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ELECTRO- H^MOSTASIS 
 
 IN 
 
 OPERATIVE SURGERY 
 
 BY 
 ALEXANDER J. C. SKENE, M.D., LL.D. 
 
 Professor of Gynecologj' in the Long Island College Hospital, Brooklyn, N. V. : formerly Professor of 
 
 Gynecology in the Xew York Post-Graduate Jledical School: Gynecologist to the Long Island 
 
 College Hospital ; President of the American Gynecological Society, 1SS7 ; Corresponding 
 
 Member of the British, Boston, and Detroit Gynecological Societies, of the Royal 
 
 Society of Medical and Natural Sciences of Brussels, of the Obstetrical and 
 
 Gynecological Society of Paris, and of the Leipzig Obstetrical Society; 
 
 Honorary Member of the Edinburgh Obstetrical Society : Fellow 
 
 of the New York Academy of Medicine; ex-President of the 
 
 Medical Society of the County of Kings; ex-President 
 
 of the New York Obstetrical Society 
 
 BOSTON 
 
 SHERMAN, FRENCH Is COMPANY 
 
 1910 
 

 ^. V 
 
V 
 
 ^ 
 
 TO 
 
 JOHN BYRNE, M. D., LL. D., M. R. C. S. E., 
 
 AS AN ACKNOWLEDGMENT OF HIS 
 
 ORIGINAL AND MOST VALUABLE CONTRIBUTIONS TO 
 
 THE SCIENCE AND ART OF THE ELECTRIC CAUTERY IN SURGERY ; 
 
 HIS SUPREME PROFESSIONAL HONOR, HONESTY, AND COURTESY ; 
 
 AND IN PERSONAL GRATITUDE FOR 
 
 HIS TRUE AND CONSTANT FRIENDSHIP, 
 
 THESE PAGES ARE INSCRIBED BY 
 
 THE AUTHOR. 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/electrohaemostaOOsken 
 
PREFACE 
 
 This contribution relating to electro-hsemostasis and the 
 electric cautery in general and special surgery, is issued to 
 supplement the third edition of my work on diseases of 
 women, in which the subject was referred to, but altogether 
 too briefly discussed. 
 
 The interest manifested by the profession in this sub- 
 ject, the employment of the new methods of operating in 
 other than gynaecological surgery, a number of recent im- 
 provements in instruments and in the technique of oj^era- 
 ting, and a larger experience confirmatory of the value of 
 the principles and practice advocated, both prompted the 
 undertaking and raise the hope that the results will be 
 acceptable to the profession. 
 
 The part of the work devoted to electro-hsemostasis may 
 appear to be rather aggressive, not to say revolutionary, and 
 therefore it might be judicious to give in this preface a 
 statement explanatory of the principles involved and a 
 preliminary argument in their favor; but past experiences 
 remind me that it is unnecessary to do so. 
 
 In former contributions to medical literature I have 
 avoided all declamations and special pleadings regarding 
 the merits of that which I had to offer, in order that I 
 should have the opinion of the profession to guide me to 
 rational conclusions regarding the value of my work. 
 
vi PREFACE. 
 
 Having fared well in tLe past, I am perfectly satisfied 
 to leave the present effort to tlie judgment of those for 
 whom these pages were written — the thinking, reading, 
 working members of the medical profession. 
 
 My grateful acknowledgments are due to Dr. R. L. 
 Dickinson for taking charge of the illustrations, which 
 speak for themselves ; to Dr. W. H. Seymour for his val- 
 uable laboratoiy work and demonstrations of the process 
 of electro-hsemostasis ; and to Louis M. Pignolet, the maker 
 of the electrical instruments. 
 
CONTENTS 
 
 CHAPTER PAGE 
 
 I. — IXTRODUCTIOX 1 
 
 IT. — Descriptiox of ixstbuments 9 
 
 III. — Results of this hemostatic process 21 
 
 IV. — Electro-hemostasis in ovariotomy 30 
 
 Y. — ElECTRO-H.EMOSTASIS in myomectomy and abdominal HY'STERECTOMY 39 
 
 VI. — Electro-h^emostasis in OVARIO-SALPINGECTOMY 49 
 
 VII. — Electro-h^mostasis in appendectomy 57 
 
 VIII. — Treatment of cancer of the uterus by' the electro-cautery 
 
 and hemostasis 65 
 
 IX. — The electro-cautery in the treatment of pelvic abscess and 
 
 diseases of the vulva and vagina 85 
 
 X. — Electro-hemostasis in extirpation of the mammary^ and lym- 
 phatic GLANDS 95 
 
 XL — ElECTRO-H^EMOSTASIS in extirpation of tumors of the BLADDER . 102 
 
 XII. — The electro-cautery in the treatment of urethral affections. 113 
 
 XIII. — Electro-h.emostasis in the treatment of rectal hemorrhoids . 120 
 XIV. — The treatjient of neoplasms of the skin and mucous membranes 
 
 with the electro-cautery and electrolysis .... 129 
 
 XV. — Asepsis and antisepsis in surgery 136 
 
 XVI. — Asepsis and antisepsis (continued) 156 
 
LIST OF ILLUSTRATIONS 
 
 NO. PAGE 
 
 1. Electro-haemostatic forceps 9 
 
 2. Electro-haemostatic forceps chamber 10 
 
 3. Electro-haemostatic forceps chamber 10 
 
 4. Transformer 11 
 
 5. Flexible cable 12 
 
 6. Portable storage battery 14 
 
 7. Use of alternating street current . 15 
 
 8. Use of continuous street current 16 
 
 9. Portable battery with amperemeter 17 
 
 10. Artery, treatment of 19 
 
 11. Artery, macroscopic appearance 21 
 
 12. Artery, macroscopic appearance 22 
 
 13. Artery, macroscopic appearance 22 
 
 14. Artery, microscopic appearance 24 
 
 15. Artery, microscopic appearance . . .24 
 
 16. Fallopian tube, macroscopic appearance 26 
 
 17. Fallopian tube, macroscopic appearance 27 
 
 18. Omental adhesions 31 
 
 19. Artery forceps 32 
 
 20. The dome 32 
 
 21. Visceral protection during treatment 33 
 
 22. Intestinal adhesion . . . .34 
 
 23. Shield forceps for laparotomy 35 
 
 24. Small pedicle forceps for ovariotomy 35 
 
 25. Large pedicle forceps 36 
 
 26. Pedicle, treatment 37 
 
 27. Pedicle of fibroid, treatment 39 
 
 28. Sessile fibroid, incisions 40 
 
 29. Sessile fibroid, cuff of peritoneum 40 
 
 30. Dome controlling haemorrhages 41 
 
 31. Steps in treating stump in myomectomy 42 
 
 32. Treatment of broad ligament . .43 
 
 33. Treatment of broad ligament 44 
 
 34. Final treatment of vessels 45 
 
 35. Use of dome in sac of Douglas 47 
 
 36. Removing tube and ovary 54 
 
 37. Removing tube and ovary 55 
 
 38. Seizure in appendectomy 61 
 
 39. Treatment of mesentery 62 
 
X ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 NO. PAGE 
 
 40. Second seizure in appendectomy 63 
 
 41. Stump after appendectomy .63 
 
 42. Epithelioma of cervix 66 
 
 43. Epithelioma of cervix 66 
 
 44. Byrne's speculum 67 
 
 45. Byrne's speculum in position . . . . . . . . .68 
 
 46. Byrne's cautery loop 69 
 
 47. Byrne's special loop carrier 70 
 
 48. Passing loop around tumor 71 
 
 49. Diverging volsellum 73 
 
 50. Cautery knife 72 
 
 51. High amputation of cervix = ... 73 
 
 53. High amputation of cervix . . . 73 
 
 53. High amputation of cervix . , . . 74 
 
 54. Cervix excised 75 
 
 55. Dome electrode . ' . 75 
 
 56. High amputation of cervix . . . 76 
 
 57. Stump after removal of cervix 77 
 
 58. Cautery incision in vagina 77 
 
 59. Elytrotomy 78 
 
 60. Hysterectomy, treating broad ligament 79 
 
 61. Diagram of seizures in hysterectomy .79 
 
 63. Shield forceps for vagina 80 
 
 63. Hysterectomy, treating broad ligament 80 
 
 64. Hysterectomy, treating ovary and tube 81 
 
 65. Peritoneal sutures 83 
 
 66. Peritoneal sutures tied 83 
 
 67. Pedunculated tumor of bladder . 105 
 
 68. Protecting bladder wall 106 
 
 69. Treating urethral gland 116 
 
 70. Treating urethral gland 117 
 
 71. Ha?morrhoidal clamp .131 
 
 73. Operation for hiemorrhoids 133 
 
 73. Operation for haemorrhoids 133 
 
 74. Dickinson's oblique seizure of haemorrhoids 134 
 
 75. Treating fissura in ano 137 
 
 76. Ordinai'y window frame 144 
 
 77. Improved window frame 145 
 
 78. Ordinary door frame 146 
 
 79. Improved door frame 147 
 
 80. Improved door frame with wood trimming 148 
 
 Plate I — Reorganization of stump . facing 36 
 
 Plate II — Reorganization of stump 28 
 
ELECTRO-H^MOSTASIS 
 IN OPERATIVE SURGERY 
 
 CHAPTER I 
 
 I N T E O D U C T I N 
 
 In looking backward upon tlie evolution of surgical 
 lisemostasis, one of the most agreeably surprising steps ob- 
 served in the progress toward the ideal is the discovery 
 that an aseptic ligature can be inclosed in the tissues with- 
 out disturbing the healing process. Catgut ligatures, prop- 
 erly prepared and sterilized, soon answered all the require- 
 ments of the surgeon in so many operations that he has 
 been disposed since then to rest satisfied in the belief that 
 the ideal method had been attained, so vastly superior was 
 the new way to the old. Even at the present time one is 
 liable to be considered hypercritical and fastidious if he 
 questions the utility and competence of the surgery of the 
 day in controlling haemorrhage in incised wounds. Never- 
 theless, the modern ligature has its defects and failings 
 when employed in certain operations and in some con- 
 ditions. 
 
 Some of those who first used catgut as a ligature ac- 
 knowledge that it is difficult to sterilize and keep perfectly 
 clean, and that it is not altogether reliable in ligating blood 
 vessels in the pedicle of an ovarian tumor, for example 
 More recently it has been discovered that it is objection 
 able in wounds which are septic or contain necrotic tissue 
 Take, for example, a suppurating ovarian tumor or a pyo 
 salpinx : the broad-ligament pedicle is nearly always sep 
 
2 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 tic, and no matter how clean the ligature may be when 
 applied it soon becomes contaminated by contact with the 
 diseased tissue, and, being dead animal tissue, it adds of its 
 own seK to the field for the culture of bacteria. A ligature 
 thus contaminated is not absorbed, but acts as a foreign 
 body for the promotion of evil and the interruption of the 
 process of repair, and is responsible for the bad results 
 which have sometimes followed when I had operated ac- 
 cording to all the rules of modern surgery. Others have 
 had similar failures from the same cause, if I may judge 
 from cases which have come to my notice. On this account 
 catgut is the worst material that can be left in a wound 
 which is not perfectly free from germs of disease. Of minor 
 importance, but still worthy of notice, is the fact that dry 
 catgut is not very flexible and easily handled, and if softened 
 by immersion in a sterilized or antise^Jtic solution it stretches 
 or breaks, and can not be depended upon to close vessels 
 and hold them. This tendency to stretch is increased by 
 the softening which takes place while the ligature is in the 
 tissues, and therefore haemorrhage may occur. This has 
 happened in abdominal operations, and on that account 
 many operators, even in the early days of modern surgery, 
 preferred silk ligatures for much of their work. 
 
 If I mistake not, the majority of surgeons at the pres- 
 ent time use silk ligatures in ovariotomy, hysterectomy, and 
 similar operations ; and yet the silk ligature does not meet 
 all the demands of surgery. The objectionable features of 
 silk are, that it is not absorbed bat remains in the tissues 
 where it is placed, quiescent in many cases, but occasion- 
 ally causing much mischief. The unfavorable behavior of 
 the silk ligature has been so fully recognized by some of 
 the leading surgeons that they have raised the question 
 whether this non-absorbable ligature should ever be used 
 in abdominal surgery. Judging from my own limited ob- 
 servations and the meager records found in surgical litera- 
 ture on this subject, it appears that silk ligatures either 
 become encysted and remain where they are placed, or, 
 
INTRODUCTION. 3 
 
 becoming freed from the protecting exudate, wander about 
 until they are thrown out by the eliminative process of 
 suppurative or ulcerative inflammation. 
 
 Fine ligatures of silk applied to small blood vessels in 
 areolar and muscular tissue become walled in with repara- 
 tive exudates and may remain indefinitely, but those used 
 in abdominal operations are likely to work their way out 
 through the skin or escape into some neighboring viscus. 
 Under favorable circumstances the harmful action of silk 
 ligatures has escaped observation, owing to the fact that 
 they cause no trouble until long after recovery from the 
 operation in which they were employed. If the silk is 
 clean when used, no immediate disturbance of the jDrocess 
 of healing is caused, and so far silk appears to be a perfect 
 agent ; still, it is not so, for the necessary walling in of a 
 silk ligature requires more time than the disposal of an 
 absorbable ligature, and the quantity of new material left 
 in the wound surrounding the ligatures retards the process 
 of repair. On this account the tissues in the neighborhood 
 of the wound remain indurated, and do not regain their 
 elasticity and freedom from tenderness for a long time, even 
 when union takes place promptly and without sujipuration. 
 
 These facts regarding the slow recovery or repair caused 
 by the presence of silk in the tissue, and the disposition of 
 such ligatures to be thrown out in course of time, are illus- 
 trated in an extirpation of the mammary gland which occurred 
 in ray practice. The patient being spare of habit and to a 
 slight degree hsemorrhagic, more ligatures were required than 
 usual, and all of the fine silk on hand was used up, and so 
 one ligature of thick silk had to be used. Healing took 
 place without delay, but the tissues remained indurated and 
 irregular, and fixed to the wall of the thorax for a long 
 time. There were also slight pains at times and tender- 
 ness. Two years afterward the patient returned for advice 
 regarding an inflamed part about an inch in diameter, pre- 
 senting all the signs of a small abscess, situated about an 
 inch and a half from the original incision. The parts were 
 
4 ELBCTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 incised and a mass of exudate or scar tissue remov^ed with 
 a curette. In this mass I found the large ligature which 
 I had used in operating. The silk was in a state of good 
 preservation, and only the short ends of the ligature pro- 
 truded from the mass in which the ligature was imbedded. 
 The patient rapidly recovered, and there was no return of 
 the cancer one year and a half afterward. This shows 
 that the whole trouble came from the ligature and not 
 from the recurrence of the disease. 
 
 Were this all of the evil that can be charged fairly 
 against the silk ligature one might rest satisfied, but 
 worse follows the use of ligatures of all kinds in abdom- 
 inal and pelvic surgery. Ligatures apj)lied to the broad- 
 ligament pedicles of ovarian tumors and Fallopian tubes 
 are guilty of much wrong-doing. For example, unless 
 the conditions are unusually favorable, the pedicle of 
 an ovarian tumor can not be tied tightly enough to close 
 the arteries in the way that surgeons say they should be 
 ligated to make sure of controlling haemorrhage with cer- 
 tainty. There is a liability, in thick pedicles, for the 
 tissues to shrink under the pressure of the ligature and 
 permit the vessels that have been temporarily closed to open 
 again and allow bleeding to take place. This inefficiency 
 of the silk ligature has been observed by Dr. Howard A. 
 Kelly, so that he has adopted the method of ligating the 
 pedicle in two sections, by including the ovarian arteries 
 in one ligature and the tubal and uterine side of the 
 pedicle in the other, and in addition to that he also ligates 
 the larger vessels in the end of the stump. 
 
 Whenever the tissues of the pedicle are rendered friable 
 by disease or degeneration, it is well-nigh impossible to con- 
 trol haemorrhage with a ligature of any kind. Silk is as 
 bad as or worse than anything else, for it cuts the tissues if 
 tied as tight as possible without breaking. 
 
 These are some of the charges which can be brought 
 fairly against the silk ligature as a means of immediately 
 and permanently arresting haemorrhage. The subsequent 
 
INTRODUCTION. 
 
 behavior of the ligature, and the character of the stump to 
 be repaired after ligation, are still more unsatisfactory to 
 both the patient and the surgeon. The pressure of the 
 ligature upon the nerve tissue and the traction of the parts 
 toward the point of constriction, especially in a short, 
 broad pedicle, cause irritation and pain. There is a large 
 mass of tissue projecting beyond the ligature which has to 
 be disposed of by a process of degeneration and absorp- 
 tion ; the ligature and the tissue of the pedicle beneath it 
 have to be closed in by a deposit of plastic material, which 
 in time is disposed of by absorption, and the ligature set 
 fi'ee. During all these weeks or months required to com- 
 pletely repair the stump there is oftentimes considerable 
 pain and distress in the site ; nothing dangerous or alarm- 
 ing but annoying. Not infrequently when a diseased Fallo- 
 pian tube forms part of the pedicle there is a secondary 
 attack, maybe several, of inflammation in the stump, caused 
 by the tube remaining open and giving out septic material. 
 These sequelae have passed unnoticed by many surgeons, 
 and are lightly spoken of by others, presumably because 
 there was no danger to the life of such patients ; but the 
 best operators have given attention to the subject, and, 
 having watched their results with scientific accuracy, have 
 observed these results and recorded them. 
 
 What becomes of silk ligatures that are left in the 
 peritoneal cavity is a question of vast importance. One 
 opinion which for a long time prevailed was that a silk 
 ligature applied to a broad-ligament pedicle becomes en- 
 cysted and remains quiescent for all time. Exceptions to 
 this rule were admitted, and were accounted for by some 
 unclean operating or a septic ligature that caused suppura- 
 tive inflammation in the stump by which the ligature was 
 set free or found its way into some neighboring viscus. 
 This is almost altogether incorrect. Occasionally it may 
 happen that a ligature becomes firmly fixed to the broad 
 ligament by an exudate and remains imbedded for all time, 
 but that, I believe, is the exception, not the rule. 
 
6 ELEOTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 This very interesting question of tlie disposal of silk 
 ligatures, as a rule, has not yet been answered fully, so far 
 as I can ascertain. Guided by my own experience, I be- 
 lieve, as already stated, that ligatures left in the peritoneal 
 cavity are at first encysted and finally liberated, and remain 
 in the peritoneum or escape through some of the viscera or 
 the abdominal wall. So many cases of this kind have been 
 reported that I need say nothing on that subject, except 
 that they make their exits by being first set fi'ee fi'om the 
 plastic stuff that surrounds them and travel outward by a 
 pi'ocess of ulceration or suppuration and necrosis of the 
 tissues in the way of their outgoing. At least that is the 
 way of it according to my own observations. 
 
 By way of illustrating what has been said about liga- 
 tures being set free in the peritoneal cavity, I give the 
 history of a specimen brought to my clinic at the New 
 York Post-Graduate School by Prof. F. Ferguson. The 
 patient from whom the specimen was obtained died of some 
 thoracic disease, and while making the autopsy Professor 
 Fero;uson learned that she had had her ovaries and tubes 
 removed about one year prior to her death. The pelvic 
 organs were removed entire, and I had every facility for 
 their examination. The stumps were rounded off even 
 with the posterior surface of the broad ligaments, showing 
 that all that portion of the stumps outside of the ligature 
 had been disposed of, and also the exudate that had been 
 thrown around the ligatures to inclose them. The ends of 
 the tubes were open. The ligatures of thick silk were 
 found in the most dependent part of the sac of Douglas, 
 quite free fi'om, but resting upon, the thickened peritoneum. 
 The thickening of the peritoneum in the sac resulted from 
 cellular proliferation and exudation, jDOSsibly brought about 
 by irritation arising fi^om the presence of the ligatures. 
 What would have become of the ligature finally, if the 
 patient had lived, I know not. 
 
 From among a number of cases recorded in which the 
 ligature migrated I give the following : The patient had 
 
INTRODUCTION. Y 
 
 s, severe puerperal peritonitis followed by chronic ovaritis 
 and varicose veins of the broad ligaments. This, with very 
 extensive old adhesions of all the j^elvic organs, caused so 
 much suffering that it became necessary to operate. The 
 tubes and ovaries were removed, the veins closed, and ad- 
 hesions separated. One ovary and tube were found high 
 up and held in this abnormal position by adhesions. When 
 these were ligated and removed the stump rested near the 
 lower part of the wound in the abdominal wall. The 
 recovery was quite favorable, but about two months after 
 the patient was dismissed she returned, complaining of 
 pain in the scar near its lower end. The scar at that point 
 was stretched, and there was a slight protrusion, not un- 
 like a beo-innino; hernia, but there was some fluctuation and 
 flatness on percussion, which led to a diagnosis of abscess. 
 An opening was made and a small amount of serum and 
 tissue debris escaped, but not any visible pus. The sinus 
 was washed out, but it would not close. A little serous dis- 
 charge continued for six weeks or two months, when she re- 
 turned for treatment. Suspecting the presence of a ligature 
 that had escaped from its environing exudate, it was fished 
 out with a blunt hook, and then healing soon closed the sinus. 
 Having observed these disappointing actions of liga- 
 tures, I naturally looked for something better in surgical 
 hsemostasis. This I found in the work of Dr. Thomas Keith, 
 who taught me his method of treating the pedicle in ovari- 
 otomy by the clamp and cautery, which in theory and prac- 
 tice was most satisfactory. No doubt this feature of his 
 operating contributed largely to making him the most suc- 
 cessful ovariotomist of his time. The experience of years 
 and a large number of operations in which his method was 
 used has fully confirmed my confidence in this way of 
 controlling haemorrhage. The method of treating the 
 pedicle of ovarian tumors employed by Keith and his 
 followers was never adopted by surgeons in general. This 
 was due, apparently, in part, to ignorance of the principles 
 of the method, but more especially to the diflficulties in the 
 
8 ELECTEO-H^MOSTASIS IX OPERATIVE SUR&ERY. 
 
 tecliniqne cf tlie procedure. Many belie\'ed. and still be- 
 lieve, tliat it wa.s necessary to char the stump with the cau- 
 tery in order to stijp the Ijleeding : Ijiit the fact is, Keitli 
 applieil a clamp witli Ijroad jaws to the pedicle and com- 
 pressed it strr^ngly. an<l then apjdied a large cauterv iron 
 to the upper sifle <ji the cktmp until the instiTunent was 
 heateil sufficiently to desiccate the tissues and not to char 
 them. This required much time and lar2"e experience in 
 handling the cautery irr^n. in crder tC) rjl^tain the desTee of 
 heat necessary ami t'j kn^iw the length of time it should 
 be apjjlied. In other words, to treat a bi'-o ad -ligament 
 pedicle in this way reijuired a knr.wledge and Judo-ment 
 that but few had the patience to acipdre. 
 
