
 the abdominal muscles. This posture is a favorable one as re- 
 gards postoperative hernia, and, if carried on for a long time, 
 results in a certain amount of disuse atrophy of the muscles. 
 This is, of course, objectionable, and also so because of the round- 
 shouldered pose of the patient. Some of this is frequently the 
 outcome of timidity, and is seen more often in females than in 
 males. In these cases massage of the abdomen achieves a double 
 result, stimulating peristalsis and toning up the muscles in the 
 abdominal wall. 
 
 A not inconsiderable number of patients are victims of con- 
 stipation following celiotomy, for obvious reasons. Massage pro- 
 vokes a favorable outcome in this connection. Electricity ap- 
 plied to the abdomen at intervals is a measure which may be 
 regarded as of service in these cases. 
 
 ABDOMINAL BELTS AND SUPPORTERS 
 
 It is common practice to supply patients who have been sub- 
 jected to celiotomy with some form of abdominal supporter which 
 is to be worn for periods varying from several to six months fol- 
 lowing the operation. Much has been said with respect to the 
 superfluity of the measure. As a matter of fact, the apparatus 
 does no harm, and probably is indicated when the section is made 
 below the umbilicus. In young persons or in women who have 
 not borne children, the belt or supporter may be dispensed with, 
 provided primary union has been obtained in the wound. Even 
 in the cases last mentioned, if the wound has healed by granu- 
 lation, some form of abdominal supporter should be worn for 
 several months after convalescence is established. 
 
 Later in adult life, that is, after thirty-five, the abdominal 
 walls of all individuals undergo certain changes. The ribs flare 
 out at their lower aspects, and the abdomen attains a certain ro- 
 tundity, which is not necessarily due to the deposit of fat, This 
 is due in part to relaxation of the muscles, and in part to a physi- 
 ological " dropping down " of all of the abdominal viscera in- 
 cluding the liver. Especially is this true in women who have 
 
476 COMPLICATIONS IN CELIOTOMY 
 
 borne several children. The strain in these instances of the 
 intra-abdominal pressure is brought to bear upon the lower two 
 quadrants of the abdomen, and, if a portion of the abdominal 
 wall is weakened as the outcome of section, hernia is liable to 
 occur. It is the writer's belief that a well-fitting abdominal sup- 
 
 Fig. 296. — Method of Strapping Abdomen. Preliminary Step. (Kemp.) 
 
 porter tends to' support the abdominal wall and lessens the 
 chances of hernia, certainly during the first few months follow- 
 ing abdominal section. It is to be remembered, though, that the 
 supporter should be removed at night and massage and exercise 
 of the abdominal muscles practiced, with the view of obviating 
 the undoubtedly objectionable resting of the abdominal muscles, 
 which may be the outcome of the constant wearing of an artificial 
 support in this situation. 
 
 The influence support has on the lower two quadrants of the 
 abdomen is illustrated by testing the effect of strapping with ad- 
 hesive strips. Kemp employs the method shown in Figs. 296, 
 
ABDOMINAL BELTS AND SUPPORTERS 
 
 477 
 
 297, 298. The strapping may be done in the way shown, begin- 
 ning from below with the patient in the recumbent position, im- 
 mediately subsequent to the operation, and these may later be 
 replaced with a belt. This method of procedure is especially 
 useful, following operations made necessary by enteroptosis. 
 The material employed is two and a half inch moleskin, zinc 
 oxid plaster, and each strip is carried around behind to the me- 
 dian line, in the oblique direction indicated in the illustrations. 
 It will be seen in the illustrations that the strips of the second 
 layer (Fig. 297) cross those of the first, and then all the straps 
 are finally held in place by a third layer of transverse straps 
 
 Fig. 297. — Method of Strapping Abdomen. Second Step. (Kemp.) 
 
 placed over the points of crossing of those underneath (Fig. 298). 
 
 If the celiotomy wound be not quite healed, it is dressed with a 
 
 few layers of sterile gauze and the straps made to cross the wound. 
 
 The straps, of course, have to be changed at each subsequent 
 
478 
 
 COMPLICATIONS IN CELIOTOMY 
 
 dressing. Repeated strappings are not conducive to a healthy 
 condition of skin, and the measure is to be regarded as simply a 
 
 Fig. 298. — Method of Strapping Abdomen. Final Step. (Kemp.) 
 
 temporary one, to be followed by apparatus, as is described fur- 
 ther on. 
 
 It is not sufficient to give the patient general directions, to go 
 to an instrument maker or to send to one and purchase the sup- 
 porter. The attendant should make the measurements himself, 
 and see the supporter in place in order to 
 determine whether the intent has been at- 
 tained. 
 
 The necessary measurements are shown 
 in Fig. 299. The illustration speaks for it- 
 self, the dotted lines representing circum- 
 ference. M should be taken about eight 
 
 Fig. 299. — Lines of • i -i ,r i • t j a 
 
 , T inches above the pubis, L corresponds to 
 
 Measurement for r " 
 
 Abdominal Belt. the umbilicus ; these two measurements 
 
ABDOMINAL BELTS AND SUPPORTERS 
 
 479 
 
 are horizontal. L be- 
 gins at the pubis in 
 front, and crosses the 
 ilium just below the 
 anterior spine U and 
 extends ascendingly 
 backward to a point 
 four inches below the 
 posterior aspect of M. 
 
 The supporter 
 should be of elastic ma- 
 
 FlG. 
 
 300. — Abdominal Supporter 
 Celiotomy. 
 
 Used after 
 
 terial, cotton or silk, depending upon the 
 financial condition of the patient. The char- 
 acter of fabric is not essential as long as the 
 elasticity is sufficient for the purpose. 
 
 Tig. 300 shows a supporter made of elas- 
 tic fabric which is strapped behind. The 
 two hooks are for perineal bands, which are 
 shown in part attached to the posterior lat- 
 eral aspect of the sup- 
 porter. This appara- 
 tus is simple and 
 effective. The belt 
 may be made to lace 
 on the sides over the 
 hips in cases where 
 the abdomen is boat-shaped and the ilii 
 prominent. The kind shown in the cut will 
 be found effective in the majority of in- 
 stances. 
 
 The patient must be instructed to apply 
 the supporter while in the dorsal position 
 with the hips elevated. Fig. 303 shows the 
 position which the patient should assume 
 while applying the apparatus. This posi- 
 tion gravitates the viscera toward the dia- 
 phragm, and the supporter maintains them 
 
 ,i t ,• TTi- oai i Fig. 302. — Abdominal 
 
 there to a relative extent, h lg. 301 shows ,,„„.. 
 
 ■ Supporter and Corset 
 
 the supporter in position, being worn over Combined. 
 
 Fig. 301. — Abdominal 
 Supporter in Posi- 
 tion. 
 
480 
 
 COMPLICATIONS IN CELIOTOMY 
 
 Fig. 303. — Adjusting Lower Segment of Combined Abdominal Supporter and Corset. 
 
 the undergarment. The perineal straps are not shown, hut should 
 always be employed to prevent the supporter from slipping up- 
 ward, the latter contingency causing pressure from above, which, 
 
 of course, is more undesirable than wear- 
 ing no support at all. 
 
 Women patients frequently object to 
 the increase of bulk about the lower ab- 
 domen when the supporter is worn. In 
 these cases a corset fashioned in the man- 
 ner shown in Fig. 302 may be advanta- 
 geously employed. Of course, the pre- 
 vailing fashion with regard to general 
 effect from an artistic viewpoint must 
 needs be disregarded. The illustration 
 shows a combined supporter and corset 
 arranged in two pieces which are laced 
 separately. The lower segment is ap- 
 plied while the patient is in the position 
 shown in Fig. 303, and the upper portion 
 may be adjusted later, as shown in Fig. 
 304. The latter step may possibly be 
 sufficiently, readily modified to produce 
 certain artistic effects so dear to the 
 feminine heart. In a general way, the 
 patient should be admonished not to 
 draw the upper segment so tightly as to force the viscera down- 
 ward and thus, perchance, lessen the efficiency of the lower one. 
 
 Fig. 304. — Adjusting Upper 
 Segment of Combined 
 Abdominal Supporter 
 and Corset. 
 
CHAPTEK XXIV 
 
 OPERATIONS ON THE ABDOMEN (Continued) 
 
 OPERATIONS ON THE STOMACH 
 
 Gastrostomy — Gastroenterostomy: Hemorrhage; Regurgitant vomiting; In- 
 testinal obstruction; Ulcer of the jejunum; Diarrhea — Gastrectomy, etc. 
 
 GASTROSTOMY 
 
 Gastrostomy is usually done at a time when the patient's gen- 
 eral condition has already suffered to a considerable extent as the 
 outcome of lack of nourishment. It is necessary to partake of 
 liquid food in large quantities to maintain not alone life itself, 
 but to furnish the system with resistance. It is a fortunate cir- 
 cumstance that the operation itself is not attended with much 
 shock, and that the exhaustion following it is not great. How- 
 ever, ample provision should be made to obviate shock which may 
 occur during or immediately subsequent to the operation. 
 
 When the patient is about to be operated upon an effort should 
 be made to sterilize the stomach by the administration of sterile 
 food, as already discussed (page 430). Gastric lavage is not 
 readily executed, for obvious reasons. An attempt, however, 
 should be made to accomplish it by means of a stomach tube of 
 narrow caliber. Passing of the tube should be carefully executed, 
 as any trauma to the seat of esophageal obstruction will render 
 subsequent infection of the stomach wound more likely. Imme- 
 diately before the operation and subsequent to the last cleansing, 
 enema, a nutritive enema of peptonized milk (cold process), 
 should be given. Severe manipulations in the region of the anus 
 should be avoided, as it may be necessary to nourish the patient 
 by the rectum for several days following the operation, and this 
 may be seriously interfered with if the anus be irritated. The 
 existence of persistent cough is an objectionable complication, 
 
 481 
 
482 
 
 OPERATIONS ON THE STOMACH 
 
 and should be controlled if feasible before the operation. It is 
 easy to see how coughing would interfere with union of the 
 stomach with the anterior abdominal wall. If cough be present 
 and the operation be not imperatively indicated, a slight post- 
 ponement of it is wise; if, however, the condition of the patient 
 do not warrant the delay, it may be necessary to administer suf- 
 
 Fig. 305. — Tube Leading into Stomach Following Gastrostomy Held in Place. 
 
 ficient opiate immediately after the operation to control the symp- 
 tom, and this may have to be maintained for several days. It is, 
 of course, not a desirable indulgence, but is in some cases the 
 lesser of the evils. 
 
 The operative technic most commonly employed at this writ- 
 ing contemplates the formation of a valvular opening into the 
 stomach, this viscus itself furnishing the valve. The wound is 
 quite closed, except for the point of exit of the rubber tube to be 
 subsequently used for the purpose of introducing food, the usual 
 protective dressing is applied, the tube, which should be 12 to 16 
 
GASTROSTOMY 
 
 483 
 
 inches in length, is led out through the dressing, and after being 
 clamped at its distal end is held in place with a safety pin (Fig. 
 305). The feeding is done through the tube without disturbing 
 the dressing, which latter is, if there be no indication to the 
 contrary, not disturbed until the eighth or tenth day. How 
 soon food is to be administered is a question of some import- 
 ance. In a general way, it may be said that it is best not to 
 administer any nourishment by the fistula for twenty-four to 
 forty-eight hours, though if there be no nausea and the patient's 
 general condition has been poor for a considerable period of time, 
 
 Fig. 306. — Introduction of Liquid Nourishment through Gastric Fistula. 
 
 small quantities of sterile milk, diluted 50 per cent., may be in- 
 jected through the tube into the stomach. In most cases rectal 
 alimentation will meet the indications for forty-eight hours fol- 
 lowing the operation, and at the end of this time the introduction 
 of food into the stomach may begin. At first only small quan- 
 tities of liquid food (2 to 4 oz.) should be introduced, and for 
 33 
 
484 OPERATIONS ON THE STOMACH 
 
 the first six days subsequent to the operation this should be 
 sterilized (page 430). After this time the food need not be sterile. 
 Nourishment is introduced by means of a small glass funnel 
 which is readily connected with the end of the rubber tube (Fig. 
 306). It will be found convenient to use a rubber tube with a 
 flared distal end, such as is used for irrigating catheters in lavage 
 of the bladder. After repair of the wound takes place, it will be 
 found irksome to the patient to constantly wear the tube. It is 
 not wise to let the serous surface with which the valvular folds 
 of the stomach fistula is lined to lie in contact with each other, as 
 they have a tendency to contract. 
 
 If this happen, it will be found that irrigation into the ex- 
 ternal opening with a sterile saline solution will reestablish the 
 lumen of the canal. However, it is advisable to have left in the 
 opening some dilating apparatus at all times. Fig. 307 shows a 
 
 plug made of soft rub- 
 ber and furnished with 
 a shield. The latter 
 prevents the little in- 
 strument from slipping- 
 into the stomach. The 
 apparatus should be 
 about three inches in 
 length and be conical 
 
 Fig. 307. — Soft Rubber Obturator to be Worn . . 
 
 in Gastric Fistula between Feedings. &" *tS intragastric end 
 
 to obviate irritation. 
 The writer has had a patient wear this apparatus for eighteen 
 months following a Senn gastrostomy with satisfaction to the 
 patient. 
 
 Gastric feeding soon relieves the distressing thirst from which 
 these patients suffer, and they almost invariably gain weight, 
 even though the gastrostomy have been done for malignant dis- 
 ease of the esophagus. In instances in which the esophageal ob- 
 struction is due to impermeable cicatricial contraction, or to 
 pressure from aneurism, the gain in weight is very marked. 
 
 In nourishing the patient, an important factor is that of the 
 mental state the patient develops after a time as the outcome of 
 the necessity of feeding himself by a tube and, while the saliva 
 is not essential to digestion, the act of mastication undoubtedly 
 
GASTROSTOMY 485 
 
 has an influence upon nutrition in this much, that appetite is 
 stimulated by the act. Patients suffering from esophageal ob- 
 struction who have been subjected to gastrostomy may be said to 
 be hungry but devoid of appetite. It is well to permit the patient 
 to thoroughly masticate small particles of ordinary articles of diet 
 and expectorate the mass in small quantities into the funnel from 
 which it can be washed into the stomach by the addition of liquids. 
 In the event of the tube becoming obstructed by the particles of 
 food, the funnel may be disconnected and a syringe (Fig. 251) 
 filled with boullion inserted and the semi-solid mass forced into 
 the stomach. The writer has found that no preparation on the 
 market for the purpose of nourishment will take the place of meat 
 fiber. A means of introducing this into the stomach has already 
 been taken up in connection with sterile diet. However, for the 
 purpose of feeding a patient who has a gastric fistula, a pound 
 of lean beef is mangled and shaken up with cold water. This 
 need not be heated for the purpose, but is sucked into the syringe 
 (Fig. 251) and forced into the stomach (Fig. 308). Cooking 
 meat does not increase its digestive characteristics ; indeed, it 
 lessens it and the measure suggested may be advantageously em- 
 ployed once a day or three times a week. Indeed, the patient will 
 improve most rapidly if the physiology of digestion be borne in 
 mind, and the introduction of food be based on the well-known 
 fact that man is essentially on omnivorous animal, and he be 
 treated accordingly. Radical and peculiar views in this connec- 
 tion should be combated. 
 
 The fats are, of course, readily administered, as their con- 
 sistence is only a question of temperature. It is true that the 
 fat contained in milk is in the form of an exceedingly fine emul- 
 sion, and in a condition favorable to ready digestion. However, 
 it will contribute not a little to the patient's conception of his 
 status if fats be introduced in other forms. For the purpose, an 
 ounce or two of butter slightly warmed to render it readily in- 
 troduced, may be forced through the tube into the stomach at in- 
 tervals. A fatty soup, while not palatable, may be injected, and 
 the " gravy " of roast meat may be fed to the patient in a similar 
 way. The carbohydrates are, of course, soluble in water, and 
 present no difficulty with respect to administration. The use 
 of the constituents of the classes mentioned will obviate the 
 
486 
 
 OPERATIONS ON THE STOMACH 
 
 necessity of too frequent feedings, for it is to be remembered 
 that physiologically digestion is an intermittent process, and 
 this fact should be conserved in feeding patients subjected to gas- 
 trostomy. 
 
 During the intervals between feedings the plug shown above 
 (Fig. 307) is worn, and the wound is cleansed with a mild solu- 
 
 Fig. 308.- 
 
 -Forcing Macerated Beef into Stomach through Gastric Fistula by 
 Means of Syringe. 
 
 tion of carbolic acid or simple sterile water immediately before 
 and after feeding. The patient should be furnished with several 
 feeding tubes, and these should be kept clean. The character of 
 the stools should be subjected to examination at intervals with 
 the view of determining which of the articles of diet are not com- 
 pletely digested. A record of the patient's weight is a useful in- 
 dex as to the nutritive value of the food administered. 
 
GASTROENTEROSTOMY 
 
 487 
 
 GASTROENTEROSTOMY 
 
 Gastroenterostomy should be prepared for by an attempt at 
 sterilization of the gastric mucosa. This is more readily attained 
 than sterility of the intestinal lumen for the reasons above stated 
 (page 424). In all instances systematic gastric lavage should be 
 practiced for some time (several days) before the operation. The 
 operation is performed for the purpose of draining the stomach, 
 
 Fig. 309. — Moynihan Position after Gastric Operations. 
 
 and the conditions which provoke stasis in this organ also permit 
 of the decomposition of food, and a certain amount and degree 
 of gastric inflammation always coexists. This is attended with a 
 coating of the gastric mucosa with a thick, tenacious mucus se- 
 cretion which is difficult to remove and which, if left in situ, pre- 
 sents exceedingly favorable conditions for infection. The gastric 
 lavage had best be done by means of solutions which will dissolve 
 the mucous coating, thus rendering the efforts at sterilization of 
 
488 OPERATIONS ON THE STOMACH 
 
 the interior of the organ more readily executed. A teaspoonful 
 of sodium bicarbonate to the quart of sterile water or a teaspoon- 
 ful of magnesium sulphate to the quart of sterile water are effica- 
 cious agents for the purpose. The use of antiseptic solutions of 
 sufficient strength to be efficacious are dangerous, and should 
 not be used. The administration of isoform is justifiable and 
 of service. The diet for several days preceding the operation 
 should consist of organic nitrogenized substances (sterilized, 
 page 430), and fats and carbohydrates are to be avoided, as the 
 latter are not digested in the stomach and only complicate the 
 problem. 
 
 Lavage of the stomach with considerable quantities of sterile 
 cleansing solution immediately before the operation, when the pa- 
 tient is in the anteroom and under narcosis, is a measure which 
 gives additional security to the operative procedure with respect 
 to the avoidance of infection. 
 
 Immediately after patient regains consciousness following 
 gastroenterostomy, he should be postured in the sitting position 
 (Fig. 309 )j with the idea of facilitating drainage of the stomach. 
 The accumulation of secretions, the outcome of a certain amount 
 of atony of the stomach, due to handling together with the over- 
 dilatation, the result of the affliction for which the operation is 
 performed, renders the emptying of the stomach a difficult prob- 
 lem and the supine position may permit of collections in the or- 
 gan. This will be, in a measure, obviated by posturing the pa- 
 tient as stated. The complications following the operation may 
 be stated as follows : 
 
 HEMORRHAGE 
 
 Hemorrhage is of significance in proportion to its amount. A 
 slight bleeding always results from the oozing of the edges of the 
 wound and blood, more or less changed in character and appear- 
 ance as the result of the action of the gastric digestion, appears 
 in the vomitus in most instances. This need not be regarded as 
 significant, however, if unattended with other symptoms. Bleed- 
 ing itself is rarely fatal, though fatal cases from this cause have 
 been reported. Unless due to some defect in technic (failure to 
 deligate the bleeding points), the appearance of blood in the vom- 
 
GASTROENTEROSTOMY 489 
 
 itus in considerable quantity suggests acute dilatation of the 
 stomach, a condition which from the nature of the affliction for 
 which the case is subjected to operative attack, is an exceedingly 
 likely occurrence. 
 
 Hemorrhage per sc will give the characteristic symptoms of 
 loss of blood in contradistinction to the clinical picture already 
 described under acute dilatation of the stomach (page 277). 
 Measures of relief should be directed toward arrest of the hemor- 
 rhage. It is doubtful if a secondary operation, exposure of the 
 bleeding point or points and ligature of them will be recovered 
 from. However, it is wisest that it should be undertaken be- 
 fore too much time has been expended in futile efforts to con- 
 trol the hemorrhage by the introduction of hemostatics into the 
 stomach. 
 
 A moderate amount of bleeding with persistent vomiting and 
 no particularly striking symptoms of loss of blood justifies lavage 
 of the stomach, and if, at the end of several hours a second lavage 
 again reveals the presence of accumulation of blood in the stom- 
 ach, and at the same time pallor, acceleration of pulserate and 
 inordinate thirst are manifest, a secondary celiotomy should be 
 undertaken without delay, as giving the patient the best oppor- 
 tunity for recovery. 
 
 REGURGITANT VOMITING 
 
 Regurgitant vomiting, a common, fatal complication, has been 
 made the subject of considerable study. The mechanical causes 
 relate to the method of technic of the operation, i.e., the method 
 of anastomosis. A discussion along these lines does not belong 
 here. In a general way it may be said, in this connection, that 
 the employment of the more modern methods of anastomosis (the 
 posterior) has made this distressing, and often unsurmountable 
 postoperative complication a less frequent occurrence than pre- 
 viously obtained. It is also proper to state here that the influx 
 into the stomach of bile and pancreatic juice of themselves is no 
 longer regarded as a causative factor in the problem. The latter 
 point has been quite definitely settled in an experimental way on 
 the lower animals, and Moynihan reports a case of complete rup- 
 ture of the gut at the duodenojejunal junction, in which he closed 
 
490 OPERATIONS ON THE STOMACH 
 
 by suture the torn end of the duodenum and joined the jejunum 
 to the stomach. All the bile and pancreatic juice flowed into the 
 stomach without any unfavorable occurrence as the result. If re- 
 gurgitant vomiting persist, it is fair to assume that a mechanical 
 cause exists which is only remediable by secondary operation, and 
 this should not be postponed until the patient's condition becomes 
 menacingly enfeebled. The operative relief is, of course, not 
 properly discussed here. This does not mean, however, that a 
 moderate regurgitation should be looked upon with great appre- 
 hension and, indeed, it is astonishing how readily a certain num- 
 ber of cases of this sort clear up under copious gastric lavage. 
 The lavage need only be employed once in twenty-four hours to 
 achieve relief. It may be said that if regurgitant vomit recur 
 within a few hours after the primary lavage, the case should be 
 subjected to careful scrutiny with the view of promptly employ- 
 ing operative measures of relief. In the majority of instances it 
 will be found that the cause of the disturbance lies in there having 
 been left too long a loop of jejunum between its beginning and the 
 site of the anastomosis. 
 
 INTESTINAL OBSTRUCTION 
 
 Intestinal obstruction from mechanical causes follows in a cer- 
 tain number of cases. It is quite easy to realize how the kinking 
 and snarling of the gut as the outcome of normal structures, ab- 
 normally placed, may occur sequentially to an operation, involv- 
 ing opening of the transverse mesocolon or displacement of the 
 omentum. These cases differ in causation from those presented 
 in intestinal paresis or paralysis due to abolition of enervation. 
 The latter are at times amendable to non-operative treatment ; the 
 former are fatal unless relief is afforded by operation. 
 
 The clinical picture of mechanical intestinal obstruction fol- 
 lowing gastrointestinal anastomosis does not differ from that due 
 to other causes. The differential diagnosis between it and intes- 
 tinal paralysis rests most upon the absence of pain in the latter 
 instance, and the fact that intestinal paralysis is quite continuous 
 with the immediate postoperative symptomatology, while obstruc- 
 tion does not occur for several days after the operation. 
 
GASTROENTEROSTOMY 491 
 
 ULCER OF THE JEJUNUM 
 
 Ulcer of the jejunum after gastroenterostomy has the same 
 etiological factors as obtain with duodenal ulcer. It is consequen- 
 tial to the operation, inasmuch as the ulcer occurs in the jejunum. 
 Its occurrence is heralded by disturbances of digestion, pain and 
 vomiting, as is ulcer of the duodenum. Its possible occurrence 
 should be borne in mind during the postoperative treatment, with 
 the view of affording operative measures of relief. 
 
 DIARRHEA 
 
 Diarrhea occurs in a small number of cases. It is rarely fatal, 
 though fatal occurrences have been reported. The cause of the 
 diarrhea has not been satisfactorily explained. The theory that 
 the entrance of abnormal amounts of acid secretion from the 
 stomach into the intestine, before being subjected to the imme- 
 diate neutralizing effect of the bile and pancreatic juice, is not 
 accepted on the ground that marked hyperchlorhydria has not been 
 observed in the cases afflicted with the malady. Attention to diet, 
 as subsequently advised, the administration of opiates, isoform, 
 naphthol, and colic lavage relieves very soon the symptoms in the 
 majority of instances. 
 
 GASTRECTOMY, ETC. 
 
 The complications enumerated above are all likely to occur 
 after gastrectomy, plastic operations for hour-glass contraction of 
 the stomach, excision of ulcers, and, indeed, any operative attack 
 upon the stomach and may be regarded as indicative of the prob- 
 lems encountered after each one of the operations mentioned. 
 Gastrostomy permits of introduction of food into the stomach, 
 which requires considerable exercise of its digestive functions 
 soon after the operation, because in this class of cases leakage is 
 not liable to occur, and the stomach itself has not been the seat 
 of affliction impairing its functions. It would seem proper, there- 
 fore, to discuss more extensively the question of postoperative 
 administration of food at this time. 
 
 The introduction of food into the stomach after operations in- 
 vading its lumen should be avoided for five days, if this be fea- 
 
492 OPERATIONS ON THE STOMACH 
 
 sible, and the patient fed by the rectnm (page 291). The explana- 
 tion of the apparent inconsistency of this advice, and the recom- 
 mendation that copious gastric lavage immediately subsequent or 
 soon after the operation is justifiable, lies in the fact that the 
 layage is attended with muscular effort on part of the stomach 
 only as the lavage is made, and that the cleansing fluid is entirely 
 withdrawn, leaving the stomach empty. On the other hand, the 
 effort at digestion following the administration of nutritive sub- 
 stances provokes an irregular contraction of the stomach which is 
 prolonged over a considerable period of time, and disturbance of 
 the line of union may occur in consequence. It is frequently 
 noticed that distention of the approximated portions of gut and 
 stomach does not result in leakage of gas at the time of the opera- 
 tion, and the anastomosis is regarded as " tight." This is about 
 the condition of affairs which obtain during cleansing lavage, and 
 differs quite radically from those which attend the movements of 
 the stomach during digestion. 
 
 It is true that union of apposed peritoneal surfaces takes place 
 at the end of twenty-four to thirty-six hours. However, the union 
 is not sufficiently firm at the end of this time to warrant taking 
 unnecessary risks. This does not mean that small quantities of 
 water may not be partaken of at intervals at the end of twenty- 
 four hours following the operation, but it is certainly best to omit 
 the introduction of fluids containing substances requiring the ex- 
 ercise of the digestive function at an earlier time than here men- 
 tioned, provided the conditions will warrant. It also does not 
 mean that, if diarrhea, or irritation of the rectum be dominant 
 factors, small amounts of liquid food might not be taken by the 
 patient on the fourth day after the operation. Yet, on general 
 principles the patient should be nourished by rectum for five days 
 after the operation, if this be at all possible. 
 
 At the end of this time peptonized milk in small doses, fre- 
 quently repeated, soups, boullion, indeed liquids of any kind may 
 be given. The chief reliance as far as nutrition is concerned may 
 be placed in the milk and its products. Eggs, raw or slightly 
 coagulated, may be given on the seventh day. Solid food should 
 not be allowed for twelve days and, indeed, had best not be taken 
 until at the end of two weeks after the operation. 
 
 All substances introduced into the stomach for a week follow- 
 
GASTRECTOMY 493 
 
 ing the operation should be sterile (page 430). Of course this 
 applies also to cleansing fluids. While healing of the apposed se- 
 rous surfaces undoubtedly has taken place at the end of the five 
 days, the same does not obtain with regard to the mucosa and, in- 
 deed, when the technic of the anastomosis is borne in mind- — how 
 firmly the through and through stitching is made — it is easy to 
 conceive that more or less necrosis of the tissues along the line of 
 suturing is probable. This raw surface should not be unneces- 
 sarily exposed to infection. The gastric secretion is only markedly 
 acid during digestion, being neutral or alkaline in the intervals. 
 The avoidance of nourishment by mouth for the time mentioned 
 may obviate the maceration of the mucosa, which would result 
 from contact with the acid juice while repair is going on. All of 
 this can, of course, not be avoided, either by abstinence from food 
 or by the subsequent sterilization of the ingesta. However, the 
 dangers in this connection are certainly lessened by careful ob- 
 servance of the suggestions offered. The care and treatment of 
 the superficial wound does not differ from that of celiotomy made 
 for other reasons (page 448). The wearing of a supporter after 
 operations on the stomach is not indicated, unless, as is at times 
 necessary in stout individuals, the abdominal section is carried 
 below the umbilicus, or if extensive infection of the wound has 
 taken place, with' sloughing and loss of substance. In the latter 
 contingency, an abdominal supporter, as described (page 475), 
 made somewhat wider and devoid of the perineal straps, may be 
 worn as a precautionary measure, if the patient be engaged in an 
 occupation requiring the exercise of great muscular effort. In 
 women the corset (page 480) will be found to answer the purpose 
 very well. 
 
CHAPTEK XXV 
 
 OPERATIONS ON THE ABDOMEN {Continued) 
 
 OPERATIONS ON THE INTESTINES 
 
 Enterectomy, etc.: The Diet; Catharsis; Fecal fistula — Appendectomy — 
 Appendicostomy — Colostomy : Colostomy pad — Colectomy. 
 
 ENTERECTOMY, ETC. 
 
 Enterectomy, enteroanastomosis of the small intestine, and, in- 
 deed, operations contemplating opening of the lumen of the gut, 
 call for the same local and general preparation taken up under 
 celiotomy and sterile diet, etc. A repetition of these measures is 
 superfluous. It is probable that comparative sterility of the small 
 gut requires for its achievement a longer period of time than ob- 
 tains with respect to the stomach. This time is not available in 
 all instances. However, if the operative procedure is not urgently 
 indicated, five or six days of preparation along the lines laid 
 down above is desirable. 
 
 The use of mechanical devices to facilitate anastomosis, such 
 as the Murphy button and the like, has been quite abandoned. 
 However, unless the surgeon have some experience in sewing gut, 
 it is well to have available at the time of the operation a " Murphy 
 button " or similar instrument to conserve speed in operating. 
 Again, it at times happens that the general' condition of the pa- 
 tient becomes alarming during the operation, the outcome of shock, 
 and if the operation need be rapidly completed, recourse to these 
 aids is justified, even though they are less accurate in their accom- 
 plishments than is desirable. 
 
 When the operation is undertaken for the relief of acute ob- 
 struction, delay is, of course, objectionable, and the preparation 
 of the patient as far as the cleansing of the intestinal lumen is 
 concerned, must be restricted to gastric lavage and cleansing of the 
 
 494 
 
ENTERECTOMY, ETC. 495 
 
 colon by enema. The former must under no circumstances be 
 neglected for the reasons taken up under the head of sterilizing 
 the digestive tract. The after-treatment in this class of cases dif- 
 fers only from that of celiotomy generally, inasmuch as the pa- 
 tient is kej3t in the dorsal position, unless for especial reasons the 
 semi-sitting posture is indicated (page 457). 
 
 THE DIET 
 
 The diet following operations on the small intestine should be 
 sterile for several days after the introduction of food by mouth is 
 begun. The time of beginning gastric feeding is not necessarily 
 as long after the operation as is permitted to elapse following at- 
 tack upon the stomach. In a general way, it may be said that the 
 lower down, nearer the anus the operation is, the sooner may 
 gastric alimentation begin. However, no food should be given by 
 mouth for forty-eight hours after the operation in any event. In 
 the meantime, the patient is nourished and stimulated by the lower 
 bowel. Thirst, this exceedingly distressing symptom following all 
 operations involving the intestinal tract, may be more readily re- 
 lieved in this class of cases by supplementing the colic irrigation 
 with small doses of hot water given by mouth within twenty-four 
 hours after the postoperative vomiting has ceased. 
 
 CATHARSIS 
 
 Catharsis is a problem which in these cases presents some dif- 
 ficulties. From the viewpoint of the histology of wound repair, 
 the intestine should be kept quiet for several days following the 
 operation to conserve repair. However, the administration of 
 agents destined to inhibit peristalsis favor intestinal paralysis, and 
 this is a serious complication. The attendant must take all the 
 factors into consideration. 
 
 Certain it is that no cathartic should be administered after the 
 lumen of the gut has been invaded for three days after the opera- 
 tion, and then only if a special indication for its employment pre- 
 sents. It is difficult to see just what this indication may be, how- 
 ever, if eserin and belladonna stimulate peristalsis, they may be 
 regarded as cathartics and, indeed, act as such ; if symptoms of in- 
 
496 OPERATIONS ON THE INTESTINES 
 
 testinal paralysis develop they do not, as a rule, constitute a men- 
 acing factor for twenty-four hours or more subsequent to the 
 operation, and their administration should be withheld for at least 
 this period of time. Indeed, the writer does not administer cathar- 
 tics to cases of intestinal surgery for ten days following the opera- 
 tion, employing a sterile diet for five days and daily cleansing of 
 the lower bowel by enema, until normal defecation takes place, or 
 until sufficient time has elapsed to make safe the use of cathartics. 
 The postoperative complications following enteroanastomosis are 
 in all respects similar to those discussed under gastroenterostomy 
 (page 488), and are met in the same way. 
 
 FECAL FISTULA 
 
 Fecal fistula may be mentioned in this connection as occurring 
 in a certain number of cases. This, of course, means infection of 
 the superficial wound and requires drainage (page 185). When a 
 fecal fistula occurs, the wound must be cleansed daily and the skin 
 surrounding it covered with an ointment containing some anti- 
 septic, like iodoform or aristol, to obviate irritation of the skin in 
 the -neighborhood of the wound, the result of the discharge. Fecal 
 fistula frequently heals spontaneously, and this need not be de- 
 spaired of even at the end of several weeks following the operation. 
 The care of the superficial wound, removal of stitches, the after 
 care with regard to hernia, etc., are all taken up under the general 
 head of celiotomy (page 433, et seq.). 
 
 APPENDECTOMY 
 
 Appendectomy is frequently an emergency operation. In the 
 emergency cases the preparatory measures described above are of 
 necessity modified to meet the special indications. When appendec- 
 tomy is done in the intervals between attacks, the preparation for 
 the operation is in all respects similar to that for intestinal sur- 
 gery. 
 
 Interval appendectomy, being usually made through an inter- 
 muscular incision, requires perhaps less prolonged confinement in 
 the dorsal position than is necessary when the approach it attended 
 with division of the muscular fibers. However, the attendant is 
 
APPENDECTOMY 497 
 
 warned not to be hasty in this regard. Patients who have suffered 
 from a mild appendicitis, and who are willing to have the appendix 
 vermiformis removed as a precautionary measure, are in a meas- 
 ure influenced in their willingness to be operated upon by the con- 
 sideration that only five or six days of confinement and ten days' 
 absence from the usual occupation will be required. This is not a 
 wise procedure. Indeed, even after an intermuscular appendec- 
 tomy the patient should not be permitted to leave the sick room 
 for ten days, and prolonged muscular effort should be refrained 
 from for two weeks. 
 
 Of course, if infection of the superficial wound occur as a 
 complication during the postoperative period, the patient should 
 not be permitted to exert the abdominal muscles until repair of 
 the wound in the muscle and aponeurosis of the external oblique 
 has taken place. If the appendectomy or approach to the site of 
 the appendix with abscess is made and subsequent drainage is 
 introduced, the confinement to bed should be maintained until 
 repair is quite complete. Fecal fistula follows quite frequently 
 the ablation of the appendix when the inflammatory process in- 
 volves the portion contiguous to the base of the appendix. These 
 fistulas usually heal spontaneously, unless the infection is tuber- 
 culous, and the care of the wound is in all resj^ects similar to 
 that of infected wounds elsewhere (page 305), with the excep- 
 tion that drainage of the wound should be provided for, and pack- 
 ing introduced only in portions of the wound to either side of the 
 canal leading to the opening in the gut. If the packing interfere 
 with free egress of the feces, the latter will at times infiltrate the 
 tissues between the muscles, giving rise to cellulitis of consider- 
 able magnitude, and necessitating the making of additional drain- 
 age openings. The dressing should be changed daily or, in the 
 event of free discharge of feces, twice daily. The introduction 
 into the fistulous tract, if it persist after the major portion of the 
 wound is repaired, of tincture of iodin is a serviceable measure. 
 
 The patient should be kept quiet until healing is quite accom- 
 plished, although, when only a small fistulous tract exists, he 
 may be permitted to go about with a firm abdominal supporter 
 (page 475) placed over the protective dressing. Cases which 
 have been subjected to intermuscular appendectomy and in which 
 primary union has been attained need not wear an abdominal 
 
498 OPERATIONS ON THE INTESTINES 
 
 supporter. However, it will be best to furnish those cases in 
 which drainage has been employed with a bandage, which should 
 be worn for three months after the operation. The postoperative 
 complications following appendectomy are in all respects similar 
 to those taken up under gastroenterostomy. 
 
 APPENDICOSTOMY 
 
 Appendicostomy executed by the intermuscular method ren- 
 ders infection of the peritoneal sac during the healing process 
 quite unlikely. Some surgeons after developing the fact that the 
 appendix is patent, deligate it near its point of emersion from 
 the abdomen and permit the extra-abdominal portion to slough 
 off. 
 
 This measure is less apt to result in infection than the intro- 
 duction of a rubber tube while the isolating adhesions arc being 
 formed. If the tube is used it is clamped, but is not brought out 
 through the dressing, as lavage of the colon is not practiced until 
 sufficient repair has taken place to obviate the danger of leakage 
 of the cleansing fluid into the peritoneal sac. The primary lavage 
 should not be undertaken for five days after the operation. The 
 dressing need not be changed during this period of time, unless 
 some special indication for doing so appear. 
 
 There is no leakage of feces from the lumen of the appendix 
 after the operation, its entrance appearing as a small dimple, 
 which at times secretes a small quantity of serous fluid. For this 
 reason the patient should wear a square of gauze, several layers 
 in thickness, fastened to the portion of undergarment contiguous 
 to the opening. When improvement of the condition for which 
 the appendicostomy is done becomes manifest, the irrigations are, 
 of course, less frequently made. If an interval of more than five 
 days between injections is regarded as advisable, the patient must 
 be instructed to pass into the canal a glass rod or the handle of a 
 steel nasal applicator or similar device, at the end of the third 
 day after the last lavage, in order to assure patency of the com- 
 munication with the cecum. The appendicostomy opening has 
 been known to heal in six days, and as the chronic inflammatory 
 process, for the relief of which the treatment is employed, is ex- 
 ceedingly liable to recur for a period of years, it is best to obviate 
 
COLOSTOMY 499 
 
 the possibility of closure of the opening in the manner stated for 
 this period of time. 
 
 The technic of the colic lavage is exceedingly simple. The 
 water receptacle is raised to about four feet above the wound, and 
 the distal end of the connecting tube furnished with a wide, 
 straight eye-dropper which is readily passed into the canal. The 
 temperature of the lavaging fluid should be about 105° F. 
 
 The solutions employed vary, of course, with the character of 
 the affliction from which relief is attempted. It is not improb- 
 able that mechanical cleansing is the most effective factor in the 
 treatment, and this may be achieved by normal saline solution, 
 the salt being added to sterile water, with the view of obviating 
 the extraction of inorganics from the colic mucosa consequent to 
 the use of water alone. 
 
 Patients past forty years of life should wear a light ab- 
 dominal supporter to obviate the chances of a ventral hernia. The 
 danger in this regard is not great. However, it is exceedingly 
 exasperating to have a portion of the cecum push its way out 
 through the opening in the muscles. The gauze pad spoken of 
 may be affixed to the inner side of the supporter. This is quite 
 essential, for the supporters are not readily cleansed, and when 
 stained with secretion are liable to become offensive. 
 
 COLOSTOMY 
 
 Colostomy, being undertaken for relief of obstruction, is pre- 
 pared for in respect to direct cleansing of the colon with difficulty. 
 For obvious reasons, however, an attempt at irrigation of the 
 colon for several days with a solution of acetozone fifteen grains 
 to the quart should be made. It is not infrequently feasible to 
 pass through the stricture from below a rubber tube of small 
 caliber and effect gradually a comparative cleansing of the colon. 
 For the purpose the patient should be placed in the Sims lateral 
 position (Fig. 346), with the hips elevated or in the knee-chest 
 posture. Great gentleness in manipulations should be exercised 
 in the attempt, as the portion of colon above the obstruction is 
 likely to be quite thin and perchance ulcerated from pressure. 
 Then, too, large quantities of fluid should not be allowed to flow 
 
 into the gut for the same reason. It is at times wise to precede 
 34 
 
500 
 
 OPERATIONS ON THE INTESTINES 
 
 the colic lavage by gently injecting beyond the obstruction four 
 or six ounces of sterile olive oil, which will soften hardened por- 
 tions of feces, and this may be followed by the careful introduc- 
 tion of a solution of sodium carbonate ^ per cent, with the view 
 of saponifying the mixture of oil and feces, thus facilitating dis- 
 charge of the contents of the bowel through the stricture. The 
 precautions with respect to sterile diet should- be taken. The ad- 
 
 Fig. 310. — First Step of Colostomy. Appearance of Wound. (Tuttle.) 
 
 ministration of cathartics should aim at liquid stools for a con- 
 siderable period of time preceding the operation. A more or less 
 empty colon at the time of the operation facilitates much the sur- 
 gical technic and should be attained if possible. 
 
 Colostomy is almost always done in two stages, unless the in- 
 dications call for immediate relief of obstruction. In the latter 
 instance the wound is treated in the same way as a fecal fistula 
 (page 496). When the intact colon is brought into the wound 
 and fastened in place, the immediate treatment is that of a clean 
 wound. The colon is usually held in place by a glass rod or a 
 supporting stitch, and the colon is sectioned on the fourth day 
 after the primary operation. 
 
 Fig. 310 shows the appearance of the wound and colon when 
 the first stage of the operation is completed, except for tying of 
 
COLOSTOMY 
 
 501 
 
 the sutures in the superficial wound which holds the distal por- 
 tions of the extra-abdominal portion of the colon in place. 
 
 During this time the bowel is kept quiet by the administra- 
 tion of ;J grain of morphia given under the skin. The dose 
 should be repeated in twelve hours and usually need not be 
 again repeated. 
 
 At the end of four days the peritoneal healing will have suf- 
 ficiently progressed to render infection of that membrane very 
 improbable. However, the superficial wound will not be healed 
 by this time, and great cleanliness and careful drainage of the 
 wound should be maintained to prevent burrowing of infective 
 secretions. The surrounding skin should be covered with an 
 antiseptic ointment. The retaining glass rod or supporting 
 
 Fig. 311. — Incision of Protruding Gut in Colostomy. (Tuttle.) 
 
 stitch need not be removed for eight days after the operation. 
 The segment of gut below the colostomy should be irrigated daily 
 with a saline solution. 
 
 At the end of four days after the primary operation the gut 
 is sectioned. For the purpose Tultle advises that the colon be 
 divided across at the center of the protruding portion and then 
 sectioned in a longitudinal direction (Fig. 311). By this means 
 
502 
 
 OPERATIONS ON THE INTESTINES 
 
 the upper triangular flaps roll backward and dry up. The 
 straight lower flap of the lower segment of gut falls downward 
 and inward, practically closing the opening. The fecal discharges 
 are thus carried outside of the abdominal cavity, and there is 
 scarcely any possibility of their gaining access to the lower bowel. 
 
 COLOSTOMY PAD 
 
 After convalescence is established, the patient wears a pad of 
 soft rubber held in place by an elastic band running about the 
 body (Fig. 312). The pad is slipped into a steel ring which per- 
 
 Fig. 312. — Colostomy Pad Held in Place over Artificial Anus. 
 
 mits of easy removal of the pad. This permits of interchange 
 at frequent intervals of a second similar pad which is kept on 
 
COLOSTOMY 
 
 503 
 
 hand. The feces are received in a receptacle fashioned to fit the 
 body (Fig. 313). The pad is removed twice daily, the feces re- 
 
 g. t i em ann & co 
 
 Fig. 313. — Receptacle Suitable for Receiving Feces from 
 Colostomy Opening. 
 
 ceived in the receptacle (Fig. 314), and the colon cleansed "by 
 injecting saline solution into the upper opening (Fig. 315). The 
 
 Fig. 314. — Emptying Colon into Receptacle. 
 
 lower portion of the bowel, that distant to the fistula, is cleansed 
 at frequent intervals. 
 
Fig. 315. — Cleansing Colon through Colostomy Opening. 
 
 Fig. 316. — Colostomy Pad with Abdominal Belt and Perineal Straps. The 
 Straps are Fastened to the Buttons on the Belt. 
 
 504 
 
COLECTOMY 
 
 505 
 
 The pad is affixed to a band which goes about the body, the 
 latter being held down by two perineal bands furnished with 
 buttonholes to allow of modification as to tension. Fig. 316 
 shows the apparatus complete, Fig. 317 shows the pad removed 
 
 Fig. 317. 
 
 -Colostomy Pad and Ring. Pad Shown from Side 
 Turned toward Fistula when Worn. 
 
 and turned with the side that goes over the colostomy opening 
 turned out. The cuts show the facility with which the pad may 
 be removed. 
 
 COLECTOMY 
 
 Colectomy when followed by anastomosis of the sectioned 
 colon and closure of the abdominal wound does not call for espe- 
 cial consideration beyond those taken up under abdominal sur- 
 gery and colotomy. It is well to bear in mind that the colon 
 does not heal with the same rapidity as the small intestine after 
 
506 
 
 OPERATIONS ON THE INTESTINES 
 
 Fig. 318. 
 
 L 
 
 -Paul Tubes in situ Connected with Rubber Tubes for Drainage of 
 Contents of Colon. (Moynihan.) 
 
 section, and also that colic lavage immediately following the 
 
 operation must be avoided, 
 for fear that the line of 
 union may be ruptured. 
 
 Colectomy and tempo- 
 rary colostomy is a pro- 
 cedure which has been 
 largely employed within 
 recent years. The method 
 unites laterally the ends 
 of the colic lumen and 
 drains both the proximal 
 and distal portions of the 
 gut. Fig. 318 shows the 
 operation completed. The 
 Paul tubes (Fig. 319) 
 afford excellent drainage, 
 
 Fig. 319. 
 
 FOR 
 
 — Paul's Tube. Showing Flanges 
 Drainage Tubes. (Moynihan.) 
 
COLECTOMY 507 
 
 and if they are, as shown in the illustration (Fig. 318), con- 
 nected with rubber tubes of large caliber, the wound is not con- 
 taminated by the discharges from the gut. The rubber tubes are 
 led into a suitable receptacle fastened to the side of the bed, the 
 receptacle being partially filled with a solution of corrosive sub- 
 limate, 1 in 1,000, or other antiseptic. There is no odor, and the 
 protective dressing need not be changed until the usual time, 
 governed by the rules laid -down under celiotomy. When the time 
 arrives for reestablishment of the continuity of the canal the 
 wound will be found clean, an advantage of some importance. 
 
CHAPTEE XXVI 
 OPERATIONS ON THE ABDOMEN {Continued) 
 
 OPERATIONS ON LIVEE AND FEMALE PELVIC 
 
 ORGANS 
 
 Hydatid cysts of liver — Hepatic abscess — Kesection of liver — Operations on 
 gall-bladder and biliary passages — Cholecystotomy — Cholecystectomy — 
 Hepaticostomy, choledocotomy, chole and cholecystenterostomy : Biliary 
 fistula — Transperitoneal operations on the uterus and adnexa. 
 
 The general preparation of patients about to be subjected to 
 operative attack upon the liver should take into account the con- 
 siderations taken up under jaundice, and its coexisting lessening 
 of the coagulability of the blood (page 21). Operations on the 
 liver are likely to be attended with severe bleeding, because of the 
 intimate association of the parenchyma with the walls of the 
 veins, and provision should be made to meet the indications in this 
 regard. The actual cautery should be available, and the assistants 
 should test the same before the operation as to its serviceability, 
 with the view of obviating delay in this connection. Large quan- 
 tites of normal saline solution, a liberal number of gauze pads, 
 and proper provision for combating shock should be available. 
 The local preparation does not differ from that made for celi- 
 otomy (page 422). 
 
 HYDATID CYSTS OF LIVER 
 
 Hydatid cysts are usually drained after the contents have 
 been evacuated. In some instances tube drainage is employed, 
 but in the majority of instances the cyst cavity is drained with 
 gauze. In a certain number of cases a Mikulicz tampon (page 
 268) is introduced which is removed at the end of twenty-four 
 hours and a gauze or tube-drain is placed into the inferior angle 
 of the wound, after which the incision in the abdominal wall is 
 closed in the usual manner. The shortening of the drain and its 
 
 508 
 
HEPATIC ABSCESS 509 
 
 ultimate removal is governed by the same rules laid down in con- 
 nection with drainage, discussed under that head (page 186). 
 
 As a rule, unless infection has complicated the cyst before 
 the operation, there is little discharge from the wound, and it is 
 not improbable that subsequent purulent discharges are the out- 
 come of infection, the result of postoperative manipulations. For 
 this reason, though moderate infection is attended with little 
 danger under the circumstances, care should be taken in chang- 
 ing the dressing to obviate this contingency. It is also to be re- 
 membered that infection is more likely to predispose to the occur- 
 rence of ventral hernia, although hernia in this situation is not 
 common, for obvious reasons. 
 
 Especial measures with respect to the postoperative care of 
 the wound relate to the possibility of grafting of hydatid cysts, 
 as the outcome of contact of the contents of the sac with the sur- 
 faces contiguous to the wound. It is not always possible to be 
 certain that no minor residuum of cyst contents remains behind, 
 and this may contain the causative parasite. For this reason, 
 cleansing of the wound during the postoperative treatment should 
 be made with corrosive sublimate solution or other antiseptic, in 
 preference to the use of saline solution or sterile water for the 
 purpose. The use of hydrogen peroxid is permissible when the 
 tampon is being removed, or for the purpose of cleansing the cyst 
 cavity immediately after its removal, i.e., when ready egress of 
 the fluid is provided for. After the superficial wound is closed to 
 its greatest extent and simple drainage is introduced, the injec- 
 tion of fluids into the cavity is unwise until it is quite obliterated 
 by granulation tissue. 
 
 At times a small cavity persists for a considerable period of 
 time. It is of service, in these instances, to apply to the interior 
 of the cavity tincture of iodin, introduced by means of a cotton 
 pledget wound on an applicator or probe. This measure stimu- 
 lates healing and destroys what slight infection may have oc- 
 curred. 
 
 HEPATIC ABSCESS 
 
 Hepatic abscess is always drained after the pus is evacuated. 
 For the purpose tube-drainage is usually employed until the dis- 
 
510 OPERATIONS ON LIVER AND FEMALE PELVIC ORGANS 
 
 charge of pus is very small in quantity, when a cigarette drain 
 or a strip of gauze will meet the indications. 
 
 Surgical attack of hepatic abscess does not involve any prob- 
 lems as regards preparation of the patient and subsequent treat- 
 ment not taken up under celiotomy and drainage after abdominal 
 operations. The dressings should be changed daily for a week 
 following the operation, and thereafter every forty-eight hours 
 will suffice until repair takes place. As adhesion between the 
 liver substance and the anterior abdominal wall are contemplated 
 in the operative procedure, the occurrence of ventral hernia is 
 not likely. 
 
 The writer approaches abscess of the liver through a liberal 
 celiotomy wound, packs off the surrounding peritoneum, and after 
 evacuation of the contents tampons the residual cavity with the 
 Mikulicz tampon. The packing is quite firmly introduced. At 
 the end of twenty-four hours the tamponade is removed (page 
 268). At the time of the operation through and through sutures 
 are introduced into the abdominal wound, and these are tied when 
 the tampon is removed. At this dressing a goodly-sized " cigarette 
 drain" (Figs. 154 and 155) is introduced at the inferior angle 
 of -the wound. When the discharge of pus lessens silk-worm gut 
 drainage is introduced (Figs. 147 and 148), and this removed 
 strand by strand until the expulsion of inflammatory exudate 
 ceases entirely. 
 
 After the first forty-eight hours following the operation, 
 drainage is conserved by posturing the patient in the sitting po- 
 sition, similar to that employed after gastroenterostomy (Fig. 
 309). 
 
 Abscess of the liver may be regarded as most commonly due 
 to infection from the gastrointestinal canal. An effort to obviate 
 the causative condition in the digestive tract should be made as 
 soon as the immediate postoperative symptoms subside. For the 
 purpose the administration of intestinal antiseptics and the use 
 of gastric lavage will be found useful. 
 
 The diet need not be restricted in the manner usually em- 
 ployed following celiotomy for invasion of the digestive tract. 
 However, the precautions with respect to postoperative vomiting- 
 should be observed, as the straining of the abdominal muscles co- 
 incident to the act of vomiting interferes with the prompt forma- 
 
RESECTION OF THE LIVER 511 
 
 tion of adhesions between the sectioned liver and the abdominal 
 wall. The movements of the diaphragm, also, should be con- 
 . trolled as far as feasible with the view of aiding in the formation 
 of adhesions in this situation. For this purpose the judicious 
 use of opiates for the twenty-four or forty-eight hours immedi- 
 ately subsequent to the operation will be found a useful measure. 
 
 RESECTION OF THE LIVER 
 
 Resection of the liver presents no special indications with re- 
 spect to postoperative care. In most instances the wound in the 
 liver is repaired at once and the abdominal incision closed in its 
 entirety. In rare instances tamponade of the traumatized area 
 of liver is necessary with the view of arresting hemorrhage. In 
 these cases removal of the tampon and subsequent care of the 
 wound is carried out along the lines already laid down. On the 
 whole, the postoperative treatment and operations on the liver are 
 similar to that of celiotomy, and the postoperative complications 
 and their treatment are the same as described under that head. 
 
 Peritonitis and intestinal obstruction, either due to paralysis 
 of the gut or to mechanical causes, are less frequent in this class 
 of cases than obtains following either manipulation or section of 
 the intestinal canal: As already stated, the liver moves with res- 
 piration, and operations which contemplate adhesion of the sur- 
 face of the liver to the anterior abdominal wall should be fol- 
 lowed by the administration of opiates in sufficient dosage to 
 control the pain consequent upon the strain brought to bear on the 
 sutures introduced with the view of fixing the liver. In instances 
 in which the liver wound is closed and the abdominal section re- 
 paired by suture without drainage this need not be considered. 
 However, in the class of cases alluded to, it had best be met in 
 the manner stated. 
 
 The tampon introduced for the purpose of arresting oozing of 
 blood must be carefully loosened before removal, with the view of 
 avoiding trauma to the clots obliterating the divided ends of the 
 hepatic vessels, especially the veins. For the purpose the gauze 
 strips introduced into the " umbrella " gauze is thoroughly moist- 
 ened, and, after their removal, hydrogen peroxid is syringed 
 under the edges of the outer layer of gauze, which will lift it from 
 
512 OPERATIONS ON LIVER AND FEMALE PELVIC ORGANS 
 
 contact with the surface of the wound. The writer has used a 
 mixture of adrenalin solution, a drachm to a pint of hot saline 
 solution in this manner, with considerable success. Hydrogen 
 peroxid is not readily heated, and the added atom of oxygen is 
 likely to be displaced by application of the degree of heat neces- 
 sary to act as an hemostatic. Cold peroxid of hydrogen has some 
 
 Fig. 320. — Sand Bag in Position for Approach to Biliary Passages. (Moynihan.') 
 
 hemostatic qualities, but is not as efficient for this purpose as the 
 mixture mentioned. 
 
 It is probable that the tamponade should not be left in situ 
 for longer than forty-eight hours after the operation. The por- 
 tion of peritoneum covering the liver is quite in contact with the 
 lower surface of the diaphragm, an anatomical fact which ex- 
 plains the occurrence of hiccough and respiratory difficulties fol- 
 lowing operations in this situation. 
 
 OPERATIONS ON THE GALL-BLADDER AND BILIARY 
 
 PASSAGES 
 
 Access to the gall-bladder and biliary passages is greatly en- 
 hanced by placing under the patient's back a sandbag at, or a 
 little above, the level of the liver (Fig. 320). Modern operating 
 tables are supplied with an apparatus which achieves the object 
 and mav be raised or lowered as desired. Fig. 87 shows this 
 
CHOLECYSTOTOMY 
 
 513 
 
 apparatus affixed to the operating table. By this means the liver 
 is made to be present in the wound, and access to the cystic and 
 common duct is made comparatively easy. In addition to this, 
 the head of the table may be elevated to the extent of 35°, caus- 
 ing the intestines to gravitate toward the pelvis. When the liver 
 is held by retractors air enters between the liver and intestines, 
 making still more accessible the operative field. A disadvantage 
 of this position is that the abdominal muscles are made tense, 
 and before the wound of approach is repaired, the horizontal po- 
 sition should be reassumed in order to relieve tension and make 
 possible proper approximation of the abdominal wound. 
 
 CHOLECYSTOTOMY 
 
 Cholecystotomy, with fixation of the gall-bladder to the an- 
 terior abdominal wound, has been quite abandoned in favor of 
 
 tube drainage of the gall-bladder. 
 
 and at times fixation of the 
 
 Fig. 321. — Drainage Arrangement Following Choubcystotomt. 
 
 fundus to the anterior peritoneum. As frequently the parietal 
 peritoneum is quite merged with the sheath of the rectus abdomi- 
 nalis, this latter step is not always feasible nor is it, indeed, es- 
 sential to a favorable outcome. This method of dealing with the 
 
514 OPERATIONS ON LIVER AND FEMALE PELVIC ORGANS 
 
 gall-bladder has quite removed the necessity for prolonged care 
 of the wound, following the older method of ventral fixation. The 
 tube leading into the gall-bladder is connected by means of a 
 glass pipette with a long rubber tube, which latter is led into a 
 receptacle partially filled with an antiseptic solution affixed to 
 the side of the bed (Fig. 321). For the purpose a wide tube, 
 equivalent to 26° F., should be used. It will be found convenient 
 to employ an angular rubber tube (Fig. 322), which, because of 
 
 its conformation, is less likely to 
 kink than if a straight tube is 
 used. Drainage of the surface 
 contiguous to the gall-bladder is 
 made with a cigarette drain, 
 which is brought out at the lower 
 angle of the abdominal wound. 
 If no evidence of infection be 
 manifest at the end of the third 
 day following the operation, the 
 cigarette drain may be removed. 
 The tube drain is left in the gall- 
 bladder until the seventh day fol- 
 lowing the operation, when it is 
 removed. The inverted serous 
 surface of the gall-bladder comes in contact, as the rubber 
 drain is removed, and closes the opening in a few days. 
 During this latter time the valvular action of the inverted gall- 
 bladder wall may not be sufficiently tight to obviate a certain 
 amount of leakage of bile. However, the quantity of bile dis- 
 charged is usually very small and soon ceases spontaneously. In 
 any event, sufficient adhesions of the surrounding peritoneum 
 will have formed by this time to prevent entrance of the secre- 
 tion from the biliary passages iuto the peritoneal sac. It is 
 obvious that the point of exit of the drain in the gall-bladder 
 is not the same as that in the superficial wound, the latter 
 being lower down, thus conserving isolation of the gall-bladder tract 
 by adhesions. 
 
 Practically the same method of procedure with respect to 
 drainage is employed when cysticotomy is necessary for removal 
 of stone impacted in the cystic duct. The gall-bladder is drained, 
 
 Fig. 322. — Axgulae Soft Rubber 
 Tube, Useful for Drainage of 
 Gall-bladder Following Chole- 
 
 cystotomy. 
 
HEPATICOSTOMY, CHOLEDOCOTOMY, CHOLE, ETC. 515 
 
 as stated, and a separate drain is inserted down to the point of 
 invasion of the cystic duct. In these cases it is best to leave the 
 lower drain in situ five days, until repair of the wound in the 
 duct is assured. 
 
 CHOLECYSTECTOMY 
 
 Cholecystectomy with immediate closure of the abdominal 
 wound is rarely done, except perhaps when the gall-bladder is 
 removed for neoplasm, a rare condition. Indeed, it may be laid 
 down as a quite unmodifiable rule, that drainage of the biliary 
 passages following invasion of their lumen is always indicated. 
 Certain it is that if infection of the biliary passages have oc- 
 curred, there is no reason to assume that the infective process 
 will reverse the general law w T ith respect to the action of infective 
 process which in other situations extend in the direction of least 
 resistance. It is, therefore, difficult to assume that infection is 
 more liable to invade the gall-bladder than the hepatic ducts, and 
 if there is one well-established law in surgery, it is that drainage 
 is indicated when infection exists. 
 
 The technic of drainage of the biliary passages following chole- 
 cystectomy is, of course, not properly discussed here. Tube 
 drainage is employed, and the postoperative care of the wound is 
 in all respects similar to that following cholecystostomy. The 
 cigarette drain which takes care of the field outside the biliary 
 passages is left in situ until the fifth day following the operation 
 and is then removed. 
 
 HEPATICOSTOMY, CHOLEDOCOTOMY, CHOLE AND 
 CHOLECYSTENTEROSTOMY 
 
 These procedures all present the same picture as obtains with 
 
 the operations just discussed. The postoperative treatment and 
 
 removal of drainage agents being governed in a similar manner. 
 
 In this class of cases, however, the rule is reversed and the drain 
 
 in the area surrounding the tube is left in after the tube itself 
 
 has been removed from the biliary passages. That is, the tube 
 
 drain is removed on the fifth day, and the gauze drain is left in 
 
 place until the eighth or tenth day after the operation, in order 
 35 
 
516 OPERATIONS ON LIVER AND FEMALE PELVIC ORGANS 
 
 that should there be any leakage of bile after the tube is removed, 
 it will be led to the surface by the latter drain. By the end of 
 the tenth day the avenue of exit between the biliary passage and 
 external wound will be sufficiently established to warrant allow- 
 ing it to take care of itself in this respect. Daily cleansing of 
 the wound at this time will be necessary, which did not obtain 
 while the rubber tube led away the biliary secretions. 
 
 Biliary fistula at times follows this class of operations, but in 
 the majority of instances spontaneous healing takes place. While 
 there is much difference of opinion with respect to the question as 
 to whether the secretion of bile into the gut is essential to life, it 
 is best to give the digestive function the benefit of the doubt in 
 the care of cases in which the biliary secretion is diverted from 
 the gut as the outcome of operative measures. 
 
 During the repair of the wound and reestablishment of the 
 natural avenue of flow of the bile, the diet should contain as little 
 fat as possible and the quantity of carbohydrates be reduced. It 
 is true that the digestion of carbohydrates and the emulsification 
 of fats are performed by the pancreatic juice, yet there can be no 
 doubt that the bile contributes not a little to these functions. 
 Again, when the common or hepatic ducts are attacked it is not 
 improbable that the entire duct is interfered with and the pan- 
 creatic secretion is no doubt also impaired. The appearance of 
 bile in the feces is the guide as to when full diet may be adminis- 
 tered. The cessation of discharge of bile from the drainage open- 
 ings does not mean that full diet may be partaken of at once. 
 
 Constipation and tympanitis are common complications follow- 
 ing operations which divert the biliary secretions. These are, of 
 course, taken care of in the usual manner. However, it is not im- 
 probable that the bile is an antiferment, and if the case present 
 any especial difficulty in this connection, recourse may have to 
 be had to the administration for a few days of sterile diet and 
 isoform (page 430). Gastric lavage and cleansing of the colon 
 are useful measures, and will afford considerable relief in in- 
 stances where the symptoms are sufficiently marked to warrant 
 their employment. The latter, that of colic lavage, may be em- 
 ployed in any event. The gastric lavage, because of the imme- 
 diate contiguity of the field of operation to the stomach, must not 
 be lightly undertaken, though if used judiciously and after 
 
BILIARY FISTULA 517 
 
 twenty-four or more hours subsequent to the operation is a justi- 
 fiable measure. 
 
 BILIARY FISTULA 
 
 Biliary fistula, as already stated, follows invasion of the 
 biliary passages in a certain number of instances. When the 
 gall-bladder has been drained by a tube around which it is in- 
 verted, the leakage of bile ceases in a few days after the drain is 
 removed. However, a certain number of surgeons fasten the gall- 
 bladder at the operation to the abdominal wall, with the view of 
 obviating the occurrence of leakage of biliary secretions into the 
 contiguous peritoneum. 
 
 This measure is followed by copious discharge of bile through 
 the wound, which may persist for several months. During this 
 time frequent changing of the dressings is necessary. The skin 
 soon becomes excoriated, and unless great cleanliness is exercised, 
 a distressing suppurative cellulitis of the tissues about the fistula 
 occurs. This may be obviated by covering the skin with a rather 
 thick layer of sterile zinc ointment, with the view of preventing 
 contact of the biliary secretions with the skin. 
 
 The ointment is gently removed once daily with soap and 
 water. For the purpose a pledget of cotton is used, and the oint- 
 ment patiently removed as the outcome of prolonged manipula- 
 tion, rather than as the result of harsh, scrubbing with tincture of 
 green soap and a brush. It must be remembered that the char- 
 acter of secretion, coming from the gall-bladder and ducts, is in- 
 fective in character, and that trauma to the skin at this time fa- 
 vors the occurrence of cellulitis and abscess. The attendant may 
 assure his patient that although a fistula of this sort at times per- 
 sists for months, it will frequently heal spontaneously at the end 
 of this time. 
 
 The mucosa lining of the fistulous tract is, as a rule, much 
 thickened as the result of an inflammatory hyperplasia, and this 
 membrane persists in secreting for a long time. It will be found 
 expedient to apply to the tract tincture of iodin, carried into the 
 lumen of the gall-bladder at intervals by means of cotton wound 
 on a probe, with the view of destroying infection and stimulating 
 repair. Pure carbolic acid may be used in the same way at in- 
 tervals of one week. The latter should be neutralized, as far as 
 
518 OPERATIONS ON LIVER AND FEMALE PELVIC ORGANS 
 
 contact with the skin is concerned, by a liberal lavage with alcohol 
 (95 per cent.), though the alcohol need not be carried into the 
 deep wonnd. 
 
 A few days after the application of carbolic acid sloughing of 
 a superficial portion of the tract occurs, which may interfere 
 with discharge of secretion. This will be manifested by evidence 
 of inflammation, pain, tenderness and a slight rise of tempera- 
 ture. Introduction of a slender dressing forceps will permit of 
 removal of the slough, and the reassumption of drainage is soon 
 followed by disappearance of the manifestations mentioned. 
 During the time that the bile is copiously discharged on the skin, 
 the patient is apt to give some evidence of malnutrition. This 
 occurs, of course, only when the fistula remains patent for a long 
 time. However, the constitutional effect of withdrawal of the 
 biliary secretion from the gut has in some instances caused suf- 
 ficient emaciation as to arouse suspicion that the process in the 
 gall-bladder was tuberculous. In these instances secondary opera- 
 tion, with the view of reestablishing the normal discharge of bile 
 into the gut, should be considered, and, indeed, this question 
 should be taken up before the patient's general condition becomes 
 sufficiently impaired as to influence the prognosis as regards the 
 operation. 
 
 Patients who have been subjected to operation upon the liver 
 do not frequently suffer from postoperative hernia. However, 
 women past middle life, who have thin recti muscles and a pendu- 
 lous abdomen, had best be furnished with an abdominal supporter 
 (page 475). 
 
 TRANSPERITONEAL OPERATIONS ON THE UTERUS AND 
 
 ADNEXA. 
 
 Approach to the female pelvis by the abdominal route calls 
 for the same general and local preparation described under celi- 
 otomy. 
 
 Salpingectomy for gonorrheal salpingitis is likely to be fol- 
 lowed by infection of the superficial wound, and this infection at 
 times does not become manifest until the tenth or even the four- 
 teenth day. It is a singular fact that evidence of peritoneal in- 
 fection may not, and in the majority of cases does not, manifest 
 
TRANSPERITONEAL OPERATIONS ON UTERUS AND ADNEXA 519 
 
 itself at any time in the vast majority of the cases including those 
 which are attended with infection of the superficial wound. This 
 would argue that the peritoneum is better suited to take care of 
 a certain amount of infection than the abdominal wound. There 
 is a prevalent notion that pyosalpinx is an almost sterile process 
 after the expiration of a certain period of time, and this is in a 
 measure true. However, this should not engender a harmful 
 complacency with respect to asepsis during the operative proce- 
 dure. It is not improbable that the fact that there is no wide solu- 
 tion of continuity of the peritoneum during the operation, as com- 
 pared to the sectioning of the abdominal wall, has some bearing 
 on the greater susceptibility of the latter. The abdominal wound 
 presents a surface in which the blood-vessels and lymphatics are 
 freshly sectioned, and this presents a more favorable condition of 
 affairs as regards infection than does the smooth peritoneum, 
 which undergoes repair in a very short time after being injured. 
 
 In view of the frequency with which infection of the super- 
 ficial wound occurs following celiotomy for salpingitis, the pa- 
 tient should be kept in bed for at least two weeks following the 
 operation. When infection becomes manifest the wound is treated 
 as already described (page 305). 
 
 Ovariotomy, hysterectomy, hysteromyomectomy, etc., are all 
 taken care of as stated in connection with celiotomy. Catheteri- 
 zation of the bladder for postoperative retention of urine is more 
 frequently necessary than after operations on other organs in 
 the abdomen. This may be due to the trauma which the bladder 
 is indirectly subjected to during the operation in this situation. 
 
 The Trendelenburg posture is more frequently employed dur- 
 ing operations in the female pelvis than for any other class of 
 cases. For the purpose a table so constructed as to permit of 
 placing the patient in this position should be available. Fig. 90 
 shows the table placed in this position. The nurses should be 
 careful to place the patient in such a position as to permit of at- 
 tainment of the Trendelenburg position when the necessity for it 
 arises without disturbing the relationship she bears to the table 
 while in the dorsal posture. This is an important consideration, 
 as, if the precaution be omitted, the changing of the patient's 
 position may result in fertilization of the operative field. When 
 the patient is placed in the Trendelenburg posture, the footpiece 
 
520 OPERATIONS ON LIVER AND FEMALE PELVIC ORGANS 
 
 of the table is dropped by the non-sterile nurse, the shoulder 
 braces are placed in contact with the shoulders, and the anesthe- 
 tist raises the lower end of the table by means of the wheel (Fig. 
 
 Fig. 323. — Patient in Trendelenburg Position, Draped for Celiotomy. 
 
 323) until the desired elevation is attained. Fig. 323 shows the 
 patient placed in the Trendelenburg posture. 
 
 The postoperative complications following transperitoneal 
 operations upon the uterus and adnexa are similar to those dis- 
 cussed under celiotomy, and are treated in the same way. As a 
 rule, an abdominal supporter (Fig. 300) or a special corset (Fig. 
 302) should be worn for several months after celiotomy in this 
 situation, as these organs are attacked through a portion of the 
 abdominal wall, which is of necessity exposed to considerable 
 strain and pressure. 
 
CHAPTEE XXVII 
 
 GYNECOLOGICAL OPERATIONS BY THE PERINEAL 
 
 ROUTE 
 
 Position of patient — Isolation of operative field — Irrigation — Care during con- 
 valescence — The care of the wound — Vaginal drainage of pelvic abscess — 
 Vaginal hysterectomy. 
 
 POSITION OF PATIENT 
 
 The vulva is shaved and cleansed in the manner described 
 under preparation of the skin. Catharsis is employed the day 
 
 Fig. 324. — Position of Patient for Perineal Operation. Surrounding Parts 
 Protected by Sterile Drapery. 
 
 before the operation, and no enema is given for six hours before 
 the operation (page 41). 
 
 The position of the patient during the operation most corn- 
 
 521 
 
522 GYNECOLOGICAL OPERATIONS BY PERINEAL ROUTE 
 
 monly employed is the so-called lithotomy posture (Fig. 324). 
 Modern operating tables provide for drainage when this position 
 
 Fig. 325. 
 
 -Clover's Crutch for "Lithotomy" Position during Perineal Opera- 
 tions. (Keyes.) 
 
 is employed. 
 
 Fig. 326. — Adjustable 
 Leg-holders for 
 "Lithotomy" Posi- 
 tion in Operations 
 on the Perineum. 
 
 However, if no such arrangement is available, a 
 Kelly pad (Fig. 13) is placed beneath the 
 buttocks for the purpose. In private prac- 
 tice the lithotomy position, if a portable 
 table (Fig. 134) is not available, may be at- 
 tained by means of the Clover (Fig. 325) 
 crutch or similar device. Portable uprights 
 which clamp on the ordinary deal table and 
 are furnished with foot straps (Fig. 326) 
 are exceedingly convenient, and do away 
 with the strain upon the shoulders which 
 results when the crutch or similar device 
 is used. 
 