 I cijnfe-s that I was n'jt sure ijf niv wr»rk in mv tirst 
 operations, and sometimes applied a light li2"ature to feel 
 safe before I dared return the stump intu the abdominal 
 cavity. A^ hen civarioti;any Ijecame impr-jved, so that better 
 results Avere oljtaineil. anil material f':ir ligatures was made 
 aseptic and m<:ire ay)prripriate. I gave iij) the clam|:i and 
 catiterv and tised the ligattire : Ijiit I was never satisfied 
 Avith the results, and earnestly sijiight to overcome the 
 ob]ectii:in to the clamp and heat to ci;»ntrrd htemorrhage — 
 namely, the application ni the heat ^uppl}'. While thiuk- 
 ino; of h<jw tij riverci'jme these difficulties, my attention was 
 calleil trj the tise oi electricity in heatiuo' laundiy smoothing 
 irons. It then <;iecurred to me t'j a<la}it the same heating 
 power X'\' -uroieal instruments, such as the clamp and forceps. 
 
 My re<juirements in this regard were exjdained to Mr. 
 Louis M. Pio'nolet. an electrician, who has given much 
 attenti'iin t^ electricitv as tised in medicine and surgery. 
 He at once took u|» th^ -tudy uf the subject Avith enthu- 
 siasm, and soon |:iri>;lueed the in-truments ami a}:)pliances re- 
 (juired. He fir>t made an artery forceps, then a clamp, and 
 linally a full set >:d h,*mr)Stati(j instruments. I should say 
 that it was his adaptation -jf the -ysteni of electric heating 
 t(» these instruments, wliich enabled me to employ the 
 method for the cijntr<:il <A Ijleeiling in all -urgical operations. 
 
CHAPTER II 
 
 DESCRIPTIOX OF LXSTEOIEXTS 
 
 The followiug description of the instruments is given 
 by Mr. Pignolet. 
 
 In tliese forceps tlie lieat is generated by the passage 
 of an electric current thi'ougli a resistance wii'e in a cham- 
 ber in one of the jaws, for it has been found to be suJfficient 
 to heat but one of them. 
 
 The method of heating is simple, and is applicable to 
 forceps of various forms and sizes since the mechanism 
 of the instrument is not altered by the electiical attach- 
 ments. The construction is shown bv the illustrations, of 
 
 Avhich Fig. 1 is a side view of a compression forceps heated 
 on this pi'inciple. Fig. 2 is a longitudinal section, and Fig. 
 3 a top view of the heated jaw on an enlarged scale, with 
 the cover D and the insulatins; material 6' removed. 
 
 A resistance wire, A^ is located at the bottom of the 
 chamber, close to the face of the jaw, fi'om which it is 
 
10 
 
 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 insulated by a thin layer, i?, of fireproof material. The 
 chamber above the wire is filled with an electrical insulator, 
 Cj which is also a non-conductor of heat, such as asbestos, 
 and is closed water-tight by the sheet-metal cover D. One 
 end of the resistance \vire is connected to the jaw, and the 
 other to an insulated copper vdre, E^ placed in a metal 
 
 tube, F^ which extends 
 from the chamber to the 
 
 fi metal block, G^ attached 
 to the handle of the for- 
 
 FiG. 2. 
 
 ceps. Here the copper wire is connected to an insulated 
 terminal, H, mounted in the block. A similar terminal, I^ 
 is attached directly to the block and is uninsulated. By 
 this method of construction the electrical wires are incased 
 in metal, so that the forceps can be sterilized and handled 
 without injury, the same as an ordinaiy instrument. Start- 
 ing at the insulated terminal, the path of the cuiTent is 
 through the copper wire and the resistance wire to the 
 tip of the jaw, thence through the blade of the forceps 
 to the uninsulated terminal. The copper wire and the 
 blade of the forceps form a path of good electrical conduc- 
 tivity, and are consequently but very slightly heated by the 
 passage of the current used. On the other hand, the wire 
 in the chamber is a poor conductor, and is heated to a 
 greater or less degree according to its resistance and the 
 strength of the current. 
 
 The electrical energy required to heat the forceps varies 
 from ten to thirty-five watts, according to the size of the 
 instrument, and is less than that required by the ordinary 
 cautery electrodes. A 
 storage or primary bat- 
 tery that will heat the 
 electrodes will gener- 
 ally answer for the 
 forceps ; Ijut, as all batteries require care to keep them in 
 working order, the use of the electric light or power cur- 
 rent from a dynamo is preferable wherever it is available. 
 
 Fig. 
 
DESCRIPTION OF INSTRUMENTS. 
 
 11 
 
 The dynamo current can be used througli a controlling 
 rheostat, or, if the current be alternating, through a trans- 
 former capable of furnishing a low voltage current of vari- 
 ous strengths and pressui'cs to suit the different forceps. 
 A special advantage of the transformer is that the cui-rent 
 for use is of very low pressui'e, and is generated in an insu- 
 lated coil of wire by the inductive action of the dynamo 
 current which flows through an adjacent coil. If the wires 
 or connections be accidentally touched, nothing is felt on 
 account of the low pressure of the transformer current, but 
 with a rheostat under similar conditions a disagreeable 
 shock might be experienced. Furthermore, the insulation 
 
 Fig. 4. 
 
 between the two coils prevents leakage of the high-j^ressure 
 current to the low-pressure circuit, so that freedom from 
 shocks is insured. If the djmamo current be continuous, 
 the transformer can be used by converting the continuous 
 into an alternating current, by means of a small rotary 
 transformer. 
 
 An eflS^cient and convenient type of transformer is rejDre- 
 sented by Fig. 4. It will furnish current for heating the 
 forceps, and for all sizes of cautery electrodes, as well as 
 for lighting small incandescent lamps. The pressure and 
 quantity of the current is increased by moving the switch 
 
12 
 
 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 arm to the right from one contact button to the next until 
 the ]3roper amount is obtained. By noting the contact at 
 which the desired heat is developed for a particular for- 
 ceps, the switch may be set at that point, and the forceps 
 used with the certainty that the heat will be suitable. 
 
 As shown by Fig. 5, one end of the flexible cable for 
 conveying the electric current to the forceps is inclosed in 
 
 a soft - rubber tube, 
 and is provided with 
 two hollow metal 
 sleeves, Z K, which 
 are mounted in a 
 piece of insulating 
 material, and are 
 adapted to slip over 
 the two terminals, 
 I IT, of the forceps. 
 Each sleeve is insulated from the other, and is connected 
 with one of the two conductors composing the flexible 
 cable. 
 
 Fig. 5. 
 
 DIEECTIOlSrS FOE USINa THE ELECTRICAL FORCEPS. 
 
 The method of arresting haemorrhage with these for- 
 ceps consists in firmly compressing a portion of the bleed- 
 ing tissues or the end of a vessel between the jaws of the 
 instrument, in order to expel as much of the moisture as 
 possible, and then desiccating the compressed tissues by 
 heat generated in the jaws by the electric current. In 
 this way the walls of the arteries become united and 
 haemorrhage is effectually prevented. . The temperature 
 required for desiccation is fi^om 180° to 190° F., which is not 
 high enough to char or burn the tissues, but simply to 
 desiccate or cook them. 
 
 The forceps are sterilized in the same manner as the 
 ordinary instruments, but after removal from the sterilizer 
 it is not advisable to place them immediately into cold 
 water, while they are hot, as the contraction of the heated 
 
DESCRIPTION OP INSTRUMENTS. 13 
 
 air inside may eventually cause water to enter at the insu- 
 lated terminals. After sterilizing, a little sterilized vaseline, 
 or similar preparation, is rubbed over the inner faces of 
 the jaws of the forceps to cover them with a thin film, 
 which will prevent the tissues from adhering to the instru- 
 ment. The iTibber-covered end of the electrical cable is 
 sterilized in boiling water and afterward wrapped in a 
 sterilized towel or immersed in an antiseptic solution — such 
 as a five-per-cent carbolic solution — until needed. Bichlo- 
 ride of mercury should not be used, as it attacks the metal 
 sleeves at the end of the cable. 
 
 In aj)plying the forceps, all the tissues to be treated 
 should be firmly compressed between the heated jaws of 
 the instrument, for if a portion extend beyond, a second 
 application will be necessary. Before the electric current 
 is turned on, a piece of gauze or a shield is applied where 
 needed between the forceps and the adjacent tissues to 
 protect them from injury by contact with the hot instru- 
 ment. Tissues which do not touch the jaws require no 
 protection. 
 
 The two connector sleeves at the end of the flexible 
 cable are then slipped over the two terminals on the end 
 of the forcej^s and pushed firmly into place to make a 
 good electrical connection. If the electric current has been 
 previously turned on, the putting of the connector sleeves 
 into place completes the circuit and establishes the cur- 
 rent ; but if this has not been done, the current is now 
 turned on. 
 
 The method of connecting the forceps to the battery 
 or transformer, which may be used as a source of electricity, 
 is plainly shown by Figs. 6, 7, 8, and 9, so that no expla- 
 nation is needed. The current required to properly heat 
 the forceps is noted for each one made. Therefore, it 
 can be regulated to suit the forceps from the indications 
 of an amperemeter included in the circuit to measure the 
 strength of the cun-ent. This is the best way ; but if no 
 amperemeter be convenient, experiments upon a piece of 
 
14 
 
 ELECTRO-H^MOSTASIS IX OPERATIVE SURGERY. 
 
 raw meat will enable one to regulate tlie current to suit 
 tlie forceps, so that desiccation is obtained in the proper 
 time. Experience will enable the operator to tell if the 
 
 Forceps. 
 
 Fig. 6. — Forceps heated by the electric current from a storage battery. 
 
 temperature be right by touching the forceps from time to 
 time ; tliis can be done without pain as the lieat is concen- 
 trated upon the inner surfaces of the jaws, and tlie other 
 parts of tlie instrument are not as hot. One setting of a 
 transformer or of the rheostat of a storage battery will be 
 sufficient, if the same adjustment be made in subsequent 
 operations ; but the battery should not be used when its 
 charge is nearly exhausted, if uniform results are desired, 
 unless an amperemeter be employed. For the same reason, 
 the transformer should be fed by an electric-light current, 
 as this has an almost constant pressure, and not by one 
 used exclusively for power, as such a current is subject to 
 considerable changes of pressure. An amperemeter should 
 be used with the ordinary primary battery for the polariza- 
 tion, as the varying strength of the exciting fluid prevents 
 it from being adjusted so as to furnish a current of uniform 
 strength. 
 
DESCRIPTION OF INSTRUMENTS. 
 
 15 
 
 Before removing tlie forceps, the tissues projecting be- 
 yond its jaws are cut oif, whidi may in some cases be done 
 while the heat is being applied, in order to save time. 
 There being danger of losing sight of the stump by its 
 dropping back into the abdominal cavity, as for example 
 may happen in ovariotomy, the tissues on the under side 
 of the jaw^s should be grasped by a shield or compression 
 forceps to hold the stump in place for inspection. The 
 electrical forceps is then carefully opened far enough to 
 allow the desiccated stump to slide out from between the 
 jaws in the direction of the teeth. Care in this is impor- 
 tant, for if the tissues should adhere to the instrument, 
 which may happen if vaseline be omitted, they might be 
 torn apart and a ragged stump be left. 
 
 Socket dndlP/ug: 
 
 Fig. 7. — A transformer connected by a cable and plug to an incandescent lamp 
 socket on an alternating electric-light circuit, and heating a forceps by the 
 low-pressure current generated in its secondary. 
 
 Before using the forceps for the first time, it is instruct- 
 ive to experiment with them on a piece of raw meat, so 
 as to become familiar with their action, as well as to ascer- 
 
16 
 
 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
DESCEIPTION" OF INSTRUMENTS. 
 
 17 
 
18 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 tain whether the source of electricity is suitable and can be 
 properly controlled. 
 
 Absence of bleeding upon the removal of the forceps 
 shows that the desiccation has been effective, and the 
 stump can be left without fear of secondary haemor- 
 rhage. The occurrence of bleeding immediately upon 
 the removal of the forceps indicates that the desiccation 
 has been insufficient, or that some of the tissues have 
 escaped the grasp of the forceps. In this event, reap- 
 ply the forceps to the stump and repeat the heating, 
 giving about ten per cent more current, or continuing 
 the heat for a longer time if the bleeding has been due 
 to insufficient desiccation. 
 
 The time required for desiccation varies from a half 
 to two minutes, according to the thickness of the com- 
 pressed tissues or size of the arteries, two minutes being 
 required for the ordinary ovarian pedicle and the broad 
 ligament. If desired, or if the tissues be very thick, the 
 current can be continued for three or four minutes, or even 
 longer without danger, on account of the low temperature. 
 When the time of application has expired, the current can 
 be shut off by a switch or by removing the connector from 
 the forceps. The desiccation can be hastened by starting 
 with more than the usual current, and continuing the 
 greater current for about a third of the time of applica- 
 tion. For example, if the current necessary to properly 
 heat the forceps is ten amperes and the time of applica- 
 tion is two minutes, give twelve amperes for about forty 
 seconds, then decrease to ten amperes for the rest of the 
 time. It is well to commence with the forceps closed 
 on the first notch of the lock, and after the heat has 
 been applied for about half a minute and the tissues 
 have begun to shrink to close the instrument fully. In 
 this way the greatest possible compression of tissues is 
 obtained. 
 
 In the treatment of isolated arteries the end of the 
 vessel is grasped by a tenaculum, and the electric artery 
 
DESCRIPTION OP INSTRUMENTS. 19 
 
 forceps applied crosswise, or the artery is seized by tlae 
 electric forceps in the same manner as with an ordinary 
 artery forceps when a ligature is to be used. Isolated 
 arteries, or those inclosed in a mass of tissue, when treated 
 by this method are so thoroughly and completely closed 
 that they can not be opened up again either by blood 
 pressure or the most critical dissection. This has been 
 clearly observed and fully demonstrated both clinically and 
 by laboratory experiments. 
 
 The end of an artery or the stump of a pedicle when 
 thus treated resembles parchment in gross appearance. 
 The thickness depends upon the size of the vessel or mass 
 of tissue treated. A large uterine artery is reduced to 
 about a line in thickness, and an or- r- 
 dinary broad-ligament pedicle to less j i , 
 
 than an eig^hth of an inch in thickness. , ^ 
 
 See Fig. 10. The part is translucent | ' ' Ij \\ \ 
 and structureless, and thus enables the | ^> ,■ 
 
 surgeon to tell at a glance when the I 
 treatment is incomplete, by observing; b; " „ , , ,, ' 
 
 ^ . '' " Fig. 10. — An artery from 
 
 the vessels that remain unclosed ; he fresh beef closed solidly 
 
 , , ,i,,i nij_bv author's method in 
 
 knows then that the pressure and neat half a minute. Seen in 
 should be reapplied to complete the SoT'l ile size"! '"^ '''' 
 haemostasis. 
 
 Occasionally in treating a thick mass of tissue the 
 central portion of it becomes heated before being fully com- 
 pressed, and the blood is coagulated in the vessels and leaves 
 dark strips or general staining of the tissues, which causes 
 some opacity in the parts. As a rule, however, the blood 
 is pressed out of the vessels before the desiccating begins, 
 and the stump is sufficiently translucent to enable the 
 operator to see any vessel that has escaped. The indica- 
 tions or requirements for closing vessels are in this way 
 thoroughly fulfilled by the complete fusing together of the 
 walls of the vessels so that they do not, in fact can not, 
 come apart. This I have demonstrated again and again. 
 While I found in my first observations that the hsemostasis 
 
20 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 was immediately complete, I was suspicious tliat when the 
 tissue became softened by absorbing moisture the vessels 
 might open up and subsequent bleeding might return, but 
 many clinical experiences and experiments settled that 
 question beyond all doubt. 
 
CHAPTEE III 
 
 RESULTS OF THIS HEMOSTATIC PEOCESS 
 
 To my clinical observations I liave the satisfaction and 
 pleasure of adding an experiment made by Dr. R. L. 
 Dickinson. He placed a mass of tissue, one jDart of whicli 
 was treated by this method, into non-sterilized water and 
 
 Fig. 11. — A, untreated end; B, desiccated end. 
 
 let it remain immersed for about seventy-two hours. At 
 the end of that time the tissue not treated was a soft pulpy 
 mass that broke down under pressure of the iingers ; while 
 the desiccated portion remained iirai, though somewhat 
 softened by the water, but with no separation of its com- 
 ponent parts, neither could he iind any part w^here cleavage 
 
 21 
 
22 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 or dissection could be made. I have repeated this experi- 
 ment many times with the same results. 
 
 Fig. 12.— Section through A, Fig. 11: a, endothelial cells (intima); b, subendo- 
 thelial layer (intima); c, internal elastic membrane (intima); d, media; e, 
 adventitia ; /, lumen of artery. 
 
 EiG. 13.— Section through B, Fig. 11 : a, tunica adventitia ; b, tunica media : 
 c, tunica intima ; d, line of closed lumen. 
 
RESULTS OF THIS HEMOSTATIC PROCESS. 23 
 
 Finally, I may state tliat I have employed this method 
 in over two hundred abdominal operations, and in many 
 vaginal hysterectomies and other operations, and have 
 never had secondary haemorrhage in any of them. 
 
 These are the facts regarding the method as an haemo- 
 static. There still remains the question of the subsequent 
 behaviors of the ends of the vessels and the tissue thus 
 treated — in other v^ords, the process of repair. 
 
 From all the facts that I could gather on this subject 
 in actual practice, I concluded that the desiccated tissue 
 became first hydrated and then reorganized, and remained 
 as permanent structure, closing for all time the ends of the 
 blood-vessels, lymphatics, and canals so treated. There 
 was still an uncertainty on this point, until Dr. W. H. 
 Seymour, the pathologist to my department in the college, 
 conducted a series of independent experiments in the 
 Hoaglancl Laboratory. The account of these observations 
 and experiments by Dr. Seymour and the illustrations 
 made under his supervision are as follows : 
 
 In the first place, the doctor observed that an artery 
 a quarter of an inch in diameter was reduced to about a 
 twelfth of an inch in thickness (see Figs. 11, 12, 13), and 
 that the structure of the tissues was rendered amorphous by 
 the heat and pressure. The lumen of the artery was oblit- 
 erated completely, so that no trace of its original structure 
 could be found. (See Figs. 14, 15.) A piece of tissue, con- 
 taining arteries, nerves, fibrous, muscular, and areolar tissue, 
 was treated in the same way and presented the same amor- 
 phous appearance and complete closure of the arteries. So 
 completely fused together were the walls of the lumen of 
 the arteries that no trace of the original structure could be 
 found, neither could the lumen be reopened by teasing the 
 microscopic specimen. 
 
 Observations were made of sections of the Fallopian 
 tubes, appendix vermiformis, ureters, and other canals 
 lined with mucous membrane, and the same amorphous con- 
 ditions were found. The structure of the mucous mem- 
 
 3 
 
24: 
 
 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 brane was so completely changed that no part of its original 
 structure could be found by microscopical examination. 
 
 Fig. 14 (under low power). — 1, desiccated end ; a a', line of desiccation ; b, lumen 
 of artery ; c, tunica intima ; d, tunica media : e, tunica adveutitia. 
 
 Fig. 15 (under high power). — 1, desiccated end ; 2, untreated ; a a', line of desic- 
 cation ; b, remains of lumen. 
 
RESULTS OF THIS HEMOSTATIC PROCESS. 25 
 
 The thorouglmess of the closure of the arteries was 
 demonstrated by attaching a fountain syringe to the opening 
 of the artery and using double the ordinary blood pressure 
 without opening the closed end of the vessel. 
 
 The advantages that may be fairly claimed for this wav 
 of controlling bleediog in surgery are, that it is certain and 
 reliable in closing isolated vessels or those imbedded in 
 masses of tissue, like an ovarian-tumor pedicle for example. 
 At the same time that bleeding is arrested, all lymphatics 
 are sealed up, which prevents septic absorption. The 
 tissues of the stump are reduced to the smallest possible 
 size, and there are no raw surfaces left to form adhesions 
 to the abdominal or pelvic viscera, nor any foreign sub- 
 stance left in the tissues to cause mischief, advantages that 
 can hardly be overestimated. 
 
 Tissues which have become friable by disease and can 
 not withstand sufficient pressui'e of a ligature to control 
 bleeding are easily managed by this method. When the 
 tissues that form the pedicle of a suppurating ovarian cys- 
 toma or a pyosalpinx contain septic germs, a condition in 
 which the ligature is most objectionable, a better and much 
 safer stump can be made in this way. A ligature used 
 when the tissues are in this condition, especially a catgut 
 one, is very objectionable, for the dead animal tissue of 
 such a ligature forms a perfect medium for the development 
 of disease germs. It is also the only way that canals lined 
 with mucous membrane — the Fallopian tube and the appen- 
 dix veiTQiformis, for example — can be permanently closed. 
 This will be referred to when discussing special operations. 
 
 Nerves that accompany the vessels are immediately de- 
 vitalized, and hence there is less pain and irritation in the 
 stump. The heat employed sterilizes the parts involved, 
 and therefore the operation is perfectly aseptic. To these 
 many advantages may be added that it leaves the stump 
 of a pedicle or the end of an artery in a condition re- 
 quiring the least reparatory care, so that recovery is more 
 prompt, uneventful, and complete. 
 
26 
 
 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 Macroscojjic and Microscopic Appearances of the Fallopjian Tube 
 treated icith the Electro-hcemostatic Forceps. 
 
 These observations have been made on two stumps, taken from canine subjects, 
 at the end of the third and tenth day of the healing process, following laparotomy. 
 
 In each instance, prior to the application of the forceps, careful antiseptic 
 measures were followed out in the exposure of the tube and uterus. The haemo- 
 
 OPPOSITE 
 
 TUBE 
 
 STUMP 
 °^ TUBE 
 
 CEIRVIX 
 
 Fig. 16 represents the tube removed at the end of the third day of the healing 
 
 process. 
 
 static forceps of the smallest size was placed on each stump for one minute, and 
 an electric current used of sufficient strength to raise the temperature of the for- 
 ceps to 180'. 
 