 It will be seen by the illustration that 
 the leg-holders are inserted into canals in 
 the clamps and held at any desired height 
 by means of the set screws. This is desirable 
 
POSITION OF PATIENT 
 
 523 
 
 with the view of adjustabil- 
 ity with respect to varying 
 lengths of legs. The fact that 
 the clamps may be fastened 
 to the table at any desired 
 distance from each other 
 makes the holders adaptable 
 with regard to wide or nar- 
 row buttocks. In addition 
 to this, the uprights tele- 
 scope, which arrangement al- 
 lows of their transportation in a moderately sized bag 
 
 Fig. 327. — Portable Heel Cup, Useful in 
 Cleansing Perineal Wounds after 
 Operation. 
 
 The outfit 
 is also furnished 
 with heel cups (Fig. 
 327). The uprights 
 are discarded and 
 the clamps, after be- 
 ing attached to the 
 edge of the table, re- 
 ceive the heel cups. 
 This arrangement is 
 very satisfactory 
 during minor opera- 
 tions upon the per- 
 ineum, etc., under- 
 taken with local 
 anesthesia, and also 
 will be found ex- 
 ceedingly useful in 
 the local treatment 
 of cases subjected to 
 operations in this 
 situation when 
 changing dressings 
 treating the 
 
 Fig. 328. — Miller's Sponge Holder. The hook shown 
 above, in outline, hangs loose on the handle until the 
 forceps are locked, as seen in the right-hand figure. 
 (Kelly.) 
 
 or 
 
 wound after opera- 
 tion. When the up- 
 rights are used, 
 after the case is 
 
524 GYNECOLOGICAL OPERATIONS BY PERINEAL ROUTE 
 
 narcotized, the knees fall apart and the parts are readily accessible, 
 as shown in Fig. 324. 
 
 TYhen the patient is postured on the table as indicated, the 
 vulva is again cleansed and the vagina sterilized. For the latter 
 purpose tincture of green soap is introduced into the vagina, and 
 the vaginal walls scrubbed by means of a gauze sponge introduced 
 with a sponge holder (Fig. 328). This instrument holds the 
 sponge firmly in its jaws, and the lock at the handles does not 
 permit the jaws to open while manipulating the instrument in 
 deep cavities. The loss of a sponge is no great calamity in this 
 situation. However, a similar accident while the instrument is 
 introduced into the abdominal cavity from below would take on 
 a serious complexion. 
 
 The soap lather is now displaced with an irrigation of warm 
 sterile water, the vagina being " ballooned " by holding the labia 
 in apposition, to distend the folds of the mucosa and remove en- 
 tirely the lather. A douche of 10 per cent, creolin is then given, 
 followed by a copious vaginal irrigation with corrosive sublimate 
 1 in 2,000, and finally a douche of sterile water is employed. 
 
 ISOLATION OF OPERATIVE FIELD 
 
 The sterile isolation of the operative field is accomplished by 
 placing over either leg and leg-holder roomy leg-covers made of 
 linen, which are brought together over the pubis, giving space 
 enough over the perineum to leave exposed the operative field. A 
 towel is placed transversely across the anus and buttocks and 
 fastened to the leg-holder* on either side. The abdomen is cov- 
 ered with a sterile towel. Fig. 324 shows the patient prepared as 
 stated. This method of preparation has the advantage over that 
 of placing a large sheet over the parts and cutting a hole in it 
 corresponding to the operative field, inasmuch as the former 
 method permits of frequent changing of the lower towel during 
 the operation with but little disturbance of the contiguous sur- 
 faces and a minimum of interference with the operative proce- 
 dure. 
 
IRRIGATION 525 
 
 IRRIGATION 
 
 Irrigation, though not generally employed in operations in 
 other situations, should be provided for in this connection. Dur- 
 ing the operation a stream of normal saline solution may be in- 
 termittently directed against the operative field in order to facili- 
 tate the manipulations, such as removal of blood which obscures 
 the field. For the purpose a ball and socket nozzle will be found 
 convenient (Fig. 329). This little apparatus can be manipulated 
 
 Fig. 329. — Swedish Hard Rubber Ball and Nozzle Irrigator. By bending the 
 nozzle in the ball at an angle, the flow is controlled or altogether arrested. {Kelly.) 
 
 with one hand, and the force of the stream readily controlled or 
 the flow may be arrested altogether. 
 
 Following plastic operations in this situation, Kelly thor- 
 oughly drys the operative field with pledgets of dry sterile cotton. 
 
 A strip of iodoform gauze may then be inserted into the vagina, 
 as far up as the cervix, loosely filling the upper vagina and just ap- 
 pearing at the outlet ; this should be taken out in five or six days and 
 the vagina douched daily afterward. It is my practice at present to 
 use no vaginal dressing at all, but simply to protect the vulva by a 
 sterilized gauze pad held in place by a T-bandage. 
 
 The pad is changed several times daily, and if there is any offen- 
 sive discharge, the vagina is douched out with warm boric or carbolic 
 acid solution once or twice a day. I have found a powder composed 
 of boric acid 3 ounces, alum 1 ounce, carbolic acid y 2 ounce, and oil 
 of peppermint l 1 /) drachms, very satisfactory in relieving the odor 
 and irritation which are sometimes distressing during convalescence 
 from a plastic operation. 
 
 Before removing the patient from the table, draw the urine with 
 a glass catheter, loosen the leg-holder, and raise the buttocks by carry- 
 ing the feet of the patient toward the head, dry the genitals, buttocks, 
 and back with a towel, and remove the drainage pad. The external 
 genitals should be powdered with iodoform and boric acid (1-7), and 
 
526 GYNECOLOGICAL OPERATIONS BY PERINEAL ROUTE 
 
 then covered with a loose pad of sterile cotton, held in place by a T- 
 bandage. (Kelly.) 
 
 CARE DURING CONVALESCENCE 
 
 The care during convalescence frequently determines the ulti- 
 mate result. While the patient is coming out of narcosis the legs 
 may be tied together with a broad towel, to obviate strain upon 
 the sutures. As soon as consciousness returns, the restraint should 
 be removed and the cooperation of the patient depended upon to 
 avoid this occurrence. Following operations upon the perineum, 
 the patient is confined to bed for two weeks, during which time 
 the bed pan is used. Evacuation of the bladder and rectum in 
 the sitting posture brings strain to bear on the sutures and should 
 be avoided. When the cervix uteri alone is involved, the patient 
 may leave the bed on the seventh day after the operation, and 
 may empty the bladder and rectum in the sitting position after 
 the third day. 
 
 The vaginal pack may be removed when discharges appear at 
 the vulva, though, as a rule, the pack may be left in place for six 
 days following the operation. In removing the pack the labia 
 should be carefully separated and the gauze thoroughly moist- 
 ened with an antiseptic solution, which at the same time removes 
 the secretions from the labia. The pack is then seized with dress- 
 ing forceps, care being taken not to pinch in at the same time the 
 contiguous mucous membrane. With a twisting motion the pack 
 is slowly and gently loosened, as is described under removal of 
 the ^Mikulicz tamponade (page 268), and removed. The nozzle of 
 the irrigator, which should be blunt, is introduced downward and 
 backward, and the vagina cleansed with a copious lavage. After 
 the douche the parts are dried with sterile gauze and dusted with 
 aristol or the powder mentioned above. 
 
 Catheterization in these cases deserves special consideration. 
 The urine, when passed spontaneously, very soon soils the oper- 
 ative field, and, while the parts may be cleansed before and after 
 the act of urination, it is probable that catheterization at inter- 
 vals of eight hours for three days after the operation is a better 
 plan of procedure. The introduction of the catheter is performed 
 in the following manner : 
 
 The labia are gently separated and the mucosa contiguous to 
 
THE CARE OF THE WOUND 527 
 
 the urethral meatus is cleansed with pledgets of sterile cotton 
 soaked in 1 in 200 carbolic acid solution. The catheter, which 
 should be of glass and boiled before use, is then passed, and after 
 the bladder is evacuated the parts are again treated in the manner 
 employed before introduction of the catheter. If a skillful nurse 
 or a physician is available, the latter measure is more certain in 
 result as regards cleanliness of the perineal wound. However, if 
 these conditions are not obtainable, the method of preliminary 
 and subsequent cleansing is attended with less danger of infec- 
 tion, provided no cystitis has existed before the operation. In the 
 latter event, the catheterization, together with bladder lavage, 
 should be employed. When the catheter is withdrawn the finger 
 should be placed over its distal opening to prevent dribbling of 
 the urine contained in its lumen over the wound. During these 
 manipulations rubber gloves should be worn, which will make 
 contamination less liable to happen. Subsequent to either of the 
 manipulations the parts are dusted with one of the antiseptic 
 powders mentioned. 
 
 Catharsis is provoked on the second day after the operation. 
 A cathartic is given the evening of the second day, and this sup- 
 plemented by an enema the following morning. For the purpose 
 the patient is postured on the bed pan and the anus and surround- 
 ing tissues cleansed' in the manner similar to that employed about 
 the urethra. The nozzle of the syringe is gently pushed into the 
 bowel, care being taken to avoid unnecessary contact with the an- 
 terior surface of the rectum. 
 
 After the bowels have moved, the anus and surrounding sur- 
 face are again cleansed in the manner stated, and the parts dusted 
 with an antiseptic powder. When the anal outlet is being 
 cleansed subsequent to the fecal expulsion, the pledgets should be 
 wiped over the anus from before backward, to avoid dragging 
 feces toward or into the wound. 
 
 THE CARE OF THE WOUND 
 
 The care of the wound depends somewhat on the character of 
 operation performed. The precautions with respect to cleanli- 
 ness as regards urination and defecation have already been dis- 
 cussed. All manipulations should be conducted with gentleness, 
 
528 GYNECOLOGICAL OPERATIONS BY PERINEAL ROUTE 
 
 and contact of the fingers with the wound avoided. For the pur- 
 pose cotton or gauze pledgets held by forceps should be em- 
 ployed. 
 
 Removal from the perineum of stitches which emerge on the 
 skin may be done on the eighth day. Those within the vagina 
 may be left in place until the twelfth day, as their removal in- 
 volves some trauma to the line of union, and firm healing may 
 not be expected until the expiration of this time. With the proper 
 exercise of cleanliness, as stated, sutures emerging upon the 
 vaginal mucosa may safely be left in situ for two weeks. The cer- 
 vical sutures may remain in place for a long time. Silk-worm 
 gut is largely employed for the purpose, and this agent does not 
 infect very readily. In any event, it may be said that, if the 
 perineum have been repaired simultaneously with the cervix, the 
 sutures in the latter need not be removed for four weeks following 
 the operation, at which time firm repair of the perineum has taken 
 place. For the purpose of removing the stitches from the peri- 
 neum the field is cleansed with a solution of boric acid, which 
 will remove quite readily the crust of exudate and powder, mak- 
 ing visible the stitches. This may be repeatedly done for several 
 hours before the stitches are removed, the measure being executed 
 by the nurse. The patient is then postured in the Sims position, 
 the nurse or assistant holds apart the buttocks, and the stitches are 
 removed in the manner described above (page 304). 
 
 In removing sutures from the cervix, the patient is placed in 
 the Sims position, the posterior vaginal wall retracted and the 
 cervix seized with a small volsellum. The stitches are seized with 
 forceps and removed, cutting the suture material near the knot. 
 This latter step, that of removal of stitches from the cervix, should 
 be done in a good light, and an assistant should be available to 
 hold the speculum and volsellum. 
 
 After repair of the wound the patient is subjected to a general 
 tonic treatment. In cases of operation for plastic repair, espe- 
 cially where the sphincter ani has been involved, the patient's 
 mental status is apt to be somewhat demoralized. Kelly regards 
 systematic exercise with intervals of rest as important in these 
 cases following the operation. It is, no doubt, true that the en- 
 feebled muscular tone of the patient has some bearing in this con- 
 nection, and that measures directed toward improving the gen- 
 
VAGINAL DRAINAGE OF PELVIC ABSCESS 529 
 
 eral condition has an influence with respect to rapid return of 
 normal contractility of the muscles of the perineum. 
 
 Indulgence in the sexual function should be abstained from 
 for two months following plastic repair of the vagina. It is dif- 
 ficult to lay down a hard and fast rule in this connection. It is, 
 however, probable that in most instances complete repair is con- 
 served if this rule be followed. 
 
 Infection is manifested in this situation in the same manner 
 as obtains elsewhere. If infection occurs at the seat of one of the 
 sutures, it should be removed at once. Infection in the tissues 
 contiguous to the line of union should be treated with early in- 
 cision and drainage with strands of silk-worm gut. In this way 
 extension of the process may frequently be avoided. At times 
 abscess of one of the glands of Bartholin occurs. This is incised 
 early, for the reason stated. If infection of the entire wound 
 occurs, the stitches should be removed. However, the deep su- 
 tures of silk-worm gut should be kept in place until the last ; 
 drainage is accomplished at either side, with the view of obtain- 
 ing apposition by granulation healing when the infection sub- 
 sides. In this way, while a favorable cosmetic effect will prob- 
 ably not be achieved, sphincteric control is at times accomplished, 
 and an important factor in the case is eliminated. 
 
 VAGINAL DRAINAGE OF PELVIC ABSCESS 
 
 Vaginal drainage of pelvic abscess is prepared for, as stated 
 above (page 521). After the abscess is opened the residual cavity 
 is loosely packed with iodoform gauze, a second loose packing of 
 the same material is introduced into the vagina, and a gauze pad 
 
 Fig. 330. — Curved Volsellitm for Holding Cervix Uteri during 
 Manipulations. 
 
 applied to the vaginal outlet, which is held in place with a T-band- 
 age or vulvar pad (Fig. 3-i4). The gauze packing in the sac is 
 
530 GYNECOLOGICAL OPERATIONS BY PERINEAL ROUTE 
 
 not disturbed for three or four days, at the end of which time the 
 patient is placed in the lithotomy position (Fig. 324), the ex- 
 ternal parts are cleansed in the usual manner, and the vaginal 
 pack is removed. The posterior vaginal wall is retracted and the 
 cervix held forward by means of a volsellum (Fig. 330), exposing 
 
 Fig. 331. — Stout Curved Saw-toothed Traction For- 
 ceps for Removing the Gauze Pack. The jaws shown 
 in lower figure. {Kelly.) 
 
 the packing in the sac. The latter is at times left long and ex- 
 tends well into the vagina, making unnecessary the manipulation 
 of the cervix at this time in the manner stated. 
 
 The protruding gauze is seized with a saw-toothed forceps 
 (Fig. 331) and withdrawn. The cervix is now seized with the 
 
 Fig. 332. — Bozeman Return Flow Metal Irrigating Tube Used for Cleansing 
 Interior of Cavities. The instrument may be taken apart as indicated above 
 and cleansed. 
 
 volsellum in the manner stated above and the abscess cavity irri- 
 gated. For the purpose, ample provision for return of the cleans- 
 ing fluid should be made, and the vaginal speculum should be 
 left in situ. For the purpose of cleansing the abscess cavity, the 
 metal intrauterine return flow instrument shown in Fig. 332 will 
 
VAGINAL DRAINAGE OF PELVIC ABSCESS 531 
 
 be found to meet the indications. In the absence of this instru- 
 ment the Kemp tube (Fig. 345) will be found to answer the pur- 
 pose. The former discharges the return flow into the vagina and 
 cleanses it at the same time, and may be regarded as the more 
 useful instrument for the purpose. The lavage should be pre- 
 ceded by cleansing of the vagina, and the usual asepsis should be 
 observed throughout the manipulation, for although an infected 
 cavity is being treated, the introduction of additional infection, 
 the character of which may be more virulent than the one exist- 
 ing, should be avoided. 
 
 After the cavity is cleansed a fresh packing is introduced by 
 means of a long dressing forceps (Fig. 333). This manipulation 
 
 Fig. 333. — Uterine Dressing Forceps, Useful for Removing Gauze 
 from cul-de-sac. 
 
 is repeated until the discharge from the sac ceases, which requires 
 in uncomplicated cases about two weeks. The patient is encour- 
 aged to assume the sitting posture after the first change of the 
 packing, with the view of promoting drainage, and is allowed to 
 leave the bed on the tenth day following the operation. 
 
 Fecal fistula follows section of the posterior vaginal vault in 
 a certain number of cases. The fact that discharge of feces per 
 vaginam does not, in a large number of cases, occur until the 
 fifth day or later after the section, suggests that the inflammatory 
 process produces sloughing of the anterior rectal wall and the 
 fistula is not established until the slough separates. In another 
 number of cases the rectum is injured during the operative pro- 
 cedure. In either event, the discharge of the feces from the va- 
 gina heralds the establishment of the fistula, and when the pack 
 becomes odoriferous it should be at once removed and the abscess 
 cavity cleansed in the manner described above. After the fistula 
 is established care must be exercised in administering enemas, 
 
 though the rectum should be cleansed daily by means of the Kemp 
 36 
 
532 GYNECOLOGICAL OPERATIONS BY PERINEAL ROUTE 
 
 tube. The abscess cavity is cleansed daily and a gauze wick intro- 
 duced. Packing should not be employed, and the vagina should 
 be douched twice daily. Spontaneous repair of fistulse in this 
 situation occurs in most instances, the cervix becoming adherent 
 at its site and obliterating the opening. Scrupulous attention to 
 cleanliness should be employed in the manner indicated during 
 the healing. During the cleansing of the vagina a rectal specu- 
 lum should be introduced through the anus, to obviate collection 
 of the fluid employed for the purpose in that organ. During 
 lavage of the rectum the vagina should be kept open with a bi- 
 valve speculum to permit of ready egress of the fluid, which may 
 enter the abscess. cavity through the fistulous opening. 
 
 VAGINAL HYSTERECTOMY 
 
 Vaginal hysterectomy is attended with control of bleeding by 
 either clamps or ligatures. When clamps are used, those ar- 
 ranged with detachable handles are employed, and the blades left 
 in situ. The instruments are surrounded with an iodoform gauze 
 roll which extends well up into the vault of the vagina. The 
 presence of the clamps and gauze makes a line of communication 
 with the peritoneum, a condition of affairs favorable to infection, 
 and the suggestions offered with respect to cleanliness and the care 
 of the bladder and rectum must be thoroughly executed. With 
 the view of obviating contamination of the field with urine, a 
 retention catheter (page 569) is placed in the bladder and led 
 into a conveniently placed vessel. Fig. 334 shows the clamps 
 rolled in the gauze and the retention catheter in situ. 
 
 Patients who have been subjected to vaginal hysterectomy, 
 after which clamps are left in situ, suffer considerable pain, neces- 
 sitating the administration of opiates. The anodyne should be 
 given in sufficient quantity to control the symptom. It is wise to 
 administer hypodermically one-third of a grain of morphia under 
 the skin, before narcosis is recovered from, as the restlessnesss 
 consequent to the pain, together with the semi-consciousness, may 
 result in disturbance of the clamps. Administration of the opiate 
 should be repeated as the indications present. Peritoneal pain is 
 very severe and the crushing of the broad ligaments within the 
 jaws of the clamps creates a condition of affairs which it is easy 
 
VAGINAL HYSTERECTOMY 
 
 533 
 
 to understand would provoke much suffering. Defecation is not 
 likely to occur for forty-eight hours, for obvious reasons, and the 
 
 Fig. 334. — Hysterectomy Clamps Rolled in Gauze. (Kelly and Noble.) 
 
 introduction of enemata should be carefully executed under asep- 
 tic precautions. 
 
 The catheter is changed for a second sterile one at the end 
 
534 GYNECOLOGICAL OPERATIONS BY PERINEAL ROUTE 
 
 of twenty-four hours, at which time the bladder is lavaged with 
 boric acid solution. At the end of another twenty-four hours the 
 catheter is removed, the bladder again irrigated, and the gauze 
 roll and clamps removed. 
 
 For the purpose the gauze is thoroughly soaked with an anti- 
 septic solution (corrosive sublimate 1 in 2,000). The clamps will 
 be found quite coated with secretion and rust. The intra-abdom- 
 inal portions of the clamps are in a similar condition, and shreds 
 of crushed tissue cause the blades to stick rather firmly. In re- 
 moving the clamps this should be borne in mind. After the 
 handles are affixed to the blades the locks are released without 
 making any downward traction. If the portions of the blood- 
 vessels obliterated by the pressure are torn away, bleeding will 
 occur. After the clamps are released portions of the broad liga- 
 ments adhere to the interstices between the serrated surfaces of 
 the clamps, even after the jaws are separated. Downward trac- 
 tion must not yet be made. The clamps are slowly rocked from 
 side to side on the arch of a circle, and after this manipulation 
 has been several times repeated the clamp may be withdrawn. 
 As a rule, the highest clamp is removed first, permitting of 
 steadying of the ligament with the lower ones. 
 
 When these manipulations are performed, the patient should 
 be brought to the edge of the table or bed and a good direct light 
 should be available. At times the clamps are removed while the 
 patient is in bed. This is advised against, as the position of the 
 clamps with respect to the direction of the body has a tendency 
 to let the protruding portions of the clamps point backward, and 
 when the handles are raised undue damage to the stumps of the 
 ligaments is caused. The clamps should be released and loosened 
 at the angle of their introduction with the view of accomplishing 
 the purpose, as stated above. When ligatures are employed for 
 the arrest of bleeding they are usually left long, their ends being 
 allowed to just reach to within the vaginal outlet. The vaginal 
 vault and the space between the broad ligaments is loosely packed 
 with gauze and the vagina itself filled with gauze packing. 
 
 The gauze packing holds the rectum, bladder, and intestine 
 away from the wound and drains the operative field. The gauze 
 should be loosely introduced, the firm insertion of the packing 
 interfering with drainage. However, when the packing is insuf- 
 
VAGINAL HYSTERECTOMY 535 
 
 ficient in quantity, the object with respect to keeping the contents 
 of the abdomen away from the wound is not attained. This is 
 true as regards subsequent dressings, and the introduction of the 
 gauze should be always accomplished with the patient in the lith- 
 otomy position and under guidance of the eye, the vaginal walls 
 being held apart with a vaginal speculum or by means of trac- 
 tors held by an assistant. 
 
 Evacuation of the bowel is allowed to occur on the third day 
 after the operation. A cathartic is administered in the evening 
 and the following morning an enema of sterile water and soap 
 is given. The latter act is, as has already been stated, carried 
 out with careful aseptic technic and the contiguous surfaces are 
 thoroughly cleansed after the bowel is emptied. The discharge 
 of feces is made to occur after the clamps are removed, and there 
 is little danger of infection occurring at this time from contami- 
 nation with feces. However, the precautions mentioned should 
 be observed. 
 
 When ligatures are employed the gauze packing in the vagina 
 need not be disturbed for four or five days after the operation, 
 and pain is not so great a factor in the after care. If the gauze 
 packing in the vagina is saturated with secretions before this 
 time, it should be changed. It is best to leave the gauze in situ 
 for the four or five days, as in this way the contents of the ab- 
 domen are kept away from the surfaces of the cut vaginal vault 
 until a certain amount of repair has taken place. Theoretically 
 this lessens the dangers of postoperative infection. 
 
 As a rule, a certain amount of sloughing of the edges of the 
 sectioned vagina and broad ligaments follows the operation. This 
 interferes with healing, and while the sloughs are separating, the 
 intestine should be kept from coining in contact with the wound 
 surfaces in the manner stated. Repair of the vaginal vault does 
 not, at times, occur until weeks after the operation. If the repair 
 is permitted to go on without guidance, a loop of small intestine 
 partially prolapses into the space at the vault of the vagina in 
 some instances, and becomes adherent in this situation. The 
 writer has seen cases of this sort, and in each instance celiotomy 
 and suprapubic repair of the vaginal vault was made after the 
 intestine has been loosened. The latter step was regarded as 
 dangerous when attempted from the vagina. The ultimate repair 
 
536 GYNECOLOGICAL OPERATIONS BY PERINEAL ROUTE 
 
 contemplates repair of the vaginal vault with the rectum and 
 bladder forming the dome above the vaginal scar. With this in 
 view, the parts should be manipulated at each dressing, making 
 smaller and smaller the tamponade until healing is complete. 
 
 Fig. 335. — Appearance of Vaginal Vault after Vaginal Hysterectomy. Vault 
 of Vagina Held in Place with Stitch. (Kelly.) 
 
 At times a stitch is taken in the center of the vaginal vault 
 holding together the peritoneum (Fig. 335). This obviates, to 
 a certain extent, the contingency related above, holding away 
 from the vagina] vault the small intestine. In these instances the 
 
VAGINAL HYSTERECTOMY 537 
 
 packing is introduced on either side of the stitch, and the rest of 
 the local after-treatment executed in the manner stated above. 
 
 During the after-treatment, douching of the vagina is per- 
 missible, but should be performed when the patient is on the 
 table, as described, and the cleansing made through a speculum 
 to avoid the carrying of infection into the peritoneum. At times 
 shreds of sloughing tissue may be removed with the dressing 
 forceps. On the whole, the after care following vaginal hysterec- 
 tomy is attended with considerable labor, and should be patiently 
 carried out. 
 
 When infection occurs, following either the use of clamps or 
 ligatures, the case is treated in the manner in which infection is 
 taken care of elsewhere. 
 
 Fecal or urinary fistulae follow vaginal hysterectomy in a small 
 percentage of cases. In some instances sloughing extends into 
 either the rectum or bladder. If this occur, the packing must be 
 changed daily and the parts cleansed very thoroughly at each 
 sitting. 
 
 Enemata are given under the precautions described in con- 
 nection with drainage of pelvic abscesses (page 531). The 
 bladder is kept clean, and if the fistula into this organ is consid- 
 erable in size a retention catheter may be introduced into the 
 bladder (Fig. 336) and the latter is taken care of as stated (page 
 533). 
 
 Cystitis follows vaginal section by the perineal route in a cer- 
 tain number of cases. Ordinarily, acute cystitis with pus, mu- 
 cus and blood in the urine, subsequent to the operation, will 
 subside under mild treatment without the necessity of local treat- 
 ment. The pain and tenesmus are frequently relieved by the ad- 
 ministration of 
 
 3? Kali citrat 4 drachms 
 
 Tr. hyscyomi 6 drachms 
 
 Elix. simpl q. s. ad 6 ounces 
 
 S. Tablespoonful every two to three hours in water. 
 
 When the more acute symptoms subside, urotropin in five- 
 grain doses may be given and the anodyne mixture administered 
 at night. 
 
538 GYNECOLOGICAL OPERATIONS BY PERINEAL ROUTE 
 
 If pus is persistently present, irrigation of the bladder with 
 boric acid solution may be made once daily. For the purpose a 
 " two-way " catheter may be used, the upper connection being at- 
 tached to a long rubber tube connected with a funnel. To the lower 
 
 outlet is attached a rubber tube draining off the fluid. 
 
 Fig. 336 
 
 Fig. 336. — Irrigation of Bladder with " Two-way " Catheter. (Kelly.) 
 
 shows the apparatus in use. Care must be exercised not to permit 
 the funnel to become empty during the manipulations, or air will 
 be sucked into the bladder by the entering column of water and 
 distressing tenesmus is provoked. The advantage the method 
 has over the use of the irrigator or syringe is that the pressure 
 is easily regulated by the elevation of the funnel, and this should 
 
VAGINAL HYSTERECTOMY 539 
 
 not be held higher than will provoke a moderately rapid flow of 
 cleansing fluid into the bladder. By lowering the funnel to be- 
 low the level of the bladder the contents can be siphoned off. 
 
 The measures related above usually achieve the purpose in a 
 few days. However, in a certain number of cases the symptoms 
 persist, and, indeed, chronic ulcerative cystitis has occurred under 
 the conditions mentioned. 
 
 Fig. 337. — Method of Continuous Irrigation of Bladder with Patient in Bed 
 on Bed Pan. {Kelly.) 
 
 Kelly employs in these cases irrigation of the bladder, as 
 stated, using a solution of nitrate of silver (1-1,000) for the pur- 
 pose. A small quantity of the solution (4 ounces) is left in the 
 bladder to be voided at the next urination. In very obstinate 
 cases, where ulceration is present, Kelly subjects the bladder to 
 continuous irrigation with a warm boric acid solution. The pa- 
 
540 GYNECOLOGICAL OPERATIONS BY PERINEAL ROUTE 
 
 tient is postured as shown in Fig. 337. A double soft rubber 
 catheter (Fig. 336) is introduced through the urethra into the 
 bladder, and held in place with a perineal pad fastened with a 
 tape around the waist. The upper catheter is connected with an 
 irrigator, as shown in the illustration, the lower one is led into 
 a pan, and the latter drains into a jar, as shown in Fig. 337. The 
 irrigation may be maintained for several hours at a time, at the 
 end of which time the irrigating tube is disconnected and the 
 bladder emptied. An instillation of nitrate of silver solution, as 
 stated above, is introduced into the bladder. Exceedingly ob- 
 stinate cases of infection of the bladder will yield to this form of 
 treatment. 
 
CHAPTEK XXVIII 
 OPERATIONS ON THE RECTUM AND ANUS 
 
 Operations on the rectum by the sacral route — Operations on anus and rectum 
 by the perineal route — Fistula in ano — Removal of hemorrhoids — Prolapse 
 of rectum, perineal proctectomy, from the rectum and excision of tumors. 
 
 When the rectum is approached by the transperitoneal route, 
 the preparation of the patient and subsequent care and treatment 
 do not differ from those described above in connection with celi- 
 otomy and invasion of the gut. Manipulations about the rectum 
 
 Fig. 338. — Tuttle's Pneumatic Proctoscope. (Tuttle.) A, obturator; B, 
 plug with glass window for closing tube; C, handle; D, cords connect- 
 ing instrument with battery or street current; E, inflating bulb; F, 
 main tube of proctoscope. 
 
 in postoperative cases will be found greatly facilitated by em- 
 ploying the outfit shown in Fig. 338. Facilities for the necessary 
 
 541 
 
542 
 
 OPERATIONS ON THE RECTUM AND ANUS 
 
 If 
 
 electric energy are not at all times available. Under these cir- 
 cumstances the outfit shown in Fig. 342 will be found to meet 
 the indication, though perhaps with less comfort to the surgeon 
 than that shown in Fig. 338. The outfit shown in Fig. 338 has 
 the advantage of permitting of inspection and treatment of con- 
 ditions in the rectum without the use of in- 
 direct light. In addition to this, the forceps 
 shown in Fig. 339 will be found a useful 
 addition to the armamentarium, especially 
 in cleansing the rectal wound with gauze or 
 cotton wipes. The forceps has the lock ar- 
 ranged in such a manner as to permit of 
 opening and shutting in a small space. 
 
 OPERATIONS ON THE RECTUM BY 
 THE SACRAL ROUTE 
 
 Operations of this sort usually involve 
 much trauma and consequently are fre- 
 quently attended with considerable shock. 
 Ample provision should be made to meet 
 the indications in this regard (page 229). 
 The administration of nutritive constitu- 
 te. 339. Alligator ents and stimulants by rectum, following 
 
 Forceps for Cleansing operations in this situation, is, of course, 
 
 Wound of Rectum. . . „, 
 
 (Tuttle.) attended with some difficulty, though enter- 
 
 oclysis may be employed, provided the 
 solution is rendered sterile and asepsis be conserved during the 
 administration. 
 
 Extirpation of the rectum by the sacral route, when it is pos- 
 sible to maintain the anal outlet in the normal position, is less 
 likely to be followed by infection than when an artificial anus is 
 made in the wound. 
 
 Fig. 340 shows the appearance of the wound and anus in the 
 class of cases where the anus is left intact. Drainage of the 
 wound is employed to lead off any leakage which may occur at 
 the seat of rectal trauma, and, also, as this method of attacking 
 the rectum involves the fashioning of a bone flap, to permit of 
 the exit of secretions from the surfaces of the sectioned bone. A 
 
OPERATIONS ON THE RECTUM BY THE SACRAL ROUTE 543 
 
 certain amount of necrosis of the bone occurs in most instances, 
 and the drainage opening will permit of discharge of the sepa- 
 rated particles of bone tissue. It will be seen by the illustration 
 that a rubber tube of considerable caliber is introduced into the 
 
 Fig. 340. — Appearance of Wound after Excision of Rectum by the Sacral 
 Route. G, Gauze draining retro-rectal space ; T , Tampon and drainage tube in 
 anus. {T utile.) 
 
 rectum through the anus, which is surrounded with gauze, and 
 serves the purpose of permitting of easy expulsion of gas and 
 discharge of secretions. Distention of the rectum and sigmoid 
 following this class of operations is exceedingly distressing to the 
 patient and interferes with ready repair of the wound in the gut. 
 The drainage tube also gives an avenue of egress to the secretions 
 from the wound in the gut. 
 
 The rubber tube should be fenestrated (Fig. 14-'> ) and be passed 
 beyond the line of union in the gut. The distal portion of the 
 tube may be connected with a long flexible tube, which is led into 
 an appropriate receptacle described under colectomy (page 505). 
 When the nature of the affliction for the relief of which rectal 
 
544 
 
 OPERATIONS ON THE RECTUM AND ANUS 
 
 extirpation has been undertaken makes maintenance of the nor- 
 mal site of fecal discharge impossible, the proximal end of the 
 gnt is sutured into the wound in the manner shown in Fig. 341. 
 
 Fig. 341. 
 
 -Appearance of Artificial Anus After Sacral Resection of Rectum. 
 (Tuttle.) A, Artificial amis; G, Gauze drain. 
 
 While the protective dressing need not be changed for several 
 days following the operation where the normal outlet for feces is 
 maintained, the wound must be dressed daily or more often when 
 an artificial anus is made. 
 
 In either event the bowel is quieted with an opiate, and no 
 catharsis is provoked for four or five days following the opera- 
 tion, with the view of lessening the dangers of infection from feces. 
 The postoperative diet should be bland and contain no substances 
 which leave large residuum for expulsion by the rectum. The 
 precautions taken up under the general head of intestinal opera- 
 tions should be observed. 
 
 When finally catharsis is employed, a saturated solution of 
 magnesium sulphate in doses of one drachm every hour will re- 
 sult in catharsis in about five hours after beginning of the dosage. 
 
OPERATIONS ON THE RECTUM BY THE SACRAL ROUTE 545 
 
 Two hours after beginning of the medication four ounces of 
 sterile olive oil warmed to the temperature of 105° F. are gently 
 injected into the bowel either through the drainage tube or arti- 
 ficial anus. One hour later, a half pint of a solution of sodium 
 carbonate 2 per cent, is injected in the same way. Cleansing of 
 the bowel in this manner is attained thus with but little disturb- 
 ance to the patient. The catharsis should be so arranged as to have 
 the ultimate outcome occur at a time when cleansing of the 
 wound, which should be done soon after the bowel is emptied, is 
 made by the attendant. In the event of a spontaneous discharge 
 of feces before this time, or if the surgeon is not promptly avail- 
 able when the discharge of feces occurs, the nurse should remove 
 the dressing and cover the wound with a wet antiseptic dressing 
 until the proper dressing is applied. 
 
 The superficial drain may be removed on the fifth day if no 
 infection have occurred. If the wound is contaminated, it is 
 treated along the lines stated above in this connection. The 
 wound shown in the illustration is closed with a continuous su- 
 ture. The writer employs interrupted silk-worm gut sutures for 
 the purpose, for the reasons already stated. When catgut is used 
 the sutures need not necessarily be removed. When, however, 
 silk-worm gut is used, the sutures are removed on the tenth day 
 following the operation. 
 
 Following the primary dressing of the wound, that is, after 
 the first evacuation of feces, the drainage tube and gauze plug- 
 need not necessarily be reinserted. If, however, the superficial 
 or sacral wound show evidence of infection at this time, the drain- 
 age had best be reintroduced, with the view of draining any in- 
 fective secretions which may find their way from the retrorectal 
 space into the bowel. If this contingency occur, the rectum must 
 be cleansed daily, using the Kemp (Fig. 345) tube, or the anus 
 is distended with a speculum and the site of the wound in the 
 bowel thoroughly cleansed under guidance of the eye. The latter 
 plan is the better. However, in some instances the anus is in- 
 flamed and sensitive as the outcome of manipulations in this 
 situation, and the Kemp tube may be advantageously used for the 
 purpose. 
 
 The rectum is quite intolerant of strong antiseptic solutions. 
 For the purpose of cleansing the wound a saturated (sterile) so- 
 
Fig. 342. — Kelly's Set of Instruments for Treatment of Wounds of Rectum 
 and Sigmoid. A, Sponge-holder; B, Applicator; C, Curette; D, Anal dilator; 
 E, Anoscope; F, G, H, Protoscopes. (Tuttle.) 
 
 546 
 
OPERATIONS ON THE RECTUM BY THE SACRAL ROUTE 547 
 
 lution of boric acid may be used. The solution is introduced into 
 the rectum under very slight pressure when the Kemp tube is 
 used, and, of course, need not cause any disturbance whatever 
 when the manipulations are carried on through a speculum. 
 
 For the purpose the instruments shown in Fig. 342 will be 
 found very useful. The length of the speculum selected for a 
 given case depends upon the distance from the anus at which 
 union of the divided ends of the gut has been made. It will be 
 found expedient to dilate carefully the anus with the conical di- 
 lator (d) shown in the illustration. The introduction of the 
 cylindrical speculum is attended with very little pain, and when 
 the rectum is thus distended cleansing of the parts may be thor- 
 oughly and efficiently made. At times a small area of mucosa 
 at the site of union sloughs. This may be removed by using the 
 curette shown in the illustration (c). Collections of pus may be 
 wiped away with a gauze pledget held in the jaws of the sponge 
 holder (a). Applications of tincture of iodin, pure carbolic acid 
 or a solution of nitrate of silver, 60 grains to the ounce, may be 
 made at the site of the wound by means of cotton wound on the 
 applicator (b). 
 
 Wounds in the rectum may in this manner be treated in the 
 same way as are wounds more superficially located. The treat- 
 ment is carried on until healing is complete, which in this situa- 
 tion may require three or four weeks. 
 
 The daily introduction of a speculum into the rectum will be 
 found quite distressing, and, indeed, after four or five days fol- 
 lowing the operation, complete cleansing of the wound need only 
 be made upon each alternate day. For the purpose of cleansing 
 and treating the rectum, the " knee-chest " position will be found 
 to serve best the conditions (Fig. 343). In this position the 
 weight of the abdominal organs is taken entirely off the rectum, 
 and the dilating effect of atmospheric pressure is attained. This 
 position is very useful after convalescence has been established 
 and the need of irrigation no longer obtains, the cleansing of the 
 part being achieved by sponges soaked with a cleansing fluid. In 
 the event of considerable infection being present, and when lib- 
 eral lavage of the surface is regarded necessary, the patient had 
 best be placed in the Sims (Fig. 346) or lithotomy position. 
 
 When the Sims position is used, the irrigation should be made 
 37 
 
548 
 
 OPERATIONS ON THE RECTUM AND ANUS 
 
 through a return flow tube (Fig. 346), as the posture does not 
 allow of proper drainage of the cleansing fluid, unless some spe- 
 cial provision be made. When the irrigation is used through the 
 
 Fig. 343. — Knee-chest Position for Approaching Wound after Resection of 
 
 the Rectum. (T utile.) 
 
 speculum, the lithotomy position will be found to meet best the 
 indications. 
 
 In cases in which an artificial anus is made, the patient is 
 fitted with a pad and abdominal band similar to that worn after 
 colostomy (Fig. 317). 
 
 OPERATIONS ON THE ANUS AND THE RECTUM BY THE 
 PERINEAL ROUTE 
 
 Operations in this situation present the problem of achieving 
 asepsis under rather unfavorable conditions. It is probable that 
 despite cleanliness, as generally understood in making the toilet, 
 a certain amount of infective bacteria inhabit the hair follicles 
 contiguous to the anus and in the skin of perineum at all times, 
 
OPERATIONS ON ANUS AND RECTUM BY PERINEAL ROUTE 549 
 
 and that they exist in this situation in greater numbers than ob- 
 tains in other portions of the bod)' . 
 
 The hair, too, in this situation is likely to be abundant, and 
 this contributes to the difficulties as regards cleanliness. It is 
 wise to apply the measures laid down with the view of cleansing 
 the skin in this situation with exactness. The parts had best be 
 shaved several days before the operation, and, if a short growth 
 of hair has appeared at the time of final preparation, the razor 
 should be again employed, and this supplemented with copious 
 application of soap and prolonged lavage. 
 
 With regard to catharsis, it would seem best that the bowels 
 should not be moved by medication for twenty-four hours before 
 the operation and cleansing of the rectum and sigmoid be achieved 
 with enemata. For the purpose an enema of soap and water may 
 be given twelve hours before the operation, and six hours later 
 another of acetozone, 1 in 1,000, may be given. !No liquid should 
 be introduced into the rectum after this, as it may not be entirely 
 expelled by the time the operation is performed, as the discharge 
 of the residual amount of liquid, together with some feces, is 
 likely to occur as the patient struggles while being narcotized. 
 This latter occurrence is exceedingly disagreeable, and is likely to 
 fertilize the operative field. If there be any doubt as to the lower 
 bowel being empty, a sterile rubber tube of considerable caliber 
 may be passed into the rectum and final discharge of fluids en- 
 couraged just before the operation and immediately before the 
 final cleansing of the operative field, when the patient is on the 
 operating table. 
 
 However, accidental discharge of fluid from the rectum does 
 at times occur during the operation, and it is wise to have at hand 
 a duplicate set of the necessary instruments, and when soiling of 
 the operative field occurs, these may be made to replace those con- 
 taminated. 
 
 Also, provision should be made for a second cleansing of the 
 operative field, which is done by an assistant while the surgeon 
 cleanses himself and changes his gown. In this class of cases the 
 wearing of gloves is quite essential, for if soiling occurs it is not 
 attended with as much damage as when the infective material 
 comes in contact with the skin, and it is, of course, a simple mat- 
 ter to remove the soiled gloves and replace them with sterile ones. 
 
550 OPERATIONS OX THE RECTUM AND AXES 
 
 During operations of this kind the patient is usually placed 
 in the lithotomy position and the operative field isolated, the ar- 
 rangement in this regard being quite similar to that employed in 
 gynecological operations, and is described under that head (Fig. 
 324), except, of course, that the anus is not covered with a sterile 
 towel, as obtains with that class of cases. 
 
 The towel is lowered so as to make accessible the anus and, 
 at the same time, obviate contact with non-sterile surfaces by the 
 hands and instruments. At times the lateral Sims position is 
 employed (Fig. 346). However, better drainage and greater ac- 
 cessibility is attained by the lithotomy position, unless the opera- 
 tive procedure contemplates attack on the sacrum, in which event 
 the Sims position is preferable. 
 
 FISTULA IN ANO 
 
 Fistula in ano, for which operative relief is undertaken, in- 
 volves in preparation for surgical attack the question of the char- 
 acter of pathological process. A sufficient number of patients af- 
 flicted with fistula in this situation are tuberculous, to warrant 
 the precautions being taken discussed under the head of tubercu- 
 losis in general, and its bearing on operative procedure (page 
 11). In any event, a search should be made for the avenue of 
 infection, and if this be the lungs or the digestive tract, the pa- 
 tient should be treated in advance with the view of obviating 
 postoperative exacerbation of the distal focus of the tuberculous 
 process. In any event, chloroform narcosis should be employed 
 in preference to that of ether, for reasons already stated. In a 
 certain number of cases an attempt is made to attain primary 
 union of the wound after the fistulous tract has been excised. In 
 this event the postoperative treatment of the wound does not dif- 
 fer from that employed when immediate union of a wound is at- 
 tempted elsewhere. The bowel is kept quiet with opiates, as al- 
 ready stated, and provision made for the escape of flatus and 
 feces, as described above (page 543). 
 
 In the vast majority of instances no attempt at primary union 
 is made, and the wound is packed with gauze with the view of at- 
 taining repair by granulation. . In these cases the same precau- 
 tions with respect to keeping quiet the bowel, etc., should be ob- 
 
FISTULA IN ANO 551 
 
 served, and at the end of forty-eight hours the packing is removed 
 and replaced daily until repair ultimately takes place. When the 
 wound is dressed, the gauze is loosened with hydrogen peroxid, 
 and the line of incision thoroughly cleansed with a solution of 
 corrosive sublimate, 1 in 1,000, or acidi carbolici, 1 in 200. 
 
 For the purpose the patient is postured on the bed pan or 
 similar device which allows of prolonged irrigation. Sphinteric 
 control is not usually attained for a week following the operation, 
 and the nurse should be instructed to give an enema two hours be- 
 fore the contemplated visit of the surgeon, and, after the bowels 
 have discharged their contents, to place in contact with the anus 
 a wet dressing of gauze saturated with corrosive sublimate solu- 
 tion, 1 in 1,000, until the attendant arrives, who then packs again 
 the wound with gauze and applies the protective dressing. Ca- 
 tharsis which results in liquid stools should be avoided, unless 
 there be an especial indication for the same. 
 
 As already stated, the number of cases in which the fistulse 
 are tuberculous in origin is quite large, and as these cases do not 
 react readily after operative attack when confined to bed, it is 
 advised that as soon as the immediate eifects of the operation are 
 recovered from, the patient be allowed to leave the bed and be 
 placed in the open air. A prolonged convalescence will not in- 
 frequently be obviated, if the patient be subjected to over-feed- 
 ing and the care given cases of tuberculosis generally. The post- 
 operative care of these cases is exceedingly trying, and both the 
 patient and attendant frequently become discouraged. It should 
 be borne in mind that an ultimate favorable outcome is the re- 
 ward of persistent attention to detail, and that neglect to guide 
 the healing along proper lines may result in failure. For this 
 reason the packing should be carefully and accurately introduced 
 into the wound at each dressing. 
 
 It is not uncommon for cases to require six or eight weeks of 
 patient attention to the suggestions offered above before complete 
 repair takes place. Intelligent cooperation on part, of the patient 
 is an important determining factor. With a little care, the evacu- 
 ation of the bowels may be made to take place early in the morn- 
 ing, after breakfast, and the patient may then cleanse the anus 
 with a solution of corrosive sublimate, 1 in 1,000, and as the 
 gauze packing is usually displaced by the action of the sphincter 
 
552 
 
 OPERATIONS ON THE RECTUM AND ANUS 
 
 during defecation, a gauze pad may be gently inserted between 
 the buttocks by the patient and held in place with a T-bandage 
 (Fig. 344). He then journeys to the physician's office, who re- 
 
 Fig. 344. — T-bandage in situ. (Gerster.) 
 
 packs the wound and applies the protective dressing. While the 
 practitioner need not feel that a failure at relief is necessarily the 
 outcome of disregard of details, it may be said that failure is less 
 likely to occur if they be assiduously carried out. 
 
 REMOVAL OF HEMORRHOIDS 
 
 The removal of hemorrhoids is preceded by the same prepara- 
 tion as obtain with other operations about the anus (page 548), 
 including the precautions with respect to cleanliness before, dur- 
 ing, and after the operation. 
 
 In the after-treatment no special measures will be found neces- 
 sary, except, perhaps, that the pain and tenesmus which follows 
 the operation is more likely to occur following this operation 
 than obtains in instances where the sphincter muscle is divided. 
 The dosage of opiate may have to be somewhat larger for this 
 reason, and the use of cathartics take the place of enemata for 
 the same reason. 
 
REMOVAL OF HEMORRHOIDS 553 
 
 As a general rule, considering the thorough cleansing given 
 the lower bowel immediately preceding the operation, no effort 
 need be made to provoke catharsis until the fifth day following 
 the operation and the discharge of feces, when heralded by a de- 
 sire to defecate may be preceded by removal of the gauze tampon 
 and tube (Fig. 340), in order to facilitate matters, and be fol- 
 lowed by cleansing of the wound and reapplication of a protective 
 dressing. The tamponade and tube need not be reintroduced at 
 this sitting. However, if distention with gas and consequent dis- 
 comfort occur, a sterile rubber tube, well covered with sterile 
 lubricant, may be gently passed into the rectum and left in situ 
 until relief is obtained. 
 
 During the week succeeding the operation, the diet should be 
 restricted to milk, eggs, broths and lean meats, though, of course, 
 these are not given until postoperative vomiting has ceased. 
 
 The period of confinement after the operation depends to some 
 extent upon the method of removal of the pile employed. If the 
 ligature method has been used, the patient should be kept in bed 
 until the ligatures are either absorbed or come away. When 
 granulation is established the patient may leave the bed, but care 
 in cleanliness should be exercised until repair is complete. The 
 clamp and cautery operation is regarded as necessitating confine- 
 ment for only three days. This is assumed on the ground that 
 the cautery eliminates the danger' of infection. This is probably 
 true as regards the operation itself. However, the slough sepa- 
 rates finally, and the resultant raw surface is susceptible to the 
 invasion of infection and should be treated accordingly. On the 
 whole, irrespective of the method of excision or removal of piles 
 employed, the patient should be kept quiet until granulation is 
 established and be under the care of the practitioner who employs 
 the necessary cleanliness until repair is complete. It is not im- 
 probable that the abscesses and at times fistula? which occur as 
 sequels to operations for hemorrhoids, will be, in a measure, pre- 
 vented by exercise of caution in these respects. 
 
 Infection of the wound is treated as are infected wounds else- 
 where in the body. However, it must be remembered that piles 
 are varicosities of blood-vessels which communicate quite directly 
 with the large venous trunks of the portal system, and that a 
 septic phlebitis in this situation is a menacing occurrence. Early 
 
554 OPERATIONS ON THE RECTUM AND ANUS 
 
 incision and drainage of infected area should be practiced and, 
 if necessary, this should be given the same consideration with re- 
 gard to the precautions employed in the primary operation. 
 
 A chill and sudden rise of temperature, together with the other 
 symptoms of infection, occurring several days after attack upon 
 the veins of the rectum and anus, should be followed at once by 
 dilatation of the anus and search for the offending area. If a 
 black thrombotic area is disclosed at the site of operation, free in- 
 cision, cleansing, the application of carbolic acid and the intro- 
 duction of drainage should be employed. If necessary, the pa- 
 tient should be completely narcotized and the manipulations 
 thoroughly carried out. A policy of hesitation may be followed 
 by a septic infection of the veins of the liver and death, a con- 
 tingency the writer had the misfortune to be confronted with in 
 one instance. 
 
 PROLAPSE OF RECTUM, PERINEAL PROTECTOMY, AND 
 EXCISION OF TUMORS FROM THE RECTUM 
 
 These operations all contemplate preparations for operation 
 and after-treatment, as indicated above. The special measures 
 following operations for prolapse involve elevation of the foot of 
 the bed for several days after the operation and the avoidance of 
 tenesmus. The latter is controlled by the use of anodynes, as dis- 
 cussed on page 552. 
 
 In this connection the cleansing of the rectum by return irri- 
 gation through the undilated sphincter, a measure frequently em- 
 
 Fig. 345. — Kemp Tube for Lavage of Rectum. 
 
 ployed following attack of the interior of the rectum, may be 
 taken up. For the purpose the Kemp tube is of signal service 
 (Fig. 345). The tube is lubricated and slipped into the rectum, 
 the upper metal tube is connected with the irrigating vessel and 
 the lower connected with a long rubber tube leading into a suitable 
 
PROLAPSE OF RECTUM, PERINEAL PROTECTOMY, ETC. 555 
 
 vessel (Fig. 346). In this way copious lavage of the wound may 
 be made without distention of the rectum, and consequently 
 trauma to the wound surface is obviated. The measure may be 
 
 Fig. 346. — Cleansing Rectum with Kemp Tube. Patient in Sims' 
 Position. Attendant's fingers constrict outlet tube as indications arise. 
 
 repeated several times daily, and its employment requires no 
 special skill. It is especially useful in instances where the lower 
 portion of the rectum has been subjected to operative attack, such 
 as the Whitehead operation, partial proctectomy for prolapse, 
 and removal of internal piles by the ligature method. 
 
 The flow into the rectum will be quite meager unless the in- 
 itial amount be held by the finger compressing the outlet tube. 
 The illustration, drawn for the writer by Mr. Nast from life, 
 shows how the fingers may be made to control the amount of fluid 
 permitted to remain in the rectum at one time. When the tube 
 is pinched the rectum is filled and immediate egress occurs when 
 the compression is released. 
 
CHAPTEK XXIX 
 
 OPERATIONS ON KIDNEY AND URETER 
 
 Operations on the kidney: Nephropexy; Nephrotomy; Xephreetomy — 
 Operations on the ureter. 
 
 OPERATIONS ON THE KIDNEY 
 
 Transperitoneal approach to the kidney involves the same 
 local preparation as obtains with celiotomy, and does not call for 
 repetition here (page 422). Lumbar approach is the method 
 most generally employed. The skin is prepared in the usual way, 
 and the general preparation is in all respects similar to that em- 
 ployed in major operations. Cleansing of the colon should be 
 thoroughly made with the view of obviating the annoyance of 
 having a distended colon persistently encroaching upon the opera- 
 tive field during the manipulations. A collapsed colon shows its 
 peculiar anatomical characteristics much more plainly than does 
 a distended one, the latter being attended at times with oblitera- 
 tion of the longitudinal bands. 
 
 In either instance an attempt should be made to cause the 
 urine to be in as physiological a condition as possible at the time 
 the operation is carried out. Por the purpose urotropin, methy- 
 lene blue, sodium benzoate and similar preparations may be ad- 
 ministered for several days or a week preceding the operation. 
 In cases of infected kidney some surgeons lavage the pelvis of 
 the kidney daily by means of an uretral catheter for several days 
 before the operation. This is a measure of doubtful utility, as 
 the necessary manipulations require unusual skill and, indeed, 
 even if properly performed, the trauma to the ureter while the 
 lavage is being made is exceedingly liable to cause irritation. In 
 a general way it may be said that an interval of three days should 
 be permitted to succeed instrumentation of the ureter, for any 
 purpose, before the kidney is sectioned. 
 
 556 
 
OPERATIONS OX THE KIDNEY 
 
 557 
 
 During lumbar approach to the kidney the patient is postured 
 in a manner to increase the distance between the twelfth rib and 
 the crest of the ilium. For the purpose the patient is placed on 
 the side opposite to the one attacked, and a pad or cushion placed 
 
 Fig. 347. 
 
 -Patient Postured for Approach to the Kidney by the Lumbar 
 Route, (von Bergmann.) 
 
 under the dependent loin. Fig. 347 shows the patient postured 
 in the manner stated. The operating table shown in Fig. 87 has 
 an appliance which allows of attainment of this position with a 
 device which permits of modification of degree of elevation to 
 suit the indications 
 in a given case. 
 When no such ap- 
 paratus is available 
 an air cushion (Fig. 
 348), may be advan- 
 tageously employed, 
 or a blanket rolled 
 
 on itself to the desired thickness will answer the purpose. Xarcosis 
 is not readily administered with the patient in this position, and 
 care must be exercised in this connection, so that respiration be 
 not unnecessarily interfered with. 
 
 Fig. 
 
 348. — EdeboM's Am Cushion for Posturing 
 Patient for Approach to Kidney. 
 
 NEPHROPEXY 
 
 Nephropexy is frequently called for on both sides. In these 
 cases the patient is postured in the attitude shown in Fig. 349. 
 The administration of the narcotic becomes still more difficult 
 under these circumstances, and respiration must be carefully ob- 
 served with the view of altering the position of the patient 
 at intervals, if the necessity arises. 
 
55S 
 
OPERATIONS ON THE KIDNEY 559 
 
 Following nephropexy the patient is placed in a bed with its 
 lower portion elevated six inches. This is intended to relieve 
 strain upon the retaining sutures. In some instances the wound 
 about the kidney is packed with the view of causing adherence of 
 the kidney by cicatricial contraction. In either event the position 
 stated should be maintained for a week following the operation, 
 unless some indication to the contrary present. When primary 
 union is aimed at, the dressing is not disturbed until the eighth to 
 tenth day following the operation. 
 
 If gauze packing has been employed, the pack is removed on 
 the third day following the operation and fresh gauze introduced. 
 This manipulation is repeated at intervals of forty-eight hours 
 until complete healing takes place. 
 
 A small quantity of blood is at times present in the urine fol- 
 lowing nephropexy, especially if the kidney capsule has been sec- 
 tioned and its flaps employed in the fixation. Hematuria follows 
 in instances in which the kidney capsule has not been invaded, 
 this no doubt being due to the trauma of the kidney tissue which 
 results in sufficient contusion to cause the bleeding. The symp- 
 tom is of no great import, except in instances in which the bleed- 
 ing is sufficient to form a clot and the passage of clots through the 
 ureter is accompanied by symptoms quite typical of renal colic. 
 As a rule the administration of an opiate will control the pain. 
 When kidney colic follows nephropexy diuretics had best not be 
 given in large quantity. The pressure from the urine behind the 
 clot causes much pain, and it is best to permit the clots to pass 
 into the bladder under slight pressure. When the clots reach the 
 bladder there may be some tenesmus and sudden arrest of urinary 
 discharge from the urethra, the outcome of mechanical obstruction. 
 This is usually not severe, and the bladder symptoms promptly 
 disappear when the clots are passed. Clots from the kidney are 
 usually long and narrow, and are not of sufficient size to necessi- 
 tate removal by bladder lavage. However, if the bladder symp- 
 toms persist, a copious lavage of that organ with warm boric acid 
 solution through a roomy catheter will effect removal of the of- 
 fending agents. On the whole, instrumentation of the bladder for 
 removal of clots from the kidney should be avoided if feasible, 
 as infection finds an exceedingly favorable condition of affairs 
 for development under the circumstances. 
 
560 OPERATIONS ON KIDNEY AND URETER 
 
 Patients should be confined to bed for two weeks following 
 nephropexy, at the end of which time a proper abdominal sup- 
 porter (Fig. 300) or corset (Fig. 302) should be worn for sev- 
 eral months. More especially is the wearing of supporting ap- 
 pliances indicated, as floating kidney is usually a part of a more 
 or less general enteroptosis. 
 
 NEPHROTOMY 
 
 Nephrotomy is invariably followed by drainage. When ab- 
 scess is present, tube drainage is commonly employed, and the 
 perinephritic area drained with gauze. When the operation con- 
 templates only removal of a calculus without coexisting infec- 
 tion, gauze drainage alone will suffice the indications. In the 
 former event (of abscess), the tube drain is left in situ until the 
 superficial wound is freely granulating, and the latter is cleansed 
 and repacked every alternate day until these conditions obtain. 
 In this way an avenue of exit for the discharge of infective secre- 
 tions together with the urine which does not find its way at once 
 into the normal passages is furnished, and the occurrence of the 
 infiltration of the postperitoneal tissue is obviated. If the drain- 
 age is interfered with, the secretions accumulate in the perirenal 
 tissue, infiltrate the subserous fat and the connective tissue in 
 the region of the kidney, at times invading the pelvis and point- 
 ing anteriorly over the pubis in the space of Betzius. The tube 
 drainage should not be discarded until the discharge from the 
 cavity is seropurulent or serous, when the tubes may be removed 
 and silk-worm gut or horsehair drainage (Figs. 147 and 149), 
 substituted, until final repair takes place. If for any reason re- 
 tention of inflammatory exudates occur during the after-treatment, 
 the condition is met along the lines usually employed with abscess, 
 i.e., incision and drainage. 
 
 Renal colic with its characteristic symptoms follows nephrot- 
 omy, in some cases as the result of the passage of blood clots or 
 inflammatory exudate through the ureter. Its occurrence has been 
 taken up under the head of nephropexy (page 559). Patients 
 afflicted in this way are apt to be discouraged when this occurs, 
 on the ground that they believe the object of the operation has not 
 been achieved, indeed the practitioner may conceive the same 
 notion. The discovery of blood clots in the urine will soon dis- 
 
OPERATIONS ON THE KIDNEY 561 
 
 sipate this idea. Colic is most likely to follow nephrotomy when 
 the kidney has been made the subject of attack close to or at the 
 renal pelvis. 
 
 Urinary fistula logically is more commonly a sequel to ne- 
 phrotomy than obtains with nephrectomy, although in rare in- 
 stances urinary fistula has occurred sequentially to nephrectomy 
 when the ureter has been removed low down, the urine from the 
 opposite kidney damming up in the bladder and forcing its way 
 through the stump of the ureter and into the nephrectomy wound, 
 forming an infiltrate which after discharge leaves a fistulous tract 
 opening on the skin which intermittently discharges urine. The 
 discharge of urine from the lumbar wound after nephrotomy does 
 not necessarily mean that the ureter is obstructed. It may be the 
 result of the discharge of urine into the cavity which has been 
 drained externally from the walls, which are made up of func- 
 tionating kidney parechyma. Under these circumstances the 
 urine naturally goes in the direction of least resistance, and 
 this is toward the skin. When repair of the cavity takes place, 
 the urine, in the majority of instances, takes its normal route of 
 exit through the ureter, as the drainage opening grows smaller 
 and ultimately the fistula heals. When the fistula is established, 
 the wound should be dressed once or possibly twice daily accord- 
 ing to the amount of urine discharged through the external open- 
 ing, and the skin surrounding the wound must be kept clean. 
 The contiguous skin should be coated with an ointment consist- 
 ing of sterile vaseline and aristol. This acts largely mechanically 
 and prevents irritation. 
 
 When the discharge of urine from the fistula becomes slight, 
 and, judging from the total quantity of urine passed by the nor- 
 mal route, it is a fair inference that the ureter on the sectioned 
 side is patent, tincture of iodin may be injected into the fistulous 
 tract, with the view of stimulating repair by a reactionary in- 
 flammatory proliferation of connective tissue. If there be any 
 doubt as to the reestablishment of the flow of urine into the blad- 
 der on that side, cystoscopy, after methylene blue has been given, 
 may aid in determining whether urine comes from the afflicted 
 side. 
 
 If a permanent or persistent fistula is established and the dis- 
 charge of urine from the tract is sufficient in quantity, a urinal 
 
562 
 
 OPERATIONS ON KIDNEY AND URETER 
 
 may be worn which permits the patient to go about with little in- 
 convenience (Fig. 350). The question of operative attempt to 
 reestablish the normal course of the urine or the question of ne- 
 phrectomy are not prop- 
 
 > 
 
 \ 
 
 erly discussed here. In 
 a general way, it may be 
 said that the wearing of 
 an apparatus, as indi- 
 cated, will permit the 
 patient to go about and 
 regain his general 
 health, fitting him bet- 
 ter for subsequent surgi- 
 cal manipulations. 
 
 NEPHRECTOMY 
 
 ^Nephrectomy is fol- 
 lowed by much the same 
 local treatment em- 
 ployed after nephrot- 
 omy. In the absence of 
 infection, the wound is 
 quite closed by suture 
 and drainage from its dependent portion is made. For the purpose 
 the material discussed above (page 189) is employed. The selec- 
 tion between tube, textile fabric, or capillary drainage depends 
 upon the character and magnitude of the affliction for which 
 nephrectomy is made. When suppuration is present tube drainage 
 should be employed for at least five days after the enucleation. 
 Textile fabric drainage may then be substituted, and when there 
 has been much oozing and considerable trauma to the contiguous 
 soft parts, the cigarette drain (Fig. 154) may be used. Drainage 
 with strands of silk-worm gut or horsehair may be employed when 
 the discharges become moderate in quantity. 
 
 Uremia is a menace of some import following nephrectomy. 
 It may follow nephrotomy, but is less likely to occur after the 
 latter operation than with the former, for obvious reasons. The 
 quantity of urine excreted after nephrectomy should be carefully 
 recorded, and a quantitative analysis of the proportion of solids 
 
 y *c& 
 
 Fig. 350. — Urinal Worn by Patient with 
 -Urinary Fistula. This apparatus will be 
 found serviceable irrespective of location of 
 fistula. 
 
OPERATIONS ON THE KIDNEY 563 
 
 should be made. In all cases free catharsis should be employed 
 as soon as the postoperative vomiting is controlled, with the view 
 of eliminating a portion of the end products of metabolism by 
 the bowel. As soon as it becomes manifest that the remaining; 
 kidney is not capable of eliminating the necessary amount of urea, 
 the skin should be used for the purpose by encouraging perspira- 
 tion. The patient is caused to perspire by the administration of 
 pilocarpine gr. one-sixth hypodermatically every four hours, and 
 the methods of provoking perspiration by heat should be em- 
 ployed. Dry heat is preferable to moist heat, the former being 
 better borne by the patient. Vomiting should not be discouraged 
 after it becomes manifest that the stomach is eliminating urea, 
 and the catharsis may be produced by colic lavage. 
 
 In most instances the kidney excretion is lessened after a 
 major operation of any kind, partly as the outcome of shock and 
 in part because of the narcosis. Undue meddlesomeness should 
 not be indulged in. Persistent vomiting should arouse suspicion 
 with respect to uremia. Diruetics should not be indiscriminately 
 employed. The remaining kidney is already overburdened with 
 work, and an additional tax upon it should be avoided. The gen- 
 eral principle of meeting the indication is to use the various chan- 
 nels of elimination until such time as a physiological balance is 
 established. In most instances this is soon attained, and the prog- 
 nosis, with due care in the way stated, is not particularly unfa- 
 vorable. For some considerable time the diet of the patient should 
 contemplate avoidance of large quantities of nitrogenized food, 
 with the view of lessening the labor of the remaining kidney. 
 Urinary fistula following nephrectomy is taken up above (page 
 561). 
 
 Peritonitis follows extra-peritoneal nephrectomy in some in- 
 stances ; its consequences, such as intestinal obstruction, mechan- 
 ical and otherwise, is already taken up ; its treatment is in no 
 respect different than when it is a complication subsequent to 
 celiotomy (page 451). Permanent removal of drainage agents, 
 removal of sutures, and the indications for change of dressing are 
 similar to those already taken up under the general considerations 
 of these questions. 
 
564 OPERATIONS OX KIDNEY AND URETER 
 
 OPERATIONS ON THE URETER 
 
 "When the ureter is attacked by the transperitoneal route, the 
 preparation of the patient and the after-treatment as regards the 
 part the peritoneal sac always plays in these problems, are the 
 same as obtaiii with celiotomy, and are described under that head 
 (page 422). 
 
 The extra-peritoneal method of approach is the one most com- 
 monly employed in this class of cases. 
 
 The position of the patient is that of the lateral semi-prone 
 posture, the abdomen being slightly turned toward the table. The 
 cushion or similar device employed during the approach to the 
 kidney is not of service in this connection, as it prevents the in- 
 testine from dropping forward and away from the operative field. 
 Operations involving invasion of the ureter are invariably fol- 
 lowed by drainage. The same general rules with respect to the 
 change of dressings, the kind of drainage material best suited for 
 the purpose, etc., apply in this situation as are applicable to the 
 kidney (page 560). 
 
 Urinary fistula is also taken care of in the manner stated in 
 connection with operations on the kidney. When infection al- 
 ready exists at the time of the operation, tube drainage is em- 
 ployed until the character of the discharged secretions becomes 
 serous or seropurulent. When the ureter is implanted into the 
 skin, the wound must be cleansed twice daily and the measures 
 related above assiduously carried out. 
 
 Interference with drainage and free discharge of urine will 
 stand in a causative relationship to inflammatory infiltration, 
 extravasation of urine and formation of abscess, septicemia and 
 the like as obtains from this cause in connection with operations 
 on the kidney. This may, however, be said as regards ureteral 
 obstruction, that if the kidney is functionating, arrest of the free 
 discharge of urine is followed more certainly by the complica- 
 tions mentioned than attends with attack upon the kidney in in- 
 stances where the ureter is patent. This should be borne in mind, 
 and the patency of the avenue of drainage must be carefully con- 
 served. 
 
 Grafting of the ureter into the bladder should be followed by 
 drainage of the bladder itself. Distention of the urinary blad- 
 
OPERATIONS ON THE URETER 565 
 
 der following plastic anastomosis subjects the line of suture to 
 strain, and may result in separation of the parts. For the pur- 
 pose the bladder is drained with a retention catheter (Fig. 354). 
 If lavage of the bladder is regarded as indicated during the first 
 five or six days following the operation, the measure must be 
 carefuly carried out, no more than three ounces of cleansing fluid 
 being introduced at a time, and the bladder be allowed to empty, 
 itself before additional fluid is injected. Distention of the blad- 
 der is best avoided by the return flow attachment described above 
 (page 538). However, it must be remembered that the outward 
 flow is not as rapid as that of entrance, and the same precaution 
 with regard to the quantity introduced at a time must be ob- 
 served, as attends the manipulation when only a single tube is 
 employed for the purpose. In cases of this sort the wound of 
 approach is also drained in the manner stated above, with the 
 view of taking care of any leakage which may occur. This fact 
 should, however, not engender disregard of the precautions dis- 
 cussed in connection with bladder drainage. 
 
CHAPTEE XXX 
 
 OPERATIONS ON THE BLADDER AND PROSTATE 
 
 GLAND 
 
 Operations on the bladder: Suprapubic cystotomy; Temporary suprapubic 
 drainage; Permanent suprapubic drainage following cystotomy — Perineal 
 prostatectomy. 
 
 OPERATIONS ON THE BLADDER 
 
 SUPRAPUBIC CYSTOTOMY 
 
 Suprapubic invasion of the bladder does not mean opening of 
 the peritoneal sac in the majority of instances. However, the re- 
 lationship the peritoneum bears to the space of Retzius is not by 
 any means typical, and accidental invasion of this membrane 
 may occur. Again, a certain number of operations made upon 
 the bladder contemplate peritoneal invasion. For these reasons 
 operations of this sort should be preceded by the same prepara- 
 tion, both general and local, employed for celiotomy, and the 
 Trendelenburg posture during the operation should be provided 
 for. 
 
 In addition to this, the bladder should be lavaged for several 
 days before the operation with the view of cleansing the mucosa. 
 In many instances the mucosa is already infected at the time of 
 the operative attack, and this should be treated as such for a 
 period of time as seems permissible in view of the conditions 
 present calling for operative relief. For the purpose a solution 
 of potassium permanganate, 1 in 1,000, may be employed. Uro- 
 tropin in doses of ten grains three times daily may be given for 
 several days before the oiieration, with the view of contributing 
 to the desired end. 
 
 Immediately before the operation the bladder is distended 
 with ten or twelve ounces of sterile saline solution, in order to in- 
 
 566 
 
OPERATIONS ON THE BLADDER 567 
 
 crease the extra-peritoneal area of the bladder above the pubic 
 bones. If infection be markedly present at the time of the opera- 
 tion, the bladder may be thoroughly lavaged with the potassium 
 permanganate solution just previous to section, and this replaced 
 with saline solution before the operation is begun. 
 
 TEMPORARY SUPRAPUBIC DRAINAGE 
 
 Temporary suprapubic drainage of the bladder is established 
 following opening of the bladder in this situation. This is true 
 whether the section has been made for the removal of stone, tu- 
 mors, or for prostatectomy. For the purpose the bladder wall is 
 inverted around a rubber catheter, which in turn is connected 
 with an appropriate vessel by means of a long tube. As the angle 
 at which the drainage tube enters the bladder is that of about 
 90 degrees to the body, the tube is likely to kink and become ob- 
 literated. In addition to this, the elasticity of the bent tube 
 makes tension on the sutures, objections which should be over- 
 come. For the purpose it is best to use an angular catheter (Fig. 
 351 j. The intravesical portion may be made shorter as the con- 
 
 Fig. 351. — Angular "Double Flow" Soft Catheter for Suprapubic Drainage 
 
 of Bladder. 
 
 ditions present, so that when introduced the angle of the device 
 is a little above the level of the skin. The bladder may be lavaged 
 through one tube, and the fluid flows out through the other, 
 though care must be exercised not to inject a sufficient quantity 
 of fluid to bring strain upon the sutures. 
 
 To obviate the latter contingency and, indeed, to remove 
 the objections mentioned in all respects, suprapubic drainage 
 of the bladder may be made by means of the device shown in 
 
568 OPERATIONS ON THE BLADDER AND PROSTATE GLAND 
 
 Fig. 352. The largest tube drains the bladder, and the angular at- 
 tachment, the glass tube, is connected with a longer one draining in- 
 
 Fig. 352. — Marion Soft Rubber Apparatus for Drainage and Cleansing 
 of the Bladder Following Suprapubic Prostatectomy. 
 
 to a vessel (Fig. 353). Cleansing solutions may be introduced into 
 the bladder through the small catheter, which is furnished with a 
 
 Fig. 353. — Apparatus for Drainage and Cleansing of Bladder (shown in Fig. 
 352) in situ. The cleansing fluid is injected into the smaller tube and finds ready 
 egress through the larger one. 
 
OPERATIONS ON THE BLADDER 
 
 569 
 
 wide mouth to permit of easy access of the nozzle of a syringe. 
 The large drainage tube permits of exit of the cleansing fluid so 
 readily that deleterious distention of the bladder becomes quite 
 inrpossible. Between the intervals of treatment the smaller cath- 
 eter is clamped. The question of drainage of the bladder through 
 the urethra as supplementary to suprapubic drainage may be 
 taken up here. It may be said that, as a rule, suprapubic drain- 
 age meets the indications. However, in some instances, espe- 
 cially where the bladder is severely infected, there is no objection 
 to the additional use of dependent drainage. For this purpose the 
 retention catheter shown in Figs. 354, 355 and 356 may be used 
 Fig. 354 shows the mushroom retention catheter. The enlarge- 
 
 Fig. 354. — Mushroom Retention Catheter for Drainage of the Bladder per 
 
 urethram. 
 
 ment near the tip is engaged beyond the neck of the bladder and 
 effectually prevents its expulsion. When the catheter is intro- 
 duced, the mushroom enlargement is obliterated by inserting into 
 its lumen the stylet (Fig. 355), which is curved to conform to 
 
 Fig. 355. 
 