 Macroscopic Appearance (Fig. 16). — The forceps was placed about half an inch 
 from the bifurcation of the uterus on the Fallopian tube, broad ligament, and blood- 
 vessels. At the point of application is noted a constriction corresponding in width 
 to the cautery clamp, on the surface of which are numerous corrugations which 
 correspond to the same in the blades of the instrument. A decided compression 
 is shown to exist at the point of application, and also a quantity of recent lymph 
 
RESULTS OF THIS HAEMOSTATIC PROCESS. 27 
 
 and solid exudate found over the free end of the stump. Considerable ecchy- 
 motic haemorrhage is noticed at the uterine end of the area treated with the haemo- 
 static forceps. The free end of the tube is seen to be softened, and corresponds 
 in appearance with what might be expected in the earlier stages of coagulation 
 necrosis. 
 
 On an examination of the lumenal portion, macroscopically, the canal is seen 
 to be obliterated. 
 
 Microscopic Appearance (Plate I, Fig. 1, longitudinal section). — Under the low 
 power (Plate I, Fig. 2) the mucosa and submucosa are everywhere infiltrated with 
 countless small round cells ; the blood-vessels are obliterated, their lumena being 
 compressed. The free edges of the mucous membrane are seen to be in apposition, 
 no distinct line of demarcation (lumenal) being apparent. Considerable softening 
 exists in the outer portions of the wall of the oviduct. The small round cells 
 can, with little difficulty, be traced far back into the muscular layers of the organ. 
 
 Under the high power (Plate I, Fig. 3) are seen countless small round cells of 
 the reparative process, intermingling with which are also fine fibrous elements sur- 
 rounding small and large areas of coagulation necrosis. On studying the lumenal 
 portion of the mucous membrane the small round cells of one surface seem to 
 merge or blend with those of the opposite, thus preventing the recognition of the 
 lumenal margin of the mucous membrane. 
 
 Macroscopic Appearance (Fig. 17). — The tube resembled, in its treated portion, 
 that of the third-day specimen, the treated area, however, being much duller in 
 
 * -rrm 
 
 %. 
 
 • iBmJVi ''i^BIl l^mL -^^m i^H sB 
 
 
 m jSm i \bSSS0^^'^'^ 
 
 
 FIVE TIMES LIFE SIZE. 
 
 
 Fig. 17 represents the tube removed at the end of the tenth day of the healing 
 
 process. 
 
 outline, firmer over its end, and containing much less softened material and lymph 
 than in the former specimen. The lumen can not be macroscopically identified. 
 
 Microscopic Appearance. — A section was made of a portion of the oviduct 
 through tlie lumen and mucosa, longitudinally, at the point of application of the 
 
28 
 
 ELECTRO-HiEMOSTASIS IN OPERATIVE SURGERY. 
 
 
 g a 
 
 g ^ 
 ^ ^ 
 
 c 2 
 
 P5 
 
 be 
 
RESULTS OF THIS HEMOSTATIC PROCESS. 29 
 
 haemostatic forceps. The duller portion represents marked areas of coagulation 
 necrosis, together with some haemorrhage by diapedesis, shown in adjacent neigh- 
 borhoods. 
 
 The mucos;T3 of the two walls of the tube are seen to be in contact, thus produc- 
 ing actual obliteration of the lumen of the tube due to active jyroliferation of the 
 cells of the mucosa and infiltration of small round cells. 
 
 Plate II, Fig. 1, represents one of the areas of coagulation necrosis in the more 
 superficial portion of the mucous membrane. Plate II, Fig. 2, represents a smaller 
 area more highly magnified, showing countless small round cells from infiltration 
 processes. 
 
CHAPTER lY 
 
 ELECTEO-H^MOSTASIS IJST OVARIOTOMY 
 
 The part of this work relating to tlie management of 
 hsemorrhage in abdominal and pelvic surgery is of necessity 
 fragmentary, as it treats of hsemostasis in this class of ojDer- 
 ations only. In describing this method of arresting the 
 haemorrhage which occurs when making the abdominal 
 section, separating adhesions, and treating the pedicle in 
 ovariotomy, I shall follow the steps of the operation in the 
 order in which they have just been named. 
 
 The Jiijemorrhage in ahdonmial section comes mostly 
 from the vessels of the skin, and should be arrested if at 
 all free before dividing the deeper stmctures. The vessels 
 should be seized with the artery haemostatic forceps and 
 heated under pressure until they are closed. The method 
 of treating small vessels in incised wounds is fully de- 
 scribed under the head of extirpation of the mammary 
 gland, which will be described in a later chapter. If the in- 
 cision in the deeper structures of the abdominal wall is 
 made in the median line, as it should be, and the large 
 veins that are sometimes found in the peritoneum are 
 avoided, no important haemorrhage occurs. The advan- 
 tages of treating bleeding vessels in this part of the oper- 
 ation are that no ligatures are left in the wound, and the 
 injury of tissue caused by twisting the arteries or bruising 
 them wdth compression forceps is avoided, and therefore 
 the tissues are left in a better condition to heal promptly. 
 It is my opinion that this is a very important factor 
 guarding against subsequent ventral hernia. 
 
 30 
 
ELECTRO-H^MOSTASIS IX OVARIOTOMY. 
 
 31 
 
 Adhesions of the omentwni to the cyst wall or tumor are 
 treated by making traction upon the cyst wall to bring it 
 and the adherent portion of the omentum out of the ab- 
 dominal wound. A narrow-bladed forceps is applied to 
 the omentum, close to the cyst wall, and the portion in the 
 grasp of the forceps heated under pressure until fully 
 desiccated. The portion thus treated is divided near to 
 the cyst wall but in the line of desiccation. See Fig. 18, 
 which shows a part that has been treated and divided, and 
 another portion in the grasp of the forceps. In cases hav- 
 ing a large portion of the omentum surface attached the 
 adherent part can not be brought out of a small-sized 
 
 Fig. 18. — The treatment of omental adhesions. 
 
 wound far enough to reach the free portion to be separated. 
 In such conditions the incision should be enlarged suffi- 
 ciently to facilitate the operator's manipulations partially 
 Avithin the abdominal ca\dty. Great care is necessary in 
 such cases to protect the intestines from the heat while the 
 forceps is being used. Fortunately such adhesions are veiy 
 rare. The omentum being thin and the vessels small, only 
 about twenty to thirty seconds are requii'ed to close them. 
 In rare cases, when the omentum is thickened by inflam- 
 mation, and the vessels very much enlarged, a minute of the 
 heat may be required. 
 
32 
 
 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 Fig. 19. — Artery forceps. 
 
 Adhesions of the A'p'pendix Vermiform is. — The appendix 
 is found adherent in pyosalpinx quite frequently, and is 
 discussed in connection with that subject. Suffice it to say 
 here that when the appendix is adherent to an ovarian 
 
 tumor it should be 
 removed with the 
 tumor. 
 
 The method of 
 removing the appen- 
 dix is given in the chapter on appendectomy. 
 
 The raw, bleeding surfaces left after separation of ad- 
 hesions to the wall of the abdomen, deep down in the sac 
 of Douglas or elsewhere, are treated first by seizing the 
 largest bleeding vessels with the artery forceps (see Fig. 
 21) and closing them. Then the oozing from the very 
 small vessels is stopped by using the dome-shaped instru- 
 ment. (See Fig. 35.) This is slowly passed over the sur- 
 faces until all oozino; ceases. 
 
 The operator must guard against letting the intestines, 
 uterus, or bladder come into contact with the dome instru- 
 ment when it is in use. With ordinary care the needed 
 protection can be assured by having the patient in the 
 Trendelenburg position and keeping the abdominal and 
 pelvic viscera out of harm's way with sponges and retractors, 
 as illustrated in Fio;. 21. 
 
 The technique is exceedingly simple, and^ the results 
 most satisfactory compared with the old way of ligating 
 the larger vessels (always a most difficult thing to do) and 
 using persulphate of iron or hot water to stop the oozing. 
 
 Fig. 20.— The dome. 
 
 In fact I never was able to arrest bleeding and oozing com- 
 pletely and quickly, and make the parts clean and dry in 
 pelvic surgery of this kind until I devised this method of 
 operating. 
 
ELECTRO-H^MOSTASIS IN OVARIOTOMY. 
 
 33 
 
 Intestinal adliesions are managed by makiug gentle 
 traction and stretching the adhesion so that the forceps 
 can be placed between the cyst wall and the intestines. 
 "While the pressure and heat are being applied, the shield 
 forceps should be placed on the side toward the intestines 
 to protect them. When this is impossible, owing to close 
 and extensive adhesions, the intestine is dissected away 
 
 Fig. 21. — Protecting the uterus from the forceps. 
 
 from the cyst in such a manner as to leave a portion of the 
 external coat of the cyst wall on the side of the intestine. 
 These flaps are brought together over the raw surface of 
 the intestine and seized with the forceps, compressed and 
 desiccated. (See Fig. 22.) 
 
 In doing this the shield forceps should be used to keep 
 the heat from reaching the intestine. This instrument 
 
34 ELECTRO-HiEMOSTASIS IN OPERATIVE SURGERY. 
 
 resembles an ordinary compression forceps, but has thin^ 
 flat shields instead of jaws, as shown by Fig. 23. The 
 shields are constructed of thin blades of steel coated with 
 a substance which is a poor conductor of heat, such as 
 hard rubber, and are longer and broader than the jaws of 
 the electrical forceps. One side of each shield is flat and 
 the other is beveled, as shown, so that the inside edges are 
 chisel shaped. The flat sides are placed uppermost, close 
 against the electrical instrument. When properly placed, 
 the shield forceps is locked with sufficient pressure to re- 
 
 FiG. 22. — The treatment of intestinal adhesions. 
 
 tain the desiccated stump for inspection after the other 
 instrument is removed. 
 
 Adhesions to the rectum (the most difficult of all to 
 manage) are treated in the same way as intestinal adhesions, 
 with this difference, that when the adhesions are very 
 strong, and the cyst wall changed in structure by inflam- 
 mation, a part of the cyst wall should be left attached and 
 its lining membrane destroyed with the dome cautery. 
 
 Adhesions of the bladder to the tumor are treated by 
 dissecting off the bladder and then closing the peritoneum 
 
ELECTRO-H^MOSTASIS IN OVARIOTOMY. 
 
 35 
 
 over the bladder witli fine catgut sutures 
 
 Adliesions that 
 are recent, not very extensive, and easily separated, are 
 treated by touching the raw surface with the dome cauteiy 
 
 at a temperature of 180°, to arrest any oozing that may 
 take place. 
 
 The Pedicle.— T\iQ cyst sac or tumor being withdrawn 
 from the abdominal cavity the pedicle is examined with 
 regard to its length and thickness, to determine the point 
 at which it should be divided, and the size of forceps or 
 clamp required for its treatment. Small and medium-sized 
 pedicles call for the smallest pedicle forceps, illustrated by 
 Fig. 24, and constructed as follows : The instrument is 
 jointed at the distal end by a detachable lock, and has a 
 projection on either blade at the proximal end of the jaws, 
 which prevents the tissues fi'om spreading when the foi'ceps 
 
 is closed. The handles lock with the usual catch near the 
 proximal end. Larger pedicles require the clamp forceps, 
 illustrated by Fig. 25, and constructed in the same man- 
 
36 
 
 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 ner as the small pedicle forceps, but having a movable 
 section which can be closed by a screw attachment. By 
 this means the pressure is made parallel to the heated jaw, 
 and a greater and more equal compression is thereby ob- 
 
 FiG. 25. — Clamp forceps for larger pedicles. 
 
 tained. The forceps selected is applied at the point where 
 the pedicle is to be divided. One or two fixation forceps 
 are applied to the base of the tumor, and the pedicle 
 divided between them and the haemostatic clamp, leaving 
 a portion of the pedicle projecting above the blades of the 
 clamp to prevent slipping. This portion should be cut off 
 close to the forceps just before removing it. The shield 
 forceps is applied beneath the haemostatic forceps to pro- 
 tect the abdominal wall from the heat, and to keep the 
 stump from falling back into the pelvic cavity when the 
 haemostatic forceps is removed. (See Fig. 26.) This 
 enables the operator to inspect the stump and see if it has 
 been properly treated before it is dropped. If any portion 
 of the stump, or the whole of it, indeed, is not fully 
 desiccated, the forceps can be reapplied and the treatment 
 completed. 
 
 Sterilized vaseline should be applied to the inner surface 
 of the blades of the forceps, to prevent the stump from 
 adhering and to permit the forceps to come off easily. The 
 forceps should be closed only to the first notch in the catch, 
 and when the current has been turned on and used for about 
 half a minute the compression should be completed by clos- 
 ing the forceps to the last notch. During the time that the 
 electric current is being used the operator should examine 
 
ELECTRO-H^MOSTASIS IN OVARIOTOMY. 
 
 m 
 
 tlie other ovary and tlie otlier pelvic organs to see if any- 
 thing more in the way of operating is required. 
 
 An unusually short, thick, broad pedicle, that can not 
 be accommodated in the largest clamp forceps, should be 
 treated in three sections. The outer border, which con- 
 tains the ovarian vessels, should be grasped wdth the for- 
 ceps used for vaginal hysterectomy, treated in the usual 
 way, and divided; the inner border should be treated in 
 the same way ; the middle portion, or third section of the 
 pedicle, if not vascular may be cut oif without treatment, 
 
 Fig. 26. — Treatment of pedicle of ovarian cyst. (Diagrammatic.) 
 
 and the edges of the peritoneum of the stump closed with 
 fine sutures. If the middle part is vascular it should be 
 caught in the pedicle clamp and treated like the other 
 sections. 
 
38 ELBCTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 For one wlio is not familiar mth this treatment of the 
 pedicle it is difficult to tell when the treatment is sufficient 
 to be reliable. This was to me a most difficult question 
 in my first operations, but I soon learned that if there was 
 no disposition to bleeding when the clamp was removed, it 
 could surely be trusted. 
 
CHAPTER V 
 
 ELECTEO-HiEMOSTASIS IN MYOMECTOMY AND ABDOMHSTAL 
 HYSTEEECTOMY 
 
 I DID a number of successful myomectomies in pedun- 
 culated iibroids, and in all I found difficulty in control- 
 ling the bleeding with the ligature. Such was my ex- 
 perience that I never dared to remove a sessile subperi- 
 toneal fibroid until I obtained the haemostatic forceps. 
 Since then I have succeeded equally well with all forms 
 
 Fig. 27. — Treatment of pedicle of a fibroid. The cnff of peritoneum and the cap- 
 sule gathered together, drawn outward, and seized by electro-haemostatic 
 forceps. 
 
 of subperitoneal fibroids. The method of operating when 
 the pedicle is long enough is to apply the forceps in the 
 same way as it is used upon the pedicle of an ovarian 
 tumor, compress and desiccate it, and then cut away the 
 tumor. 
 
 4 39 
 
40 
 
 ELECTRO-H^MOSTASIS IX OPERATIVE SURGERY. 
 
 When the pedicle is short and the fibroid is in contact 
 ■with and yet movable upon the middle coat of the uterine 
 wall, the capsule is divided all around on the tumor one to 
 two inches from the uterus. It is then dissected off with 
 
 ^<j^j&^ 
 
 Fig. 28. — Line of incision preparatory to enucleation of sessile fibroid. 
 
 the dry dissector until the tumor is enucleated ; the empty 
 portion of the capsule is finally gathered together and 
 grasped in the forceps and desiccated by the electric heat. 
 (See Fig. 27.) 
 
 The shield forceps is used to protect the uterus fi'om 
 the heat. The redundant part of the stump which pro- 
 jects beyond the blades of the forceps should be cut clean- 
 ly off after the treatment is completed, and before the for- 
 ceps is removed. 
 
 Sessile fibromata are treated in the same way, excepting 
 
 Fig. 29. — Sessile fibroid enucleated. Showing cuff of peritoneum. 
 
 that when the attachment of the tumor to the uterus is 
 quite broad the incision of the capsule should be made 
 higher up on the tumor — that is to say, it should be nearly 
 as high as the diameter of the base of the tumor (Fig. 28). 
 
MYOMECTOMY AND ABDOMINAL HYSTERECTOMY. 
 
 41 
 
 When tlie incision is made, and enougli of the capsnle has 
 been freed from the tumor to get hold of, ordinary com- 
 pression forceps should be used to control bleeding until 
 the enucleation is completed (Fig. 29). The two sides of 
 the capsule should be held apart while the surface of the 
 uterus from which the tumor was detached is carefully in- 
 
 Fig. 30.— The use of the dome in treating bleeding raw surface after enucleation 
 
 of sessile fibroid. 
 
 spected, and all oozing stopped by the application of the 
 dome cautery mentioned in the description of ovariotomy 
 (Fig. 30). The flaps of the capsule should be brought 
 together, grasped by the forceps, compressed and desiccated 
 (Fig. 31). This completely arrests all haemorrhage, and 
 
42 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 leaves the smallest possible stump. Occasionally several 
 small subperitoneal fibroids accompany one or more large 
 ones. These little ones are quickly disposed of by making 
 an incision through the capsule at the summit of the tumor 
 
 FAV SURFACE \ ^H I OTl eM-"^' 
 
 Fig. 31. — Steps in treating stump after enucleation of sessile fibroid. 
 
 with the cautery knife, and enucleating and treating the 
 sac or capsule as already described. 
 
 ABDOMINAL HYSTERECTOMY FOR FIBROMATA 
 
 The abdominal incision is made long enough to permit 
 lifting both the uterus and the tumor out of the abdominal 
 cavity. The body of the uterus is drawn toward the 
 left side, and the right side of the abdominal wall is re- 
 tracted, so that the right broad ligament is fully exposed. 
 A compression forceps is applied to the upper part of tlie 
 broad ligament, including the ovarian arteiy, near the brim 
 of the pelvis. Another forceps is applied opposite the 
 fost one, near the uterus. The round ligament is caught 
 in a forceps in the same way and the ligament divided 
 down to near the uterine artery. The lower part of the 
 ligament is opened up and the uterine artery found and 
 caught in a compression forceps. If the artery can not be 
 separated from the tissues of the ligament mthout much 
 trouble, the ligament and artery may be seized e7i m.asse. 
 The uterus is separated from the bladder, and the cervix 
 uteri divided or amputated in the usual way. The uterus 
 is tilted still farther to the left side to bring up the 
 lower portion of the broad ligament and left uterine ar- 
 tery. This also is seized by compression forceps and the 
 
MYOMECTOMY AND ABDOMINAL HYSTERECTOMY. 
 
 .43 
 
 ligament divided fi"om below upward. Forceps are applied 
 to the round ligament and the ovarian artery when they 
 are approached in the process of dividing the ligament. Fig. 
 32 shows the line of incision, and Fig. 33 shows the exsec- 
 tion of the uterus and the temporary control of the arteries 
 with compression forceps. 
 
 The tumor having been thus removed, the treatment of 
 the vessels is accomplished as follows : The divided end 
 of the artery is caught up \\'ith a line dissecting forceps and 
 drawn out of the tissues of the lio-ament and seized with 
 
 o 
 
 the haemostatic forceps, compressed and desiccated. When 
 it happens that the broad ligament has been divided close 
 up to the compression forceps, the artery can not be iso- 
 
 A A, Cla7nps ^^SH 
 on ovarian ,^^^SH 
 artery. ^jW^ 
 
 
 ■^ 
 
 
 B B, Clamps on _.-' 
 artery of round' 
 ligament. 
 
 
 C C, Clamps- on ...- 
 uterine artery. 
 
 
 
 <-— - ^v 
 
 Fig. 32. — Treatment of right broad ligament and temporary control of vessels. 
 
 lated sufficiently without taking off the forceps ; but if the 
 end of the artery is grasped with the dissecting forceps the 
 tissues can be stripped back from the artery far enough to 
 admit the grasp of the haemostatic forceps. Fig. 34 shows 
 
44 
 
 ELECTRO-H^MOSTASIS IX OPERATIVE SURGERY. 
 
 the ovarian artery after it has been closed, and also the 
 uterine artery in process of being closed or treated. 
 
 I was fearful that the pressure of the forceps upon the 
 broad ligament if continued for any great length of time 
 
 Temporary clamps on divided 
 vessels of right broad liga- 
 ment. 
 
 1 F' ' '•i ^^ <?: 1 Temporary clamp 
 ^ on ovarian ar- 
 
 teiy 
 Temporary clamp 
 ^r on round-liga- 
 
 ment artery. 
 Temporary clamp 
 
 —ry-r on left uterine 
 
 - •■/ artery. 
 
 Fig. 33. — Treatment of left broad ligament and temporary control of vessels. 
 
 might so bruise the tissues that sloughing would take place, 
 and the process of repair be thereby retarded. So I treated 
 each artery as it was divided — that is, the compression for- 
 ceps was applied lightly, and the artery and ligament di- 
 vided and immediately closed wdth the haemostatic foi'ceps. 
 I'hen the other arteries were treated in the same way. Ex- 
 perience, however, indicates that unless the compression of 
 the tissues is greater than necessary, the damage done is 
 
MYOMECTOMY AND ABDOMINAL HYSTERECTOMY. 
 
 45 
 
 not sufficient to retard repair ; the circulation is re-estab- 
 lisliecl, and healing goes on rapidly. 
 
 The peritoneum is closed over the broad ligaments and 
 stump of the cervix uteri with running catgut sutures. 
 Beginning above on the left, one suture is introduced along 
 to the center of the cervix, the other suture is applied from 
 above downward on the right side until it meets the suture 
 of the left side, and the two are secured by tying their ends 
 together. 
 
 Forceps in the act 
 of being re- 
 moved from 
 round-ligament 
 artery. 
 
 Bight ovarian ar- 
 tery after treat- 
 ment and per- 
 manent closure. 
 
 Dissecting for- 
 ceps draicing 
 artery out. 
 
 'tv. 
 
 Temporary con- 
 trol of vessels 
 of left broad 
 ligament by 
 clamp. 
 
 Fig. 34. — Final treatment of vessels. 
 
 When it is necessary to remove the entire uterus, the 
 exsection of the cervix is added to the operation above 
 described. There are two w^ays of doing this : circumcising 
 the vagina from below, or opening and detaching it from 
 above. Certain advantages belong to both ways of operat- 
 ing in certain conditions ; therefore the surgeon should 
 select the method adapted to the conditions in cases as 
 they come. 
 