 -Specially Constructed Stylet for Introduction of Mushroom 
 Catheter. 
 
 the shape of the ordinary steel sound. The distal end of the 
 catheter is held by the loop of the handle of the stylet and the 
 
570 OPERATIONS ON THE BLADDER AND PROSTATE OLAND 
 
 degree of tension employed is sufficient to obliterate the mush- 
 room (Fig. 356) to a sufficient extent to make insertion of the 
 catheter into the bladder an easy matter. When the stylet is with- 
 drawn, the catheter' reassumes its original form. 
 
 In these instances lavage is accomplished by washing through 
 and through in either direction, though on general principles the 
 injection should be made suprapubically and the urethral drain 
 be made to evacuate the contents of the bladder. 
 
 Fig. 356. — Mushroom Catheter Drawn Over Stylet Obliterating Distal 
 Widening to Facilitate Introduction Into Bladder. 
 
 Following the removal of neoplasms, foreign bodies or stone, 
 drainage need not be employed for more than six days. At the 
 end of this time the tube is removed and the bladder catheterized, 
 at first every six hours and later every eight hours. Before each 
 catheterization the patient is instructed to attempt to void spon- 
 taneously the urine, and failing in this the catheter is used. In 
 all instances, even though spontaneous discharge of urine occur, 
 the bladder should be catheterized and lavaged once daily until 
 all evidence of inflammatory exudate disappears. Prolonged 
 drainage of the bladder results in lack of control of the function 
 of urination, and this should be obviated in the manner stated. 
 The valvular arrangement of the bladder wall surrounding the 
 catheter is regarded as preventing leakage when the suprapubic 
 drain is removed. Unfortunately this does not obtain in all in- 
 stances. While leakage does not always occur when the patient 
 is quiescent, efforts at urination are usually attended with the 
 discharge of a certain amount of urine through the suprapubic 
 wound. When the patient attempts to pass the urine by way of 
 the urethra, the wound should be exposed and the patient pos- 
 tured on the bed pan or similar device. The urine which leaks 
 from the wound is thus discharged into a proper receptacle, rather 
 than allowed to saturate the dressing. The wound is cleansed 
 and redressed subsequent to each urination until leakage no 
 longer occurs. In this way infiltration of the tissues contiguous 
 to the wound is avoided and secondary infection is also obviated. 
 
OPERATIONS ON THE BLADDER 
 
 571 
 
 The superficial suprapubic wound is usually approximated 
 with silk-worm gut sutures, and these are left in situ for ten days, 
 unless infection of the cellular tissue beneath require their earlier 
 removal. If this occurs, the lower sutures may be removed, drain- 
 age established, and the wound lightly packed with gauze. The 
 upper sutures, i.e., those above the point of exit of the bladder 
 drain, do not usually require removal, and their maintenance in 
 place contributes much to the ultimate comj)lete repair. 
 
 Following suprapubic prostatectomy the drainage is left in 
 place as long as there is any foul urine. In some instances this 
 requires weeks of time. The cleansing of the site of removal of 
 the gland is quite essential, and should be made several times daily. 
 Small areas of tissue frequently undergo sloughing at the site of 
 the deep wound, and their removal is much facilitated by the em- 
 ployment of the apparatus shown in Fig. 352. Patients who have 
 been subjected to suprapubic removal of the prostate gland are not 
 kept in bed longer than 
 the time required for re- 
 covery from the narcosis, 
 but are placed in the sit- 
 ting position at this time. 
 The care of the intra- 
 vesical portion of the g 
 
 drainage apparatus is \\ 
 
 taken up more largely -v5 — -• 
 
 under perineal prosta- 
 tectomy (page 573). 
 
 PERMANENT SUPRAPUBIC 
 DRAINAGE FOLLOWING 
 CYSTOTOMY 
 
 This measure is em- I j 
 
 ployed in instances 
 where there is an im- 
 permeable obstruction to 
 the egress of urine or in ''■"''■•■• l - ; -. i .-:ij 
 
 cases of uncontrollable Fig. 357. — Permanent Suprapubic Drainage 
 
 CVStitis after drainage for Jure A, Plate fitting against abdomen; 
 
 J ° B, Plate to go inside belt; C, Rubber tube into 
 
 Several days has been bladder; D, Rubber tube to urinal. (Keyes.) 
 
572 OPERATIONS ON THE BLADDER AND PROSTATE GLAND 
 
 made, as described under 
 temporary bladder drainage. 
 The apparatus found most 
 useful in these cases is 
 shown in Figs. 357 and 358. 
 Fig. 357 shows a lateral 
 view of the appliance. 
 
 It is made of silver and 
 hard rubber. The tube must 
 be of sufficient caliber to 
 carry off thick mucus and 
 clots. A short rubber drain- 
 age tube is slipped over the 
 exteremity A, and this is in- 
 troduced through the fistula 
 into the bladder. The tube is 
 held in place by a home-made 
 washable belt passing outside 
 the smaller disk (not between 
 the two), and tight enough to 
 press the inner disk firmly 
 against the skin, so that no urine can es- 
 cape outside of the tube. Continuous 
 drainage may be maintained by attaching 
 the outer side of the tube to a leg urinal 
 (Fig. 359). If the bladder will toler- 
 ate a little fluid, it is more convenient 
 to cork the tube and allow " hypogas- 
 tric urination " at stated intervals. 
 (Keyes.) 
 
 
 Fig. 358. — Front View of Apparatus for 
 Permanent Sltprapubic Drainage of 
 Bladder. '(Keyes.) 
 
 through 
 
 If the measure is used for cystitis 
 and through, lavage can be 
 practiced by the introduction of a 
 catheter through the uretha. Lavage 
 may be made through the suprapubic 
 opening. The rubber tube within the 
 bladder must be changed every twenty- Fi g. 359. — Leg Urinal Used in 
 
 xi it 1 , • Conjunction with Perma- 
 
 tour hours and a clean one substi- _ T a t. 
 
 nent Suprapubic Drain- 
 
 tuted. The fistula itself, together with age Apparatus. {Kexjes.) 
 
PERINEAL PROSTATECTOMY 573 
 
 the surrounding skin, should be cleansed daily, at the time the 
 intravesical portion of the drainage apparatus is changed. For the 
 purpose a mild solution of potassium permanganate or similar 
 preparation may be employed. The skin surrounding the wound 
 may be dusted with an antiseptic powder. Those devoid of odor 
 are, of course, to be used for obvious reasons. If at any time the 
 use of the apparatus is no longer necessary, the fistula heals very 
 rapidly. 
 
 PERINEAL PROSTATECTOMY 
 
 The preparation of the patient for perineal prostatectomy 
 should contemplate cleansing of the bladder for several days be- 
 fore the operation. Sufficient enlargement of the prostate gland 
 to justify its removal also causes retention of residual urine, de- 
 composition of the urine and infection of the bladder. The pro- 
 tracted use of the catheter, as has, indeed, usually preceded the 
 attempt at operative relief, together with the factors mentioned, 
 produce a condition of chronic inflammation in the bladder mu- 
 cosa which makes sterilization of this membrane practically im- 
 possible. However, persistent lavage, such as is described in con- 
 nection with the care of postoperative cystitis (page 537), will 
 lessen markedly the degree of infection, and is a measure well 
 worth employment, provided the condition of the patient warrant 
 the delay. Cleansing of the bladder preliminary to its invasion 
 has already been taken up (page 566). The measure is perhaps 
 of greater necessity in connection with enucleation of the pros- 
 tate gland than obtains in any other condition. The administra- 
 tion of urinary antiseptics, such as urotropin, is usually em- 
 ployed by the practitioner for a considerable period of time 
 before the case is subjected to operative attack. However, an 
 increase of dosage for several days before the operation is at 
 times advisable. 
 
 Prostatic hypertrophy is essentially an affliction of advanced 
 life. The precautions taken up under general considerations 
 should be applied in this class of cases. Albuminuria, diabetes, 
 arterial sclerosis and cardiac disease all call for sj)ecial manage- 
 ment in this connection. The administration of. the potassium 
 iodid for a week before the operation, under the restrictions al- 
 ready stated, is a measure of seeming utility. 
 
574 OPERATIONS ON THE BLADDER AND PROSTATE GLAND 
 
 The local preparation of the perineum is already taken up 
 (page 548). Cleansing of the rectum, too, should receive special 
 attention. It is not infrequently necessary to introduce the finger 
 into the rectum during the operative manipulations, and this or- 
 gan should be cleansed and the precautions with respect to avoid- 
 ing the presence of liquids in the rectum, previously stated, 
 should be taken (page 549). At times it is necessary to section 
 the abdomen during the operation. Therefore the pubis should 
 be shaved and, indeed, the abdominal wall cleansed as for celi- 
 otomy. 
 
 Fig. 3G0. — Patient in Exaggerated Lithotomy Position. {Bryant.) 
 
 The position of the patient during the operation is an im- 
 portant factor with respect to the accessibility of the parts. It 
 has been found most expedient to posture the patient in the ex- 
 aggerated lithotomy position (Fig. 360). The leg-holders usu- 
 ally employed during operations in this region are dispensed 
 
PERINEAL PROSTATECTOMY 
 
 575 
 
 with, and the lower limbs are held in the position indicated in 
 the illustration, either by the assistants or. by means of a folded 
 sheet or similar device which draws the knees toward the thorax. 
 The pressure of the limbs against the chest and abdomen inter- 
 feres with respiration, and it is at intervals necessary to lower 
 the thighs to afford relief. It would seem expedient not to fasten 
 the legs firmly in the position mentioned, but to have them held 
 by assistants, so that the necessary modification of attitude may 
 be promptly attained. It is to be borne in mind that narcosis is, 
 at best, not well borne by elderly persons, and that difficulties in 
 this connection are likely to suddenly arise. 
 
 When the enucleation is completed, drainage is provided for in 
 all instances. When the section has been made in the median 
 line, the tube drain is surrounded by an umbrella or chemise 
 
 Fig. 361. — Chemise Cannula. (Bryant.) 
 
 packing. Fig. 361 shows a cannula which is very useful for the 
 
 purpose, the openings at the distal end being used to fasten tapes 
 
 which are tied about the body. However, an ordinary catheter 
 
 arranged in the way 
 
 shown in Fig. 362 will 
 
 answer the purpose 
 
 very well, or the 
 
 "mushroom" retention 
 
 catheter (Fig. 354) 
 
 may be used. The 
 
 drain is inserted into 
 
 the perineal wound to 
 
 the desired extent, and the " chemise " is packed with strips of 
 
 gauze in much the same manner as is done in connection with the 
 
 Mikulicz tamponade. When the crescentric approach to the gland 
 
 is employed, the drain is brought out at the side of the wound 
 
 Fig. 3G2. — Chemise Catheter. (Bryant.) 
 
576 OPERATIONS ON THE BLADDER AND PROSTATE GLAND 
 
 (Fig. 363). In either instance the drain is connected with a long 
 rubber tube by means of a glass connection and the latter is led 
 into a vessel. 
 
 The bladder is lavaged twice daily, employing a solution of 
 
 Fig. 363. 
 
 -Lateral Drainage or Bladder after Crescentric 
 Approach to Prostate Gland. 
 
 potassium permanganate, 1 in 1,000, for the purpose. Carbolic 
 acid or corrosive sublimate should not be used except that, per- 
 haps, in cases of severe infection the former may be used at con- 
 siderable intervals, and only in moderate strength (1 in 250). 
 The packing should be removed at the end of forty-eight hours 
 and is not renewed, being only employed with the view of con- 
 trolling bleeding. When the crescentric approach is made, packing 
 is usually not introduced. The drain is affixed to the edge of the 
 wound by a catgut stitch, and the wound closed with interrupted 
 silk-worm gut sutures. Most surgeons of wide experience place 
 the patient in the sitting posture as soon as the effects of the nar- 
 cosis have disappeared. This would seem rational in view of 
 the fact that drainage is best conserved in this way and, also, that 
 
PERINEAL PROSTATECTOMY 577 
 
 elderly persons develop very readily a low grade of pneumonia 
 when confined to bed. It must be borne in mind, however, that 
 persons advanced in life are likely to be afflicted with changes in 
 the cardiac muscular fiber, and that the shock of so severe a meas- 
 ure as prostatectomy is liable to be considerable. The pulse rate, 
 respiration and general appearance of the patient must be taken 
 into account before the mechanical factors in the problem are 
 given precedence. The patient had best be supported by pillows, 
 and the position carefully changed without any exertion on part 
 of the patient for two days following the operation, and the ef- 
 fect of a change of posture upon the pulse-rate noted with the 
 view of being guided as to the propriety of allowing of additional 
 effort. The tube is left in situ for a week, that is, perineal drain- 
 age of the bladder is maintained for that period of time, the tube 
 being removed once daily and a sterile one inserted in its place. 
 Some surgeons remove the perineal drain at the end of forty-eight 
 hours, believing that all necessary egress of urine or inflamma- 
 tory exudate will occur through the wound, and that the retention 
 of tube drainage in the neck of the bladder for a protracted period 
 of time lengthens the time before voluntary control of micturition 
 obtains. The latter proposition is, of course, true. However, on 
 the whole, it is best to drain the bladder until the danger of in- 
 fection and infiltration of the tissues of the perineum is past. 
 If the tube is removed early, the bladder must be catheterized 
 twice daily through the perineal wound. There are some cases in 
 which tenesmus is so marked that retention of the drain is im- 
 practicable despite the administration of antispasmodics, and in 
 these instances the measure just mentioned becomes imperative. 
 
 After the immediate symptoms following the operation have 
 disappeared the patient should be postured on the side of the bed 
 with a Kelly pad (Fig. 13) under the buttocks in a good light 
 and the bladder thoroughly lavaged, a clean tube introduced, and a 
 fresh dressing applied. This measure should be thoroughly and 
 carefully carried out once daily. As soon as the patient is able 
 to be about, the measure may be carried out on the table and, in- 
 deed, this is advisable, giving as it does a condition of affairs 
 which conserves thoroughness. At the end of a week a full-sized 
 sound is passed into the bladder, per urethram, and the drainage 
 in the perineum is abolished. The perineal wound is now lightly 
 
578 OPERATIONS ON THE BLADDER AND PROSTATE GLAND 
 
 packed with, gauze, held in place by means of a T-bandage. The 
 patient is instructed to make an effort to pass the urine sponta- 
 neously every three hours, irrespective of whether he has any de- 
 sire to do so or not. This may obviate retention of urine, the 
 outcome of distention of a diseased bladder. The urine, of course, 
 escapes by way of the perineum, and so the patient must mictu- 
 rate while seated over a proper receptacle. Also, the urine leak- 
 ing into the gauze causes the perineal wound to be irritated and 
 the latter must be cleansed twice daily. 
 
 At first most of the urine is passed through the perineal 
 wound, but gradually a little, and later more and more, of the 
 urine passes by way of the urethra, and ultimately the perineal 
 wound closes and all the urine passes the natural way. During 
 all this time close attention must be paid to cleanliness, both 
 of the perineal wound and the bladder. Cystitis, the outcome of 
 prostatic disease, rarely disappears entirely, a small quantity of 
 pus being found in the urine after the most successful cases. This 
 does not mean that instrumentation and lavage of the bladder and 
 urethra should be carried on indefinitely. On the contrary, the 
 less instrumentation of the parts there be after prostatectomy the 
 better. It may be said that small quantities of pus and no clini- 
 cal evidence of cystitis is best not meddled with. 
 
 On the other hand, cystitis with frequency of urination and 
 tenesmus persists after prostatectomy for a considerable period 
 of time in a certain number of cases, and this condition should be 
 treated in the way cystitis is treated generally. Urinary anti- 
 septics, such as urotropin, may be given for a long time following 
 the operation. A plan worth following is to administer five grains 
 of urotropin three times daily for a week, and then intermit the 
 medication for a week, soon after convalescence is established. 
 Later on an occasional use of an urinary antiseptic may be in- 
 dulged in. 
 
 The passage of sounds is employed every five days until the 
 perineal wound is closed, after which a sound is passed every two 
 weeks for three months. Later than this the passage of a sound 
 is not employed, except for special reasons. A chemical and 
 microscopical examination of the urine should be made every 
 month. 
 
CHAPTER XXXI 
 OPERATIONS ON THE SCROTUM AND PENIS 
 
 Hydrocele — Castration — Varicocele — Circumcision — Plastic operations on the 
 penis — Urethrotomy for stricture. 
 
 HYDROCELE 
 
 Hydrocele, if treated by the open method with suture of the 
 edges of the sac to the skin and subsequent packing of the cavity, 
 contemplates obliteration of the tunica by granulation repair. 
 Fig. 364 shows the appearance of 
 the parts after operation. The orig- 
 inal packing is left in place for two 
 days, when it is removed, the cavity 
 irrigated with a corrosive sublimate 
 solution, 1 in 2,000, and the packing 
 renewed. This procedure must be 
 repeated at intervals of forty-eight 
 hours until healing by granulation, 
 from within outward, is accom- 
 plished. The sutures, if they be 
 of a non-absorbable material (which 
 is preferable), are removed on the 
 tenth day following the operation. 
 The patient need not be confined to 
 bed after the fourth day following 
 the operation, and may be permitted 
 
 to go about with the dressing held in place by means of an ordi- 
 nary suspensory bandage after the sutures are removed (the tenth 
 day). Complete healing does not usually occur until three 
 weeks after the operation. If the hydrocele be entirely ex- 
 cised, the wound is treated in all respects similarly to 
 wounds in other portions of the body where primary union is 
 39 579 
 
 Fig. 364. — A ppearance of 
 Wound after Incision for 
 Hydrocele (Volkmann's 
 Method). (Bryant.) 
 
580 OPERATIONS ON THE SCROTUM AND PENIS 
 
 aimed at. It is worth bearing in mind, however, that the dartos 
 is liable to undergo considerable modification of area, the result 
 of its contractility, and that undue strain upon the suture line for 
 four days after the operation is to be prevented. For this reason 
 the patient should be confined to bed for four days after the opera- 
 tion, as is advised in connection with the open operation, and 
 should not be permitted to go about until after the sutures are re- 
 moved, which in this instance may be done on the tenth day fol- 
 lowing the operation. If infection occur, the wound is treated by 
 drainage and light packing, as is described in connection with the 
 care of infected wounds generally (page 305). 
 
 CASTRATION 
 
 Castration, if done for malignant disease, is followed by com- 
 plete closure of the wound of approach and subsequent local care 
 similar to that of relief of hydrocele by the excision method. 
 Oozing and arterial bleeding at times follow the operation, dis- 
 tending the scrotum in the manner described under varicocele. 
 The complication is met by reopening of the wound and ligature 
 of the bleeding point or points. The time of removal of sutures 
 and the length of time of confinement is similar to that applied 
 to hydrocele. The operation of double castration, unless per- 
 formed late in life (how late is difficult to say), is followed by a 
 mental depression which calls for the exercise of considerable tact, 
 and perhaps justifiable deceit with regard to the sexual function. 
 
 VARICOCELE 
 
 Varicocele presents much the same problem with respect to 
 after-treatment as obtains in the conditions just discussed. As a 
 rule, the wound is entirely closed without drainage. It is, how- 
 ever, wise to permit a small drain to remain in the inferior angle 
 of the wound for several days after the operation, in order to give 
 opportunity for the discharge of blood, the outcome of a recur- 
 rence of oozing, which is not, in all cases, apparent at the time 
 of the operation. Tor the purpose a few strands of silk-worm 
 gut may be used (Fig. 147), which are removed on the third day 
 following the operation. When drainage is omitted, the tunica 
 
VARICOCELE 581 
 
 becomes distended with blood, which at times causes the formation 
 of a large tumor, and an infiltration of the subcutaneous tissue 
 upon the abdomen over the penis and down the thigh. When the 
 bleeding persists, the distention extends into the inguinal canal, 
 making pressure on the cord and testicle which gives rise to con- 
 siderable pain. Fig. 365 shows a case of this sort. The patient 
 
 Fig. 365. — Infiltration of Tunica, Scrotum and Penis with Blood following 
 Operation for Relief of Varicocele. 
 
 had an unusually extensive venous dilatation, the operative pro- 
 cedure involving considerable trauma to the adjacent tissues in 
 order to accomplish the purpose. The wound was reopened, the 
 clots removed, and drainage established. The case illustrated the 
 lessened coagulability of the blood, as the patient had just re- 
 covered from an attack of jaundice due to gastroduodonitis. 
 There was a considerable amount of oozing for some days after 
 the operation, and convalescence was exceedingly protracted. 
 
 Reopening of the wound and removal of the blood should not 
 be postponed too long, as in some instances pressure, necrosis, and 
 sloughing of the testicle have occurred as the outcome of delay. 
 
 After the wound has been reopened, the local conditions are 
 exceedingly favorable to the invasion of infection. Great care 
 should be exercised to obviate this occurrence. The contiguity of 
 the wound to the penis makes it difficult to maintain dry asepsis, 
 and for this reason a wet dressing of carbolic acid, 1 in 200, in 
 sterile water should be applied. However, this should be kept in 
 
582 
 
 OPERATIONS ON THE SCROTUM AND PENIS 
 
 contact with the wound only during the day, and be replaced with 
 a sterile dressing during the night, to obviate the sloughing and 
 maceration of the skin consequent to the prolonged application of 
 carbolic acid. The wound should be scrutinized daily, and any 
 accumulation of secretion carefully and gently expressed from the 
 scrotum. The patient must be kept confined until granulation is 
 well established. 
 
 CIRCUMCISION 
 
 As circumcision is usually done under local anesthesia, the 
 tissues are infiltrated and distended, and should for this reason 
 be apposed with sutures that do not cause tension. Horsehair or 
 fine silk-worm gut are most serviceable for the purpose. The 
 penis is dressed by loosely applying very soft gauze, which is 
 wound about the penis and held in place with a T-bandage, the 
 
 gauze being fastened to 
 the later by means of 
 a safety pin (Fig. 
 366). The operation 
 is usually followed by 
 an edema of the stump 
 of the prepuce, which, 
 however, need cause no 
 alarm and subsides 
 spontaneously in a few 
 days. The tissues, 
 both the mucosa and 
 skin, are exceedingly 
 thin, and the sutures 
 usually cut out at the 
 end of a week. If, 
 however, the sutures 
 remain at the end of 
 ten days they should 
 be removed. 
 The gauze should be renewed after each urination. At the 
 end of five days following the operation, the edema will have dis- 
 appeared and the line of union may then be covered with an oint- 
 
 Fig. 366. — Dressing after Circumcision. 
 
PLASTIC OPERATIONS ON THE PENIS 583 
 
 ment of aristol and sterile vaselin and the clothing protected by 
 wearing an apron made of a square of gauze fastened about the 
 waist with tapes, the gauze draping down over the genitals. 
 
 The glans will be found to be quite sensitive to contact for 
 some days following the removal of the prepuce, especially if it 
 has been left intact until adult life. This may be overcome by 
 frequent lavage of the glans with cleansing fluids to which a 
 small portion of tannic acid is added. At the end of a few weeks 
 the mucosa of the glans takes on more the characteristics of skin 
 and the sensitiveness disappears. The dressings should at all 
 times be so loose as not to compress the penis during erection. 
 
 PLASTIC OPERATIONS ON THE PENIS 
 
 Plastic operations on the penis for epispadius and hypospadius 
 depend largely as regards favorable outcome upon care in the 
 after-treatment. The urine should be made as aseptic as possible 
 with the view of avoiding infection in the event of infiltration of 
 the wound areas. For this purpose urotropin should be adminis- 
 tered for several days before and for a week following the opera- 
 tion. Bryant regards leaving a retention catheter in the urethra 
 as less useful with respect to the avoidance of infection, and be- 
 lieves that the presence of the instrument is irritating. He in- 
 jects into the urethra a small amount of sterile oil after each al- 
 ternate urination, and has found the procedure very satisfactory. 
 Repeated introduction of instruments into the urethra should be 
 avoided if feasible. A few strands of silk-worm gut introduced 
 into the opening and replaced after each urination is good prac- 
 tice. Care must be exercised in the manipulation to avoid infec- 
 tion. The occurrence of infection in any of the suture holes should 
 be attended with immediate withdrawal of the suture. 
 
 The occurrence of erections during the healing is productive of 
 failure of the intent. Pressure upon the vesicula) seminales from 
 distention of the bladder may be prevented by causing the pa- 
 tient to empty the bladder every four hours night and day. The 
 physiological erection due to a full bladder is thus obviated in 
 most instances. The application of cold, sterile, wet dressings 
 during the day and keeping the bladder empty at night is service- 
 able, though the execution of these measures is somewhat tedious. 
 
584 OPERATIONS OX THE SCROTUM AND PENIS 
 
 Nevertheless the precautions in this connection need not be car- 
 ried out for more than five or six days, a minor consideration in 
 comparison to the intent. Bromids may be given during this 
 time. A mixture of sodium bromid, thirty grains, and a quarter 
 of a grain of codein given every three hours seems to be of use. 
 The administration of this combination need not be employed for 
 more than three or four days. An intelligent attendant who wakes 
 up the patient every three hours during the night and causes him 
 to empty the bladder, and who redresses the parts as stated, will 
 contribute much to a favorable ultimate outcome. It seems hardly 
 necessary to state that the attendant had best be of the male 
 sex. 
 
 The sutures should be retained in place for ten days. Non- 
 absorbable sutures are preferable in this class of cases, as, indeed, 
 is the case in all plastic work. For the purpose, horsehair, which 
 may be introduced with very slender needles, is the suture mate- 
 rial of choice in operating in this class of cases. 
 
 URETHROTOMY FOR STRICTURE 
 
 -Urethrotomy for stricture should be prepared for in much the 
 same manner as is done preliminary to operations on the bladder 
 and prostate. Stricture of the urethra is most commonly a sequel 
 to gonorrheal inflammation of the urethral mucosa with the glan- 
 dular elements of this membrane, the habitat of the diplococcus of 
 Neisser. Tor this reason it is well to precede the sectioning 
 of the urethra with local treatment for some weeks before the 
 operation if this be feasible. Tor the purpose the patient visits 
 daily the practitioner, who irrigates the urethra with a solution 
 of protargol, 1 in 200, by the Janet-Chetwood method, thoroughly 
 ballooning up the urethra at each sitting, in order to distend the 
 rugae into which the normal urethra is thrown, and destroying to 
 a certain extent at least the gonococcus. This procedure is em- 
 ployed each alternate day, and upon the day between the urethra is 
 lavaged with a solution of 1 in 5,000 corrosive sublimate. The 
 latter step is employed with the view of destroying any mixed 
 infection of purulent character. 
 
 The Janet-Chetwood method of cleansing the urethra is em- 
 ployed as follows : 
 
URETHROTOMY FOR STRICTURE 
 
 585 
 
 The proper employment of the 
 treatment requires a receptacle of glass 
 or a fountain syringe, hung upon a 
 hook, which latter, suspended over a pul- 
 ley, may be raised or lowered at will, 
 to vary the pressure of the column of 
 fluid; a conical glass, two-way nozzle 
 (Fig. 367) ; some small, soft-rubber 
 catheters (8 to 12 French) with care- 
 fully beveled eyes and the scissors-like 
 shut-off (Fig. 368). 
 
 T h e alternating shut-off instru- 
 ment clasps the rubber tubes attached 
 to the nozzle, and by a scissors-like mo- 
 tion controls the inflow and the out- 
 flow alternately (Fig. 369), impeding 
 the outflow as the fluid enters the ure- 
 thra, and thus securing an even dis- 
 tention of the canal (Fig. 370), arrest- 
 ing the inflow when the urethra is full, 
 thus allowing the canal to evacuate it- 
 self entirely. A proper distention of 
 the urethra is secured by raising the 
 reservoir 4 or o feet. Such elevation will not force the membranous 
 
 urethra, and what pressure 
 there is may be moderated 
 in case of pain by partially 
 closing the inflow tube. 
 
 The advantages of the 
 alternating shut-off are ob- 
 vious. Both cleanliness 
 and effective distention of 
 the urethra are better se- 
 cured by it than by other 
 means. If a one-way noz- 
 zle is used, the urethra 
 may be properly distended, 
 but in order to effect irri- 
 gation this nozzle must be 
 constantly withdrawn and 
 
 Fig. 368. — Chetwood's Scissors Shut Off, Used . , -.. . 
 
 to Control Flow of Cleansing Fluids reinserted— a dirty expe< 1 1- 
 
 used in the Urethra. (Keyes.) ent. If a catheter is in- 
 
 Fig. 367. — Chetwood's Two-way 
 Urethral Nozzles. The vari- 
 ous sizes are used with respect 
 to caliber of the urethral meatus. 
 (Keyes.) 
 
586 
 
 OPERATIONS ON THE SCROTUM AND PENIS 
 
 Fig. 369. — Chetwood's Irrigator. Filling 
 the tube with fluid before applying it to 
 the urethral meatus. (Keyes.) 
 
 troduced to the bulb for the 
 anterior irrigation (retro-ir- 
 rigation), the urethra is not 
 properly distended, and many 
 gonococci in the sinuses and 
 the urethral folds escape. 
 
 About one quart of liquid 
 is needed for efficient anterior 
 irrigation, the time required 
 being about five minutes. 
 
 If the surgeon prefers, he 
 may irrigate the posterior 
 uretha with this apparatus, 
 simply raising the reservoir; 
 but it is better, after having 
 first thoroughl}' irrigated the 
 
 anterior urethra, to use a catheter for posterior work. 
 
 For this purpose a soft-rubber catheter, with perfectly beveled eye, 
 
 is used. The size of the catheter 
 
 should be from 12 to 15 French. 
 
 It must be anointed with a lubri- 
 cant that will dissolve in water. 
 
 Vaselin or oil will not suffice. A 
 
 saponaceous lubricant or that made 
 
 with Irish moss and called lubri- 
 
 chondrin is entirely suitable. The 
 
 catheter must be introduced slowly 
 
 and with the utmost gentleness, eye 
 
 upward, until urine flows, showing 
 
 that the bladder has been reached. 
 
 The bladder is now emptied 
 
 through the catheter and then the 
 
 latter is withdrawn a full inch, so 
 
 that its eye may lie just behind the 
 
 membranous urethra. Now from 
 
 the irrigator from 4 to 12 ounces 
 
 of fluid, according to the tolerance 
 
 of the bladder, are thrown in, wash- 
 ing backward in its course the en- 
 tire prostatic sinus, after which the catheter is gently withdrawn. 
 The patient now urinates out the contents of his bladder, thus 
 
 giving himself a very efficient final retrojection. (Keyes.) 
 
 Fig. 370. — Chetwood's Irrigator. The 
 fluid entering the urethra. (Keyes.) 
 
URETHROTOMY FOR STRICTURE 587 
 
 In addition to this the patient should be given large quantities 
 of water for several days before the operation, with the view of 
 mechanically cleansing the urinary passages. 
 
 When an external urethrotomy is made, the precautions men- 
 tioned are all carried out, and the bladder is drained as is de- 
 scribed under Perineal Prostatectomy (page 573). Sectioning of 
 the urethra for stricture is, in a large number of instances, fol- 
 lowed by a chill and rise of temperature which is transient and 
 diseappears so rapidly that it is difficult to conceive the systemic 
 disturbance as being due to sepsis. There is, perhaps, a peculiar 
 relationship between trauma to the urethra and the toxemia which 
 follows it. However, the fact that when cases are prepared in the 
 manner stated the chill and rise of temperature does not, as a rule, 
 obtain would suggest that there is some connection in this regard. 
 For this reason a careful preparatory treatment along the lines 
 mentioned is urged. 
 
 When the operation is completed, the patient is placed in bed 
 and artificial heat is applied in the manner described under Shock 
 (page 227). As a routine thing a colic lavage of saline solution 
 at a temperature of 110° P. is given at once, and this is repeated 
 in six hours, irrespective of the occurrence of chill. Whether the 
 presence of blood clots in the anterior urethra in cases of internal 
 urethrotomy, or in a bladder after deep urethrotomy, has any- 
 thing to do with the so-called urethral fever or not, it is, of course, 
 difficult to say. However, this much is true, that febrile move- 
 ment occurs less frequently as a complication later on (the second 
 day), if the bladder drainage be perfect and the anterior urethra 
 is lavaged with saline solution every twelve hours after the opera- 
 tion. The question of whether sectioning of the urethra liberates 
 into freshly traumatized tissue a certain number of bacteria 
 which have been relatively isolated by protective exudates is also 
 not quite clear. However, cleanliness and drainage, as indicated, 
 seem rational procedures, and may be regarded as preventive meas- 
 ures in this connection. The drain in the bladder is removed on 
 the fourth day after the operation, and the umbrella packing is 
 changed every twenty-four hours until this time. Following re- 
 moval of the bladder drain the wound is dressed with gauze held 
 in place with a T-bandage (Pig. 344). Urination now takes 
 place for the most part through the perinea] opening. The 
 
588 OPERATIONS ON THE SCROTUM AND PENIS 
 
 wound is cleansed after each time the bladder is emptied and fresh 
 gauze applied, the patient assuming the sitting posture while 
 voiding. On the sixth day following the operation the anterior 
 urethra is thoroughly cleansed by injecting through it a solution 
 of protargol, 1 in 200, in the manner described above, and a full- 
 sized steel sound is passed into the bladder. As the sound is 
 likely to emerge through the perineal opening, the latter is 
 closed with a gauze pad firmly pressed against the wound, and the 
 instrument carefully pushed beyond it. Should the introduction 
 of the sound be impracticable, it is removed after dilating the 
 urethra to the perineal wound, and reintroduced into the latter and 
 made to enter the bladder. During this time urinary asepsis is 
 to be maintained, as not infrequently a chill and its attendant 
 disturbances obtain subsequent to the passage of the sound. In- 
 deed, this contingency may occur at any time until the healing 
 is complete. 
 
 Daily instrumentation is to be avoided. Persistent cleanli- 
 ness is essential. However, the passage of a sound need not be 
 executed oftener than every four days. This instrumentation is 
 carried on until the wounds are healed, is then done every eight 
 days for six or seven weeks, every two weeks for three months, 
 once a month for six months, and from then on the patient should 
 have a full-sized sound passed every two months for a year or 
 more. A favorable outcome is absolutely dependent upon keep- 
 ing the canal properly dilated as stated. Eecurrence of stricture 
 will thus be avoided. 
 
CHAPTEK XXXII 
 OPERATIONS ON THE EXTREMITIES 
 
 Dupuytren's contraction — Hallux valgus — Flat-foot — Club-foot — Osteotomy — 
 Resection and excision of joints — Amputations. 
 
 Operations on the extremities involve the problem of locomo- 
 tion as far as the lower limbs are concerned, and the ability to 
 perform manual labor or the indulgence in voluntary volitional 
 action necessary to life and comfort as concerns the upper ex- 
 tremities. For these reasons the occurrence of postoperative 
 complications following operations upon these parts should be 
 carefully guarded against. Infection with its baneful sequels, 
 deformity and loss of function and impairment of the range of 
 motion of joints, the outcome of ankylosis, are in a measure con- 
 trollable by strict adherence to asepsis as far as the former is con- 
 cerned, and by intelligently employed massage, passive and active 
 motion, as far as. the latter is concerned. Operations with the 
 view of correcting deformity do not achieve the object unless the 
 subsequent treatment and management of the case be properly 
 carried out. 
 
 DUPUYTREN'S CONTRACTION 
 
 Dupuytren's contraction after the fascial contractures have 
 been divided will recur, unless complete repair has taken place 
 with the parts in the corrected position. The wound is dressed 
 in the usual manner, and the fingers held in position by either a 
 palmar or dorsal splint. As the pressure due to the stretching of 
 the skin of the palm, of itself, is liable to cause sloughing, it is 
 best to apply the splint to the dorsal aspect of the hand and band- 
 age the parts to it. Fig. 371 shows a splint which is quite useful 
 for the purpose. A pad of gauze is placed over the palm and the 
 fingers bandaged to separate portions of the splint. The wrist is 
 
 589 
 
590 OPERATIONS ON THE EXTREMITIES 
 
 also encircled with gauze and the splint applied over this. The 
 splint may consist of shellac, or soft wood, or sole-leather, or 
 malleable "tin, the latter having the advantage of permitting of 
 modification of the' degree of extension used. 
 
 Fig. 371. — Dupuytren's Contraction. Splint for Maintaining Complete Exten- 
 sion after Operation. The splint is made of malleable tin and can be bent 
 slightly upward in order to over-correct the deformity. (Cheyne.) 
 
 At first the fingers are placed in the position of over-exten- 
 sion, though this is not at all times well borne by the patient. In 
 the event of the over-corrected position being painful, or if the 
 skin of the palm shows any signs of undue pressure, the splint 
 may be bent to accord with less forcible extension. For this 
 reason the splint is best made of material which will permit of 
 these manipulations. The wound is treated as are wounds in 
 other situations. The correcting splint is worn night and day for 
 three or four weeks. Later a splint which has prolongations 
 which confine only the affected fingers is worn, thus allowing of 
 a certain use of the member. At the end of six weeks the splint 
 is worn only at night, though its noturnal application should be 
 maintained for six months. When the splint is removed during 
 the day, the hand is subjected to massage and kneading, the part 
 being covered with lanolin or other lubricant during the manipu- 
 lations, with the view of softening the skin and stretching the 
 fascia and ligaments of the joints. The superheated air appar- 
 atus, such as is used for the treatment of rheumatic joints, may 
 be used and seems to be of service. 
 
 The deformity is liable to return after a long period of time, 
 and the patient must be instructed to employ correcting manipu- 
 lations regularly for several years after the operation. This need 
 not be made a hardship. A few minutes of massage, kneading, 
 and the use of pulley weights, which extend mechanically the fin- 
 gers, every morning will be found to meet the indications. 
 
HALLUX VALGUS 
 
 591 
 
 HALLUX VALGUS 
 
 Hallux valgus when subjected to operative relief is followed 
 by immobilization of the parts, by the application of a splint to 
 the internal surface of the foot. The wound is covered with the 
 protective dressing, a gauze pad is placed between the large and 
 second toes, to make outward pressure, and a splint is applied, as 
 
 Fig. 372. — Lateral Splint for Holding Toe after Operation 
 for Hallux Valgus. (Foote.) 
 
 shown in Fig. 372. The toe is held in contact with the splint by 
 adhesive plaster. 
 
 If no special indication arises, the wound is not dressed until 
 the tenth day after the operation, at which time the stitches are 
 removed. If there has been much oozing, the wound is drained, 
 in which event the dressing is removed on the third day and the 
 drain removed. The parts are now again immobilized, as stated 
 above, and the wound is left undisturbed for the remaining seven 
 
592 
 
 OPERATIONS ON THE EXTREMITIES 
 
 days. At this time the toe is moved slightly and a silicate of 
 soda splint applied which holds the parts in place. At the end 
 of another three days the patient is permitted to go about with 
 the toe held in the position mentioned, the shoe being cut away 
 for the purpose. The corrected position is maintained for six 
 weeks, at the end of which time passive motion may be begun. 
 After recovery the patient is instructed to wear a shoe which will 
 obviate recurrence of the deformity. Fig. 373 shows an outline 
 
 Fig. 373. — Hallux Valgus. Diagram Showing the Principle Involved in Mak- 
 ing Shoes. C shows the deflection of the great toe and the cramped position of 
 the others entailed by this kind of shoe. It will be seen that the point of the shoe 
 lies along the middle line of the foot. B shows the outline of the sole of a shoe con- 
 structed on sound anatomical principles. The inner border of the flat part of the 
 sole is nearly parallel to the long axis of the foot, the boot comes to a point opposite 
 the great toe, and is sloped away from that point to the outer border in accordance 
 with the length of the other toes, which are thus not cramped at all. A, a very 
 usual form of so-called anatomical shoe, which, while it is free frcm the most flagrant 
 faults of the shoe shown at C, is not so good as B. The inner border of the sole is 
 not quite straight, and so tends to deflect the great toe somewhat, while the square- 
 ness of the end of the boot both leaves a lot of unnecessary space between it and the 
 toes and detracts considerably from the appearance of the foot. (Meyer.) (Cheyne.) 
 
 to which the shoe should correspond. The important factor in 
 the construction of a suitable shoe is to have the internal line of 
 the footwear make a straight line from the metatarsophalangeal 
 articulation to beyond a line drawn transversely across the distal 
 termination of the great toe. Patients find it convenient to wear 
 a pledget of cotton between the great and second toes (Fig. 374) 
 for a long time after recovery is complete. In some instances a 
 
FLAT-FOOT 
 
 593 
 
 specially constructed shoe with 
 a separate compartment for 
 the great toe (Fig. 375) will 
 be found of use. It is to be 
 borne in mind, however, that 
 the " toe-post " may make 
 pressure upon the inner sur- 
 face of the toe, giving rise to 
 pain and annoyance, and its 
 employment may have to be 
 abandoned for this reason. 
 When the " toe-post " is used, 
 it may be difficult to insert the 
 phalanx into the compartment. 
 For the purpose a gauze plug 
 is inserted between the toes 
 (Fig. 374), to which a string- 
 is attached. When the toe is 
 felt to engage in the compart- 
 ment, the plug is withdrawn 
 by means of the string. Of 
 course, the use of the device 
 necessitates the use, of a digital 
 sock. 
 
 Fig. 375. — Diagram to Illustrate 
 "Toe-post." The "toe-post" 
 is seen in the cleft between the 
 great toe and the second. It is 
 made of stout leather or wood and 
 is fixed to the sole of the boot, 
 which should be of the shape 
 shown in the figure. The great toe 
 is thus confined in a compartment 
 from which it cannot escape, and 
 no lateral deflection is permitted. 
 (Cheyne.) 
 
 Fig. 374. — Pledget of Gauze Arranged 
 to Overcome Tendency to Recur- 
 rence of Hallux Valgus, after 
 Operation. 
 
 FLAT-FOOT 
 
 Flat-foot is exceedingly liable to 
 recur after operative correction. 
 In most instances operative meas- 
 ures of relief are followed by pla- 
 cing the foot in the over-corrected 
 position and immobilizing it in 
 plaster-of-Paris for six week- (Fig. 
 376). A window is cu1 in tliocast 
 on the third day after the operation 
 corresponding in extent to the 
 
594 
 
 OPERATIONS ON THE EXTREMITIES 
 
 wound. The dressing is changed as frequently as is necessary with- 
 out disturbing the position of the foot. At the end of the six weeks 
 of immobilization the cast is removed" and provision is made for 
 obviating recurrence of the deformity. A suitable steel spring is 
 
 Fig. 376.— Markedly Rigid Flat Feet put up in a Corrected Position in Circu- 
 lar Gypsum Splints. (Foote.) 
 
 worn in the shoe (Fig. 377). The " artificial arch" is made of 
 steel or aluminium, the latter being preferable as less influenced 
 by moisture than the former. Fig. 377A shows a lateral view of 
 the appliance, Fig. 377B shows the spring from the plantar sur- 
 
FLAT-FOOT 
 
 595 
 
 face. When the support is fitted to the foot, it should be molded 
 so as to extend forward almost to the ball of the foot, outward 
 
 Fig. 377. — Whitman's Spring for Flat Feet. A, The splint is seen from the inner 
 side applied to the foot, it shows the prolongation upward. In B, the splint 
 is shown from below, and shows the extent of the spring in front, behind and exter- 
 nally. (Cheyne.) 
 
 to the outer edge of the foot, and backward to just in 
 front of the tuberos- 
 ity of the os calcis. 
 The foot plate ap- 
 pears as shown in 
 Fig. 378, as modeled 
 by Hoffa. The outer 
 edge of the appliance 
 is slightly raised to 
 keep the foot from 
 slipping laterally. 
 The appliances in- 
 strument makers car- 
 ry in stock should 
 not be employed, but 
 each foot must be 
 
 held in the corrected position while a mold is made and the ap- 
 pliance made to fit this. 
 
 In addition to this, a specially constructed shoe should be 
 worn. Fig. 379 shows a boot which is of great service in achiev- 
 ing the purpose. The heel of the foot is carried forward on 
 the inner side of the shoe until it meets the front part of the 
 sole. The sole and heel are made thicker on the inner side, 
 
 so as to raise the inner border of the foot. This causes the 
 40 
 
 Fig. 378. — Lateral and Inferior View of Hoffa's 
 Foot Plate for Flat-foot, (von Bergmann.') 
 
596 
 
 OPERATIONS ON THE EXTREMITIES 
 
 patient to walk with the toes turned inward and aids in 
 the intent. 
 
 It is probable that comparative weakness of the muscles of 
 the leg have a bearing on the deformity. The patient is in- 
 structed to raise himself on his toes ten to twenty times twice 
 daily, and this exercise is increased until he is able to raise him- 
 self in the manner stated a large number of times at a sitting. 
 
 c€%. 
 
 Fig. 379. — Boots for Flat-foot. In A is shown the obliquity of the heel as seen 
 from the back. In B the boot is seen from below and both the obliquity of the heel 
 and the filling up of the arch of instep by carrying the heel forward to meet the sole 
 are shown. The prolongation of the heel forward is oblique in the same direction 
 as the heel, it is represented by the unshaded area in front of the heel in C, which is 
 a view of the inner side of the boot. (Modified from Hoffa.) (Cheyne.) 
 
 He should also attempt to walk on the outer aspect of the foot 
 while barefooted. As the result of continued immobilization, 
 while the operative wound is healing, the muscles of the leg un- 
 dergo a certain degree of disuse atrophy, and the operative meas- 
 ures of relief employed will fail in their purpose unless the sug- 
 gestions offered or some modification of them be assiduously car- 
 ried out after the operation. The support and the conformation 
 of the shoe are of course mechanical measures. The shoe, per- 
 haps, tends to cause a genuine correction. However, the de- 
 formity must be overcome as the outcome of proper exercises, a 
 fact which must be borne in mind. Immediately after the opera- 
 tion, massage and manual correction movements may be employed, 
 
CLUB-FOOT 
 
 597 
 
 and, especially in young children, will be found of considerable 
 service. Fig. 380 shows the position which the manipulations 
 should aim at. 
 
 Fig. 380. — Manipulation to Overcome Recurrence of Flat-foot after Correc- 
 tion. (Foote.) 
 
 CLUB-FOOT 
 
 Club-foot may be regarded in the same light as to after-treat- 
 ment as applies to flat-foot. Indeed, the ultimate outcome is 
 greatly dependent upon persistent exercise and manual correction. 
 Immediately after division of the restraining contractures the 
 foot may be put up in the manner shown in Fig. 881. The 
 dressing consists of a piece of wood of suitable size and thick- 
 ness, such as the lid of a cigar box, long enough to extend 
 from the heel to at least three inches beyond the tip of the toes, 
 which is cut to the shape of the foot. A piece of strapping be- 
 tween two and three inches broad, and sufficiently long to reach 
 from the middle of the thigh to the toes and then twice the length 
 of the splint, is first applied to the upper surface of the splint, 
 beginning near its anterior extremity, carried along the upper 
 surface, round the posterior edge, and then along the lower and 
 
598 
 
 OPERATIONS ON THE EXTREMITIES 
 
 over the anterior edge again. This part of the strapping is then 
 firmly incorporated with the splint by means of two or three 
 transverse pieces of strapping (Fig. 381). Upon the splint thus 
 
 Fig. 381. — Sayre's Apparatus for Use after Tenotomy of Tendo-A chillis.- The 
 smaller cut shows the method of attaching the strapping to the foot splint. (Cheyne.) 
 
 prepared are laid two or three thicknesses of boric lint, so as to 
 form a padding, and the splint is then fastened at the heel, sandal- 
 wise, by a broad strip of strapping passing aronnd the instep and 
 the posterior part of the splint to the front of the foot ; the splint 
 is then secured to the foot by an ordinary bandage. The long 
 piece of strapping which now hangs over from the front of the 
 splint is next carried np along the anterior surface of the thigh, 
 the foot meanwhile being held at right angles, and the knee in 
 the fully extended position. The strapping is applied to the 
 limb and fastened in position by a bandage, which commences 
 just beneath the patella and is carried up to about the center of 
 the thigh. The free upper end of the strapping is then turned 
 down, and the bandage carried downward over it ; in this way the 
 strapping is thoroughly incorporated with the bandage, and both 
 are firmly fastened to the skin of the thigh. Should the strap- 
 ping slip, as it frequently does after two or three days, it is not 
 necessary to apply fresh strapping in order to tighten it, but a 
 
CLUB-FOOT 
 
 599 
 
 second bandage may be applied over the old one, and carried 
 down farther below the patella ; this will keep the strapping tant. 
 The patient should be encouraged to walk wearing this appara- 
 tus. The effect of this is that, as the splint is longer than the 
 foot, considerable leverage is exerted upon the ankle joint, and 
 the latter is well bent as the patient walks. The flexion is far 
 more effectually carried out than if the foot were simply incased 
 in a shoe. By the use of this apparatus, also, the calf muscles 
 are left free, and massage can be applied to them. The apparatus 
 will generally require renewal about once a week. {Cheyne.) 
 
 Plaster-of-Paris will also be found the serviceable material 
 for the purpose, being eas- 
 ily applied and holding 
 firmly the parts in position. 
 Immobilization should be 
 maintained for three 
 weeks, at which time the 
 dressing is removed and 
 the patient subjected to 
 massage, and is encour- 
 aged to freely move the 
 foot. 
 
 A tendency to. recur- 
 rence of the deformity will 
 be noted soon after the 
 plaster is removed. To 
 overcome this the patient 
 is made to wear a boot of 
 especial construction (Fig. 
 382). It will be seen that 
 the boot is furnished with 
 a brace fastened about the 
 leg by means of a padded 
 strap ; a spring forces the 
 foot in the position shown 
 by the dotted outline. The 
 shoe must be consider- 
 ably longer than the foot. The apparatus stretches continu- 
 ously the tendon and fascia, and the heel conies in contact with 
 
 Fig. 382. — Boot for Use after Tenotomy 
 of Tendo-Achillis. The dotted line shows 
 the position the boot tends to assume when 
 the foot is off the ground. It thus con- 
 tinuously stretches the Tendo-Aohillis. The 
 boot should be made a good deal longer 
 than the foot, and it should have a stop at 
 the ankle-joint hinge to prevent the toes 
 being pointed. (//<>//« — Cheyne.) 
 
600 OPERATIONS ON THE EXTREMITIES 
 
 the ground as the patient walks. It must not be considered that 
 the apparatus will permanently cure the condition; on the con- 
 trary, the spring takes the place of the flexors of the foot, and as 
 the ultimate outcome is dependent upon the resumption of con- 
 tractility of the anterior group of muscles which have long been 
 comparatively useless, it is patent that systematic massage and 
 exercise of these muscles must be carried out. Indeed, the pa- 
 tient must be taught to exercise the flexor muscles without the 
 aid of any artificial apparatus, and the brace should be discon- 
 tinued as soon as possible. 
 
 Of course the muscles of the calf are more largely used in the 
 daily functions, and for this reason special forms of exercise other 
 than locomotion must be employed. For the purpose a rowing 
 machine with a sliding seat or similar device which compels the 
 patient to pull the body forward by the anterior tibial muscles 
 will be found exceedingly useful. 
 
 OSTEOTOMY 
 
 Osteotomy for bow-legs or knock-knees is followed by immo- 
 bilization of the parts in the corrected position for six weeks. 
 Immobilization is achieved by various forms of splints. How- 
 ever, it will be found that plaster-of-Paris is the most useful agent 
 for the purpose. The wound of approach to the site of bone sec- 
 tion is rarely infected, and though horsehair or silk-worm gut 
 drainage may be employed, the drainage agent may be withdrawn 
 from the wound on the third day following the operation, through 
 a window cut into the plaster corresponding to the wound. The 
 wound is then redressed and the sutures removed • on the tenth 
 day. In most instances it will not be necessary to disturb again 
 the dressings until the immobilizing apparatus is removed. 
 
 Should, however, infection of the wound occur, it may be 
 treated through the window in the plaster cast, already men- 
 tioned, without the disturbance of the fractured bones which ob- 
 tains when splints are used, the latter, of course, having to be re- 
 moved for the purpose. 
 
 As osteotomy for deformity is usually done in cases where 
 there is a certain pathological condition of the bones, the patient 
 should be confined to the bed for several weeks after union has 
 
RESECTION AND EXCISION OF JOINTS 
 
 601 
 
 taken place, and the diet be arranged with the view of obviating 
 the constitutional fallacy. The phosphates of lime and soda, to- 
 gether with general tonics, should also be administered. In young 
 adults it is well to supplement the treatment stated with the ap- 
 plication of an apparatus which will tend to obviate recurrence of 
 the deformity. For the purpose, in cases where knock-knee has 
 been corrected, an apparatus, such as 
 shown in Fig. 383, may be used. The 
 joint in the iron brace permits of flexion 
 of the knee, and a similar one at the 
 ankle joint permits of motion in the lat- 
 ter. These provisions are essential to 
 conserving muscular tone. The traction 
 is made at the various points shown in 
 the illustration. The apparatus should 
 be worn for several months following the 
 operation. 
 
 After correction of bow-legs a sil- 
 icate of soda splint may be worn for 
 several weeks following the operative 
 relief. The splint, however, should not 
 include either the knee or ankle joints. 
 
 As exercise of the muscles of the 
 limb while held in a normal position is 
 essential to ultimate success, the appara- 
 tus should be worn during locomotion, 
 and supplemented with exercises while 
 the patient is in the sitting posture. The 
 
 practitioner must, bear in mind that the deformity of bones is 
 simply a symptom, and the constitutional treatment must be des- 
 tined to correct the fallacy. Again, the simple correction of the 
 deformity must be supplemented by protracted employment of 
 massage and exercise in order to achieve a favorable ultimate 
 result. 
 
 Fig. 383. — Apparatus for 
 Bow-legs. (Dennis.) 
 
 RESECTION AND EXCISION OF JOINTS 
 
 Resection and excision of joints, if done for the purpose of 
 correcting deformity, or to achieve motility of joints following 
 
602 OPERATIONS ON THE EXTREMITIES 
 
 afflictions which have healed, are succeeded by complete closure 
 of the wound and immobilization of the parts until the wound is 
 healed. Drainage is not employed in these cases unless for special 
 indications, such as persistent oozing of blood, or because of ex- 
 tensive trauma to the parts. For the purpose the limb is held 
 quiescent by means of splints, which latter are applied over the 
 usual protective dressing. For the purpose of immobilization, 
 plaster-of-Paris or silicate of soda will be found most serviceable. 
 If drainage has been employed, a window corresponding to the 
 wound area is cut into the incasing immobilization apparatus, 
 and the drain is removed on the third day following the operation. 
 Seven days later the wound is again exposed and the sutures re- 
 moved from the wound. Of course, when absorbable suture ma- 
 terial has been employed, the latter step need not be taken. If no 
 drainage has been introduced into the wound, and there be no 
 evidence of infection, the wound need not be disturbed until the 
 tenth clay, when the sutures are removed. At the time that the 
 drainage is removed, the dressing is made under strict aseptic 
 precautions. When the sutures are removed and there be no 
 evidence of infection expressed by pain, rise of temperature, etc., 
 the precautions with respect to asepsis are likely to be disregarded. 
 The practitioner is warned against laxity in this connection, as 
 late infection may occur as the outcome of neglect in this regard. 
 
 A moderate degree of infection is very likely to occur follow- 
 ing resection of joints, due, perhaps, to the fact that parts which 
 have been restricted with respect to motility do not seem to have 
 the same degree of resistance to the invasion of infective proc- 
 esses as obtains when the normal physiological functions have 
 been impaired only for a short period of time. 
 
 Immobilization of a limb following resection of a joint should 
 not be maintained longer than is necessary to accomplish repair 
 of the wound. The process of healing is in many regards quite 
 similar to that of the affliction which caused the pathological con- 
 dition for the relief of which operative measures are undertaken. 
 If no infection exist at the time of the operation, passive motion 
 should be employed as soon as repair of the wound is sufficiently 
 advanced to justify its use. Indeed, it is probable that joints 
 which have been subjected to operative attack should not be held 
 quiescent for more than three weeks and passive motion should 
 
RESECTION AND EXCISION OF JOINTS 603 
 
 be employed at this time, even though complete repair of the 
 wound is not yet attained. In instances in which no infection ex- 
 ists at the time of the operation and relief of impaired useful- 
 ness, the outcome of repair following injury, is aimed at, passive 
 motion may be begun from the day upon which the sutures are 
 removed. 
 
 When passive motion is begun, the original cast is cut down 
 and a second lighter one applied. This is cut down immediately, 
 that is, before the plaster is quite hard and a light gauze bandage 
 made to hold the sectioned cast in place. The splint is removed 
 daily, the wound dressed, and the limb subjected to passive mo- 
 tion. In the meantime, the patient is encouraged to move actively 
 the parts of the limb contiguous to the joint immobilized, with 
 the view of facilitating nourishment and return of function. As 
 soon as repair is complete, the patient begins to use the limb, re- 
 moving the cast for the purpose for several hours each day and 
 reapplying it at night. In this way a certain degree of recur- 
 rence of the deformity, which is very liable to occur, is obviated. 
 During this time the patient is to be kept under observation and, 
 if necessary, the apparatus worn at night should be so constructed 
 as to overcome any tendency toward deformity or ultimate limi- 
 tation of motion. 
 
 Ankylosis after resection of joints is aimed at in the knee- 
 joint. In these cases the femur and tibia are held in apposition, 
 with the view of attaining union between the two bones, either by 
 means of apparatus or by the introduction of various agents, such 
 as wire or pegs or nails. In this class of cases the immobilization 
 is maintained until union is complete, which requires from six to 
 eight weeks. However, the wound is treated in much the same 
 way as are the wounds in other portions of the body. When in- 
 fection exists at the time of the operation, such as obtains with 
 joint tuberculosis, drainage is invariably employed, and the 
 wound will have to be treated for a considerable period of time. 
 
 As regards the knee joint, the character of dressing which 
 makes accessible the wound while union of the bones takes place, 
 is similar to that following resection, when infection exists, and 
 will be described under one head. Fig. 384 shows an apparatus 
 which is of service in both classes of cases. The leg is incased 
 in plaster-of-Paris, which is carried upward posteriorly support- 
 
604 
 
 OPERATIONS ON THE EXTREMITIES 
 
 ing the popliteal space. The thigh is also incased in the same 
 material, as shown in the illustration. After a few layers of 
 plaster-of-Paris bandages have been applied, a stout steel wire, 
 
 Fig. 384. — Suspended Bracketed Plaster-of-Paris Splint. {Bryant.) 
 
 bent in the fashion shown in the illustration, is applied to the- an- 
 terior aspect of the limb, and is buried by successive layers of 
 plaster-of-Paris bandages, leaving uncovered the portions shown 
 
 Fig. 385. — Bracketed Suspended Plaster-of-Paris Splint for Excision of 
 Ankle Joint. {Bryant.) 
 
 exposed in the picture. The limb may be swung by means of 
 cords from a pulley fastened above the bed. The region of the 
 joint and the wound are thus made readily accessible, and the 
 
RESECTION AND EXCISION OF JOINTS 
 
 605 
 
 dressing may be frequently changed and the wound treated with- 
 out disturbance of the relationship of the bones. 
 
 A similar device applied to the ankle joint is shown in Fig. 
 385. Fig. 386 shows the same principle applied to the wrist. In 
 
 -^-*V , '.4 Jj . i j|iijJ>' 
 
 Fig. 386. — Bracketed Suspended Plaster-of-Paris Splint for Excision of Wrist 
 
 Joint. {Bryant.) 
 
 cases of this sort, the joints contiguous to the afflicted one are also 
 immobilized as muscles which animate them cross the afflicted 
 joint. Complete immobilization of the limb should not, however, 
 be maintained for more than three weeks, at which time the ap- 
 paratus is removed and the immobilization confined to the afflicted 
 joint. In joints where ankylosis is not aimed at, where, how- 
 ever, infection exists at the time of the operation, passive motion 
 is begun at the end of three weeks, even though repair is not quite 
 complete. The limb is incased in a removable immobilization 
 apparatus which is removed daily, and active and passive motion 
 is employed as stated above. If the repair is slow, as is likely, 
 especially if relief of joint tuberculosis is undertaken, the Bier 
 treatment may be applied for several hours each night, the con- 
 striction being applied with the immobilization apparatus in 
 place. There is a tendency to unnecessarily prolong the immo- 
 
606 OPERATIONS OX THE EXTREMITIES 
 
 bilization of the joint. While protracted quiescence of tubercu- 
 lous joints which are being conservatively treated may be justi- 
 fiable, it is not indicated in cases in which the tuberculous disease 
 has been removed by operation, and motility of the joint is aimed 
 at. During the after-treatment of cases of this sort, the constitu- 
 tional treatment directed towards correcting the cause of the joint 
 affliction should be assiduously carried out. 
 
 In the treatment of the wound itself, it must be borne in mind 
 that when complicating purulent infection does not exist at the 
 time of the operation, it is exceedingly liable to occur subsequent 
 to the operation, and must be avoided by adherence to the rules 
 of asepsis. In a measure the lessened resistance of the patient 
 makes mixed infection more likely to occur under these circum- 
 stances. A sinus leading to a small portion of bone which is ex- 
 foliating, the outcome of trauma at the time of the operation, 
 should not be turned over to the patient for treatment, unless he 
 happen to be intelligent enough to observe the necessary clean- 
 liness. 
 
 AMPUTATIONS 
 
 Amputation wounds are, as far as the after-treatment is con- 
 sidered, divided into two kinds. Those which are left open, and 
 those in which the flaps are approximated and drainage estab- 
 lished. 
 
 The open method of treating wounds following amputations 
 is employed in cases where infection exists at the time of the 
 operation, especially if the infection be irregular in its extent, 
 and the remaining stump be the residence of infective process 
 which does not invalidate the vitality of the tissues remaining. 
 For instance, an osteomyelitis involving the lower ends of the fe- 
 mur and extending into the shaft may call for amputation, but 
 the bone section may be made just above the condyles, the shaft 
 of the bones scraped out and cleansed, the wound packed and ul- 
 timately complete repair takes place, while at the same time a 
 considerable extent of the limb is saved. In these cases approxi- 
 mation of the flaps by suture would serve no useful purpose, and, 
 indeed, healing by granulation gives in the end a stump which is 
 in all respects as serviceable as obtains when primary union is 
 achieved, the only disadvantage being, perhaps, that the former 
 
AMPUTATIONS 
 
 607 
 
 method of healing is a more prolonged one. However, the cer- 
 tainty of removal of offending secretions, and the accessibility of 
 the parts to postoperative treatment and care argues strongly for 
 employment of the measure in a certain class of cases. 
 
 When the stump is treated by the open method, the wound is 
 packed moderately firm with sterile gauze for forty-eight hours 
 (Fig. 387). Iodoform gauze or other so-called medicated gauze 
 
 Fig. 387. — Open Method of Treating Amputation Wound. 
 
 should be used with discretion, as the large raw surface it comes 
 in contact with will absorb the medicament and poisoning is liable 
 to occur. The packing is left in place no longer than the two days 
 mentioned, when it is removed. When infection of the deep parts 
 is present, firm packing interferes with drainage and the gauze 
 should be only lightly placed into the wound, with sufficient spaces 
 between the layers to permit of egress of the secretions. In the 
 latter class of cases the gauze may be soaked with a solution of 
 carbolic acid, 1 in 500, and the entire limb covered with gauze 
 saturated with the same solution. This dressing should not, how- 
 ever, be left undisturbed for more than twenty-four hours, at 
 which time the wound is cleansed with normal salt solution, with 
 the view of removing thoroughly the carbolic acid solution. The 
 
608 OPERATIONS OX THE EXTREMITIES 
 
 stump should not be treated with a solution of carbolic acid for 
 more than a day, and the second dressing should be wet with saline 
 solution, in order to obviate the maceration and at times slough- 
 ing which attends the prolonged use of the carbolic acid. When 
 the gauze saturated with saline solution is removed, peroxid of 
 hydrogen may be injected into the wound, with the view of loosen- 
 ing the gauze from the raw surfaces, though this measure is not as 
 essential as in cases in which dry gauze is introduced into the 
 wound. The stump is irrigated with a solution of corrosive sub- 
 limate, 1 in 2,000, all secretions are removed and sloughing tissue 
 picked off with dressing forceps. The protective dressing should 
 be applied with just sufficient pressure to hold it in place. Firm 
 bandaging is, perhaps, justifiable for the first twenty-four hours 
 following the operation with the view of controlling oozing of 
 blood, but should not be maintained longer than this as in cases 
 where infection is present. The flaps have already lost some vi- 
 tality as the outcome of the pathological process, and should not 
 be subjected to additional burden in this regard. 
 
 When the wound is clean, that is, if no infection exists at the 
 time of operation, such as is the case when the amputation is made 
 for trauma or for the removal of deformed or useless limbs, the 
 flaps are approximated by suture and drainage is employed. 
 
 For the purpose silk-worm gut may be used, though at times 
 catgut is used. The reasons for preferring the former in approxi- 
 mating the skin has already been mentioned (page 97). Drain- 
 age with a rubber tube which emerges at either angle of the wound 
 will be found to be the most useful in this class of cases (Fig. 
 388). This arrangement enables the attendant to irrigate through 
 and through from either side, and clots and secretions are readily 
 removed. Textile fabric may be used for the purpose, but does 
 not permit of cleansing of the wound with the facility which ob- 
 tains when tube drainage is employed. The final dressing of the 
 stump in either class of cases should be supplemented by the ap- 
 plication of a splint immobilizing the limb (Fig. 389). The limb 
 should also be placed in a position which obviates tension on the 
 flaps, the thigh or arm being supported by a pillow, and the bed- 
 clothes kept from coming in contact with the parts by holding 
 them away by means of an appropriately arranged canopy. The 
 tube drainage is removed on the third day following the opera- 
 
AMPUTATIONS 
 
 609 
 
 tion, provided infection has not occurred. If infection occurs, the 
 tube is changed and another one introduced, which procedure is 
 
 Fig. 388.— Amputation Wound Closed with Interrupted Sutures and Tube 
 Drainage Introduced. 
 
 repeated at intervals of forty-eight hours until the infection sub- 
 sides, at which time horsehair or silk-worm gut drainage (page 
 
 Fig 389.— Amputation Wound Dressed, Stump Immobilized on Posterior Padded 
 Splint and Thigh Extended to Relax Muscles. 
 
 193) is used, until the secretion of inflammatory products ceases 
 to discharge. If the infection is severe, it is best to remove 
 
610 OPERATIOXS ON THE EXTREMITIES 
 
 entirely the sutures and treat the case as is described under the 
 " open method " of handling the problem. 
 
 A certain amount of secretion is discharged in all instances 
 following amputations. This is a part of the process of repair, 
 although the character of the discharge varies with respect to 
 whether pus is formed or not. A part of the secretion is due to 
 a certain amount of superficial necrosis of the divided ends of 
 bones, and, indeed, even in cases in which primary union is prac- 
 tically obtained, a small sinus corresponding to the point of egress 
 of the drainage tube may persist for several weeks after the opera- 
 tion, which finally heals when the portion of bone has been ex- 
 foliated. In cases where infection exists at the time of the opera- 
 tion, a considerable degree of necrosis of bone usually follows, 
 and this may cause the wound to remain open at some point for 
 a considerable period of time. 
 
 In clean cases it at times happens that the necrosed bone does 
 not manifest itself until after the superficial wound has healed, 
 and the case then presents the signs and symptoms of inflamma- 
 tion. An incision made into the inflamed area liberating the 
 exudate and subsequent light packing will meet the indications. 
 Sutures are removed on the tenth day following the operation. 
 When tension sutures are employed (page 215), these are re- 
 moved at the same time. 
 
 If infection of the superficial wound occurs the deep or ten- 
 sion or relaxation sutures need not be removed until the time 
 stated, even though it may have been necessary to remove the 
 greater part of the approximation sutures. Of course, if the en- 
 tire surface of the wound be infected and pus form beyond the 
 relaxation sutures, these, too, must be immediately removed. 
 Uninfected cases heal in about two weeks including the drainage 
 tube openings, which latter require a little more time for com- 
 plete healing than obtains with respect to the rest of the wound. 
 
 When healing is complete, either in the cases in which the 
 open method or closure of the wound has been practiced, the limb 
 is incased in a light dressing, and the contiguous joint is sub- 
 jected to progressive, passive, and active motion. 
 
 Systematic massage of the healed stump should be begun as 
 soon as feasible. The patient is instructed to subject the stump to 
 frequent handling and manipulations with the view of creating 
 
AMPUTATIONS 611 
 
 a tolerance for the pressure of an artificial appliance. For the 
 purpose lanolin or vaselin may be used and the skin is bathed with 
 soap and water and sponged with alcohol, after which a dusting 
 powder of bismuth or similar agent is applied. 
 
 There is no fast and hard rule applicable to what time an 
 artificial limb may be applied. On general principles it may be 
 said that as soon as the manipulations mentioned are well borne, 
 the artificial appliance may be used for a certain period of time 
 each clay and discarded when evidence of irritation appears. As 
 soon as pain and redness appears the apparatus must be laid 
 aside and the skin treated in the manner stated until the irrita- 
 tion disappears, when the artificial limb is again applied. Toler- 
 ance for the peculiar condition of affairs will soon be established. 
 Under no circumstances should an attempt be made to force the 
 situation by persistence in wearing the apparatus in the presence 
 of irritation of the stump. 
 
 As soon as the patient convalesces he should be encouraged 
 to go about. When the lower extremity has been in part or en- 
 tirely removed, the patient will be compelled to use crutches for 
 some time, while the stump is prepared for an artificial appli- 
 ance. Locomotion with crutches should contemplate coordination 
 with the lessened parts concerned in it. This is not always ration- 
 ally attempted. Even though an artificial appliance is to be used, 
 the training with crutches is essential in order to cause a certain 
 compensatory hypertrophy of the remaining limb and to estab- 
 lish a new sense of balance. For the purpose the crutch should 
 be so constructed as to permit of locomotion without undue pres- 
 sure upon the axilla. Most of the weight should be borne by the 
 hands which grasp the crutch at such a distance from the axilla 
 as to obtain the desired condition of affairs. Failure to instruct 
 the patient in this regard causes pressure upon the brachial 
 nerves, chiefly the musculo-spiral, giving rise to a condition known 
 as " crutch paralysis." This is an exceedingly distressing occur- 
 rence and should be avoided. 
 
 The additional advantage of early locomotion is the greater 
 rapidity with which patients regain a normal general condition, 
 to which may be added the improvement in the mental condition 
 as the outcome of resumption of some occupation. 
 
 41 
 
CHAPTEK XXXIII 
 
 ARTIFICIAL LIMBS 
 
 Instep amputations — Retracted heels — Ankle-joint amputations — -Leg ampu- 
 tations — Knee-bearing stumps — Thigh stumps — Hip-joint amputations — 
 Amputations of upper extremities. 
 
 With respect to artificial appliances to the stumps following 
 amputations of the lower limbs it is necessary, in order to have 
 an intelligent conception of the rationale of the apparatus, to be 
 acquainted with the mechanism of locomotion. 
 
 Kinetoscopic photography has been an exceedingly valuable 
 aid in the study of the actions of the knee and ankle joints dur- 
 ing locomotion. The conclusions arrived at would seem to jus- 
 tify the belief that a person walking at the rate of two miles an 
 hour flexes the knee but slightly and the ankle considerably. 
 When walking at the rate of three miles an hour, the knee joint 
 acts through a greater range and the ankle joint through a lesser 
 one. When walking with moderate speed, say at the rate of four 
 miles an hour, the knee action becomes considerable and the ankle 
 action scarcely perceptible. When walking rapidly, say five miles 
 an hour, the knee action is increased and the ankle becomes prac- 
 tically rigid. When running, the knee increases its action and the 
 ankle reverses its action and throws the pedestrian forward by 
 the ball of the foot. 
 
 The ratio between the range of motion of the knee and ankle 
 joints is in proportion to rapidity of the act of locomotion. An 
 impulse to walk slowly or rapidly, or to change from one gait 
 to another, is formulated in the pedestrian's mind, this is conveyed 
 to the muscles of the limbs, which act is in accord with the impulse. 
 A person whose muscles do not respond in accord with the mind 
 becomes incoordinate in his gait. If an artificial leg be sup- 
 plied with an ankle joint which is not under control of the will, 
 
 612 
 
ARTIFICIAL LIMBS 613 
 
 the wearer is in much the same position as a person afflicted with 
 ataxia. 
 
 Three miles an hour is the rate at which the average person 
 walks. Successive photographs of a man walking at this gait show 
 that there is but little motion in the ankle joint and, limited as 
 it is, it is of a character which can not be imitated by mechanical 
 means. 
 
 Artificial feet with ankle joints set to act at a constant range 
 of motion allows the wearer to walk fairly well at a slow rate of 
 speed, but at a speed of three or more miles an hour, the step 
 becomes perceptibly awkward, and the effort required to overcome 
 the too liberal motion in the ankle is fatiguing. So far as the 
 knee joint is concerned, the motions of the artificial and natural 
 legs are approximately the same, but the motions of the ankles 
 are very different. The sole of the foot is flat on the ground for 
 a considerably longer period of time with the artificial ankle joint, 
 than obtains with the natural one. As the walker advances and 
 strikes the heel of the artificial foot on the ground, almost imme- 
 diately the front of the foot drops and the entire sole rests on 
 the ground and remains there during the interval through which 
 the body passes over it. 
 