46 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 When the cervix is vdthin reach from the vagina, it is 
 easier to cii'cumcise the cervix uteri through the vagina, 
 and the lower portion of the bladder can be more easily 
 and safely separated fr'om the uteinis in this way than 
 throuo'h the pelvic cavity from above. The disadvantages 
 of this method are, that it increases the time of operating, 
 especially when the vaginal wall is vascular, since time is 
 required to stop the bleeding before opening the abdomen. 
 But when the cervix uteri is drawn up out of, or crowded 
 to one side of, the pelvis, it is better to separate the cervix 
 and vaginal wall from above. 
 
 The method of operating which I have adopted saves 
 time enough to make it preferable, in my judgment, in suit- 
 able cases. 
 
 Two incisions in the vaginal wall, one in front and one 
 behind the cervix, are made, so that they meet on either 
 side of the cervix ; the bladder is separated from the uterus 
 up to the peritoneum, the vagina is separated fr^om the pos- 
 terior wall of the cervix, but the peritoneum is not opened. 
 By this procedure the lower portions of the broad ligaments 
 are exposed. The haemostatic forceps used in vaginal hys- 
 terectomy is applied to the lower portion of one ligament, 
 which is compressed and desiccated, and cut off from the 
 supravaginal portion of the cervix. The other side is 
 treated in the same way. This frees the cervix from all of 
 its attachments, except the peritoneum, and at the same 
 time arrests all bleeding from the vessels which supply the 
 vagina. This part of the operation is performed precisely 
 as the first steps in vaginal hysterectomy. The abdominal 
 part of the operation is performed as already described, 
 except that in place of amputating at the cervix, the peri- 
 toneum in front and behind the cervix uteri is opened 
 toward the incision made from the vagina. 
 
 It is sometimes found that when the uterine artery is 
 ligated and the ligament divided down to the part sepa- 
 rated from the vagina there is a branch of the uterine or 
 vaginal artery that bleeds ; this is easily controlled by using 
 
MYOMECTOMY AND ABDOMINAL HYSTERECTOMY. 
 
 47 
 
 the haemostatic forceps. The dome is very useful in arrest- 
 ing capillary oozing in the deep locations hardly accessible 
 by other means. (See Fig. 35.) The peritoneum is closed 
 over the broad ligaments in the way already described, and 
 the vagina is closed by interrupted suture, including the 
 peritoneum and vaginal walls. 
 
 The reader will observe that I have adopted Kelly's 
 method of doing this operation, only slightly modifying it 
 
 Fig. 35. — The use of the dome deep in the cul-de-sac to arrest persistent oozing. 
 The patient is in the Trendelenburg posture. The uterus has been removed. 
 The treated stumps of the vessels are shown: B, ovarian stump; C, stump of 
 artery of round ligament; U, compressed and heated stump of uterine artery; 
 A, posterior, and I), anterior peritoneal iiap. 
 
 to suit the new method of controlling the bleeding vessels. 
 Dr. Kelly, in describing his method of doing abdominal 
 hysterectomy, adds some valuable remarks regarding its 
 advantages in complications, which I quote here : 
 
 " I have insisted particularly upon the novel way in 
 which serious complications are simplified by this plan of 
 treatment, and I would refer chiefly to two kinds of com- 
 plications : 
 
48 ELECTRO-HiEMOSTASIS IX OPERATIVE SURGERY. 
 
 " First, fibroid tumors located under the peritoneum ol 
 tlie pelvic floor ; and, 
 
 " Second, inflammatory masses situated behind the broad 
 ligaments, with dense adhesions to the pelvic peritoneum, to 
 the rectum, and often to the small intestines. 
 
 " In the case of the subperitoneal pelvic fibroids, it is 
 astonishing how difficult they are to get at from above, and 
 how easily, on the other hand, they roll out when handled 
 from beneath by this procedure. 
 
 " I would say the same of the inflammatory cases. 
 Matted masses, adherent in all dii'ections, which resist 
 enucleation from above, are often removed with, ease when 
 rolled up from the pelvic floor fi'om below. The adherent 
 stiTictures seem to be unrolled in a natural and easy way, 
 in surprising contrast to the difficulties experienced and the 
 injuries inflicted in gaining the slightest fingerhold in pro- 
 ceedino; from above. 
 
 " To recapitulate : Abdominal hysterectomy by the con- 
 tinuous incision do^vn through one broad ligament, across 
 the cervix and up through the other broad ligament, is con- 
 trasted with hysterectomy by an incision down to the cer- 
 vix through one broad ligament, and then down through 
 the other, followed by amputation of the cervix. 
 
 " The special advantages offered by this method of 
 operating are : 
 
 " 1. The saving of from sixty to eighty per cent of time 
 in the enucleating stage of operation. 
 
 " 2. The ease with which intraligamentary myomata 
 and myomata beneath the pelvic peritoneum may be enu- 
 cleated. 
 
 " 3. The ease with which inflammatory masses pos- 
 terior to the broad ligament may be enucleated by attack- 
 ing them fi'om below after dividing the cervix. 
 
 " 4. The control of a displaced ureter on the side last 
 opened up, keeping it out of the way of injury by the sim- 
 ple mechanism of the operation." 
 
CHAPTEK YI 
 
 ELECTRO-H^MOSTASIS EN^ OVAEIO-SALPINGECTOMY 
 
 Although the mortality in operations for pyosalpinx 
 and kindred diseases of the tubes and ovaries has been 
 reduced to a minimum, there has been such a large per- 
 centage of incomplete I'ecoveries that some of the best- 
 known surgeons have expressed dissatisfaction with the 
 ultimate results. During my investigation of this class of 
 uncured cases, I found that ligation of the pedicle had been 
 l^racticed in all of them, and that all kinds of ligatures 
 had been used, while in those treated with the cautery 
 clamp, according to Keith's method, no sucli results fol- 
 lowed. Those who recovered after that treatment were 
 permanently relieved. I naturally inferred from this that 
 the ligation was the cause of the unfortunate effects, and 
 in one sense that is the case. In explanation I must say 
 that while the ligature itself is the cause of some trouble, 
 the worst afflictions come from patenc}^ of the Fallopian 
 tubes, which remains after treatment by ligation. 
 
 Professor Emil Ries, of Chicago, has given (see Ameri- 
 can Gynaecological and Obstetric Journal, January, 1898) 
 the unfavorable results following the removal of the tubes 
 and ovaries, and the causes thereof, in a most interesting 
 and valuable essay, from which I have taken the following. 
 After noticing that Schauta and Chrobak report but little 
 more than fifty per cent of their laparotomy j^atients as 
 really cured. Dr. Ries suggested that one of the most im- 
 portant causes of these unsatisfactory results was to be 
 found in the formation of stump exudates, and offers a new 
 
 49 
 
50 ELECTRO-H.EMOSTASIS IX OPERATIVE SURGERY. 
 
 explanation of this cause in the following observation of 
 several cases in which microscopical examinations were 
 made of the uteri removed some time after salpingectomy. 
 
 " Stump exudates were found by Schauta in twenty- 
 eight cases out of his one hundred and seventy-two sal- 
 pingo-oophorectomies. They have been found even more 
 frequently by other observers, and in my own experience I 
 have repeatedly found them to be at the bottom of trouble- 
 some symptoms months after the operation. They produce 
 pain, sometimes so severe that the patient is unable to 
 attend to her work ; in some cases the pain is even worse 
 than it was before the operation. The exudates are found 
 around the stumps of the removed tubes, and vary in size 
 from a barely palpable thickening of the uterine horn to 
 the size of a hen's egg or larger. 
 
 "As an explanation of the formation of these tumors, 
 Schauta offered the following two possibilities : 
 
 ''1. The inflammatory process creeps on through the 
 uterine wall into the surrounding parametric and perimetiic 
 tissue ; and, 
 
 " 2. Germs were present in the broad ligament at the 
 time of the operation (though no actual observations could 
 be offered as evidence of this), the connective tissue of the 
 broad ligament was laid bare by the oj)eration, and in this 
 way the germs could invade the peritoneum. 
 
 "Though these observations did not meet with any 
 opposition, it can not be overlooked that we have no obser- 
 vations bearing out the con-ectness of these hyj)otheses. 
 Besides, I can not help feeling that they are very artificial. 
 
 " The cases are as follows : 
 
 "Case I. — Mrs. J., twenty -four years old. Seven 
 months previously a left pus tube and ovary had been 
 removed. A sinus remained which would not close. Be- 
 sides, the j^atient has an ovarian abscess the size of a fist, 
 and hydrosalpinx on the right side. Uterus adherent all 
 over, forming part of the wall of the sinus. I operated 
 September 28, 1896. Laparotomy. Removal of ovarian 
 
ELECTRO-H^MOSTASIS IX OVARIO-SALPIXGECTOMY. 51 
 
 abscess, hydrosalpinx, uterus ; excision of sinus, which leads 
 toward the right cristuni ilii and terminates in an abscess 
 which contains iive silk ligatures. Kecovery. 
 
 " The stump of the tube which had been removed seven 
 months j)i'eviously is excised, and examined in a series of 
 sections, embracing the entii'e stimap up to the interstitial 
 portion of the tube. The cavity is open throiigliout. The 
 epithelium is the usual low columnar epithelium of this 
 portion of the tube, and stops at the surface of the stump 
 without investing the cut surface of the stump. No threads 
 to be found in the stump. 
 
 "Case II. — Miss W., twenty-five years old. Several 
 years ago removal of both tubes and right ovary. Now 
 chronic pelviperitonitis and adherent retroflexion. OjDera- 
 tion by Dr. AY. H. Rumpf, on December 8, 1896. Vaginal 
 hysterectomy. 
 
 " Both tubal stumps are examined in series. They are 
 perfectly permeable, though the cavity is very narrow. 
 Epithelium well preserved up to the abdominal opening of 
 the stump. Besides, the left tube contains some epithelial 
 ducts outside the circular muscular layer of the tube, one 
 of which enters the circular muscular layer itself, but does 
 not show any communication with the tubal cavity (remnant 
 of the Wolffian body). No threads to be found in the 
 stump." 
 
 At a meeting of the American Gynaecological Society, 
 held in Boston, June 26, 1898, Dr. J. Wesley Bovee, of 
 Washington, D. C, read a paper on Patency of the Stump 
 after Salpingectomy, in which he said that he had taken 
 a special interest in this subject since 1892, and had found 
 in five specimens from cases of salpingectomy that the 
 stumps were still pervious. So far as he knew, only three 
 well-authenticated cases had previously been reported. 
 As I remember the reading of the doctor's paper, he ac- 
 counted for the patency by saying that the ligatures might 
 become infected and slip in course of time, or " mass " 
 ligatures might slip off after closure of the abdomen. He 
 
52 ELECTRO-HiEMOSTASIS IX OPERATIVE SURGERY. 
 
 suggested that these stuuips might be successfully occluded 
 by cutting out the Fallopian tube by a wedge-shaped in- 
 cision into the uterine wall at the tubo-uterine junction, 
 and closino; the wound with sutures. Care must be taken, 
 he said, in the ligation of the uterine artery in this situa- 
 tion, aud also not to pass the sutures through the mu- 
 cosa. 
 
 It appears that Dr. Bovee was not acquainted with the 
 work of others when his paper was prepared, but he de- 
 serves credit for suggesting a way of overcoming the paten- 
 cy of the tube which so often follows the use of the liga- 
 tui'e, and for adding five more to the list of unsuccessful 
 cases following the usual method of operating. This 
 method suggested by Dr. Bovee may be an improvement 
 upon the old way of operating. Still, it requires longer 
 time to introduce sutui-es than to use a ligatui-e, and if the 
 end of the tube is septic the wound in the uterus is sm-e to 
 become contaminated and so complicate the process of re- 
 pair that trouble may follow. At any rate I am quite con- 
 fident that better results are obtained more easily by the 
 method which I have adopted. 
 
 The operation for the removal of the tubes and ovaries 
 should be adapted to the pathological conditions presented 
 in given cases, simple and comp)licated. 
 
 The incision into the abdominal wall should be short, 
 just sufiicient to admit two fingers. Extra care is necessary 
 to avoid wounding the omentum or bowels. If there are 
 adhesions of the intestines to the abdominal wall, the in- 
 cision should be enlarged in order to find a part where the 
 peritoneum can be safely opened, and from which the adhe- 
 sions can be treated. This is easier than to separate the in- 
 testines from the peritoneum in the incision. This complica- 
 tion is, fortunately, seldom met. I have occasionally found 
 the omentum adherent to the tube and ovary, and some- 
 times to the abdominal wall near the median line ; but it is 
 generally free on one or both sides, so that the tubes and 
 ovaries can be reached by passing the fingers outward be- 
 
ELECTEO-H^MOSTASIS IN OVARIO-SALPINaECTOMY. 5a 
 
 yond the adhesions on the side, and then drawing and 
 pushing the omentum out of the way. When no free part 
 can be found, the omentum should be picked up and 
 divided in or near the median line, and the bleeding ves- 
 sels closed with the haemostatic forceps. Two fingers 
 should be passed into the wound and the fundus uteri 
 found. This is a guide to the tubes. Adhesions, when 
 they are not too old and strong, should be separated with 
 the fingers, but care must be exercised not to rupture the 
 tube. When both tube and ovary are freed from adhesions, 
 they should be hooked up with the fingers and brought out 
 through the wound, or up into it. By traction in this way 
 a pedicle is formed, included, and held between the fingers 
 until the haemostatic forceps is applied, the shield forceps 
 adjusted, and the pedicle treated in the way described 
 under the head of Ovariotomy for Ovarian Cystomata. 
 (See page 37.) 
 
 One sometimes finds the pedicle too short to permit the 
 tube and ovary to be drawn out of the wound far enough 
 to apply the forceps outside of the abdominal wall. In 
 that state of affairs the haemostatic forceps is applied under 
 the fingers in the abdominal incision, the distal end dip- 
 ping down into the cavity. The shield forceps is applied 
 from the same side as the haemostatic forceps, and a retrac- 
 tor is used to keep the side of the abdominal wall and intes- 
 tines away from the point of the forceps while the heat is 
 being applied. 
 
 Cutting away the tumor or tube and ovary is always 
 a serious matter, owing to the tendency of the septic con- 
 tents to escape and contaminate the stump and wound; 
 to some extent this is always the case when the ligature 
 is used. The desired object is accomplished by not mak- 
 ing traction upon the parts to be removed while the heat 
 is being applied. When the pedicle is thoroughly desic- 
 cated the part to be excised joining the forceps becomes 
 closed by the heat sufficiently to prevent leaking after being 
 divided. With a sharp knife the parts are cut close to the 
 
54 
 
 ELECTRO-HiEMOSTASIS IN OPERATIVE SURGERY. 
 
 forceps, while care is taken not to make pressure on tlie 
 tube and force out its contents. 
 
 In pyosalpiux complicated by firm and extensive ad- 
 hesions the operation is altogether different. The outer 
 ends of the tube and ovary are freed from adhesions until 
 the ovarian artery is reached and that portion of the broad 
 ligament caught in the forceps, closed with pressure and 
 heat and divided. This liberates the tube and ovary so 
 that they can be brought out through the wound (in case 
 the adhesions of the tube are not very firm), and the 
 uterine end of the tube and the remaining portion of the 
 
 Electro-therinic clamp 
 on tube and utero- 
 ovarian ligament. 
 
 Clamp on ova- 
 rian artery. 
 
 Outer end of 1.5'f.'''"\ 
 
 distended 
 tube. 
 
 Round ligament '■' ,>. , 
 drawn forward. V^ 
 
 Fig. 36. — Removal of diseased tube and ovary by the forceps. Partly diagram- 
 matic. 
 
 mesosalpinx can be grasped mth the hysterectomy forceps 
 or haemostatic clamp, sealed up, and the tube and ovary cut 
 away. (See Figs. 36 and 37.) 
 
 If the tube is distended close up to the uterus and the 
 
ELECTRO-H^MOSTASIS IN OVARIO-SALPINGECTOMY. 
 
 55 
 
 adhesions are extensive, the operation has to be modified 
 still more. After closing the ovarian artery and dividing 
 that portion of the pedicle, the ends of the tube and ovary 
 are dropped back, and the foi'ceps having been applied to 
 
 Lifted tube and 
 ovary. 
 
 Ovarian artery. •-' ) j^.jj„-v'.' ] 
 
 Bisected stump ,.•:' ***='ijvj l-' 
 of ovar to-pelvic,-'' '-^■"^^^O.A'i 
 
 ligament 
 
 Broad ligament /' ^^.fi'-^ 
 with large tor---'' <C-^^/'i 
 tuous veins. 
 
 Fig. 37. — Second step of palpingo-oophorectomy whenever the broad-ligament 
 
 veins are enlarged. 
 
 the tube close up to the uterus, they are thoroughly com- 
 pressed and desiccated, and then divided in the line of the 
 closed portion of the tube. A traction forceps is applied 
 to the end of the tube to keep it from falling back into 
 the pelvic cavity. The separation of the adhesions is com- 
 pleted and the tube and ovary brought out of the wound, 
 and the remaining pedicle — that is, the mesosalpinx — treated 
 in the usual way with a small haemostatic forceps. If the 
 adhesions are old and vascular there is generally some 
 oozing from the raw surface of the broad ligament, and 
 this should be stopped by passing the dome cautery 
 heated to 185° or 190° over the oozing surfaces until they 
 are dry. 
 
 If the tubes are largely distended and their walls are 
 thin, the adhesions should be separated only where that 
 
56 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 can be easily done ; tlie tubes are emptied, or partially so^ 
 with the aspii'ator, and then seized with the forceps and 
 brought out. The adhesions should be separated by divid- 
 ing them with scissors, or, if very vascular, the haemostatic 
 forceps should be used. The pedicle is then treated in 
 one mass or in three sections as last described. 
 
 When both tubes and ovaries are diseased, especially in 
 double pyosalpinx, the uterus should also be removed. 
 The operation is then performed in exactly the same way as 
 abdominal hysterectomy for uterine fibromata. 
 
CHAPTER A^II 
 
 ELECTEO-H^MOSTASIS IX APPENDECTOMY 
 
 FiNDZNG that the treatment of the pedicle of ovarian 
 tumors with compression and heat applied with the electric 
 current gave infinitely the best results, I employed the 
 same method in appendectomy with equally fortunate and 
 gratifying success. 
 
 That the same secondary troubles followed append- 
 ectomy as after removal of the Fallopian tube was appar- 
 ent on reading the records of many surgeons. A. Lapthorn 
 Smith says that he had several cases from one to two years 
 after the appendix had been removed, who were suffering 
 fi^om fecal fistula or pericsecal abscess. This is about the 
 same as the testimony of Armstrong also, who reported in 
 the British Medical Joui'nal, October 9, 1897, that fecal 
 fistula followed fifteen times in five hundred and forty-one 
 cases. A. Lapthorn Smith very clearly states that " because 
 of the mucous glands which are imbedded in the mucous 
 membrane of the appendix, it is quite as unsurgical to put 
 a ligature around the base of the appendix a (juarter of an 
 inch fi'om the caecum and then cut the appendix off, as to 
 propose to close an opening in the bowel by picking up 
 the edges of the opening and tying a ligature around them, 
 because this would simply bring mucous surfaces into con- 
 tact, and, when the ligature has cut through or has other- 
 wise fallen off, the secreting glandular surface would sejDa- 
 rate and the contents of the bowel escape. Those who 
 follow this method may say that they cauterize the mucous 
 membrane after cutting off the appendix, and not only 
 
 57 
 
58 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 disinfect it but also destroy its secreting surface. But 
 this, I maintain, it is impossible for them to do, because they 
 manifestly can not reach the mucous membrane brought 
 together by the ligature, and still less that part of it which 
 lies below the ligature. If there were only one case of 
 fecal fistula instead of fifteen in five hundred it would be 
 worth while preventing it. 
 
 " The ideal method, in my opinion, and which I have 
 followed in these cases, is for an assistant to hold up the 
 intestine an inch on one side of the appendix, and, after 
 tying and cutting the meso-appendix, to snip the appendix 
 off even with the caecum. The hole in the intestine is 
 then sewed up with tine silk, care being taken to include 
 the muscular coat. A director is then pressed upon the 
 line of the suture until it sinks below the surrounding 
 surface, when another row of sutures brings the peritoneal 
 surfaces together. Such a closure will almost surely unite 
 by primary union, doing away with all danger of fecal 
 fistula or circumcaecal inflammation, by which the opening 
 in the appendix is sometimes closed, and in which cases, 
 although there is no fecal fistula, the patient is subjected 
 to a good deal of discomfort while Nature is throwing out 
 a layer of plastic lymph to seal the defective closure. 
 Some authors recommend the peeling off of the peritoneal 
 coat of the appendix, so as to form a cuff a quarter of an 
 inch long, and then, after tying and cutting off the appen- 
 dix in the manner which is condemned above, make up 
 for the defect by sewing the peritoneum over the end of 
 the stump. This is much better than leaving a slough- 
 ing stump free in the abdomen, but it is by no means as 
 good as the method advocated above, in which no stump 
 at all is left, and nothing but a fine, thin line of Lembert 
 suture, which we know gives absolutely no trouble." 
 
 This same method, described above, was fully given by 
 Haggard, of Nashville, in a paper reported in the Trans- 
 actions of the Southern Surgical and Gynaecological Asso- 
 ciation, at the tenth annual meeting in St. Louis, last 
 
ELECTRO-H^MOSTASIS IN APPENDECTOMY. 59 
 
 November. He summed up its merits as follows : " Total 
 excision of* the appendix, with closure of the hole in the 
 head of the colon, was said to do away with the following 
 dangers : (1) Subsequent perforation of the stump under 
 the ligature from infection in its own cavity ; (2) abscess 
 of the wall of the csecum from invagination of the infected 
 stump ; (3) continuance of the infected process from stric- 
 ture in the stump between distal ligature and the proximal 
 opening of the appendix into the caecum ; (4) imperfect 
 invagination, with the incomplete drainage of the stump, 
 on account of the csecal wall being thickened and stiffened 
 with inflammatory exudate." 
 
 I have not had an opportunity of examining, post 
 mortem, the stump treated with the haemostatic forceps, 
 but have observed clinically that during the reparative 
 process no immediate exudation can be detected ; neither 
 have there been any remote inflammations or exudates found 
 on examination that caused pain or any other symptoms. 
 The recovery has been complete and permanent. This is 
 as might be expected, from the fact that the lumen of both 
 the tubes and the blood-vessels is completely obliterated 
 by compression and heat, and does not, in fact can not, 
 reopen. That complete disorganization of the mucous 
 membrane of tubes or vessels and permanent closure of 
 their lumen are affected has been demonstrated in the 
 several experiments detailed in the third chapter of this 
 work. 
 
 This experience in ovariotomy and kindred operations 
 led me to expect equally satisfactory results in append- 
 ectomy, and my expectations have been fully realized in 
 practice. In fact, this method of treating the stump of the 
 appendix has special advantages in being the only satisfac- 
 tory way of controlling haemorrhage in softened septic tis- 
 sues, as well as closing the appendix itself. 
 
 In salpingectomy, ovariotomy, and appendectomy the 
 surgeon often finds that the pedicle or point of separation 
 is diseased, and the ligature is likely to cut the tissues if 
 
60 ELECTRO-H^MOSTASIS IX OPERATIVE SURGERY. 
 
 made tight enougli to close tlie vessels ; and even if that 
 mishap is avoided the stump is infiltrated with septic ma- 
 terial, which causes trouble no matter how sterile or asep- 
 tic the ligature mav be. With the haemostatic forceps the 
 vessels and lumen of the tube or appendix, as the case may 
 be, are completely closed and the stump thoroughly disin- 
 fected at the same time. I have had abundant opportuni- 
 ties to prove the advantages of this method of controlling 
 bleeding vessels in pelvic surgery. I am now using it in 
 other branches of surgery with equally satisfactoiy results. 
 
 The following case history is giv^en as reported by a 
 clinical assistant : 
 
 W. S. P., aged thirty-two years; a New York mer- 
 cliaut, of medium build, active disposition, neuro-sanguine 
 temperament, regular habits ; primary assimilation and ulti- 
 mate nutrition good. Physical examination reveals appar- 
 ently perfect health. Complaint is made for the past 
 month of a dull ache in the right iliac region, usually 
 merely annoying, but at times severely lancinating and 
 markedly distressing. There are no other symptoms, either 
 .gastric or intestinal, except that the bowel is inclined to 
 constipation. 
 
 A physical examination was easily made because of the 
 laxity of the abdominal wall, and revealed a small movable 
 tumor in the region of the appendix. 
 
 The patient's condition does not prevent Ms continu- 
 ance in the regular duties of his business ; yet, in view of a 
 history of six other attacks, he seeks relief from the pain 
 and mental disquiet by operative procedure. 
 
 The patient enjoyed good health until two years ago 
 last Fall. The first attack was provoked, apparently, by 
 a bath immediately after dinner. The local symptoms 
 were typical of an inflammatory condition of the ap2:)endix 
 vermiformis. The pain at first was general over the abdo- 
 men, beginning in the epigastrium, but soon became local- 
 ized in the right iliac fossa. After four or five days of 
 rest and medication relief was obtained, and the regular 
 
ELBCTRO-H^MOSTASIS IN APPENDECTOMY. 
 
 61 
 
 business duties were resumed. In February, 1896, while 
 suffering from a severe cold, a second attack prostrated the 
 patient. At this time the pain was at once localized in 
 the region of the appendix, and recovery under treatment 
 was retarded for nearly two weeks. Again, in May, 1896, 
 after partaking heartily of lobster, the patient was seized in 
 a similar manner for the third time. On this occasion his 
 condition was deemed so critical that he was advised to 
 submit to an immediate operation. After nine or ten 
 
 
 Fig. 38. — First seizure by forceps in appendectomy. The heating forceps grasps 
 the meso-appendix, the shield forceps protecting the bowel. 
 
 days, however, he was relieved by medical treatment, and 
 in a short while was able to attend to his business duties. 
 Six months later. Thanksgiving Day, 1896, an extended 
 railroad trip was suddenly interrupted by a fourth attack 
 similar to the preceding ones. This was followed by a 
 fifth in February, 1897, and a sixth in May of the same 
 year. 
 
 The attacks were all similar in their onset, nature, and 
 
62 
 
 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 course. The pain came suddenly, without any premonitory 
 symptoms, and after the first time it was at once localized 
 in the region of the appendix ; there ^vas no gastric dis- 
 turbance except a slight nausea, nor intestinal, except 
 tympanites ; relief followed the exhibition of opium and 
 local hot comj^resses. At the present time of comparative 
 quiescence, and while he is yet in first-class condition to 
 bear an operation, the patient has at last consented to the 
 repeatedly advised surgical interference. 
 
 The operation was done Janu- 
 ary 11, 1898. For the first time 
 iu the history of appendectomy the 
 method of operating mth the elec- 
 tric haemostatic forceps was fol- 
 lowed. This de2:)arture from the 
 current methods of ligature, su- 
 ture, cauterization, invagination, and 
 others is the logical outcome of the 
 success of this practice \vhen operat- 
 ing upon the pelvic viscera. All 
 the other steps of the operation 
 were such as are advised by sur- 
 geons generally. The incision was 
 the ordinary one over McBurney's 
 point, two inches in length. On in- 
 FiG39.-Compieted treatment gpectiou, both the appendix and the 
 
 of mesentery in appendec- -■- ' . -•- -L 
 
 tomy. The scissors have bi- meSO-appCudix WCrC f OUud to be 
 
 sected the seizure. •, -, t -i ,t • i i -i 
 
 much enlarged and thickened, and 
 supeiUcially traversed by numerous dilated blood-vessels. 
 There were no adhesions. The first grasp of the forceps 
 was upon the meso-appendix close to its mesenteric at- 
 tachment. (See Fig. 38.) A current which heated the 
 forceps to 180° F. was then induced for half a minute. 
 Upon removal of the forceps the tissues were found to be 
 not charred but dried, having the appearance of white 
 homy matter. Scissors were used to bisect this desiccated 
 area. (See Fig. 39.) A second seizure was made upon 
 
ELECTRO-H^MOSTASIS IN" APPENDECTOMY. 63 
 
 the appendix itself close to the caput coli, and the same 
 current continued for ninety seconds. The forceps was 
 
 Fig. 40. — Second seizure of forceps in appendectomy. The dried surface of th© 
 first seizure has been bisected. The appendix is grasped. The shield for- 
 ceps are shown faintly. 
 
 then removed and the tissue divided in the line of the 
 desiccated area away from the caput. (See Figs. 40 and 
 41.) The same result was mani- 
 fested. ISo charred tissue, no 
 bleeding, and, more important than 
 all, no escape of the contents of 
 the appendix. The tissues had 
 simply been dried out. Just at 
 this point a rather violent attack 
 of retching came upon the pa- 
 tient, which continued for nearly 
 a minute, yet without inducing 
 any change whatever in the 
 
 stump. All the severe pressure Fig. 41.— stump after appendec- 
 
 and strain had not forced even tomy, showing the two seizures. 
 a speck of blood or serum into the compressed area. 
 The abdominal cavity was left perfectly free from any 
 
64 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 foreign matter whatever. Sutures and dressings as usual. 
 Time of operation fifteen minutes. 
 
 iVnaestbetic, Schleieli solution No. 3, nine drachms. Time 
 for induction of narcosis, seven minutes. 
 
 The specimen measures seventy-five millimetres in length 
 and forty-five millimetres in circumference, and is of an 
 irregular 8 shape. The contents were about a drachm of 
 pus, mucus, and broken-down cellular tissue. The meso- 
 appendix is also much thickened, even to ten millimetres, 
 and its greatest width is twenty millimetres, 
 
 A microscopic section made shortly after the operation, 
 according to the Johns Hopkins " fifteen-minute " method, 
 confirmed the diagnosis by revealing the typical structure 
 of an old recurrent hypertrophied inflammatory change. 
 
 The convalescence has been unmarked by any compli- 
 cations due to the operation. When the sutures were 
 removed after a week the parietal wound was perfectly dry 
 and clean. At the close of another week the patient was 
 sitting up, enjoying his newspaper and cigar, and was dis- 
 charged from our care on the seventeenth day. He was 
 seen eight mouths after the operation, and reported that 
 his health had been perfect, and that he had had no pain 
 or tenderness in the region of the operation. 
 
 I do not expect the judicious, cautious surgeon to 
 accept the history of this one case as evidence of the 
 superiority of this method to others that have been tried 
 more fully ; but my experience with it gives me full con- 
 fidence that the verdict rendered by a full and fail' trial 
 will be favorable in the highest degree. 
 
CHAPTEE YIII 
 
 TREAT^rEXT OF CA:N"CEE OF THE ETEEUS BY THE ELECTEO- 
 CAUTEEY AXD HiEMOSTASIS 
 
 DuEEs^G the past few years tlie treatment of cancer of 
 the uterus has been vaginal hysterectomy almost exclu- 
 sively, and upon theoretical grounds that appears to be 
 the most appropriate way of dealing mth this disease. 
 Yet a careful comparison of all methods practiced leads to 
 the conclusion that other methods of operative treatment 
 are called for in certain conditions and give better results 
 than any one operation. 
 
 The unprejudiced observer who has read the writings 
 of Dr. John Byrne, and has seen his work and the results 
 in amputation of the cervix uteri Avith the galvano-cautery, 
 will be convinced that this practice is worthy of the sur- 
 geon's confidence. In veiy recent times, that is in 1895, 
 Dr. Kelly and Dr. Clark reported a more radical method 
 of aljdominal hysterectomy for cancer, which, judging from 
 theii' subsequent results, also merits attention and appears to 
 meet the requirements in advanced cases of cancer of the 
 uterus. 
 
 In my own practice at the present time I choose the 
 operation best adapted to the stage, location, or condition 
 of the disease in question. The condition or character of 
 the disease and its location presents several forms. 
 
 In the majority of cases the disease begins in the cervix. 
 In some the tissues around the os externum are first in- 
 volved and the new tissue grows downward into the 
 vagina. Fig. 42 illustrates this stage, in vrhich only the 
 
 65 
 
fi6 
 
 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 lower or vaginal portion of the cervix is involved. In 
 other cases the disease begins in the mucous membrane 
 
 Fig. 42. — Malignant disease of cervix developing downward. A, seen in section ; 
 B, as seen through Sims's speculum. 
 
 within the cervical canal and dilates the cervix extensively 
 before it protrudes into the vagina. (See Fig. 43.) A con- 
 
 'S^ftu.. 
 
 YiG. 43. — Malignant disease of cervix beginning in cervical canal. A, seen in sec- 
 tion ; B, seen through Sims's speculum. 
 
 dition which resembles this is that in \vhich the disease 
 begins in the lower part of the cervix and extends upward 
 
TREATMENT OF CANCER OF THE UTERUS. 
 
 67 
 
 into the cervix wliile the portion that protruded into the 
 vagina has sloughed ofl*. In rare cases the disease begins 
 in the body, or fundus uteri. In the first condition de- 
 scribed amputation vrith the galvano-cautery ecraseur is 
 called for. In the next state high amputation is required 
 with the cautery knife. In the last condition mentioned, 
 cancer in the corpus uteri, hysterectomy is the only opera- 
 tion indicated. These operations I shall describe in the 
 order named. 
 
 Amputation of the Cervix Uteri tvith the Galvano-cautery Ecraseur. 
 
 Dr. John Byrne having been the first to operate suc- 
 cessfully with the galvano-cautery and continuing to be the 
 
 Fig. 44. — Byrne's speculum for vaginal hysterectomy. 
 
 highest authority on the subject, I shall give his descrip- 
 tion of the operation. First, in regard to the exposure of 
 the part to be amputated. Dr. Byrne uses his own sjDecu- 
 lum, which he describes as follows : " The instrument re- 
 ferred to is the speculum introduced and described by me 
 about fifteen months ago, and a modification of which is 
 here shown (Fig. 44). 
 
 "This speculum, it mil be observed, differs none in 
 principle from that previously noticed ; and as to the" sev- 
 eral pieces of which it is composed, they may be considered 
 the same, with one exception — namely, the frame on which 
 the lower or perineal blade moves is much wider and a 
 little longer, thereby affording more working space and 
 
68 
 
 ELECTRO-H.EMOSTASIS IX OPERATIVE SURGERY. 
 
 greatly facilitating operative manipulations. The fore- 
 shortened view in the above sketch will serve to explain 
 more clearly the points of difference between this ' operat- 
 ing ' and the ordinary speculum. 
 
 " Some advantages, however, will be found by having 
 the intra vaginal parts of this instrument a little longer^ — 
 say half an inch — and from one quarter to three eighths 
 wider than the ordinary size. I have also occasionally re- 
 sorted to a piece of bent spring wire, to be introduced after 
 
 Fig. 45. — Byrne's speculum in position. 
 
 the speculum has been adjusted and the uterus fixed in 
 position, for the pui'pose of still further separating the 
 lateral walls. This, though by no means an indispensable 
 requisite in any case, may nevertheless be made to render 
 good service, under certain circumstances, and on this ac- 
 count I have given directions to have some such device 
 supplied with each ' operating ' speculum. 
 
 " Fig. 45 is intended to represent more clearly the prin- 
 ciples on which this speculum is constructed and the modus 
 
TREAT3IEXT OF CANCER OF THE UTERUS. 69 
 
 operandi by which the curved vaginal canal is not merely 
 dilated but straightened by pressing back the perineum 
 helow, while the vesical wall is elevated above. The under 
 blade, it will be noticed, is made to move in a circle in 
 which the center is indicated by its point, so that the rela- 
 tions of the latter to the cul-de-sac, when the instrument is 
 first introduced, does not materially change, no matter to 
 what extent the perineal blade may be pressed backward. 
 The various directions, too, in which the upper double rod 
 may be made to move is a most important feature in the 
 instrument ; for, however displaced a uterus may be, more 
 especially if anteverted, and provided no firm adhesions 
 exist, there is no difiiculty in bringing it into view, and so 
 fixing it for examination or treatment. 
 
 "Fig. 46 represents an improved loop instrument." 
 In operating for epithelioma of the cervix uteri charac- 
 terized by exuberant outgro^\iihs from a base, Dr. Bj^rue 
 places the patient upon the back, exposes the cervix with 
 his speculum and applies the platina wire loop as high up 
 in the cervix as possible, and made moderately tight, the 
 heat is applied and little or no contraction of the loop being 
 affected for a few seconds, so that the tissues to be cut may 
 be thoroughly cauterized. 
 
 Ti'action by the cautery instrument should, in all cases, 
 be carefully avoided and the instrument kept steady and in 
 
 Fig. 46. — Byrne's cautery loop. 
 
 the same position from the beginning to the end of the oper- 
 ation. 
 
 The loop should be slowly and very moderately tight- 
 ened just enough to follow up the tissues as they are divided 
 by the cautery heat. When the tissues are firm enough to 
 
YO ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 stand traction, the part to be cut off sLoulcl be seized with 
 a forceps and traction made continuously while the amputa- 
 tion is going on. This leaves a dome- or cup-shaped stump, 
 thereby removing the central tissues higher up. 
 
 AVhen the portion of the cervix is conical and the cautery 
 loop is difficult to apply, Dr. Byrne has employed the fol- 
 lowing ingenious method of operating, which I have taken 
 from one of his histories of an operation : 
 
 "A large-sized rubber crochet needle, rounded at the 
 end, was heated and slightly bent so as to accommodate 
 itself to the curve of the sacrum and posterior contour of 
 the tumor. 
 
 " A small hole was drilled transversely near its distal 
 extremity, and at right angles with the direction of its 
 curve, and through which a stout platina wire was passed 
 
 r 
 
 Pig. 47. — Byrne's special loop carrier. 
 
 half its length. The fi'ee ends of the ware were now passed 
 through two copper tubes, each three sixteenths of an inch 
 in diameter and eight inches long, and bent nearly the 
 same as the rubber rod. Fig. 47. 
 
 "An anaesthetic having been administered, and the 
 patient placed on her left side, the two tubes with the 
 rubber rod between were carried behind the tumor as far up 
 as deemed safe. The rubber support being now intrusted 
 to an assistant, and maintained steadily in position, one of 
 the copper tubes was carried around half the circumference 
 of the tumor, the wire being pushed up, piece by piece, 
 from below, and, when the center anteriorly had been 
 reached, was so held until the opposite half had been en- 
 circled in like manner. Two small pieces of wood, each 
 one-inch copper conductors, were one after the other slipped 
 up so as to unite, yet insulate the latter. 
 
TREATMENT OP CANCER OF THE UTERUS. 
 
 71 
 
 " This being accomplislied, tlie free ends of the platina 
 wire were next passed through a modification of the loop 
 instrument as shown in Fig. 48 and the copper conductors 
 firmly fastened in the socket. All being now in readiness, 
 the battery connections were made, when the heated wire 
 cut through the rubber support and imbedded itself in the 
 substance of the tumor. 
 
 "The rubber rod was now withdrawn, and the loop 
 very slowly contracted, the time occupied in cutting through 
 the whole mass being fully thirty minutes, exclusive of 
 
 Fig. 48, — Method of passing loop around tumor. 
 
 necessary interruptions. There was no haemorrhage from 
 the stump, but the vagina was tamponed as a precautionary 
 measure." 
 
 HIOH AMPUTATION 
 
 In conditions admitting of high amputation, the follow- 
 ing is the method usually resorted to : The uterus is to be 
 exposed and the vaginal walls protected in the manner 
 already described. The diverging volsellum (Fig. 49), 
 after being passed well into the cervical canal, should now 
 be expanded to a proper degree and locked, so as to afford 
 complete control of the uterus during the entire operation. 
 
72 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 By alternate traction and upward pressure of the uterus^ 
 an accurate idea may now be obtained as to the proper 
 point to begin the circular incision, so as to avoid injuring 
 the bladder or opening into the cul-de-sac of Douglas. As 
 to the latter, however, should it be found that the disease 
 has involved the retro-uterine tissues, and that its excision 
 or destruction by the cautery can not be effected without 
 
 Fig. 49. — Diverging volsellum. 
 
 opening into the peritoneal cavity, there need be no hesita- 
 tion in doing so. I have never known any harm to come 
 from it whether it was done accidentally or by design. 
 Should it be evident at the outset that the operation, in 
 order to be thorough, must include a portion of the cul-de- 
 sac, it will be better to make the line of incision anterior to 
 this, until the cervix has been removed, and leave the inci- 
 sion of the retro-uterine parts hy the cautery hnife to be the 
 final proceeding. Under these circumstances all that will 
 be needed will be an antiseptic tampon properly applied. 
 
 In proceeding to make the 
 circular incision the cautery 
 knife (Fig. 50), slightly curved 
 s and cold, should be applied close 
 
 Fig. 50.—^, straight cautery knife, up to the vaginal I'unction, and 
 
 B, curved cautery knife. pi i 
 
 from the moment that the cur- 
 rent is turned on, should be kept in contact with the parts 
 being incised (Figs. 51 and 52). 
 
 Before removing the electrode for any purpose, such as 
 change of position, or altering the curve of the knife, the 
 current should first be stopped and the instrument again 
 placed into position while cool before resuming the incision. 
 In other words, if the hnife^ though heated only to a dull red^ 
 
TREATMENT OF CANCER OP THE UTERUS. 
 
 T5 
 
 It is important to add that, in carrying the knife toward 
 the sides of the cervix, circular and other arteiial branches 
 
 Fig. 54. — Cervix having been excised, the dotted lines indicate higher incisions. 
 
 are likely to be encountered, and hence, in this locality par- 
 ticularly, a high degree of heat in the platinum blade is to 
 be carefully avoided. As an additional security against 
 haemorrhage, the convexity of the 
 knife should be pressed against 
 
 ,1 i 1 i? J? 1 „ Fig. 55. — Dome-shaped electrode. 
 
 the external surface oi each par- ^ 
 
 ticular section cut, so as to close the vessels more effectually. 
 
 (Figs. 56 and 57.) 
 
 It is well to state that the metallic parts of the elec- 
 trode for the distance of about two inches should he covered 
 with a strip of thin flannel^ so that the vagina may he pro- 
 tected from injury through the refected heat. 
 
 VAGINAL HYSTERECTOMY IN CARCINOMA UTERI 
 
 Vaginal hysterectomy offers superior opportunities for 
 the use of the haemostatic forceps in arresting haemorrhage. 
 I have tried every known method of doing this operation. 
 
<6 
 
 ELECTKO-H^MOSTASIS IX OPERATIVE SURGERY. 
 
 and found them all objectionable, and so I was led to do 
 the operation as follows : The general preparation of the 
 patient is the same as for all major oj)erations, but the 
 cleansing and disinfecting of the vagina is difficult and 
 requires s^Decial care. 
 
 If the body of the uterus alone is affected, the cervical 
 canal must be washed out, packed loosely with cotton, and 
 closed ^vith a pair of forcex^s or with sutures. If the dis- 
 
 FlG. 56. — High amputation by one incision. (Byrne.) 
 
 ease involves the cervix, so tliat the cancerous mass pro- 
 trudes into the vagina, it should be removed with the cau- 
 tery or curette, and then the canal closed in the manner 
 described. The object of this closm^e of the canal is to 
 keep the parts clean and fi'ee from infection dming the 
 removal of the uterus. 
 
 It is always difficult to make tlie vagina and external 
 genetalia aseptic, but in cancer of the uterus it is well- 
 nigh impossible. On that account, I have removed the 
 cancerous gi'owths from the cervix preliminary to hysterec- 
 tomy, and then made the parts as clean as possible. 
 
TREATMENT OF CANCER OF THE UTERUS. 
 
 81 
 
 metal core to give strength, and, being poor conductors of 
 heat, effectually protect the adjacent tissues from injury. 
 
 A little practice is needed in order to know the length 
 of time that the heat should be continued. When one is 
 
 Fig. 64. — Diagram of seizure of upper portion of broad ligament when diseased 
 tube and ovary are to be removed with uterus. 
 
 doubtful about this, the forceps may be removed and the 
 parts inspected ; and, if need be, the forceps should be re- 
 applied and the heat continued long enough to obtain the 
 desired effect. The lisrament is divided with knife or 
 
82 
 
 ELECTE0-H^3I0STAS1S IX OPERATIVE SURGERY. 
 
 scissors between the forceps aud the uterus as far up as 
 the vessels have been closed. The lower portion of the 
 ligament on the other side is treated in the same way. 
 The uterus is drawn down, and the remaining portions of 
 the ligaments are treated in sections until the uterus is 
 completely fi'eed. (See Figs. 63 and 64.) The operation 
 may be briefly described by sapng that it is performed in 
 the same way as Avhen forceps are used to control the 
 bleeding (commonly called the French method), with the 
 diiference that instead of leaving the forceps on long enough 
 for the compression alone to arrest the haemorrhage (twenty- 
 four or forty-eight hours), the heat completes the hsemo- 
 stasis, and the forceps is removed at once. 
 