 A person walking with natural feet throws the left foot for- 
 ward, barely touching the heel to the ground. Instantly the 
 right foot under control of the tendo- Achilles extends and the heel 
 is raised from the ground, throwing the weight of the body on the 
 ball, supplying the impetus that urges the body forward. As the 
 body is carried forward, the ball of the foot reaches the ground at 
 about the time the body is vertically over it. At this point the 
 right foot is in the act of leaving the ground, and is passing the 
 left which, still being flat on the ground, performs no function, 
 except that of supporting the body. The right leg is carried a 
 little farther forward when a slight amount of flexion occurs in 
 the left ankle joint. But this is quite transient. The tendo- 
 Achilles instantly contracts and the foot extends, the entire body 
 is lifted and thrown on the ball of the foot, and when the weight 
 of the body is placed on the heel of the right foot, there is a slight 
 flexion in the knee-joint which permits the sole to reach the ground. 
 At this time the knee-joint of the left foot is flexed and the foot 
 of that leg is raised, and when the weight of the body is practi- 
 
614 
 
 ARTIFICIAL LIMBS 
 
 cally over the right foot, the knee is extended, so as to support the 
 weight securely. 
 
 Artificial feet without ankle joints when supplied with rubber 
 cushions and the so-called " spring-mattress " are capable of imitat- 
 ing more closely the natural mechanism of locomotion than obtains 
 with those supplied with artificial ankle joints. As the walker 
 advances on the rubber foot, he touches the heel to the ground, the 
 weight is applied, and the sponge rubber in the heel compresses 
 sufficiently to allow him to roll on the bottom of the foot. The 
 moment the body is carried a little in advance, he rises on the ball 
 very much the same as he does on the natural foot. 
 
 The studies mentioned would show that the artificial foot fur- 
 nished with an ankle joint remains longer on the ground during the 
 act of locomotion than is desirable, and that an artificial foot with 
 a rigid ankle joint and the foot itself constructed of elastic mate- 
 rial imitates more closely the mechanism of locomotion and, there- 
 fore, preferable. Practical observation seems to bear out this 
 notion. The normal foot is an exceedingly complicated mechan- 
 ism. This can in no sense be duplicated by mechanical means. 
 The office of the artificial foot is to supply a means of locomotion 
 only, and with this principle in mind, the studies quoted above 
 permit of a conclusion which is valuable. 
 
 The artificial foot as alluded to seems to be of sufficient im- 
 portance in connection with the problem to warrant an extended 
 description. The appliance is the outcome of the ingenuity of 
 A. A. Marks of New York who describes his product substantially 
 as follows: 
 
 The rubber foot consists of a wooden core, carved to size and shape 
 to secure the best results (Fig. 390). The faint lines in the illustra- 
 tion represent the core 
 which reaches the ball of 
 the foot, localizing the toe 
 movement. The distance 
 from the core to the floor 
 at the heel is consider- 
 ably greater than at any 
 other part ; this is done 
 a. a. marks, n. v ^ obtain the proper de- 
 
 Fig. 390. — Profile View of Rubber Foot. gree of compressibility at 
 
ARTIFICIAL LIMBS 
 
 615 
 
 A- A. MARKS, N. Y. 
 
 Fig. 391. — Spring Mattress for Rubber Foot. 
 
 the heel. The core is entirely surrounded with rubber of great porosity 
 which will yield under the weight of the wearer sufficiently to make 
 the step realistic. Less rubber is placed at the ball so as to provide 
 phalangeal support and create a supporting medium at the front of 
 the foot, ample to steady him when standing, and to act as a lever 
 when walking. A spring mattress is floated in the foot below the 
 core, covering the entire distance from the back of the heel to the 
 tips of the toes, as 
 shown b}' the lines run- 
 ning lengthwise in the 
 illustration (Fig. 391). 
 The spring mattress is 
 formed by a series of 
 composition strips em- 
 bedded in strong sail 
 duck, each having a pocket of its own (Fig. 391), the strips occupying 
 the pockets a, a, a, a. 
 
 The spring mattress is a device intended to give additional re- 
 silience for both toes and heel. Every movement of the foot when in 
 action, applies pressure to the springs at the heel, ball, or on the sides. 
 The counteracting tendency of the strips aids in forcing the foot back 
 to its proper shape as soon as pressure is removed. 
 
 Fig. 392 shows the rubber foot with the weight applied to the ball 
 
 as it is when the wearer 
 is being urged forward 
 while walking. The 
 spring mattress is now 
 forced upward at the 
 ball and the sponge rub- 
 ber is compressed above 
 and below the mattress. 
 This pressure pulls the 
 mattress forward in the 
 foot. These movements 
 — the yielding of the 
 spring, the compression 
 of the rubber, and the 
 pulling of the spring mattress forward — form a very powerful result- 
 ant force that brings the foot back to its original lines as soon as the 
 foot is relieved of weight. 
 
 The condition of the appliance when under heel pressure, as it is 
 when the wearer places the artificial limb forward and applies his 
 
 a. a. marks, n. y. 
 
 Fig. 392. — Position of Rubber Foot When 
 Walking. 
 
616 
 
 ARTIFICIAL LIMBS 
 
 weight upon it, is somewhat the same. The spring mattress is forced 
 upward, the sponge rubber is compressed above and below, the heel 
 
 becomes flattened, and 
 the mattress being pulled 
 lengthwise, all combine 
 to force the foot to its 
 shape as soon as pressure 
 on the heel is removed. 
 The compression of the 
 heel permits the toes and 
 the front part of the foot 
 to reach the ground, 
 while the shaft of the leg 
 is obliquely back of the 
 vertical line. Fig. 393 
 shows the foot on an in- 
 clined surface. On ac- 
 count of the yielding quality of the rubber, the up-hill side of the foot 
 will compress and accommodate itself to the incline and allow the foot 
 to remain on its base. This is accomplished without complicated 
 mechanical lateral articulation. 
 
 It can readily be seen that any motion in the ankle that cannot be 
 controlled by the will must be mechanical in action. The approach 
 to the mechanism of locomotion is more positive by their omission. 
 
 INSTEP AMPUTATIONS 
 
 A. A. MARKS. N. Y. 
 
 Fig. 393.- 
 
 -Position of Rubber Foot on 
 Inclined Surface. 
 
 Instep amputations 
 which include the Lisfranc, 
 Chopart, Hays, Hancock and 
 other methods will be found 
 to call for the application of 
 some device other than the 
 mere padding of the shoe, if 
 the best possible kind of lo- 
 comotion is to be obtained. 
 It is absolutely useless to 
 apply any form of apparatus 
 in these cases unless the arti- 
 ficial appliance is held so 
 firmly that the wearer may 
 
 Fig. 394, 
 
 -Appliance for Instep 
 Amputation. 
 
INSTEP AMPUTATIONS 
 
 617 
 
 Fig. 395. — Appliance for In- 
 step Amputation in Place. 
 
 rise on the ball of the foot, and sup- 
 port his weight while in that position. 
 Fig. 394 shows an appliance which 
 serves the purpose very well. A half 
 leg, or front, including the core of the 
 foot, is made of aluminium, without 
 articulation at the ankle. The rear 
 half is made of leather, shaped to in- 
 case the leg and the aluminium shell 
 and hold the appliance in place (Fig. 
 395). The sole of the foot including 
 the toes is made of rubber with a 
 spring mattress (Fig. 391). Com- 
 fortable bearings are provided by 
 proper fittings and suitable linings. 
 The pressure needed to secure firm- 
 ness is distributed over the entire leg 
 from the ankle to the knee. With this appliance the wearer can 
 
 rise on the ball of the foot without 
 subjecting to pressure the face of 
 the stump or straining the ankle 
 joint. If there be a tendency to 
 retraction of the heel, the leather 
 sheath at the back is reinforced 
 with metal, shaped to hold the heel 
 down and obviate the deformity. 
 With this appliance in place the 
 wearer walks, striking the heel 
 first, then rolling on the sole until 
 the ball is reached, and then ris- 
 ing on the ball and receiving as- 
 sistance in walking. Fig. 396 
 shows the appliance in place with 
 the shoe on and the wearer walk- 
 ing with the weight on the ball of 
 the foot, similar to the position 
 taken by the natural foot when 
 in the act of throwing the body 
 
 396. — Appliance for Instep ° d 
 
 Amputation in Use. forward. 
 
 A. A. MARKS, N. Y. 
 
 Fig. 
 
618 
 
 ARTIFICIAL LIMBS 
 
 RETRACTED HEELS 
 
 Fig. 397. — Appliance for 
 Retracted Heel follow- 
 ing Tarsal Amputation. 
 
 Retracted heels occur as sequels to tarsal amputations which 
 remove the insertion of the muscles op- 
 posed to the muscles of the calf. In 
 passing, it might be proper to state that 
 an amputation through the ankle joint 
 or immediately above it is to be pre- 
 ferred to those which do not leave re- 
 maining the insertion of the anterior 
 tibial muscles. 
 
 The apparatus just described will 
 not meet the indications presented by 
 " retracted heels." Pressure on the 
 face of the stump is not tolerated, and 
 the weight must be borne immediately 
 below the knee or about the thigh. For 
 the purpose the appliance shown in Fig. 
 397 will be found serviceable in a cer- 
 tain number of cases. The rear half is made of metal, the front 
 of leather, capable of 
 being laced. This permits 
 of close fittings about the 
 heel and tends to force it 
 back to its proper position. 
 If the sides of the leg are 
 sloping, the fitting can be 
 such as to apply all the 
 weight on the leg imme- 
 diately below the knee. 
 !Fig. 398 shows the appa- 
 ratus applied with the 
 patient sitting. Disuse, 
 atrophy of the muscles of 
 the leg, make the applica- 
 tion of this appliance of 
 doubtful utility after a 
 certain period of time fol- 
 lowing the amputation. 
 
 Fig. 398. — Appliance for Retracted Heel 
 following Tarsal, Amputation in Place. 
 
ANKLE-JOINT AMPUTATIONS 
 
 619 
 
 Fig. 399. — Appliance with An- 
 nular Top for Retracted Heel 
 following Tarsal Amputation. 
 
 When this appliance is not found to meet the indications, it 
 becomes necessary to fit the patient with an apparatus having an 
 annular top or possibly a knee-joint 
 and thigh support. The annular top 
 can be applied to a leg constructed 
 as described. An appliance of this 
 sort is shown in Fig. 399. Knee- 
 joints and thigh supporters can be 
 applied to either kinds of artificial 
 legs. Fig. 400 shows an apparatus 
 with knee-joint and thigh supporter. 
 When the annular top is employed 
 the support is calculated to be lo- 
 calized immediately below the knee. 
 When the knee-joint and thigh sup- 
 port are required as shown in the 
 illustration the lower section is 
 made of aluminium, with the rear 
 
 sheath of leather. The thigh support incases the thigh and holds 
 
 it sufficiently firm to obviate 
 slipping of the leg in the socket. 
 
 ANKLE-JOINT AMPUTATIONS 
 
 Ankle-joint amputations, or 
 so-called tibio-tarsal amputa- 
 tions (Syme of Pirogoff), with 
 the malleoli removed and the 
 heel flap utilized over the face 
 of the stump, present conditions 
 exceedingly favorable to the 
 application of artificial appa- 
 ratus. If the scar be across 
 the face of the stump, they be- 
 come non-end-bearing stumps ; 
 per contra, if the scar be placed 
 anteriorly they are end-bearing 
 
 Fig. 400,-Appliance with Knee Joint blimps, which latter condition 
 and Thigh for Tarsal Amputations. is, of COUl'Se, the most f aVOl'- 
 
620 
 
 ARTIFICIAL LIMBS 
 
 able one for prothesis. Fig. 401 shows an appliance suitable to 
 cases with end-bearing stumps. The construction of this appli- 
 
 ance is very simple. The front, 
 
 Fig. 401. 
 
 -Appliance for Ankle-joint 
 Amputations. 
 
 which is the resisting part, and 
 the core of the foot, are cast in 
 aluminium, the interior surface 
 being formed to receive the an- 
 terior surface of the leg from 
 
 the knee down. It is so fitted 
 that pressure will be distributed 
 over the front area, the shin- 
 bone and the soft parts of the 
 leg being protected and not al- 
 lowed to bear pressure. The 
 rear part is of leather, shaped 
 to fit the calf and back of the 
 leg. It is attached at its lower 
 end to the aluminium socket 
 and when the stump is in place, 
 
 it incases the whole apparatus from the knee down, holding the 
 
 leg in place with firmness, the pressure being regulated by the 
 
 lacing. The foot is of sponge 
 
 rubber, reinforced with the 
 
 spring mattress (Figs. 390 
 
 and 391). Weight is taken 
 
 by the end of the stump rest- 
 ing on a surface of proper 
 
 shape, covered by a suitable 
 
 pad. The strain resulting 
 
 from rising on the ball of the 
 
 foot is not permitted to come 
 
 on the stump, being distrib- 
 uted over the leg, about the 
 
 sides of the shin from knee 
 
 to ankle. A stocking and 
 
 shoe are drawn over the foot. 
 
 Fig. 402 shows the appliance 
 
 in place as stated. If the 
 
 end of the stump is tender *, ino . . 
 
 i .biG. 402.— Appliance for Ankle-joint 
 
 because of sensitive nerve Amputations in Place. 
 
LEG AMPUTATIONS 
 
 621 
 
 endings, or because the 
 scar crosses the face of the 
 stmnp, an appliance which 
 is supported by an annular 
 arrangement of the upper 
 portion may be used, though 
 this will probably have to 
 be supplemented by a thigh 
 support. Fig. 403 shows 
 the annular arrangement 
 spoken of, which is intended 
 to support the pressure be- 
 low the knee, but is also 
 fitted with a thigh sup- 
 porter. 
 
 LEG AMPUTATIONS 
 
 Fig. 404. — Appli- 
 ance foe Taper- 
 ing Tibial Stump. 
 
 Fig. 403. — Appliance 
 ron End-bearing 
 Stumps at Ankle 
 Joint. 
 
 Leg amputations may 
 usually be fitted with arti- 
 ficial appliances similar to those described in 
 connection with amputations at the ankle 
 joint. However, it is desirable to apply an 
 apparatus which does not require lacing at the leg itself, and this 
 is only possible if the stump ta- 
 pers toward the end. If the dis- 
 tal portion of the remaining 
 stump is wider than any portion 
 higher up, as obtains when the 
 bone section is made below the 
 junction of the middle and lower 
 thirds of the tibia, it will be 
 necessary to use artificial appli- 
 ances similar to those described 
 under ankle-joint amputations. 
 Tapering stumps must be 
 
 fitted with appliances that give 
 
 „ „ i „ <• ,i , ■■ Fig. 405 — Appliance for Tapeki.no 
 
 ample room tor the extremity. „ 
 
 1 J Tibial Stumps, Showing JJegpee 
 
 That is, the ends are Suspended of Knee Flexion Obtainable. 
 
622 
 
 ARTIFICIAL LIMBS 
 
 in space. As they taper towards the 
 ends, they may be inserted from the 
 tops of the sockets, in contradistinction 
 to those just discussed. The socket is 
 hollowed out near the bottom and an 
 abundance of room provided, allowing 
 of free circulation of air. The leg 
 socket and foot core are made of a single 
 piece of wood. The rubber foot is con- 
 structed as already shown (Figs. 390 
 and 391). Figs. 404 and 405 show sec- 
 tional views of an appliance for the pur- 
 pose. 
 
 Short tibial stumps which are two or 
 
 Fig. 406. — Appliance for 
 Short Tibial Stumps. 
 
 more inches in length, with the knee 
 articulation capable of a range of mo- 
 tion through 90 degrees or more, may 
 be advantageously fitted with an ap- 
 pliance shown in Figs. 406 and 407. 
 Fig. 407 shows the appliance with the 
 patient standing, the action of the knee 
 joint being clearly presented. 
 
 This appliance is constructed as 
 follows : The socket which receives the 
 stump is excavated to accommodate 
 the stump. Sufficient space is allowed 
 for in the socket to allow of circula- 
 tion of air, and the stump is permitted 
 to hang freely in space. The appli- 
 ance is made of basswood strongly 
 
 Fig. 407. — Appliance for Short 
 Tibial Stumps in Place. 
 (Posterior View.) 
 
LEG AMPUTATIONS 
 
 623 
 
 Fig. 408. — Mechanism of Knee 
 Joint for Short Tibial 
 Stumps. 
 
 A. A- MARKS, N Y 
 
 Fig. 409. — Knee Joint in Place, Sho\vin< 
 Degree of Flexion. 
 
 banded together with rawhide. Knee joints are of the ginglymoid 
 
 pattern. The thigh-piece is made of leather. Fig. 408 shows the 
 
 upper section of the leg and the lower section of the thigh-piece, 
 
 with the knee joints disconnected 
 
 at their articulations ; aa are 
 
 screws which hold the bolts bb in 
 
 place; cc are the bushings which 
 
 work on the bolts and receive the 
 
 wear ; a lacing is used to regulate 
 
 the action of the knee. Fig. 409 
 
 shows the apparatus in place with 
 
 the knee bent. 
 
 KNEE-BEARING STUMPS 
 
 Knee-bearing stumps are fitted 
 with appliances similar to those 
 just described. A bolt joint fitted 
 with a spring forms the axis of 
 the knee. It is flanged on one end _ 
 
 ° riG. 410. — Mechanism of Appli- 
 
 and threaded 011 the Other. When ance in Knee-bearing Stumps. 
 
624 
 
 ARTIFICIAL LIMBS 
 
 Fig. 411. : — Appliance for 
 kxee-bearixg stumps. 
 
 the bolt is passing through the metal ear 
 which is riveted to the lower leg, the head 
 sinks into its bed and the threaded end 
 screws into the ear riveted to the oppo- 
 site side. Fig. 410 shows the mechanism 
 of the apparatus ; a is the bolt. The set 
 screw ~b, placed into the flanged end, pre- 
 vents the bolt from moving and working 
 out; c is the check cord screw; d the 
 check cord; g the spring piston; h the 
 spiral spring; i the cylinder. The rela- 
 tions and functions of these parts can be 
 understood by an examination of Figs. 
 411 and 412. 
 
 The action of the spring holds the leg 
 at flexion when the wearer is seated, and 
 urges the leg forward when walking. 
 The range of articulation can be regu- 
 lated by means of a pad placed between 
 the lower end of the check cord and the 
 bridge under which it passes. These 
 pads can be reached through the opening 
 in the calf of the leg. The upper loops 
 
 of the check cords rest in 
 their respective channels 
 and through them a steel 
 screw is passed and set. 
 The center of motion, 
 being placed below the 
 natural knee, causes a 
 disparity in length in the 
 two thighs. This is a 
 minor consideration 
 when balanced against 
 the utility of the mech- 
 anism. 
 
 Disarticulated knee 
 stumps are fitted with 
 
 Fig. 412. — Appliance for Knee-bearixg Stump, 
 Showing Degree of Flexion Obtaixable. 
 
LEG AMPUTATIONS 
 
 625 
 
 practically the same appliances described under " knee-bearing 
 stumps." It may be said that disarticulations at the knee joint 
 bear pressure very well and present a condition of affairs quite 
 favorable to prothesis. 
 
 THIGH STUMPS 
 
 Thigh stumps are fitted with much the same appliances as are 
 applied to knee-bearing stumps. The application of an artificial 
 
 limb should not be post- 
 poned beyond what is 
 
 necessary to obtain a 
 
 tolerant stump. Persons 
 
 who carry an idle thigh 
 
 stump for a considerable 
 
 period of time usually 
 
 have a certain degree of 
 
 contracture of the flexor 
 
 muscles (the psoas, etc.) 
 
 which inclines the stump 
 
 forward, and this must 
 
 be overcome before a 
 
 comfortable appliance 
 
 can be advantageously 
 
 worn. As a rule thigh 
 
 stumps will not bear 
 
 pressure on their ends. 
 
 Fig. 413 shows the usual 
 
 form of artificial limb 
 
 applied to thigh stumps ; 
 
 Fig. 414 shows a rear 
 
 view of the same. A rub- 
 ber foot as already de- 
 scribed is attached at the 
 
 ankle, and the leg por- 
 tion is hollowed out to 
 
 415 shows the parts of the knee mechanism. 
 A is the T-joint which is secured to the knee-block located at the 
 lower end of the stump socket. The two arms work in journals 
 made in the leg section; bb are the cap screws that hold the T-joint 
 
 Fig. 413. — Appliance 
 for Thigh Stump. 
 (Lateral View.) 
 
 decrease weight. Fij 
 
 Fig. 414. — Appli- 
 ance for Thigh 
 Stump. (Pos- 
 terior View.) 
 
626 
 
 ARTIFICIAL LIMBS 
 
 c 
 
 b b 
 
 c 
 
 
 r 
 
 
 1 f 
 
 3 
 
 H> 
 
 ® 
 
 
 
 
 ® 
 
 
 ill 
 
 
 
 
 iiiiiii 
 
 
 Fig. 415. — Mechanism of Kxee Joint in Ap- 
 pliance for Thigh Stump. 
 
 to its place; cc the caps; 
 d the spring piston ; e the 
 spiral spring; / the cyl- 
 inder cover, and parts 
 of the spring together ; 
 Hi represent the steel 
 screws used to hold the 
 T- joint firmly to the 
 thigh. The joint a has the 
 shape of an inverted T, 
 hence its name, T-joint. 
 When the leg and thigh 
 sections are placed to- 
 gether, the arms of the 
 T-joint rest in boxes and 
 are held by two hard- 
 wood caps, cc, which are 
 secured by long screws, 
 
 bb, which depend for their security on steel nuts, imbedded in the 
 
 front part of the leg. The pressure of the caps 
 
 on the joints can be regulated by the screws; 
 
 thus any desired tension on the articulation can 
 
 be made. The steel lever with ball on the end, 
 
 projecting from the back of the joint, operates 
 
 in the cavity of the hardwood piston d; the pis- 
 ton is inserted in one end of the steel spring, e, 
 
 which has its lower part incased with leather, 
 
 and then placed in a metal cylinder /. The 
 
 lower convex end of the cylinder is received on 
 
 a bridge placed in the interior of the leg in the 
 
 region of the calf. The operation of the spring 
 
 is twofold ; it urges the lower leg forward in 
 
 walking, and holds it at full flexion when sit- 
 ting. This is done in the following manner: 
 
 When the leg is extended, the point at which 
 
 the spring pressure is applied is on the end of 
 
 a steel lever projecting an inch back of the cen- Fig. 416. — Appli- 
 
 ter of motion in the knee. This urffes further ^ NCE ° 
 
 o Stump. Knee in 
 
 extension (Fig. 416), the lever revolves with Full Extension. 
 
Fig. 417. — Appliance for Thigh 
 Stump. Knee in Partial 
 Flexion. 
 
 Fig. 418. — Appliance for Thigh 
 Stump. Knee in Full Flexion. 
 
 Fig. 419. — Appliance 
 for Hip Amputa- 
 tion. (Anterior 
 View.) 
 
 42 
 
 Fig. 420. — Appliance 
 for Hip Amputa- 
 tion. (Posterior 
 View.) 
 
 Fig. 421. — Ap- 
 pliance FOR 
 Hip Amputa- 
 tion. (Lat- 
 eral View.) 
 
 627 
 
628 
 
 ARTIFICIAL LIMBS 
 
 Fig. 422. — Appliance for Hip 
 Amputation. (Patient Sitting.) 
 
 the joint, and when the leg is 
 partly flexed (Fig. 417), it has 
 been carried to a neutral point 
 where the spring neither urges 
 flexion nor extension , but when 
 the knee is farther flexed (Fig. 
 418), the lever has passed for- 
 ward of the neutral line and the 
 spring forces the ball upward, 
 urging farther flexion, and when 
 the flexion is at its limit, the leg 
 is kept in that position by the 
 spring. Thus, the objection to 
 the usual spring knee articula- 
 tion is removed, that of the ten- 
 dency of the leg to fly out when 
 the wearer is sitting and un- 
 guarded. 
 
 HIP-JOINT AMPUTATIONS 
 
 Hip-joint amputations require conditions of ap- 
 paratus quite similar to that just described, except 
 that suspension is more complex. For the purpose 
 an appliance such as is shown in Fig. 419 is ser- 
 viceable. The waist belt and suspenders hold the 
 limb in apposition to the pelvis. Figs. 420, 421, 
 and 422 show the appliance in place. The latter 
 shows the conditions when the patient is seated. 
 
 AMPUTATIONS OF UPPER EXTREMITIES 
 
 Artificial appliances following amputations at 
 the upper extremities do not, of couse, involve quite 
 the same problem as obtains with those of the lower 
 extremity. Cosmetic effect plays an important 
 part in this connection, and this is readily con- 
 served by mechanical means. Amputation of the 
 hand lessens greatly the utility of the limb. How- 
 ever, if the forearm is intact, an artificial appli- 
 
 Fig. 423.— Ap- 
 pliance FOR 
 Amputation 
 of Hand. 
 
AMPUTATIONS OF UPPER EXTREMITIES 
 
 629 
 
 ance such as is shown in the illustration (Fig. 423 ) will be found 
 of service. Amputations through the forearm are fitted with 
 much the same style of apparatus. 
 
 Amputations above the elbow joint are fitted with an appliance 
 which is fitted with a 
 spring permitting of 
 flexion of the elbow. 
 Fig. 424 shows an 
 apparatus of this 
 sort. Disarticulation 
 at the shoulder joint 
 is also followed by 
 the application of 
 apparatus which con- 
 serves cosmetic ef- 
 fect, but, of course, 
 utility is not achieved 
 by this means, except 
 
 by the exercise of a complicated mechanism which is of necessity 
 operated for a given purpose by the opposite hand. 
 
 The greatest achievement in the part of artificial appliances 
 following amputations is the aid given the afflicted in locomotion. 
 In addition to this, the usefulness of certain kinds of stumps in 
 various portions of the limbs as applied to subsequent prothesis 
 has been developed to no small degree, as the outcome of the arti- 
 san's labor. It is to be regretted that more attention has not been 
 paid to this portion of the problem in teaching operative surgery. 
 The general surgical rule that every inch of limb should be saved 
 is not uniformly wise. A perusal of the discussion offered above 
 may lead to some valuable conclusions in this connection. The 
 problem of what occupation the afflicted person is to follow should 
 enter into the question and, if this.be borne in mind, no doubt re- 
 amputation will become less frequently necessary. 
 
 Fig. 424. — Appliance for Amputation' of Arm. 
 
CHAPTEE XXXIV 
 MISCELLANEOUS OPERATIONS 
 
 Fracture of the patella — Union of fractured bones — Xailing the neck of the 
 femur — Skin-grafting. 
 
 FRACTURE OF PATELLA 
 
 Fracture of the patella when treated by operative measures 
 of relief presents a problem in which the question of infection 
 plays a more important part than obtains in other portions of the 
 body, when the condition for which relief is attempted is bal- 
 anced against the dire results of the infection. For some un- 
 known reason the knee joint is peculiarly susceptible to infection, 
 and also for an unknown reason its occurrence results fatally at 
 times, and often in complete loss of function of the joint. For 
 this reason especial precautions should be taken against the intro- 
 duction into the wound of infectious substances, and, whatever 
 may be said of the question of wearing gloves when the surgeon 
 operates in other portions of the body, they should be worn by the 
 operator and his assistants when the knee joint is invaded. 
 
 The technic of the operation does not call for special adroit- 
 ness nor the exercise of finesse in manipulation, and the gloves 
 need not be regarded as hampering the operator in the least. 
 Again, the operation does not call for the exercise of prolonged 
 physical exertion, and the temperature of the operating room need 
 not be high, consequently the surgeon is not caused to perspire 
 freely, as obtains during operations of greater magnitude, and the 
 objection to the use of gloves on the score that accidental perfora- 
 tion might liberate into the field sweat infested with bacteria 
 from the skin of the operator's hands need not be taken into ac- 
 count. 
 
 In other respects, the field of operation is prepared in a man- 
 ner similar to that employed in other portions of the body. When 
 
 630 
 
FRACTURE OF PATELLA 631 
 
 the region of the knee has been injured by the force causing the 
 fracture, healing of the trauma should be complete before the 
 operation is undertaken, or, if this be regarded as an objectionable 
 delay, the solution of continuity in the skin should be sterilized 
 with pure carbolic acid and alcohol immediately before section 
 of the skin is made. After the apposition of the fragments is com- 
 pleted, the superficial wound is. closed with silk-worm gut. The 
 joint is not drained as a rule. In some instances a small drain is 
 carried through the skin from the dependent portion of the joint, 
 i.e., at its external aspect. However, the use of drainage in this 
 class of cases is objectionable and may constitute an avenue of en- 
 trance of infection. If drainage is employed, horsehair or silk- 
 worm gut are the most useful and least objectionable agents for the 
 purpose. After the skin wound is closed the usual protective dress- 
 ing is applied, though in this situation it is well to be somewhat 
 lavish in the use of gauze, in order to permit of an equable appli- 
 cation of the immobilizing apparatus. 
 
 The limb may now be placed on a posterior splint. It will 
 be found, however, that plaster-of-Paris is the best dressing to 
 use for the purpose. The patient is placed in bed with the thigh 
 flexed upon the pelvis and the leg supported by pillows. The 
 quadriceps extensor is thus relaxed and strain upon the approxi- 
 mation sutures which hold the fragments in apposition is avoided. 
 If drainage has been employed, a window is cut into the plaster 
 cast on the third day following the operation, which corresponds 
 in size and location to the site of egress of the drain, which is 
 located some distance from the wound of approach to the site of 
 fracture, thus minimizing the danger of the introduction of in- 
 fection at this time. The drainage wound is redressed at once. 
 On the tenth day after the operation the cast is cut clown, the 
 stitches removed from the skin, and, after cleansing, under aseptic 
 precautions, the entire knee and contiguous parts the cast is re- 
 applied to the limb and held in place by encircling strips of ad- 
 hesive plaster. The posture of the limb as previously employed is 
 reassumed. At the end of another three days the wound is again 
 dressed. At this time the attendant grasps the patella between 
 the thumbs and forefingers of both hands, holding firmly the frag- 
 ments in position (Fig. 425), and moves it carefully from side to 
 side. The object of this manipulation is to avoid adherence of 
 
632 
 
 MISCELLANEOUS OPERATIONS 
 
 the posterior surface of the patella to the condyles of the femur. 
 If this can be avoided, the subsequent manipulations destined to 
 restore motility in the joint are less liable to cause refracture. 
 
 
 
 
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 ^^ 
 
 
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 JsBHI 
 
 
 
 
 
 
 
 
 
 
 
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 J 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Fig. 425. 
 
 -Lateral Manipulation of Patella to Obviate Adherence to Con- 
 dyles of Femur. 
 
 Xormally the patella glides on the smooth surfaces of the con- 
 dyles, and if it becomes adherent, it is easy to see how an effort 
 to flex the leg would cause the line of union to give way. 
 
 The limb is now immobilized in a new plaster cast, in which 
 it is allowed to remain for three weks. At this time the cast is 
 cut down, the patella moved again laterally as described, and the 
 cast fastened back in place. Complete immobilization is now no 
 longer necessary. Each day the cast is removed and lateral ma- 
 nipulation of the patella practiced, but at this time flexion of 
 the limb, either passively or actively, is to be avoided. The latter 
 is to be avoided until seven weeks after the operation, and at first 
 the patella should be steadied as the leg is cautiously and carefully 
 bent. As a rule, no attempt to obtain complete flexion of the 
 joint should be attempted until after the expiration of twelve 
 weeks after the operation. In the meantime the limb should be 
 
UNION OF FRACTURED BONES 
 
 633 
 
 massaged daily. If infection of the joint occurs, the cast must 
 be cut down, the wound completely opened, drainage established 
 and the joint treated as infected joints are taken care of from 
 other causes. 
 
 UNION OF FRACTURED BONES 
 
 The union of fractured bones by holding in apposition the 
 fragments by means of wire, nails, pegs or similar device is fol- 
 lowed by drainage in most instances. The use of the drainage is 
 governed by much the same rules which are applicable to wounds 
 generally, except, perhaps, that in this class of cases the oozing 
 of blood from the traumatized bone may be regarded as a special 
 indication for its use. After the protective dressing is applied, 
 
 Fig. 426. — ParkhiU's Screws in situ. (Bryant.) 
 
 the bone and contiguous joints are immobilized in plaster-of- 
 Paris, and on the third day following the operation the drain is 
 removed through a small window cut into the cast for the pur- 
 pose. On the tenth day after the operation the window in the 
 cast is enlarged and the sutures removed from the wound. The 
 wound is then dressed, and in most instances need not be dis- 
 turbed until the cast is cut down for some other purpose. If 
 there be a superficial infection, the dressing is changed every two 
 days until healing takes place. In instances where long bones, 
 such as the tibia cannot be held in proper apposition, a devise 
 employed by ParTchill is frequently introduced into the frag- 
 
634 MISCELLANEOUS OPERATIONS 
 
 ments. When the device is in situ it presents the conditions 
 shown in Fig. 426. This method of treatment renders the appli- 
 cation of a plaster cast a trifle more complicated, as the instru- 
 ment protrudes through the plaster cast and constitutes an avenue 
 of entrance of infection. This may be obviated by covering the 
 device with an additional dressing independently of the cast. The 
 latter precaution must not be neglected. The wires and pegs are 
 not always well borne and at times cause irritation and must be 
 removed. The appearance of redness, pain and swelling at the 
 site of the operation, several weeks after the repair has been 
 made, suggests that the foreign substance is causing trouble and 
 should be removed. INTails are usually left protruding from the 
 soft parts, and should be removed five weeks after the operation. 
 ParTehill's device should be removed at the expiration of the same 
 period of time. 
 
 The principle of treatment in these cases is quite similar to 
 that applicable to fractures generally. The wound may be re- 
 garded as wounds are in a general way, except, perhaps, for the 
 variations from the rule mentioned above. In a certain number 
 of cases a superficial necrosis of bone corresponding in extent to 
 the perforations made by the retaining apparatus occurs, a small 
 abscess forms and a sinus persists for some time after the opera- 
 tion. This need not be regarded as a serious complication, nor 
 indicative of failure of the measure of relief. It means, however, 
 that the wound needs to be cleansed at intervals of two days 
 through the window in the plaster cast, and may, indeed, demand 
 somewhat protracted attention after the case has recovered in all 
 other respects. An application of tincture of iodin to the sinus 
 at intervals of four or six days will at times stimulate granulation 
 and destroy mild infection. 
 
 NAILING THE NECK OF THE FEMUR 
 
 bailing the neck of the femur for fracture is practiced in a 
 certain number of cases where immobilization by mechanical 
 means is contraindicated, because of the age of the patient, or be- 
 cause of the coexistence of some complications proclnding the em- 
 ployment of the more usual methods of treatment. 
 
 As a rule, the fixation of the fragments by nailing is followed 
 
NAILING THE NECK OF THE FEMUR 635 
 
 by the application of a plaster-of-Paris cast which consists of a 
 hip spica extending down to but not including the knee joint. 
 The wound which permits of the introduction of the nail does 
 not require drainage, and the hip joint may be immobilized and 
 the dressing left undisturbed for two weeks following the opera- 
 tion. In a small number of cases it may be necessary to cut a 
 window into the cast corresponding to the point of insertion of 
 the nail in order to cleanse the area. However, this will only 
 rarely be necessary. 
 
 The patient is permitted to leave the bed, and is encouraged 
 to go about on crutches after the third day following the opera- 
 tion. The cast, as already stated, is removed at the end of two 
 weeks following the operation, and the nail may be relied upon 
 to hold the fragments in apposition after this. The hip joint may 
 be lightly dressed with sterile gauze held in place with a roller 
 bandage. The nail is removed at the end of six weeks following 
 the operation. The nail is left protruding from the skin at the 
 time of the operation, and, for the purpose of removal, it is firmly 
 grasped by a strong forceps and slowly twisted until it becomes 
 loosened when it is readily removed with slight traction. As a 
 rule, a slight degree of necrosis corresponding to the seat of the 
 nail causes it to be quite loose at the end of the six weeks men- 
 tioned. If the nail be firmly fixed and do not permit of easy re- 
 moval, it may be grasped near its head by a strong hysterectomy 
 clamp and this given a sharp blow in the direction away from the 
 limb with an ordinary mallet, such as is used for gouging bone. 
 
 In most cases the wound heals immediately after the nail is 
 removed. In a few cases, however, a sinus persists for several 
 weeks after the nail has been withdrawn. This, as mentioned in 
 connection with the wiring of fractures, need not give rise to any 
 alarm, and the sinus actually heals in a short time. Infection 
 should not occur in these cases. If it happens, however, the nail 
 must be at once removed, and drainage established. 
 