 After the uterus is removed a careful examination of 
 the parts should be made, and if any portion of the broad 
 
 Peritoneum. 
 
 Peritoneum. 
 
 YiG. 65. — Diagram showing sutures ready to be tied. 
 
 lio-aments shows that the disease has extended beyond the 
 uterus, the suspected parts should be removed. This is done 
 by seizing the stump ^vith a fixation forceps and making 
 traction enough to bring the part within reach and then 
 applying the haemostatic forceps outside of the traction 
 forceps and desiccating sufficiently to destroy the diseased 
 
TREATMENT OP CANCER OF THE UTERUS. 
 
 83 
 
 tissue. Tlie cavernous tissue is completely destroyed by the 
 electric heat applied in this way, and the results are as 
 good as if the part had been exsected. According to Dr. 
 Byrne, cancer can be eradicated in this way at points in 
 deep pelvic structures that can not be safely reached by the 
 ordinary methods of extirpation. 
 
 The next step is to sponge the field of operation dry and 
 clean, and then unite the peritoneum to the anterior and 
 
 ■ Peritoneum 
 
 Pig. 66. — Diagram showing sutures tied. 
 
 posterior vaginal w^alls with line catgut sutures. The 
 peritoneal cuts should be sponged clean. One end of each 
 suture is then cut off and the remaining ends are tied to the 
 opposite sutures, thus completely closing the wound, except 
 in the center, where space enough is left to admit a small 
 gauze drain. (See Figs. 65 and 6Q.) The vagina is loosely 
 packed with gauze, and the operation is completed. 
 
 The advantages which may be fairly claimed for this 
 method of doing hysterectomy are many in favor of both 
 patient and operator. In the first j)lace, and most desir- 
 able, it is a bloodless operation. Most of the patients hav- 
 ing cancer are anaemic and can ill afford to lose blood. 
 Then the operation can be done in less time than in any 
 
84 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 other way, excepting by the so-called French method, 
 which is most unsatisfactory in its results, and should not 
 be considered in comparing the operations. Again, there 
 is no ]3ain and little if any constitutional disturbance. Be- 
 sides, the time required for recovery is the shortest on 
 record, and, judging by my own experience, the mortality 
 is less than one half of one per cent. In addition to all 
 this, the broad ligament stumps are reduced to the smallest 
 size, the blood-vessels and lymphatics are completely closed, 
 and hence the process of repair, which takes place by reor- 
 ganization, is accomplished in very little time, and the 
 thorough disinfection of the stumps by desiccation guards 
 against reinfection and immediate recurrence of the disease. 
 The time and taxation saved on the part of the surgeon can 
 be realized only by one who has repeatedly operated in 
 both this and other ways. 
 
CHAPTEE IX 
 
 THE ELECTRO-CAUTERY IK^ THE TREATMENT OF PELVIC AB- 
 SCESS AND DISEASES OF THE VULVA AND VAGINA 
 
 Pelvic inflammations ending in abscess were all treated 
 by opening from the vagina in the times when salpingitis 
 and ovaritis were not understood. At that date there were 
 many cases requiring such treatment. But after the re- 
 moval of diseased Fallopian tubes by abdominal section be- 
 came established surgery, the vaginal route of getting at 
 pus in the pelvis was given up. Within the past few 
 years, and since vaginal hysterectomy has been perfected, 
 vaginal section has become as popular as abdominal section 
 was. I never gave up vaginal section for pelvic abscess in 
 a given class of cases. I refer especially to pelvic cellulitis 
 following parturition and secondary pelvic cellulitis caused 
 by pyosalj^inx with extensive adhesions, and in cases of 
 general pelvic inflammation in which the pelvis is filled 
 with the products of inflammation, so that the organs first 
 involved, be they ovaries or tubes, and the site or depot of 
 suppuration can not be removed by coeliotomy. 
 
 There are really three forms or conditions w^hich call for 
 vaginal section : the one a pyosalpinx, lying in the most de- 
 pendent part of the sac of Douglas and bound down by 
 products of inflammation which fill the upper part of the 
 pelvis ; the other where by ulcerative perforation the tube 
 has opened into the cellular tissue of the broad ligament 
 and there developed a cellulitis ; and, finally, primary cellu- 
 litis following parturition or septic injuries of the cervix 
 uteri. 
 
 85 
 
86 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 Treatment — The preparation for the operation and the 
 position of the patient should be the same as in vaginal 
 hysterectomy. The posterior fornix of the vagina being 
 exposed by retractors, the vaginal wall should be divided 
 with the cautery knife, heated while in contact with the 
 tissues, throughout the entii-e width of the cervix uteri 
 and outward on either side, in case the cervix is small, for 
 half an inch. It sometimes happens that a divided vessel 
 bleeds freely. That should be controlled by seizing the 
 tissue at the bleeding point with a haemostatic forceps and 
 heating until the hgemorrhage is controlled. At this stage 
 of the procedure an examination should be made for fluctu- 
 ation or a soft part in the mass behind the uterus. If no 
 such spot is found, a curved aspirating needle should be 
 introduced to search for pus ; when found, the needle 
 should be left in place as a guide for the incision with the 
 cautery. When the incision is made large enough to intro- 
 duce the finger, a further examination should be made to 
 determine whether there is one abscess or many. If the 
 latter, the walls between them should be broken down and 
 the cavity thoroughly washed out with carbolized water or 
 such disinfectant as the surgeon prefers. 
 
 The wound should be enlarged in case it is not sufficient 
 to secure free drainage. I prefer a roll of gauze, large 
 enough to fill the wound and long enough to extend up to 
 the upper portion of the abscess cavity. This drain of 
 gauze should be removed at the end of twenty-four hours, 
 and the cavity again irrigated and the smaller gauze drain 
 used. This change of drains is most easily made with the 
 patient in Sim's position. After this a double rubber 
 drainage tube should be used and held in place by a suture, 
 carried through the edge of the wound and the tubes. The 
 cavity should be washed out daily until the sac contracts 
 down, then the rubber tubes should be removed and a 
 small pledget of gauze placed into the vaginal wound until 
 the ca\dty is completely closed. 
 
ELECTRO-CAUTERY IN TREATMENT OF PELVIC ABSCESS. 8Y 
 CYSTS OF THE LABIA 
 
 Complete exsection is the proper treatment of the cysts 
 that are quite frequently found in the labia. But this has 
 proved to be very difficult in my practice, and I infer from 
 reports that others have not been much more successful. I 
 have tried in a great many cases to remove such cysts with- 
 out rupture^ but have invariably failed. The cyst wall is 
 very thin, and so closely adherent to the surrounding tissue, 
 especially at the deepest part, that complete enucleation is 
 impossible, so far as my experience goes. Lack of success 
 drove me to seek some more satisfactory method of operat- 
 ing, which I found in the following: In the large cysts 
 that were near the surface, by making a free incision with- 
 out wounding the cyst wall, I have succeeded in separating 
 the cyst from the greater portion of its attachment ; and 
 by retracting the sides of the wound so that the base of 
 the attachment was brought within easy reach, and then 
 applying a narrow-bladed haemostatic forceps to control 
 bleeding and compress the tissue and form a stump, the 
 stump is divided at the desiccated point, and the cyst set 
 free thereby. 
 
 In some cases it is necessary to separate the adhesions 
 in sections ; that is to say, a portion of the cellular tissue is 
 seized by the forceps, compressed and desiccated, and then 
 divided in the center of the desiccation ; another portion is 
 treated in the same way until the cyst is completely liber- 
 ated. All bleeding being arrested by the process, the 
 wound can be closed with sutures, and healing proceeds 
 without interruption as a rule. The cyst will be ruptured 
 sometimes, though the greatest care be taken ; then the 
 next best thing to do is complete cauterization of the cyst 
 wall. The wound is held open with forceps or tenacula 
 and a fine cautery point or knife blade passed over the 
 surface until every portion of the cyst wall is cauterized. 
 The cauterization should be very superficial, but complete. 
 If any portion of the cyst wall is left undestroyed, it will 
 
88 ELECTRO-H.EMOSTASIS IN OPERATIVE SURGERY. 
 
 continue to secrete and retard healing, or form another 
 cyst. 
 
 When cauterization is employed, the wound should he 
 left open until the charred tissue separates and is thrown 
 off. When this separation takes place it is necessary to 
 wash the deb?' is away or sponge it out of the wound. The 
 healing process goes on very rapidly under the crust of 
 charred tissue, and when this separates, the closure of the 
 cavity or wound is completed in a very short time. 
 
 This method of operating upon labial cysts involves 
 much more time and trouble than the old way, but the 
 comparatively little after-care required, the shorter time of 
 recovery, and the relief from suffering, more than compen- 
 sate both the patient and the sui^geon. 
 
 CYSTS OF THE VAGLN'A 
 
 These cysts of the vagina are caused in some cases by a 
 closing and distention of the vaginal glands, but they more 
 frequently are developed from distention of Grartner's ducts, 
 a portion of one of them remaining patent. 
 
 This has been clearly pointed out by Amand Routh in 
 his most interestino; article in volume xxx^' of the Transac- 
 tions of the Obstetrical Society of London. Their recog- 
 nition is not difficult, pro\dded that a careful inspection is 
 made of the vaginal canal. The treatment with the gal- 
 vano-cautery is easy, and the results good. A free incision 
 is made with the cautery knife through the vaginal wall, 
 the cyst is laid open, and the cyst wall cauterized with the 
 knife blade applied flatwise. The healing is accomplished 
 in less time than when the incision is made with the 
 knife ; the bleeding vessels are ligated, and caustic is used 
 to destroy the cyst wall. 
 
 Were it possible to remove the entire cyst intact by dis- 
 section, and to close the wound with sutures, that would be 
 the most perfect procedure. 
 
ELECTRO-CAUTERY IX TREATMENT OF PELVIC ABSCESS. 89 
 VARICOSE VEINS OF THE VULVA 
 
 The veins about the vulva, like those iu other portions 
 of the body, may take on a varicose condition. This com- 
 monly occurs in those who have borne children ; and, in- 
 deed, pregnancy appears to stand in a causative relation 
 thereto, although cases undoubtedly do occur in those who 
 have never been pregnant. 
 
 Causation. — Anything wliich obstructs the venous cir- 
 culation will, by increasing the intravenous pressure, 
 tend to produce this varicose condition, whether it be 
 a pregnant uterus, a tumor, or, as mentioned by Winckel, 
 the straining at stool, in. case of obstinate constipa- 
 tion. 
 
 Sym2?tomatology. — A patient may liave well-marked vari- 
 cose veins of tlie vulva, and yet be entirely unaware of the 
 fact. Or a sense of heat and irritation may be experienced 
 of so disagreeable a nature as to cause her to consult a phy- 
 sician, when the presence of varicose veins may be recog- 
 nized. In still other cases tlie enlars"ement or swellino; is 
 so great as to attract her attention, thougli other symptoms 
 may be absent. 
 
 Physical Signs. — Upon examination, in slight cases, the 
 varicose condition of the veins is observed, and the swelling 
 disappears on pressure, but returns immediately when the 
 pressure is removed. However, in more aggravated cases, 
 there may be so muck tumefaction of the labia and other 
 parts as to mask this peculiar condition of the veins. Hol- 
 den describes a case in which a tumor existed as large as 
 the head of a child. 
 
 The diagnosis iu these cases is to be made by excluding 
 other affections, such as hernia, hsematocele, cysts, and cellu- 
 litis. 
 
 Surgical treatment should be limited to cases that are 
 suffering, and in which there is danger of rapture from the 
 extreme distention of the veins. Indeed, the only operative 
 treatment advised is lia'ation and exsection of the veins. 
 
90 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 This has not been veiy satisfactory, owing to very slow 
 recovery. 
 
 The method of operating which I have adopted is as 
 follows : 
 
 An incision is made through the skin over the raost 
 prominent part of the mass of veins. The skin and sub- 
 cutaneous tissues are separated from the vessels with the 
 scissors or dry dissector, until the parts to be removed can 
 be drawn out of the wound. Then when possible the cen- 
 tral portion of the mass is dissected out, leaving the veins 
 attached above and below ; the upper end of the veins is 
 grasped with the forceps, com23ressed and heated until they 
 are closed firmly. The lower end of the veins should be 
 treated in the same manner, and the whole mass cut away. 
 Any small vessels in the wound that bleed should be closed 
 with the haemostatic force^^s, and the w^ound closed with 
 sutui^es. While the haemostatic forceps is being used, the 
 shield forceps should be placed underneath to protect the 
 tissues fi'om the heat in the way described in treating the 
 pedicle of an ovarian tumor. 
 
 If the mass of distended veins is not very large, they 
 can all be seized in one grasp of the forceps, and treated in 
 one piece and not in two sections. 
 
 This method of operating is so easily carried out, and 
 recoveiy is so uneventful, that I have employed it in cases 
 of lesser degree of development. I have the impression 
 that the method might be employed in treating varicose 
 veins of the leo-s. 
 
 Contused Wounds of the Pudendum, — These are of 
 two degrees of severity. A slight bruise, causing rupture 
 of only a few small vessels (which very soon stop bleeding), 
 gives rise to an ecchymosis, which quickly disappears. Oc- 
 casionally inflammation follows, and an abscess develops, 
 which is managed in the usual way. More severe are con- 
 tused wounds which rupture the large vessels of the bulbi 
 vestibulares or existing varicose veins of the labia, and pro- 
 duce pudendal htematocele — i. e., an accumulation of blood 
 
ELECTRO-CAUTERY IN TREATMENT OF PELVIC ABSCESS. 91 
 
 in the loose cellular tissue of the parts. The pathology of 
 this injury is the same as that of bruises or contused wounds 
 generally. There are laceration of the vessels and hasmor- 
 rhao'e into the cellular tissue. 
 
 In contusion of the pudendum two conditions conspii'e 
 to make the injuiy grave in character — the large size of 
 the vessels wounded, and the loose character of the cellular 
 tissue, ^vhich admits of a very large accumulation of blood. 
 The size of the hsematoma depends upon the size of the 
 vessels lacerated. In case the vessel is small, the bleeding 
 may be controlled by the ]3ressure from the blood in the tis- 
 sues ; but when large varicose vessels or the vessels of the 
 bulb of the vestibule are lacerated, the size of the hsemato- 
 cele is very great. I have seen one nearly as large as the 
 two fists. 
 
 The course and teiinination of the haematocele vary. If 
 the blood-clot is small it may disappear by absorption with- 
 out causing much discomfort, after the first pain of the 
 injury subsides ; but when the accumulation of blood is 
 large, then inflammation follows which may terminate in 
 sloughing or suppuration, and finally septicaemia, 
 
 Sijmpomatologij. — The symptoms are pain following 
 the injury, and then a feeling of fullness, heat, and some- 
 times throbbing. In one case that came under my observa- 
 tion the pressure was sufficient to prevent urination, and it 
 was very difficult to pass the catheter. The attention of 
 the patient being directed by the pain to the location of 
 the injury, she discovers the swelling by the touch. 
 
 Fhysiccd /%n.s.— The physical signs vaiy in the differ- 
 ent stao-es of the disease. At first the tumor is elastic and 
 like a local oedema, except that it does not pit on pressure. 
 After the blood has coagulated the parts are denser and 
 slightly irregular or slightly nodular ; discoloration of the 
 skin occurs in twenty-four hours, or less. (Edema of the 
 skin also occurs. 
 
 Diagnosis. — In regard to the diagnosis, it may be said 
 that pudendal hsematocele can hardly be confounded with 
 
92 ELECTRO-H^MOSTASIS IX OPERATIVE SURGERY. 
 
 any of the diseases of the pudendum except pudendal liemia ; 
 but tlie mode of development and physical signs of the two 
 affections are so unlike that the differentiation is easy. 
 
 Causation. — The causes of pudendal hsematocele are 
 predisposing and exciting. Varicose conditions of the ves- 
 sels, degeneration of the vessel walls, and marked engorge- 
 ment from any cause which interrupts the venous circula- 
 tion, render the vessels more susceptible to rupture when 
 subjected to any injuiy. 
 
 Pregnancy predisposes to rupture of the jDudendal ves- 
 sels, and labor is one of the most prominent of the exciting 
 causes, but the present discussion of this affection is limited 
 to causes occuriing in the nonpueii^eral state. The reader 
 will find a very full account of this affection, as it occurs in 
 labor, in a monograph by Prof. Fordyce Barker. 
 
 In regard to the exciting causes of the affection, it may 
 be said, in brief, they are always traumatic. Difficult labor, 
 direct blows, are the usual means by which the vessels are 
 ruptured ; indirect injuries — from a fall, for instance — might 
 produce rupture of the pudendal vessels, but I have not 
 seen any case in which the injujy was caused in that way. 
 
 Treatment. — When the patient is seen while the bleed- 
 inp- is still going on, a free incision should be made through 
 the skin and the blood pressed out; the bleeding vessels 
 seized singly or in mass with the haemostatic forceps and 
 closed by the pressure and heat. The wound is then closed 
 with sutures. 
 
 In cases of longer standing in which a hsematoma has 
 been formed by the coagulation of the blood, the incision 
 should be made with the cautery knife and the blood-clot 
 turned out. Since the cellular tissue is infiltrated with 
 blood, the whole coagulum can not be removed without 
 starting bleeding. Hence it is necessary to control the 
 bleeding vessels in the way described. The cavity being 
 thus freed from blood-clots and the bleeding completely 
 controlled, it should be packed with gauze and allowed to 
 heal fi"om l)el<)\v uutward. 
 
ELECTRO-CAUTERY IN TREATMENT OF PELVIC ABSCESS. 93 
 
 I have operated by making tlie incision witli the knife 
 and ligating the vessels, and am able to compare the old 
 method ^vith the new. The advantages are all with the 
 new method of operating. 
 
 CARBUNCLE 
 
 All surg-eons ao-ree that free incision is indicated in car- 
 buncle, but they admit that there are objections to the use 
 of the knife, chief among them being the loss of blood that 
 can ill be spared by the subjects of carbuncle, for they are 
 always in a low state of general health. 
 
 There is, in my opinion, still another objection of equal 
 imjDortance, and that is the absorj)tion of septic matter from 
 the incised wound, which causes a further, and often dan- 
 gerous deterioration of the general health. 
 
 These objections are met and the dangers avoided by 
 using the cautery knife in making the incision. It is desira- 
 ble to open a carbuncle before death of the deeper tissues 
 takes place. At this stage of the disease one fi^ee incision 
 through the skin, extending across the parts involved, is 
 required. When the skin is divided the tension is usually 
 sufficient to throw the wound open so that the incision can 
 be continued down through all the tissues involved. When 
 the carbuncle is large and induration well marked, two sub- 
 cutaneous incisions should be made at rio^ht ano-les to the 
 first. Clean gauze should be placed into the wound to 
 keep it open and permit the serum, which soon begins to 
 ooze fi'om the tissues, to escape. There is no haemorrhage 
 if the incisions are made slowly and with a knife at red 
 heat and the wound surfaces are rendered incapable of 
 absorption. The pressure is taken off the blood-vessels, 
 the circulation is re-established, and necrosis prevented. 
 When necrosis has taken place the whole of the dead tissue 
 should be exsected. That can be done by making a circular 
 incision, retracting the edges of the incision in the skin, and 
 with the cautery knife dissecting out all the necrosed tissue. 
 It is necessary to keep within the line of demarcation be- 
 
94 ELECTRO-HiEMOSTASIS IN OPERATIVE SURGERY. 
 
 tween dead and living tissue. The separation of tlie core 
 or necrosed tissue can be quickly done because the tissues 
 are softened and bloodless. If by chance any portion of 
 the dead tissue is left it can be easily seized and cut off. 
 It sometimes happens that a large artery spurts, having 
 been too quickly severed with the cautery knife. In that 
 case it should be seized with the haemostatic forceps and 
 closed. A gauze packing should be loosely applied and 
 left until it becomes saturated with the discharge. 
 
 Before the thin crust of charred tissue separates, the 
 healing process is well advanced, so that an ordinary gauze 
 dressing is all that is required to complete the treatment. 
 
CHAPTEE X 
 
 ELECTEO-HJEMOSTASIS IJS^ EXTIEPATIOlSr OF THE MAMMAEY 
 AND LYilPHATIC GLANDS 
 
 I coNTrNUED to use tlie ligature for controlling the haemor- 
 rhage in extirpation of the mammary gland long after I had 
 given it up in all my other surgical work. This was owing 
 to the fact that the classical method had given general satis- 
 faction. Occasionally there would be suppuration and de- 
 layed healing, but such imperfections were attributed to 
 some surgical sin of commission or omission on the part of 
 the operator and assistants. Then a rigid investigation 
 would be made in order to discover the source of infection. 
 Some possible cause of the objectionable effects were usually 
 discovered, but in no case was the ligature found guilty or 
 responsible, excepting on one occasion when there was cause 
 for a suspicion that the catgut used was not aseptic. There 
 was no reason in this to induce me to give up the ligature, so 
 I continued to use it in this operation, until my first assistant 
 said that he had forgotten how to tie a ligature, and, what 
 was more to the point, the fact of having forgotten to pro- 
 vide clean, reliable catgut ligatures, suggested that the 
 haemostatic forceps should be used in the extirpation opera- 
 tion then on hand. Though belie\dng that more time would 
 be required to operate in this way, there was no apparent 
 objection to trying. The operation was performed accord- 
 ingly and proved to be so gratifying that I have followed 
 this method ever since. Not that this method of operating 
 has proved to be so* much superior to the old way, but 
 because it has been more satisfactory in being followed 
 
 95 
 
96 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 by less pain and a shorter period of recoveiy, and saves all 
 the trouble and time of obtaining reliable catgut ligatures. 
 
 There are so many ways of preparing catgut ligatures 
 that one is in doubt regarding which to choose, and I find 
 that many surgeons prefer preparing their own, or to have 
 them prepared by assistants, rather than to obtain them 
 fi'om dealers in surgical supplies. This involves an amount 
 of labor and trouble, and withal a feeling of doubt which 
 the surgeon would gladly escape, I am sure. Perhaps this 
 doubt regarding the sterility of catgut ligatures is personal, 
 and others may have confidence in them when prepared as 
 they direct or practice. I can only say that, not having 
 time to prepare my own ligatures myself, I always have a 
 fear that they may be imperfectly treated or contaminated 
 in keeping. Therefore this made me the more willing to 
 give up ligatures in removing the mammary gland, though, 
 as already stated, I was fearful that more time would be 
 required to control the bleeding with the new haemostatic. 
 JVIy opinion on that subject was a mistaken one. In actual 
 practice I saved time. 
 
 Operation. — The incision is made and the gland and sur- 
 rounding adipose tissue exsected in the usual way. As the 
 arteries are divided the assistant catches them with ordi- 
 nary compression forceps to temporarily control the bleed- 
 ing. When the whole breast is removed and all suspicious- 
 looking parts of the fascia and muscle, each forceps is 
 removed in the order of its application and the haemostatic 
 forceps applied exactly to the part from which the other 
 forceps has been removed ; the heat is turned on for a half 
 ■or a quarter of a minute ; the assistant holds the forceps 
 while the heat is being applied, and meanwhile the operator 
 applies the haemostatic forceps to another artery and trans- 
 fers the current from one forceps to another. The forceps 
 is left on for a time after the current is discontinued. This 
 is done because I found that the heat in the forceps was 
 sufficient to continue the desiccating for some time after 
 the heat supply was cut oif. It will be seen from this 
 
EXTIRPATION OF THE MAMMARY AND LYMPHATIC GLANDS. 97 
 
 account tliat two or three arteries can be under treatment 
 simultaneously and much time saved thereby. 
 
 In looking over the history of cases I find one of extir- 
 pation of the mammary and axillary glands performed in 
 half an hour, and another in forty minutes. This compares 
 very favorably ^\dth operations in the old way so far as 
 time is concerned. 
 
 In extirpation of the axillary glands for cancer con- 
 nected with disease of the breast, I have found this method 
 of controlling haemorrhage very satisfactory. 
 
 The mammary gland is first removed, then the incision 
 is continued along the border of the pectoralis muscle ; the 
 glands and adipose tissue are then dissected away from the 
 skin and fascia. Each gland is isolated with the dry dis- 
 sector and fingers, and drawn away from the large vessels 
 and nerves ; in other words, they are made pedunculated. 
 A narrow-bladed haemostatic forceps is applied between the 
 gland and the vessels and nerves, the heat used long enough 
 to close the vessels, and then the gland is cut away. By 
 being careful in separating the glands from the vessels in 
 this way there is less danger of injuring the vessels, the 
 large veins especially. 
 
 The results that follow compare favorably with those 
 obtained by other surgeons, and are superior in several re- 
 spects to those obtained in my own practice by operating in 
 the usual way. There is less pain and the healing process 
 is completed in much less time. This can be best illustrated 
 by the following notes of a case recently treated : The 
 patient was operated upon years ago at different times for 
 laceration of the cervix uteri, laceration of the pelvic floor, 
 and rectal haemorrhoids ; subsequently one of her ovaries 
 was removed by vaginal section ; last of all her right breast 
 was extirpated for cancer. Her experience certainly quali- 
 fied her to judge of pain after surgical treatment. Her 
 testimony regarding the last oj)eration was that she had no 
 pain whatsoever. There was no rise in temperature, and 
 the pulse after her recovery from the anaesthetic remained 
 
98 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 normal throughout her convalescence. Her appetite and 
 nutrition were normal, and she slept well. On the morning 
 of the fourth day she left her bed and was about her room. 
 The sutures were removed on the seventh day, all of them 
 coming away dry and without any bleeding. Two drops of 
 clear serum escaped from the track of one suture after its 
 removal ; union was complete and perfect, and there was no 
 swelling or induration of the parts. There was no traction 
 upon the edges of the wound. A thin layer of sterilized 
 cotton was placed over the chest and a bandage applied. 
 This dressing was removed on the twelfth day and was 
 found to be dry and clean. At that time the process of 
 repair was complete. There was no tenderness anywhere, 
 the skin was everywhere movable upon the thorax to a 
 slight extent, and the arm could be moved in every way 
 without pain. Such perfect healing of the skin incision 
 and between the skin and deeper tissues of the thoracic 
 wall I have never known to take place in so short a time when 
 a number of ligatures were used to control the bleeding. 
 
 A comparative study of this and others operated on in 
 this way indicates that the process of repair is simpler and 
 is completed in less time than in cases in which ligatures 
 have been used, and have to be disposed of by absorption 
 or becoming encysted. Therein the clinical phenomena and 
 the laboratory experiments coincide, and prove as clearly 
 as need be that the use of the haemostatic forceps has just 
 claims upon the surgeon's confidence in regard to the repair 
 of wounds. 
 
 Having found that extirpation of the breast is a rather 
 long operation, owing to the time required to arrest the 
 haemorrhage, I was of the opinion that the new haemostatic 
 would prolong the operation still more ; but, as already 
 hinted at, less time was required to close the arteries com- 
 pletely and leave the wound so dry that no drainage was 
 required. More time was needed to close the large vessels 
 than if the ligature had been used, but the small vessels, 
 ignored by some operators, which I always take pains to 
 
EXTIRPATION OF THE MAMMARY AND LYMPHATIC GLANDS. 99 
 
 stop, were managed in less time, so that a complete drying 
 state of tlie wound was obtained in as little or even less 
 time than I had ever employed while operating in the old 
 way. This may be made clear by giving an illustrative 
 case : The patient had carcinoma involving about two 
 thirds of the left mammary gland. The tumor was not 
 large ; the skin was not perceptibly involved, but the axil- 
 lary glands were very large, indurated, and matted together, 
 forming one irregular mass a third of the size of the tumor 
 in the breast. I do not remember having seen the axillary 
 glands so extensively involved in connection with so moder- 
 ate an advancement of the disease in the breast. 
 
 By an unexplained omission the blood had not been 
 examined, and I was surprised by the discovery, during the 
 operation, that she was hsemorrhagic. There was no great 
 vascularity apparent, and I was not expecting any trouble 
 with the haemorrhage, nor were the principal arteries large, 
 but the smallest vessels kept on bleeding so that I was 
 obliged to close them after the removal of the breast and 
 before clearing out the axillary glands. Troublesome 
 haemorrhage was anticipated in removing the lymphatics in 
 the axilla, but I was pleased to find that I had less trouble 
 than was expected. Some bleeding was avoided by not 
 extending the incision of the skin as far upward as usual, 
 and there being no adhesions of the parts to the muscles, 
 there was no bleeding from small muscular arteries such as 
 were so troublesome in the breast part of the ojDeration. 
 The main arteries were treated in the way described in the 
 first operation given, and the small ones were caught in the 
 small artery forceps (which was kept heated continuously) 
 and held for the few seconds required to stop them. The 
 small arteries in exposed muscles and in the skin were the 
 most difficult to manage; still they were all closed and 
 the wound made quite dry, far more so than I could have 
 made it by using ligatures. The surface of the wound was 
 freely studded with the stumps of closed vessels, but was 
 smooth and clean compared with what it would have been 
 
100 ELECTRO-H^MOSTASTS IX OPERATIVE SURGERY. 
 
 if I had used ligatures. How long it would have taken me 
 to operate if I had used ligatures I do not know, but I am 
 very sui'e that I could not have so completely arrested the 
 haemorrhage in a bleeder like that one by ligation, and I 
 have never been able to do such an operation in less than 
 forty-five minutes, the time required in this case. 
 
 The incision in the skin was made short to avoid 
 haemorrhage and to save the necessity of many sutures, the 
 latter giving great advantage, because needle punctures- 
 bleed freely in such patients. Only two sutures were em- 
 ployed, and the remaining part of the wound closed with 
 adhesive strips. The healing was without interruption. 
 There was no suppuration and only a very little escape of 
 pinkish-colored serum dming the first day after the oper- 
 ation. 
 
 EXTIRPATIOlSr OF DISEASED LYMPHATIC GLAJSTDS 
 
 The affections of the lymphatic glands characterized by 
 enlargement that call for extirpation are not to be con- 
 sidered here. The classical method of exsection gives entire 
 satisfaction no doubt, but in scrofulous and tubercular dis- 
 ease of the glands in the inflammatory stage, especially 
 ^vhen there is suppuration, much more gratifying results 
 can be obtained by operating with the galvano-cautery. 
 At least, such has been my exj^erience. 
 
 The method of operating should be adapted to the con- 
 dition present in an adenitis in the first stage — that is, be- 
 fore suppuration has taken place. The incision is made 
 Avith the cautery knife through the skin, and the adhesions 
 of the gland to the neighboring parts separated by dry dis- 
 section ; vessels that are large enough to bleed are closed 
 with an application of a haemostatic and divided. Very 
 often the main artery which supplies the gland is imbedded 
 in a mass of exudate and cellular tissue from which it can 
 not be isolated. In that case the whole mass should be 
 treated with the haemostatic forceps and the gland set free 
 by dividing the desiccated portion of tissue containing the 
 
EXTIEPATION OF THE MAMMARY AND LYMPHATIC GLANDS. 101 
 
 vessels and nerves. Small bleeding vessels that are found 
 should be closed, and any exudate or products of inflamma- 
 tion that have been left should be dissected out and the 
 cavity loosely packed with gauze and an aseptic dressing 
 applied. 
 
 At the end of twenty-four hours the gauze packing 
 should be removed and the wound redressed. It is not 
 necessary to introduce any drain afterward at the second 
 dressing, unless the wound is very deep ; the incision in the 
 skin having been made with the cautery, the surface wound 
 will not heal before the cavity is closed. 
 
 Suppurating cases are operated by first opening into the 
 abscess with the cautery knife and removing the gland tis- 
 sue and inflammatory products wdth a curette, thoroughly 
 washing out the cavity and drying it, and then superficially 
 but completely cauterizing the surface ; finally packing and 
 dressing, as described above. 
 
 This method of operating in suppurating tubercular 
 disease of the glands gives superior results, as indicated by 
 a speedy and complete recovery. Making the incision with 
 the cautery knife prevents haemorrhage and reinfection, and 
 the cauterization of the cavity surface arrests the suppura- 
 tive disease so that recovery promptly takes place, instead 
 of continued suppuration and extension of tubercular infec- 
 tion, which so frequently follows after evacuation by curet- 
 ting alone, and finally the scar is smaller than that which 
 follows the usual way of operating. 
 
CHAPTEE XI 
 
 ELECTEO-H^MOSTASIS IN EXTIEPATIO^iT OF TIHMOES OF THE 
 
 BLADDER 
 
 Iisr times past I had considerable experience in tlie treat- 
 ment of neoplasms of the bladder, according to the methods 
 given by the best surgical authorities. 
 
 Either vaginal or suprapubic cystotomy was performed, 
 the choice between the two avenues of approach being de- 
 termined by the location of the growth to be removed. 
 When the part to be removed was reached, it was cut off 
 with the scissors or removed with the cm*ette, and the 
 haemorrhage stopped by ligation of the vessels or the appli- 
 cation of such styptics as hot water, persulphate of iron, or 
 acetic acid. The bladder was drained until healing took 
 place. I never cured a case in this way, and I am not sure 
 that the life of the patients was prolonged by the treat- 
 ment. In fact, in two of my patients life was probably 
 shortened, though great relief was given by the treatment. 
 
 With such discouraoina: results before me I determined 
 to try the clamp and cautery method of operating. 
 
 The first removal of a neoplasm, supposed to be malig- 
 nant, from the bladder with the clamp and cautery was 
 one in which I was able to make an accurate diagnosis of a 
 tumor, about an inch and a half in diameter, on the upper 
 part of the anterior wall of the bladder. The patient had 
 for months suffered almost continuously from hsematuria. 
 I made a vesico- vaginal fistula by dividing the tissues with 
 the knife and scissors ; then, by having pressure made above 
 the pubes and raising the vaginal wall, brought the tumor 
 
 103 
 
EXTIRPATIOX OF TUMORS OF THE BLADDER. 103 
 
 down to the vaginal fistula, and succeeded in drawing it 
 through into the vagina, and with it, of course, a portion of 
 the anterior wall of the bladder. I clamped the base of 
 this growth with the forceps and then cut it off with the 
 cautery, and, applying the cautery to the blades of the for- 
 cep, desiccated the portion within the grasp of the forceps, 
 most of which was normal mucous membrane ; the forceps 
 was then removed, the bladder thoroughly washed out, and 
 the vesico-vaginal fistula closed with silk sutures. The 
 bladder was drained with a retained catheter for twenty- 
 four hours after the operation, and then catheterized every 
 four hours for three or four days. The patient made a 
 complete recovery. Having succeeded so well with the 
 clamp and cautery, I was led quite naturally to expect that 
 still better work could be done with the haemostatic for- 
 ceps ; and- soon after that instrument was devised, I found 
 an opportunity to try it, and it came quite up to my highest 
 expectations. 
 
 This, in brief, is the story of the evolution of the present- 
 time operation for neoplasms of the bladder. 
 
 EXTIRPATIOlSr OF NEOPLASMS OF THE BLADDER THROUGH A 
 VESICO-VAGESTAL FISTULA 
 
 Sing^le tumors of small size attached to the bladder wall 
 at any point, excepting the middle of the posterior wall, 
 can be removed through a vesico-vaginal fistula, and it is the 
 best way of operating. 
 
 The patient is placed in the Sims position, and an open- 
 ing made in the median line large enough to permit the 
 tumor to pass through. The vaginal wall is pressed up- 
 ward with a long forceps, the open blades of which are 
 placed against the edges of the fistulous opening. An as- 
 sistant makes pressure over the hypogastric space to crowd 
 the bladder down to the opening, and force the tumor out 
 into the vagina. The operator holds the forceps which sup- 
 ports the vaginal wall in his left hand, and aids in the de- 
 livery of the tumor with a small sponge in a holder. The 
 
104 ELECTRO-HiEMOSTASIS IN OPERATIVE SURGERY. 
 
 sponge is used instead of the traction forceps to aid in the 
 delivery of the tumor, as the tissues are always friable, and 
 the forceps would tear them. When the base of the tumor 
 is thus brought into view, the haemostatic forceps is applied, 
 and a thin shield adjusted to prevent the heat from injuring 
 the bladder or mucous membrane, and also keep the partial- 
 ly inverted bladder from getting away from the operator. 
 It is better to include a portion of the mucous membrane 
 of the bladder in the haemostatic forceps than to run the 
 risk of letting any part of the diseased tissues escape. The 
 heat should not be above 175°, but should be continued for 
 tw^o minutes and a half ; and very little traction should be 
 made on the forceps, because the tissues are friable and 
 easily torn from their attachment to the bladder wall. 
 When such a mishap occurs, the bleeding should be con- 
 trolled by singeing the points that bleed with a small haemo- 
 static and closing them, or a cautery below red heat may 
 be used. 
 
 The tumor is cut off close and the forceps opened 
 enough to loosen their hold, and the stump is permitted to 
 escape by slipping off the forceps as one would take a ring 
 off the linger. In that way the delicate stump is not torn. 
 Formerly I washed out the bladder before closing it, but 
 that is not necessary. 
 
 The opening in the bladder is closed with silk sutures, 
 and drained for a day or two with a catheter of soft rub- 
 ber. Fig. 67 shows the tumor croAvded out through the 
 opening, with the forceps and shield in place. 
 
 The Suprapubic Operation. — Large and multiple neo- 
 plasms and those inhabiting the lateral walls and base of 
 the bladder can be successfully removed only through the 
 suprapubic opening. 
 
 In addition to the usual preparation for the operation 
 the bladder should be thoroughly washed out and disin- 
 fected, using every care not to start bleeding. A mild 
 solution of acetic acid is the best, as it is a good styptic 
 and a fair disinfectant. The bladder should be filled but 
 
EXTIRPATION OP TUMORS OF THE BLADDER. 
 
 105 
 
 not be distended with air or water, and kept so until the 
 opening is made. Distention invariably causes haemorrhage 
 less or more, and complicates the operation. 
 
 The opening should be made as large as possible ; the 
 edges of the wound held apart with retractors, and the 
 interior illuminated with direct or refracted light. The 
 bladder is emptied with the catheter and then sponged 
 dry. In case there are a number of growths situated at 
 different parts of the bladder each one is caught at its base 
 with the haemostatic forceps, treated, and cut off. Single 
 
 Fig. 67. — Bladder tumor drawn out through a vaginal incision. The haemostatic 
 clamp grasps the pedicle; the shield forceps is shown by dotted lines beyond 
 the clamp. The jjatient is in the Sims's posture. 
 
 large growths with broad attachments are treated in sec- 
 tions ; that is to say, a portion, such as can be grasped at 
 once with the forceps and treated, and then another, until 
 the whole is exsected. Long retractors are used to keep 
 the bladder walls away from the hot forceps in cases where 
 there is not room enough to use the shield forceps con- 
 veniently. Fig. 68 illustrates this part of the operation. 
 
 When the disease has involved the muscular wall of 
 the bladder (a condition found only in cancer) the entire 
 
106 
 
 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 base of the tumor, including the bladder wall, should be 
 removed. That is done by first removing the tumor which 
 projects above the surface, then seizing the stump in the 
 middle, and by traction drawing it inward and upward 
 until the haemostatic forceps can be applied and the whole 
 
 ric i-^:^Si:^Ti;a^r^!ii 
 
 L': 
 
 Fi&. 68. — A pedunculated growth of the bladder clamped by the haemosratic 
 forceps ; the bladder wall is protected by the shield forceps. On the anterior 
 bladder wall the stump of a previously treated tumor is shown. 
 
 of the diseased part removed ; or, if that can not be done at 
 once, it can be done in sections. This radical treatment of 
 advanced cases should not be undertaken if the disease 
 involves or goes close to the ureters or urethra. In the 
 majority of eases the bladder should be drained from 
 
EXTIRPATION OF TUMORS OF THE BLADDER. 107 
 
 above until healing is completed; but if the base and 
 fundus are normal the wound may be closed and drainage 
 made with the catheter. 
 
 The stumps are thrown off in course of the healing, 
 and should be washed out. Any scrap of dead tissue left 
 would form a nucleus for a calculus. 
 
 There being no haemorrhage in operating in this way, 
 the procedure is easily accomplished compared with the 
 old way. 
 
 The wounds left to heal are very small, and the stumps 
 being glued together, as it were, become almost completely 
 healed before the desiccated portions are thrown off. It 
 may be said that the bases from which the tumors were 
 removed heal under a scab, thus avoiding ulcerating sur- 
 faces that are slow to heal. 
 
 By removing single small neoplasms in this way the 
 opening in the bladder can be closed immediately, and the 
 treatment completed in one operation. The thoroughness 
 of the operation prevents or delays the recurrence which 
 followed sooner or later in all my cases treated according 
 to other methods. The following case selected from a 
 number illustrates the clinical history and treatment of 
 this class of affections: 
 
 Mrs. H. H. C. came under observation in January, 1892, 
 saying that for some little time past, following convales- 
 cence from a severe attack of la grippe, she had been notic- 
 ing blood in her urine. At first but little attention was 
 given to this condition for she never suffered any pain ; 
 but during the past six months she became aware of feel- 
 ing easily fatigued, and felt that she was " running down " : 
 at the same time the hsematuria was becoming more and 
 more pronounced, until for the six weeks prior to her ad- 
 mission the urine constantly showed the presence of large 
 amounts of blood. 
 
 The haemorrhages were at once controlled by irrigations 
 with acetic acid and the administration of instillations of 
 fifteen drops of fluid extract of hydrastis canadensis before 
 
108 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 meals. In a few days a tliorough cystoscopic examination 
 could be made. The bleeding was traced to a papillo- 
 matous growtli in the upper left lateral quadrant of the 
 bladder. The tumor was removed on January 28th, by 
 way of the vagina, with the clamp and cautery. The 
 fistula was closed at once. 
 
 The recovery was favorable. Some large granules of 
 phosphates were found in the urine for a few days after 
 the operation. When the sutures were removed in the 
 following week the fistula had closed, except a small open- 
 ing of the mucous membrane of the vagina in the lower 
 angle. This w^as obliterated within the week, and the pa- 
 tient left the sanatorium nine days later. 
 
 In the fall of 1894 the patient returned with a history 
 of entire relief until a few months ago ; but that now her 
 mine again shows some color almost constantly, and at 
 times is decidedly bloody. She has been well otherwise 
 except for a severe siege of typhoid fever, but this did not 
 seem to have any influence upon her bladder. She is free 
 fi'om pain, retains her urine the usual length of time, and 
 feels just as she did at the time of the previous operation. 
 
 The cystoscope shows a possible return of the neoplasm, 
 but the area is darker in color and looks more like a deposit 
 of urine salts on the scar. The examination was not entirely 
 satisfactory, as there had been bleeding the day before ; so 
 the bladder was irrigated and prepared for another exam- 
 ination. This time the cystoscope reveals several neoplasms 
 near the fundus ; they are smooth, lobulated, of a grayish 
 color. There is also a body in the base of the bladder, 
 round and like a stone, but it does not give the character- 
 istic click when touched with the sound. When the blad- 
 der was opened this area was found to be a deposit of 
 urinary salts on a soft papillomatous base. A suprapubic 
 cystotomy was done, and a number of small papillomatous 
 tumors removed by the new method. The patient was dis- 
 charged after an uneventful recovery. 
 
 Six years after the first operation the patient once more 
 
EXTIRPATION OP TUMORS OF THE BLADDER. 109 
 
 returns for relief. But this tiuie tlie history is very differ- 
 ent. She has been in almost constant pain for a year. At 
 times there would be a temporary amelioration of her con- 
 dition, but for the greater part of the period she has been 
 most at ease only when lying on her back. Micturition 
 has been nonnal, but frequent, and at times would be pre- 
 ceded, again followed, by shai-p spasmodic pains. The his- 
 tory is meager as to the appearance and character of the 
 urine. It is thought that two small gravel stones were 
 voided in the fall of 1895, yet the diagnosis of calculus was 
 not made by the physician in charge. The case was treated 
 as simple catarrhal cystitis. The only other important inci- 
 dent observed was an occasional incontinence. 
 