 A certain degree of motility of the joint occurs at the end 
 of the two weeks of treatment, and this will be found to be suffi- 
 cient to obviate complete ankylosis. However, the motion in the 
 joint will be found much impaired after healing is achieved. 
 At the end of the six weeks, the joint is subjected t<> passive motion 
 and massage as employed following fractures in general. It 
 
636 MISCELLANEOUS OPERATIONS 
 
 is not wise to employ very largely measures destined to obviate 
 ankylosis until after union has taken place. Indeed, the nail, 
 while meeting the indications when treated with care, will not be 
 found to hold the fragments in place when the joint is subjected 
 to passive motion too early in the postoperative period. It is 
 best to permit the patient to move the joint only as much as is the 
 inevitable outcome of going about in the ward on crutches. As 
 this operation is usually undertaken on patients advanced in life, 
 the precautions with respect to hypostatic pneumonia and bed 
 sores are to be observed. As far as the former is concerned, the 
 patient must be caused to leave the bed or at least be raised to 
 the sitting posture as soon after the operation as is possible. The 
 latter, of course, is a question of frequent change of posture and 
 attention to the skin. 
 
 SKIN-GRAFTING 
 
 Skin-grafting is undertaken, in the vast majority of instances, 
 for the relief of conditions when infection to a greater or lesser 
 degree already exists. This factor in the problem would suggest 
 the employment of antiseptic measures throughout the care of the 
 case. However, the repair of the wound is dependent upon the vi- 
 tality of the grafts, and as this is more or less impaired as the result 
 of contact with antiseptic solutions, the operative technic must 
 be carried on without the employment of these agents. 
 
 The local preparation of the patient may be carried out with 
 antiseptics, and, indeed, these may be liberally used at this time. 
 However, immediately before the operation all antiseptics must 
 be removed before the grafts are brought in contact with their 
 new residence. For the purpose, the parts are cleansed in the 
 usual manner and ultimately a liberal lavage made with normal 
 salt solution. During the operation, normal saline solution 
 should be used as a cleansing fluid. The salt solution is regarded 
 as a contributing factor to the maintenance of the nutrition of 
 the grafts. 
 
 On the other hand, great care must be taken to avoid accidental 
 contamination of the operative field, for, while the use of salt solu- 
 tion may contribute to the vitality of the grafts, it also constitutes 
 a culture medium exceedingly favorable to the growth of bacteria, 
 
SKIN-GRAFTING 
 
 637 
 
 a fact borne out by the rather virulent character infection takes 
 on when developed under the conditions presented. 
 
 One of the most prolific causes of failure in achieving a favor- 
 able ultimate outcome in these cases is the fact that the protec- 
 tive dressing becomes adherent to the grafts, and when it is 
 removed the grafts are torn away. This applies with equal force 
 to Thiersch, Riverdian or other grafts. To avoid this, the pro- 
 tective dressing is kept constantly moist with normal salt solution, 
 the theory being that the gauze will not adhere to the grafts under 
 
 Fig. 427. — Method of Preparing Rubber Tissue for Dressing Wound after 
 
 Skin-grafting. 
 
 these conditions. This has not been found to achieve the object, 
 and in addition the moist dressing constitutes a condition very 
 favorable to the entrance of infection. 
 
 A method which has yielded the best results is as follows: 
 After the wound is thoroughly dried, rubber tissue is cut to a 
 suitable size, and this is fenestrated at intervals of a square inch 
 by first folding the tissue and then excising diamond-shaped por- 
 tions in the manner shown in Fig. 427. When the entire portion 
 of tissue is prepared, it presents a condition shown in Fig. 428. 
 
638 
 
 MISCELLANEOUS OPERATIONS 
 
 The wound is now covered with sterile olive oil and, after the 
 rubber tissue has also been submerged in sterile olive oil, it is 
 
 Fig. 428, 
 
 -Rubber Tissue Prepafed for Application to Wound after 
 Skin-grafting. 
 
 Fig. 429. — Fenestrated Rubber Tissue Applied to Wound after Skin-grafting. 
 
 applied directly to the wound. Whatever secretion the wound 
 may throw off finds its way into the protective dressings through 
 the diamond-shaped openings. Fig. 429 shows the rubber tissue 
 
SKIN-GRAFTING 639 
 
 applied. The square of gauze (Fig. 187) applied directly con- 
 tiguous to the rubber tissue is also saturated with the sterile oil, 
 and outside of this the usual protective dressing is applied. 
 
 When the dressing is changed, which should be done every 
 forty-eight hours subsequent to the operation, the rubber tissue is 
 readily removed without damage to the grafts. At the end of 
 the third dressing the collection of oil adherent to the wound and 
 contiguous skin may be removed by gently swabbing the surface 
 with tincture of green soap applied by means of a cotton pledget 
 and the resultant lather removed by liberal lavage with sterile 
 water or salt solution. 
 
 In most cases sloughing of a portion of the grafts takes place. 
 This will become manifest at the end of a week and is accompanied 
 by a liberal discharge of offensive secretion. By this time, how- 
 ever, the healthy grafts will have become sufficiently adherent to 
 warrant employment of a mild solution of carbolic acid (1 in 250) 
 as a cleansing solution. The carbolic acid solution should, how- 
 ever, be ultimately displaced with sterile water, and under no cir- 
 cumstances should a wet dressing containing an antiseptic be per- 
 mitted to remain in contact with the wound before the total num- 
 ber of grafts have become adherent, unless the wound present 
 evidence of infection. 
 
INDEX 
 
 Abdomen, drainage of, 433 
 
 operations on, 422 
 
 strapping of, 476 
 Abdominal adhesions, 474 
 
 ■massage for, 474 
 Abdominal belts, 475 
 Abdominal operations, lung complica- 
 tions after, 4G1 
 
 parotitis after, 464 
 Abdominal supporters, 475 
 Abdominal supporting corsets, 480 
 Abdominal wound, closure of, 435 
 
 dressing of, 436 
 
 superficial drainage of, 436 
 Abscess of liver, 509 
 Absorbable ligature material, 86 
 Acquired obesity, '31 
 Acute cardiac dilatation in transfu- 
 sion, 253 
 Adamkiewicz's formula for rectal 
 
 feeding, 296 
 Adhesions following celiotomy, 473 
 Adrenalin in shock, 234 
 Alcohol, 23 
 
 abstinence from, 25 
 
 administration of, after operations, 
 28 
 in alcoholics, 27 
 Alcoholics, preparation of, 23 
 Alcoholism, chronic, 24 
 
 diet in, 26 
 Amputations, 606 
 
 at ankle, 619 
 
 at hip joint, 628 
 
 at instep, 616 
 
 drainage after, 609 
 
 of leg, 021 
 
 of upper extremities, 628 
 
 open treatment of, 607 
 
 retracted heels after, 618 
 
 Ankle-joint amputations, 619 
 Antisepsis in cleansing skin in in- 
 fected cases, 51 
 Antiseptic powders, 217 
 
 application of, 220 
 Antiseptic solutions, 117 
 Anus, fistula of, 550 
 
 operations on, 548 
 Appendectomy, 496 
 Appendicostomy, 498 
 Arrangement of furniture in office, 8 
 
 of reception room and office, 8 
 Artificial feet, 613 
 Artificial larynx, Gliick's, 387 
 
 Gussenbauer's, 386 
 Artificial limbs, 612 
 Aspiration after thoracotomy, 401 
 Assistants, preparation of, 124 
 Attire of patients, 53 
 
 of non-sterile nurse, 138 
 
 of sterile nurse, 138 
 
 of surgeon, 137 
 
 B 
 
 Bacteria in gastrointestinal canal, 425 
 
 Balsam of Peru gauze, 77 
 
 Basin, handling of, 116 
 
 Beard, care of, 43 
 
 Bed for abdominal cases, 39 
 for head cases, 39 
 for shock, 229 
 
 Bedside table for postoperative care, 
 232 
 
 Belts, abdominal, 475 
 
 Biliary fistula, 517 
 
 Biliary passages, tympanitis after 
 operation on, 516 
 
 Binder, many-tailed, SO 
 
 Bladder, drainage of, after prosta- 
 tectomy, 576 
 
 641 
 
642 
 
 INDEX 
 
 Bladder, operations on, 566 
 
 permanent suprapubic drainage of, 
 
 571 
 temporary suprapubic drainage of, 
 567 
 Blood examination, record of, 4 
 
 significance of, 5 
 Blood-vessel anastomosis by suture, 
 
 238 
 Brain operations, 328 
 
 discharge of cerebrospinal fluid 
 after, 341 
 Brain prolapse, 343 
 care of, 344 
 
 ultimate outcome of, 347 
 Brain substance, softening of, 336 
 Breast, excision of, 395 
 Bronchitis, care of, 10 
 
 Calcium chlorid, 70 
 
 in hemophilia, 23 
 Canton flannel gloves, 132 
 Cannula anastomosis in transfusion, 
 
 242 
 Caps, 68 
 
 Caps and masks, 133 
 Carbolic acid, 117 
 Cardiac and arterial disease, 15 
 
 diet in, 16 
 Cardiac tone, Katzenstein's test for, 
 17 
 
 Riva-Bocei test for, 18 
 Care of hair before operations, 43 
 in operations on face, 358 
 
 of mouth before operations, 43 
 
 of prolapse of brain, 344 
 
 of surgeon's hair and beard, 44 
 Castration, 5S0 
 Catallou's formula for rectal feeding, 
 
 295 
 Catgut, 86 
 
 chromieized, S9 
 
 diameter of, S6 
 
 in hermetically sealed tubes, 93 
 
 iodized, 95 
 
 plain, 88 
 
 removal of fats from, 88 
 
 sterilization of, 88 
 
 Catgut, sterilization of, in cumol, 
 91 
 with mercury, 89 
 
 stored in jars, 91 
 Catgut drainage, 194 
 Catharsis, 41 
 
 after celiotomy, 444 
 
 after enterectomy, 495 
 
 after rectal operations, 544 
 Catheter, self-retaining, SI 
 Cavities, training of manipulations in, 
 
 36 
 Celiotomy, 422 
 
 adhesions following, 473 
 
 administration of opiates after, 433 
 
 after-treatment of, 439 
 
 catharsis after, 444 
 
 feeding after, 446 
 
 peritonitis after, 451 
 
 phlebitis after, 470 
 
 retention of urine after, 443 
 
 secondary repair of wound after, 
 449 
 
 time of leaving bed after, 447 
 
 tympanitis after, 445 
 
 vomiting after, 442 
 Celiotomy sheet, 84 
 Cerebrospinal fluid, discharge of, 341 
 
 retention of, 335 
 Cervical lymphatics, excision of, 374 
 
 preparation for, 375 
 Changing dressings, material for, 301 
 Cholecystectomy, 515 
 Cholecystenterostomy, 515 
 Cholecystotomy, 513 
 Choledocotomy, 515 
 Chole-enterostomy, 515 
 Chromic gut, in tissues, 94 
 Chromieized catgut, 90 
 Cigarette drain, 80, 190 
 Circumcision, 582 
 Cleansing and drainage of infected 
 
 wounds, 305 
 Cleansing hands, 126 
 
 chemical, 129 
 
 immersion bowls for, 130 
 
 material for, 127 
 
 mechanical, 129 
 
 wash stand for, 12S 
 Cleansing mouth, 362 
 Cleansing nose, 362 
 
INDEX 
 
 643 
 
 Cleansing skin, 47 
 
 care of raw surfaces in, 51 
 
 ether in, 50 
 
 gauze for, 49 
 
 in infected cases, 51 
 
 Kelly pad in, 48 
 
 Moynihan's method of, 50 
 
 nail brushes for, 49 
 
 rubber sponge for, 49 
 Cleansing wounds of mouth, 370 
 . Janet-Frank syringe for, 370 
 Cleft palate, 367 
 
 care of wound in, 369 
 Clover's crutch, 522 
 Club-foot, 597 
 
 dressing for, 598 
 Cocain, 30 
 
 Coe's needle with handle, 205 
 Colectomy, 505 
 Colon, irrigation of, after colostomy, 
 
 503 
 Colostomy, 499 
 
 irrigation of colon after, 502 
 Colostomy pad, 502 
 Combined dressing, 77 
 Continuous suture, 211 
 Corrosive sublimate gauze, 224 
 Cotton for dressings, 225 
 Cranial bones, care of wounds of, 
 326 
 
 necrosis of, 332 
 Cranial contents, operations on, 328 
 after care in, 330 
 retention of cerebrospinal fluid 
 
 after, 335 
 secondary hemorrhage after, 333 
 Cranium, application of dressings to, 
 348 
 
 retention of dressings on, 352 
 Crile mask, 137 
 
 Cumol sterilization of catgut, 91 
 Cumolizer, 91 
 Cystitis after perineal operations, 
 
 537 
 Cystotomy, suprapubic, 566 
 
 Decortication of lung, 408 
 Deformity following thoracotomy, 413 
 43 
 
 De Garmo's femoral needle, 206 
 Depilatory mixture, 48 
 Diabetes, 33 
 
 diet in, 34 
 Diarrhea after gastroenterostomy, 
 
 491 
 Diet after entereetomy, 485 
 
 before operations, 44 
 
 in cardiac and arterial disease, 16 
 
 in diabetes, 34 
 
 of alcoholics, 26 
 
 sterile, 430 
 Dilatation of stomach and gut, 277 
 Donor, in transfusion, 250 
 Double roller head bandage, 349 
 Douche bags, 83 
 Drain, cigarette, 80 
 
 rubber tube, 80 
 Drainage, in infected cases, 188 
 
 in uninfected cases, 187 
 
 indications for kinds of, 199 
 
 of abdomen, 433 
 
 of amputation stumps, 609 
 
 of operative wounds, 186 
 
 of pelvic abscess, 529 
 
 with catgut, 194 
 
 with " cigarette," 196 
 
 with glass tubing, 190 
 
 with rubber tissue, 195 
 
 with rubber tubing, 190 
 
 with silk-worm gut, 193 
 
 with textile fabric, 196 
 Drainage agents, 189 
 
 indications for use of, 199 
 Drainage tube, 193 
 Dressing, after excision of breast, 
 397 
 
 after perineal operations, 525 
 
 cotton for, 225 
 
 of abdominal wound, 436 
 
 of wounds of face, 359 
 
 oil silk for, 226 
 
 paraffin paper for, 226 
 
 preparation for change of, 300 
 
 rubber tissue for, 226 
 Dressing sterilizer, 63 
 Dressing table, 146 
 
 draping of, 158, 160 
 Dreyfuss depilatory mixture, 48 
 Dry heat sterilization, 61 
 Dupuytren's contraction, 589 
 
644 
 
 INDEX 
 
 E 
 
 Edema and softening of brain, 336 
 Emergency sture in hermetically 
 
 sealed glass tube, 95 
 Endocarditis following operations, 19 
 Enema preliminary to operation, 42 
 Enterectomy, 494 
 
 catharsis after, 495 
 
 diet after, 495 
 
 fecal fistula after, 496 
 Enteroclysis, 264 
 Ermold needle holder, 208 
 Esophagotomy, 392 
 
 care of wounds after, 393 
 Ether for cleansing skin, 50 
 
 avoidance of burns in, 50 
 Excision of breast, 395 
 dressing after, 397 
 
 of ribs, 400 
 Excision and resection of joints, 601 
 Exothyropexy, 391 
 Exposure of operative wounds, 302 
 Extremities, operations on, 589 
 Eye, care of, after intracranial neu- 
 rectomy, 356 
 
 Face, bandaging of, 359 
 
 operations on, 358 
 
 suturing wounds of, 361 
 Fecal fistula, after enterectomy, 496 
 
 after vaginal section, 537 
 Feeding after celiotomy, 446 
 
 after gastrostomy, 483 
 
 after intubation of larynx, 379 
 
 after operations, 288 
 
 by mouth, 288 
 
 by rectum, 291 
 Femur, nailing of, 634 
 Finger cots, 136 
 
 Fissure of Rolando, localization of, 317 
 Fissure of Sylvius, localization of, 317 
 Fistula in ano, 550 
 Flat-foot, 593 
 
 manipulations for, 597 
 
 shoes after, 596 
 
 spring for, 595 
 Fleiner's formula for rectal feeding, 
 297 
 
 Fluffed gauze, 223 
 Formulae for rectal feeding, 295 
 Fracture of patella, 630 
 Fractures, union of, 633 
 
 Gall bladder and biliary passages, 
 
 operations on, 512 
 Gastroenterostomy, 487 
 
 diarrhea after, 491 
 
 hemorrhage after, 488 
 
 intestinal obstruction after, 490 
 
 regurgitant vomiting after, 489 
 
 ulcer of jejunum after, 491 
 Gastro-intestinal canal, bacteriology 
 of, 425 
 
 special preparation of, 424 
 
 sterility of, 430 
 Gastrostomy, 481 
 
 feeding after, 483 
 
 rubber plug after, 484 
 Gauze, fluffed, 223 
 
 for cleansing skin, 49 
 
 for dressings, 75, 223 
 
 for packing, 75 
 
 sterile, 224 
 Gauze pads, 70 
 
 Gelatin injections in hemophilia, 23 
 General preparation of patient, 42 
 Glass tubing for drainage, 190 
 Glisson sling for torticollis, 374 
 Gloves, Canton flannel, 132 
 
 during operation, 133 
 
 rubber, 69 
 Gold wire, 102 
 
 sterilization of, 103 
 Gowns, 68, 132 
 Grafting ureter into bladder, 564 
 
 H 
 
 Hagedorn needle, 203 
 
 with Gentile handle, 205 
 Hair, care of, before operation, 43 
 in operations on face, 358 
 protection of, during operation, 55 
 removal of, with depilatory mix- 
 ture, 48 
 shaving of, 47 
 
INDEX 
 
 645 
 
 Hallux valgus, 591 
 
 shoes after, 592 
 Halsted-Leur needle holder, 208 
 Hands, cleansing of, 126 
 Harelip, 367 
 
 dressing of, 367 
 Harelip pins, 216 
 
 Head, retention of dressings of, 348 
 Hemolysis, 255 
 Hemophilia, 21 
 
 blood test in, 22 
 
 calcium chlorid in, 23 
 
 gelatin injections in, 23 
 
 thyroid extract in, 21 
 Hemorrhage after gastroenterostomy, 
 
 488 
 Hemorrhoids, removal of, 552 
 Hepaticostomy, 515 
 Hereditary obesity, 31 
 Hip- joint amputations, 628 
 History, method of ke*eping, 3 
 History cards, 3 
 Horsehair, 102 
 
 sterilization of, 102 
 Hospital operating room, 139 
 Hydatid cysts of liver, 508 
 Hydrocele, 579 
 Hypodermic injections, 235 
 Hysterectomy, 519 
 
 vaginal, 532 
 Hysteromyomectomy, 519 
 
 Improvised sick bed, 40 
 Indications for kinds of drains, 199 
 Infected cases, cleansing skin in, 51 
 
 drainage in, 188 
 Infected operative wounds, cleansing 
 and drainage of, 305 
 
 packing of, 308 
 Infusion, by needling artery, 263 
 
 in shock, 259 
 
 instruments used in, 260 
 
 solution for, 262 
 Injection of mercury in syphilis, 20 
 Instep amputations, 616 
 Instrument sterilizers, 56 
 Instrument table, 154 
 
 draping of, 154 
 
 Instrument tray, adjustable, 148 
 
 draping of, 156 
 Instruments used in infusion, 260 
 
 in transfusion, 239 
 Interrupted suture, 215 
 Intestinal obstruction after gastro- 
 enterostomy, 490 
 Intestines, acute dilatation of, 277 
 
 treatment of, 281 
 Intracranial neurectomy, 356 
 
 care of eye after, 356 
 Intubation of larynx, 378 
 
 feeding after, 379 
 Iodin catgut, 95 
 
 Iodoform and its modifications, 219 
 Iodoform gauze, 76 
 Irrigation, 151 
 
 in perineal operations, 525 
 Irrigator, 151 
 Island of Reil, localization of, 324 
 
 Jaccoud's formula for rectal feeding, 
 
 296 
 Joints, resection of, 601 
 
 K 
 
 Kangaroo tendon, 96 
 
 Katzenstein's test of cardiac tone, 17 
 
 Kelly pads, 48 
 
 Kelly's needle holder, 209 
 
 Kemp's tube, 554 
 
 Kidney, operations on, 556 
 
 renal colic after, 560 
 Kidney position, 557 
 Knee-bearing stumps, 623 
 Knives, sterilization of, 59 
 Kroenlein's construction, 316 
 
 Laminectomy, 415 
 
 water bed after, 415 
 Laryngectomy, 383 
 
 avoidance of pneumonia after, 385 
 Larynx, artificial, 386 
 
 intubation of, 378 
 
 operations on, 378 
 
646 
 
 INDEX 
 
 Lateral ventricles, localization of, 324 
 Lathier's formula for rectal feeding, 
 
 296 
 Lavatory for surgeon, 149 
 Leg, amputations of, 621 
 Ligature material, 86 
 Lithotomy position, 521 
 
 exaggerated, 574 
 Liver, abscess of, 509 
 
 hydatid cysts of, 508 
 
 operations on, 508 
 
 resection of, 511 
 Lubricating agents, 82 
 Luer's needle holder, 208 
 Lung, decortication of, 407 
 Lung complications following celi- 
 otomy, 461 
 
 M 
 
 Major operations, requisites for, 66 
 
 Many-tailed binder, 80 
 
 Marion suprapubic drain, 568 
 
 Mask, Crile's, 137 
 
 Massage for- abdominal adhesions, 474 
 
 Mastoid operations, 352 
 
 after-care of wound in, 353 
 
 radical, 355 
 Material necessary for changing 
 
 dressings, 301 
 Mercury, 119 
 Method of handling steam pressure 
 
 sterilizers, 64 
 Microscopical findings of tumors, 4 
 Mikulicz tampon, 268 
 
 removal of, 268 
 Miscellaneous operations, 630 
 
 in mouth, 369 
 Moist heat sterilization, 61 
 Morphin, administration of, 30 
 
 withdrawal of, 30 
 Mouth, care of, before operations, 43 
 
 cleansing of, 362 
 Moynihan's method of cleansing skin, 
 
 50 
 Murphy treatment of peritonitis, 457 
 Murphy's rubber dam, 52 
 Mushroom catheter, 569 
 Myxedema after thyroidectomy, 389 
 
 treatment of, 390 
 
 N 
 
 Nail brush, 69 
 
 for cleansing skin, 49 
 Narcotist, preparation of, in head 
 
 operations, 311 
 Narcotist's table, 148 
 
 with necessary materials, 156 
 Neck, dressing after operations on, 
 377 
 
 operations on, 373 
 Needle holders, 207 
 Needle wounds, 204 
 Needles for suturing, 203 
 Needling of artery in infusion, 263 
 Nephrectomy, 562 
 
 peritonitis after, 563 
 
 uremia after, 562 
 Nephritis, 13 
 Nephropexy, 557 
 Nephrotomy, 560 
 Neurectomy, intracranial, 356 
 Non-absorbable suture material, 97 
 Nose, cleansing of, 362 
 
 Obesity, 31 
 
 acquired, 31 
 
 classification of, 31 
 
 diet in, 32 
 
 hereditary, 31 
 
 thyroid extract in, 32 
 
 withdrawal of carbohydrates in, 32 
 of fats and oils in, 42 
 Office arrangement, 6 
 Oil silk for dressing, 226 
 Operating room, arrangement of ap- 
 paratus in, 152 
 
 illumination of, 140 
 artificial, 141 
 
 in hospital, 139 
 
 in private practice, 169 
 cleansing of, 172 
 
 tables arranged in, 153 
 Operating table, 142 
 
 extemporized, 177 
 
 portable, 173 
 Operating suits, 125 
 Operations on abdomen, 422 
 
INDEX 
 
 647 
 
 Operations on anus, 548 
 
 on bladder, 567 
 
 on cavities, training in, 36 
 
 on cranial contents, 328 
 
 on cranium, 316 
 
 on extremities, 591 
 
 on face, 358 
 
 on gall bladder and biliary pas- 
 sages, 512 
 
 on kidney, 556 
 
 on larynx and trachea, 378 
 
 on neck. 373 
 
 on rectum, 541 
 
 by perineal route, 548 
 
 on scalp, 311 
 
 on scrotum and penis, 579 
 
 on thorax, 395 
 
 on ureter, 564 
 
 on uterus, 518 
 Operative wounds, cleansing and 
 drainage of, 305 
 
 drainage of, 186 
 
 exposure of, 302 
 
 suturing of, 201 
 
 time of dressing, 299 
 Operator, preparation of, 124 
 Operator and assistants during opera- 
 tion, 169 
 Opiates after celiotomy, 443 
 Osteomyelitis of spine, 420 
 Osteoplastic rhinoplasty, 366 
 Osteotomy, 600 
 Outfit for sterilization, 110 
 Ovariotomy, 518 
 
 Packing of infected wounds, 309 
 Pagenstecher thread, 100 
 
 sterilization of, 101 
 Pain, treatment of, 285 
 Paraffin paper for dressing, 226 
 Parotitis, after abdominal operations, 
 
 465 . 
 Patella, fracture of, 630 
 
 lateral manipulation of, 632 
 Pathological report record, 4 
 Pelvic abscess, drainage of, 529 
 Penis, plastic operations on, 583 
 Perineal operations, 521 
 
 Perineal operations, care of, 526 
 
 care of wound in, 527 
 
 cystitis after, 537 
 
 dressing after, 525 
 
 fecal fistula after, 537 
 
 irrigation in, 525 
 Perineal prostatectomy, 573 
 
 drainage after, 575 
 
 position of patient for, 574 
 Peritoneum, flushing of, 453 
 Peritonitis after celiotomy, 451 
 
 after nephrectomy, 563 
 
 Murphy treatment of, 457 
 
 prevention of, 451 
 
 treatment of, 456 
 Peroxid of hydrogen, 121 
 Phlebitis after celiotomy, 470 
 Pitchers, 68 
 
 for handling water, 115 
 Plastic operations on penis, 583 
 Pleuritis after operation, 19 
 Postoperative care, bedside table for, 
 232 
 
 feeding in, 288 
 
 in necrosis of cranial bones, 332 
 
 of pain, 285 
 
 of thirst, 284 
 
 of vomiting, 272 
 
 of wounds, 298 
 Powders, antiseptic, 215. 
 
 application of, 220 
 
 sprinkler for, 220 
 Preparation of operative field. 46 
 
 of operator and assistants, 124 
 
 of patient, final, 168 
 general, 42 
 
 Kocher's method of, 42 
 Moynihan's method of, 43 
 
 of scalp, 312 
 
 of skin in infected cases, 51 
 Preparatory care, in bronchitis, 10 
 
 in cardiac and arterial disease, 15 
 
 in cases of rheumatism and gout, 18 
 
 in nephritis. 13 
 
 in pulmonary tuberculosis, 11 
 
 in tuberculosis of glands and bones, 
 12 
 
 of alcoholics, 24 
 
 of diabetics. 33 
 
 of hemophiliacs. 22 
 
 of obese patients, 34 
 
648 
 
 INDEX 
 
 Preparatory care of patients using 
 tobacco, 28 
 
 of syphilitics, 20 
 Preparatory diet, 44 
 Principles of sterilization, 60 
 Prognostic value of assembled history 
 
 record, 5 
 Prolapse of brain, 343 
 
 of rectum, 554 
 Prostatectomy, perineal, 573 
 
 drainage after, 575 
 Protective dressing, 221 
 
 gauze for, 223 
 
 method of application of, 222 
 Protoscope, 541 
 Pulmonary tuberculosis, 11 
 
 R 
 
 Ratjen's formula for rectal feeding, 
 
 297 
 Raw surfaces in cleansing skin, 51 
 Reception room and office plan, 8 
 Recipient in transfusion, 253 
 Recording the history, 2 
 Record of blood examination, 4 
 
 of urinary analysis, 4 
 Rectal bougie, 294 
 Rectal feeding, 291 
 
 formula for, 95 
 
 in pulmonary tuberculosis, 11 
 Rectal operations, catharsis after, 544 
 Rectal tube, 82 
 Rectum, cleansing of, 555 
 
 operations on, 541 
 by perineal route, 548 
 by sacral route, 542 
 
 prolapse of, 554 
 Removal of hair with depilatory mix- 
 ture, 48 
 
 of sutures, 304 
 Renal colic following kidney opera- 
 tions, 560 
 Repair of wounds in syphilitics, 21 
 Requisites for major operations, 66 
 Resection of liver, 511 
 Restraint of patient after operation, 
 
 441 
 Retention of cerebrospinal fluid, 335 
 
 of urine after celiotomy, 443 
 
 Retracted heels after amputation, 
 
 618 
 Rheumatism and gout, 18 
 Rheumatism following operation, 19 
 Rhinoplasty, 364 
 
 osteoplastic, 366 
 Riegl's formula for rectal feeding, 
 
 295 
 Riva-Rocci apparatus, 18 
 Roll gauze, 77 
 Round needles, 205 
 Rubber dam, Murphy's, 52 
 Rubber drainage tube, fenestration 
 
 of, 191 
 Rubber gloves, 69 
 Rubber sheets, 84 
 
 Rubber sponge for cleansing skin, 49 
 Rubber tissue drainage, 195 
 
 for dressing, 226 
 Rubber tube drain, 80 
 Rubber tubing for drainage, 190 
 
 Sacral approach to rectum, 542 
 Saline solution, 81, 122 
 Sand's needle holder, 208 
 Scalp, care of wound of, 314 
 
 outlining of fissures on, 317 
 
 preparation of, 312 
 
 in minor operations, 313 
 Scalp wounds, drainage of, in infec- 
 tion, 315 
 Schlesinger's formula for rectal feed- 
 ing, 297 
 Scissors for removing sutures, 304 
 Scrotum, operations on, 579 
 Scultetus binder, 438 
 Secondary bleeding, 267 
 
 following brain opei-ations, 333 
 Self-retaining catheter, 81 
 Shaving, 47 
 
 Shock, cannula anastomosis of ves- 
 sels in, 242 
 
 direct suturing of blood-vessels in, 
 238 
 
 enteroclysis in, 264 
 
 following operations, 227 
 
 infusion in, 259 
 
 needling of arteiy in, 263 
 
INDEX 
 
 649 
 
 Shock, transfusion in, 237 
 
 general management of, 246 
 
 treatment of, 233 
 
 use of adrenalin in, 234 
 Shock bed, 229 
 Sick bed, 39 
 Sick room, 38 
 
 cleansing of, 38 
 
 temperature of, 54 
 Silk, 98 
 
 braided, 98 
 
 in hermetically sealed glass tubes, 
 100 
 
 sterilization of, 99 
 
 twisted, 98 
 Silk- worm gut, 97 
 
 in hermetically sealed glass tubes, 97 
 
 sterilization of, 97 
 Silk-worm gut drainage, 193 
 Silver wire, 102 
 
 sterilization of, 103 
 Singer's formula for rectal feeding, 
 
 297 
 Single roller head bandage, 348 
 Skin, cleansing of, 47 
 
 in infected cases, 51 
 Skin grafting, 636 
 Skull, frontipetal type of, 320 
 
 occipitopetal type of, 321 
 Soap, 69 
 
 Solution for infusion, 262 
 Solutions of carbolic acid, 118 
 
 of mercury, 119 
 Steam sterilizers, 62 
 Sterile cotton, 75 
 Sterile diet, 430 
 Sterile gauze, 224 
 Sterile nurse, attire of, 138 
 Sterile saline solution, 81 
 Sterile towels, 81 
 
 Sterile water, in private practice, 180 
 Sterilization, in general, 60 
 
 of catgut, 88 
 in cumol, 91 
 
 of dressings, 63 
 
 of gastro-intestinal canal, 430 
 
 of gold wire, 103 
 
 of horsehair, 102 
 
 of instruments, 56 
 
 of knives, 59 
 
 under pressure, 59 
 
 Sterilization of Pagensteeher thread, 
 101 
 
 of silk, 99 
 
 of silver wire, 102 
 
 of water, 104 
 Sterilization outfit, 110 
 
 under steam pressure, 62 
 Stomach, acute dilatation of, 277 
 
 treatment of, 280 
 Stumps, 623 
 
 tapering, 621 
 Supporters, abdominal, 475 
 Suprapubic cystotomy, 566 
 Suprapubic drainage, permanent, 571 
 
 temporary, 567 
 Surgeons, complete attire of, 137 
 
 hair and beard of, care of, 44 
 Surgeon's lavatory, 149 
 Surgeon's needles, 203 
 Surgeon's outfit for sterilization, 112 
 Suture, continuous, 211 
 
 improperly tied, 202 
 
 interrupted, 215 
 
 properly tied, 202 
 
 removal of, 304 
 scissors for, 304 
 Suture and ligature material, 85 
 Suture material, absorbable, 86 
 Sutures to relieve tension, 215 
 Suturing, needles for, 203 
 
 of operative wounds, 201 
 
 of wounds of face, 361 
 Syphilis, 19 
 
 injections of mercury in, 20 
 
 Tampon, Mikulicz, 268 
 
 T-bandage, 38 
 
 Temperature of sick room, 54 
 
 Tension on sutures, 215 
 
 Textile fabric drainage, 196 
 
 Thermometer, 82 
 
 Thiersch's fluid, 120 
 
 Thigh stumps, 625 
 
 Thirst, 283 
 
 treatment of, '283 
 Thoracic wall, resection of, 408 
 Thoracoplasty, 406 
 Thoracotomy, 399 
 
 aspiration after, 401 
 
650 
 
 INDEX 
 
 Thoracotomy, deformity after. 413 
 
 Fell-O'Dwyer apparatus in, 409 
 Thorax, wounds of, 395 
 Thyroid, cysts of, 391 
 Thyroid extract, 22 
 
 in hemophilia, 22 
 
 in obesity, 32 
 Thyroidectomy, 387 
 
 fever after, 388 
 
 myxedema after, 389 
 
 pneumonia after, 388 
 Tobacco, 28 
 
 use of, after operation, 29 
 before operation, 25 
 
 withdrawal of, 29 
 Torticollis, 373 
 
 Glisson sling for. 374 
 
 manipulations after correction of, 
 374 
 Tournier's formula for rectal feeding, 
 
 296 
 Towels, sterile, 81 
 Trachea, operations on, 378 
 Tracheotomy, 380 
 
 position after, 381 
 
 use of moist air after, 381 
 Tracheotomy tube, removal of, 382 
 Transfusion, 237 
 
 acute dilatation of heart in, 253 
 
 direct, 238 
 
 donor in, 250 
 
 general management of, 246 
 
 hemolysis in, 255 
 
 local anesthesia in, 248 
 
 recipient in. 253 
 
 requisite instrument for, 238 
 Triplex drainage tube, 193 
 Tube drainage, 189 
 Tuberculosis of glands, bones, etc., 12 
 
 pulmonary, 11 
 
 care of, before operations, 11 
 Tuberculous cervical adenitis, 375 
 Tying of sutures, 201 
 Tympanitis, after celiotomy, 445 
 
 after operations on biliary pas- 
 sages, 516 
 
 U 
 
 Ulcer of jejunum after gastroenter- 
 ostomy, 491 
 
 Uninfected cases, drainage in, 187 
 Uremia after nephrectomy, 562 
 Ureter, grafting of, 564 
 
 operations on, 564 
 Ureteral operations, fistula after, 564 
 
 position of patient in, 564 
 Urethrotomy, 584 
 Urinary analysis, significance of, 5 
 Urinary fistula, 561 
 
 after ureteral operations, 564 
 Urinary record, 4 
 Utensil sterilizer, 151 
 
 Vaginal hysterectomy, 532 
 
 Varicocele, 580 
 
 Vomiting, after celiotomy, 442 
 
 after gastroenterostomy, 489 
 
 postoperative, 272 
 Vomitus, character of, 276 
 Vulvar pad, 84 
 
 W 
 
 Wales' rectal bougie, 294 
 
 Wash stand for cleansing hands, 128 
 
 Water, 104 
 
 apparatus for sterilization of, 105, 
 106, 197, 198 
 
 drawing from sterile retort, 116 
 
 in pitchers, 115 
 
 plain sterile, 121 
 
 sterilization of, 104 
 by heat, 105 
 Wipes, 72 
 Wounds, in diabetics. 36 
 
 made by needles, 204 
 
 of abdomen, closure of, 435 
 
 of cranial bones, 326 
 
 of esophagus, 393 
 
 of face, dressing of, 359 
 suturing of, 361 
 
 of mouth, cleansing of, 370 
 
 of scalp, 314 
 
 postoperative care of, 298 
 
 Zinc chlorid, 120 
 
 (1) 
 
DUE DATE 
 
COLUMBIA UNIVERSITY LIBRARIES (hsl.stx) 
 
 RD 66 H29 C.1 
 
 Preparatory and after treatment in opera 
 
 2002125072