 A vesical calculus was discovered at once, and the diag- 
 nosis confirmed February 15, 1898, by doing a vaginal 
 cystotomy and removing a large stone. The weight is 
 fifty-six grammes ; it is fifty -five millimetres long, thirty-five 
 millimetres wide, and one hundred and ten millimetres in 
 transverse circumference. The shape is that of a slightly 
 irregular ovoid flattened at one of the poles, and is fairly 
 smooth. On section only a few lamellae are seen, and these 
 are toward the periphery. The nucleus is distinguished 
 from the rest only by being imbedded in a deeper mass of 
 more porous matter. Chemical analysis places it in the 
 class defined by Hoffman and Ultzman as " metamorphosed " 
 stones, for it is composed of earthy phosphates forming a 
 quite homogeneous and porous mass. 
 
 Convalescence was rapid ; there was no return of the 
 pain ; and the urine showed a rapid decrease in crystalline 
 deposit and the usual evidences of bladder irritation caused 
 by a calculus. The wound was left open to insure perfect 
 drainage for a time. It would have closed of its own ac- 
 cord had it not been for a prolapsus of a portion of the 
 mucous membrane into the lower angle of the opening. 
 
 The after-treatment has consisted in daily irrigations, 
 and for a week maintaining continual drainage during the 
 night by catheter. Within a fortnight the patient was 
 
110 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 able to sit up several hours daily without any discomfort 
 or any return of her former ill feeling or symptoms, and 
 about a month after the operation returned to her home. 
 
 The interest in the case centers largely in there being 
 no recurrence of the former growths, in the age of the pa- 
 tient (she is now sixty-three years of age), in the size of 
 the stone, its rapid formation, and that its formation was 
 due to some scrap of dead tissue that remained after the 
 second operation. 
 
 After remaining at home for two months, during which 
 time she Avas well and regained her strength, she returned, 
 and I closed the small fistulous opening that remained. 
 Before operating to close the fistula a most rigid examina- 
 tion of the bladder was made, but no foreign body was 
 found, and not the slightest evidence of a recurrence of the 
 papillomatous growths. It is now nearly a year since she 
 went fi'om under my care, and she is perfectly well in 
 every respect. 
 
 THE TREATMENT OF ULCERS OF THE BLADDER WITH THE 
 GTALVANO- CAUTERY 
 
 I was induced to use the galvano-cautery in the treat- 
 ment of ulcers in the bladder by a somewhat curious expe- 
 rience. 
 
 A girl nineteen years of age came to my clinic suf- 
 fering from hsematuria, which had troubled her for over 
 two months. Her health was good and the urine normal, 
 excepting the blood which it contained. I first made sure 
 that the blood came from the bladder, and then put her 
 upon the usual internal remedies for haemorrhage of the 
 bladder, but with no benefit to her. A bimanual examina- 
 tion of the bladder gave negative evidence, but it increased 
 the haemorrhage for a time. A solution of acetic acid, 
 which was used to wash out the bladder, controlled the 
 bleeding long enough for a cystoscopic examination. On 
 the lower part of the posterior wall I found a whitish-gray 
 colored body about three eighths of an inch in diameter, 
 
EXTIRPATION OF TUMORS OF THE BLADDER. m 
 
 surrounded by a border of papillomatous or granulation 
 tissue very red and vascular. A diagnosis of calculus 
 partially encysted was made upon the physical signs ob- 
 tained with the cystoscope. The use of the sound and a 
 bimanual examination gave no evidence confirmatory of the 
 diagnosis. The bladder was opened through the vagina, 
 and I found that the object which appeared to be a stone 
 was a thick deposit of urine salts upon an ulcerated sur- 
 face. The deposit and soft vascular tissue around it were 
 removed with a curette and pressure made upon the raw 
 surface with a sponge until the bleeding ceased. A small 
 galvano-cautery was applied — at dull red heat — to the 
 whole surface long enough to destroy the whole of the 
 diseased tissue and form a thin dry crust over all. 
 
 The wound in the vagina was closed, and the bladder 
 drained with a catheter for three days. After that the 
 patient was made to urinate every four hours for the re- 
 mainder of the week. About that time a number of black- 
 ish particles were passed with the urine — the debris of the 
 cauterized tissue. For several days thereafter the bladder 
 was washed out to make sure that no bits of dead tissue 
 remained to cause the formation of a calculus. 
 
 The patient made a good recovery, and was well a year 
 later, at which time she was and gave promise of continu- 
 ing free from recurrence of the affection. 
 
 The benefit derived from the cautery in this case in- 
 duced me to employ the same treatment in cases of ulcera- 
 tion of the bladder. In chronic cystitis of long standing, 
 especially in aged women, an ulceration occasionally occurs 
 generally at the base of the bladder. These are seldom 
 cured by instillations or caustic applications. This was 
 another inducement to try the cautery. The diagnosis and 
 the localization of the ulcer is made with the cystoscope. 
 The operation or application is made by placing the patient 
 in the knee-chest position, introducing the largest endo- 
 scope that can be used with safety, and bringing the dis- 
 eased part into the field of vision and applying the cau- 
 
112 ELECTEO-HiEMOSTASIS IN OPERATIVE SURaERY. 
 
 tery. Ulcers of considerable size can not be all seen at 
 once, and so one requires to cauterize portions at a time, 
 doing one part and then another till tlie whole is treated. 
 Considerable experience and practice is necessary in order 
 to operate successfully, but the benefits derived compensate 
 fully for all that. 
 
CHAPTEE XII 
 
 THE ELECTEO-CAUTEEY IN THE TREATMENT OF URETHRAL 
 
 AFFECTIONS 
 
 The diseases of the urethra in which the electro-cautery 
 is most eilective are neoplasms about the meatus, urethritis, 
 narrowing of the meatus, either congenital or acquired, and 
 inflammation of the urethral glands and follicles. 
 
 In regard to the pathology of these neoplasms at the 
 meatus urinarius, there are two forms to which I wish to 
 call attention. One, the rarest, is angioma^ caused usually 
 by malnutrition and deranged circulation. These growths 
 closely resemble rectal haemorrhoids in both the pathology 
 and the causes which produce them. The other is a pro- 
 liferation of tissue, caused by a chronic inflammation of the 
 glands or follicles in the vaginal side of the urethra. 
 Both varieties have been known as vascular growths of the 
 meatus or caruncle. 
 
 The diagnosis is of course easily made when the dis- 
 ease is confined to the exposed portion of the meatus, but 
 when these growths are within the urethra the diagnosis 
 can be made only by the use of the endoscope. I may 
 state in passing that many do not use this instrument for 
 diagnostic purposes, owing to its being rather inconvenient 
 and requiring experience in its use. To meet that, I find 
 in many cases a diagnosis can be made by exclusion. Dis- 
 placements and dislocations can be detected or excluded by 
 the touch and sound, and cystitis can be disposed of by fre- 
 quent and careful urine examinations. 
 
 Most important of all in this connection is the cysto- 
 us 
 
114 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY, 
 
 scope, wliicli is so valuable in detecting or excluding dis- 
 eases of the bladder wliicli simulate in a marked way cer- 
 tain diseases of the urethra, but this instrument is not 
 always at command. I find that the differential diagnosis 
 must be made by the majority of practitioners, if made at 
 all, by examinations of the urine and from the symptoms. 
 When it is determined by exclusion that the disease is con- 
 fined to the urethra, the question rests then between inflam- 
 matory affections and displacements and dilatation. The 
 latter can be detected, as before stated, by the touch and 
 sound. 
 
 To return to the treatment of neoplasms, the indications 
 are to thoroughly and completely destroy the diseased tis- 
 sue and nothing more. To do this with caustics in the way 
 usually commended is impossible — at least I find it so. 
 The diseased tissue can be destroyed, if not by one, by 
 several applications ; but the line of demarcation between 
 the normal and abnormal tissue can not be clearly and accu- 
 rately drawn, and the action of the caustic limited to that 
 one part. After the eschar separates the surface left to 
 heal is large, painful, and tender, and during the healing 
 process there is great liability to the recuiTence of the orig- 
 inal disease. This is one of the reasons for the frequency 
 with which these growths return, as noted by all writers on 
 the subject. Exsection is a more surgical method which 
 gives better results when well done than caustics ; but un- 
 less sutures are used to close the wound the healing is slow 
 and uncertain, especially if the urine is in any degree 
 morbid. 
 
 The galvano-cautery fulfills all the requirements per- 
 fectly and completely. There is less pain in its use. Heal- 
 ing is more rapid, and there is less likelihood of the disease 
 returning. 
 
 The cautery instrument which I employ is the fine point. 
 (See Fig. 75.) 
 
 A larger cautery can be used with advantage in remov- 
 ing large neoplasms, but for all general purposes the small 
 
TREATMENT OF URETHRAL AFFECTIONS. II5 
 
 one is the best. I may here mention the fact that it should 
 be brought to the desired heat before applying it to the 
 tissues, and then after making one incision or application it 
 should be withdrawn from the tissues and reheated. This 
 is necessary, because the moment this fine point is brought 
 into contact with the tissues there is so much leakag'e of 
 the current that the cautery very soon cools off a little. I 
 mention this because I have so often seen the inexperienced, 
 who were not aware of this fact, bothered by the cautery 
 cooling and not doing its work fast enough. 
 
 The method of ojoerating for angioma at the meatus 
 urinarius is as follows : 
 
 The neoplasm to be removed is seized by narrow-bladed 
 forceps at the junction of the normal and abnormal tissue ; 
 the forceps is closed and locked and the neoplasm cut off. 
 The current is turned on and continued to heat the forceps 
 enough to desiccate, not char, the tissues in its grasp. When 
 this is accomplished the forceps is carefully removed by 
 first unlocking it, then rocking it gently, so as not to pull 
 the pedicle or stump apart and start bleeding. If the work 
 is well done, the thin stump of desiccated tissue will pro- 
 ject from the surface of the mucous membrane. If there 
 is any portion of the diseased tissue left, it should be 
 touched with the cautery. 
 
 It is important that the patient should not urinate for 
 several hours after the operation, because if the stump can 
 be kept dry for a time it will not spread but hold together, 
 and leave a very small surface to heal when the desiccated 
 portion separates. The application of stearate of zinc helps 
 to protect the stump until it heals. 
 
 The forceps which I use is like the compression forceps 
 but with very narrow blades. 
 
 This method of operating is sufficient in the ordinary 
 forms of angioma. When the neoplasm is caused by a 
 chronic inflammation of the urethral glands, the best method 
 is to pass a fine probe uj) into the canal and cut down upon 
 it with the cautery point from the vaginal surface ; in other 
 
116 
 
 ELECTRO-HJEMOSTASIS IN OPERATIVE SURGERY. 
 
 words, lay the ducts of the glands open. This divides the 
 neoplasm on one side, and an incision should be made with 
 the cautery on the opposite side, which divides the neo- 
 
 FiG. 69. — Operation upon diseased urethral giands. A fine probe is passed into 
 the gland ; the tissue is rendered tense ; the knife is about to cut down upon 
 the probe. 
 
 plasm into two equal parts ; then each part is grasped in 
 the forceps and removed in the way I described in the 
 treatment of angioma. The method of treating the disease 
 of the urethral glands is illustrated by Figs. 69 and 70. 
 
 I have succeeded in completely curing the chronic in- 
 flammation of the glands by laying their ducts open in this 
 way and removing the neoplasms at their terminal ends, 
 excepting in a few cases where the inflammation still per- 
 sists in the glands. To correct this I generally do a second 
 operation. I pass the cautery point into the gland and 
 cauterize it sufficiently to destroy it. I have succeeded in 
 
TREATMENT OF URETHEAL AFFECTIONS. 
 
 iir 
 
 curing all cases in this way, except in tuberculosis of the 
 urethra. That disease has continued when the upper por- 
 tion of the canal was involved before operating. 
 
 The method of operating in cases of narrowing of the 
 meatus urinarius is this : I pass a bivalve speculum into 
 the urethra and put the meatus on the stretch. The band 
 of tissue below or on the vaginal side which extends from 
 one blade to the other is made tense, and is easily divided 
 with the cautery ; in fact, it is necessary to be deliberate in 
 making the incision, or else haemorrhage will follow ; not a 
 hgemorrhage which will give any trouble except delay, as it 
 prevents continuing the use of the cautery to complete the 
 operation. 
 
 In cases of papillae within the urethra, caused by hyper- 
 
 FiG. 70. — The incision gapes after splitting open the gland. 
 
 plasia around the follicles, the treatment with the cautery 
 is difficult, but if properly employed gives the most prompt 
 relief in those cases of chronic inflammation which have 
 been called o-ranular urethritis. After havino; made a clear 
 
118 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 diagnosis and localized tlie points to be destroyed, I intro- 
 duce the endoscope with an open end, up as near to the 
 neck of the bladder as can be without permitting a flow of 
 urine ; the instrument is then withdrawn until one of the 
 points to be touched comes into the field of vision; the 
 cautery is then passed up, and the point slowly touched 
 once, which is, as a rule, sufiicient. The endoscope is then 
 again withdrawn until another diseased portion appears, 
 which is treated in the same way, and so on until the treat- 
 ment is completed. 
 
 IRRITABLE ULCER OF THE NECK OE THE BLADDER 
 
 The most troublesome of all diseases of the urinary 
 organs, both in the way of causing suffering to the patient 
 and botheration to the surgeon, is this ulcer or fissure at 
 the junction of the urethra and bladder. 
 
 The first difficulty is in making a diagnosis. In fact, I 
 have never been able to fully expose a fissure in the loca- 
 tion except with the glass endoscope, and I have tried all 
 other instruments in use. The treatment also is difficult. 
 When the fissure is exposed by means of an endoscope open 
 at the distal end there is a continual oozing of urine, which 
 interferes with the use of the cautery. If the fissure is on 
 the vaginal side of the urethra, this is obviated by using a 
 fenestrated endoscope and bringing the fissure into the field 
 of vision, while making pressure against the endoscope from 
 the vagina with the finger, to force the diseased portion of 
 the mucous membrane into the fenestrum and prevent the 
 outflow of urine. I then dry the part with a small piece of 
 bibulous paper, and apply the cautery by simply drawing 
 the point slowly through the ulcer so as to completely 
 destroy its surface. 
 
 To a certain extent lateral fissures can be managed in 
 the same way, but when the fissure occurs above, which 
 fortunately seldom happens, it is almost impossible to em- 
 ploy this treatment. Perhaps when I have had more ex- 
 perience I may be able to report quite favorably of this 
 
TREATMENT OF URETHRAL AFFECTIONS. 119 
 
 treatment. Up to the present time it is not completely sat- 
 isfactory, though the best that has been obtained so far in 
 treating those forms of urethral affections already alluded to. 
 I find that with the use of cocaine general anaesthesia is 
 not necessary, at least in patients who possess a fair degree 
 of self-control, but I should advise the use of an anaesthetic 
 until the surgeon has acquired some skill and dexterity in 
 the management of the endoscope and the cautery. 
 
CHAPTEE XIII 
 
 ELECTRO-H^MOSTASIS IIST THE TREATMENT OF EECTAL 
 H^MOEEHOIDS 
 
 The clamp and cautery was used for a long time in 
 operating for hsemorrhoids, but tlie results obtained were 
 not altogether satisfactory. The clamp spread out the 
 tissues so that a broad stump was formed, and after re- 
 moving the clamp the tissue of the stump separated, leaving 
 a broad surface to heal. Bleeding was often caused by the 
 action of the bowels unless confined for a long time, and 
 healing was retarded. 
 
 These unfavorable conditions were avoided to some 
 extent by using a clamp with broad Jaws, and after cutting 
 off the hsemorrhoid, applying the cautery to the forceps 
 long enough to desiccate the stump in the way that Keith 
 treated the pedicle of ovarian tumors. This required alto- 
 gether too much time, and it was so difficult to avoid too 
 much or too little heat that I became discouraged and re- 
 turned to the ligature until the introduction of the haemo- 
 static forceps. Since then I have adopted that method, 
 and practice it exclusively. 
 
 In the preparatory treatment plenty of time should be 
 taken to get the digestive organs into the best possible 
 condition. If the tongue is coated and the appetite im- 
 paired, small doses of mild chloride of mercury should be 
 given, followed by a cathartic. A laxative should be given 
 in the evening before the day preceding the operation, so 
 that the bowels shall move in the morning, and at night 
 
 120 
 
TREATMENT OF RECTAL HEMORRHOIDS. 121 
 
 before tlie operation tlie rectum should be washed out 
 thoroughly. 
 
 The sphincter is slowly stretched with a bivalve spec- 
 ulum to a degree sufficient to temporarily paralyze the 
 muscle, but not to tear its fibers or lacerate the hgemor- 
 rhoidal veins if possible. The most prominent hsemorrhoid 
 tumor is caught with a Pean forceps and drawn outward 
 (see Fig. 72, A), the hj^morrhoidal clamp is applied to its 
 base, and the electric heat continued until desiccation is com- 
 plete ; this requires from half a minute to a minute, rarely 
 more than half a minute, unless the tissues are very large. 
 A shield forceps with shields of horn, tortoise shell or 
 
 Pig. 71. — Haemostatic haeraorrhoidal clamp. 
 
 ivory, similar to the shield forceps used in ovariotomy, is 
 placed under the clamp to protect the tissues while the heat 
 is being applied. 
 
 The clamp (see Fig. 71) is made on the same prin- 
 ciple as the ovariotomy clamp described in the chapter on 
 ovariotomy, but is much smaller. 
 
 Fig. 72, I^, shows the clamp in place parallel to the 
 axis of the canal while the current is being used. 
 
 Fig. 73 shows the clamp opened just enough to per- 
 mit the stump to escape from its grasp. 
 
 Fig. 72, C, shows the stump after treatment; the long 
 
122 
 
 ELECTEO-H^MOSTASIS IX OPERATIVE SURGERY. 
 
 measurement is in tlie axis of tlie canal, as it should be, in 
 order that it may rest in the folds of the mucous membrane 
 when the sphincter contracts. 
 
 During the process of repair the stump becomes soft- 
 ened by absorption of moisture, and part of it, at least, 
 separates and comes away, but not until the base has com- 
 pletely healed. The reader will observe that a stump ex- 
 posed on a fi'ee surface is not reorganized as is a stump 
 inclosed in the abdominal cavity or in cellular tissue. It 
 appears that the portion of the dried stump joining the liv- 
 
 PiG. 72. — A, the hEemorrhoid is drawn outward by a forceps ; B. the haemostatic 
 clamp and shield forceps in position while the current is being used ; C, the 
 stump after treatment ; the long measurement is in the axis of the canal. 
 
 ing tissue may become organized during healing, but the free 
 end separates and is thrown off as stated above. The 
 
TREATMENT OF RECTAL HEMORRHOIDS. 
 
 123 
 
 mucous membrane remains tender at the site of operation 
 until the process of repair is complete, therefore the parts 
 
 Fig. 73. — The clamp has been opened to permit the stump to escape from its grasp. 
 
 are easily torn open by distending the sphincter out to any 
 great extreme. On that account the bowels should be kept 
 at rest for several days after operation. 
 
 Owing to the stump in its greatest length running par- 
 allel to the axis of the rectum, it is in the position most 
 exposed to being opened up when the bowels are evacuated. 
 
 Dr. E,. L. Dickinson suggested that the danger of open- 
 ing up the stumps might be guarded against by applying 
 the clamp at right angles to the axis of the rectum, or 
 rather he suggested that it should be made obliquely. (See 
 Fig. 74.) The effect of distending the sphincter would be 
 to draw the edges or sides of the stump more closely to- 
 gether, not to pull them apart. This appeared to me to be 
 a valuable suggestion, and I shall try it, taking care to have 
 the stumps all outside of the grasp of the sphincter when 
 the location of the hsemorrhoid is such that this can be 
 
124 
 
 ELECTRO-H.EMOSTASIS IN OPERATIVE SUROERY. 
 
 done. That is to say, I shall form the stump at the junc- 
 tion of the skin and mucous membrane. 
 
 After-treatment. — The parts are dusted with dry, finely 
 powdered bicarbonate of soda or subgallate of bismuth, 
 applied with the insufflator. 
 
 The patient is kept at rest for a week or ten days, and 
 liquid diet given — soups, broths, and gruels being preferable 
 to milk. 
 
 As this operation is followed by much less pain than 
 when the ligature is used, opium is seldom required. When 
 
 Fig. 74. — Diagrams of sears or stumps after removal of piles, and the strains ap- 
 plied to those lines of union. A, ordinary seizure of forceps in removing pile. 
 The tip of the clamp pointing directly in long axis of anus, three bites being 
 sketched, the edges of the mucous membrane of the upper one having pulled 
 apart as rectal plug is withdrawn or fasces pass, leaving a fissure to granulate; 
 B, oblique bite here advocated as least likely to be dragged open; C, "White- 
 head operation partly sutured, circular line of union. The stresses are two — 
 longitudinal, in the axis of the anus ; and transverse, at right angles to that 
 axis. The longitudinal stress, shown by the stumpy arrows, and produced by 
 the shoving onward of the mucous membrane or skin about the anus as a 
 faecal mass makes exit, can have little hurtful effect on A, and much on C. 
 The transverse tension, produced by stretching of sphincter by fa?cal mass, 
 shown by the longer curved arrows, does no harm to C, but great hurt to A. 
 The oblique bite, B, is least likely to be hurt by the combined strain. — Brook- 
 lyn Medical Journal, vol. xiii. No. 1, p. 54, January, 1899. 
 
 called for, I use liquor opii comp. and tincture of belladonna, 
 instilled into the rectum with a soft catheter or pipette. 
 The bowels can be safely moved on the second or third day, 
 but it is better to keep the patient on spare liquid diet, 
 and wait until the fourth or fifth day. On the evening of 
 the fourth day a small laxative dose of pulve. glycerrhiza 
 comp. is given, and followed in the morning with a dose of 
 phosphate of soda and two hours later an enema of flax- 
 
TREATMENT OF RECTAL HEMORRHOIDS. 125 
 
 seed tea. The flaxseed tea is the most agreeable and efficient 
 enema in all rectal diseases when this aid to action is re- 
 Cjuired. iVfter the bowels are evacuated the parts should be 
 thoroughly cleansed by irrigation, then dried with absorb- 
 ent cotton, and the subgallate of bismuth powder employed. 
 The bowels are pemiitted to rest for one day, and after that 
 they should be moved each day. Some of the best author- 
 ities permit their patients to sit up in about three days, 
 and in about a week they are allowed to go about ; but I 
 am sure that this is not the best after-care. It is better to 
 keep the patient quiet until healing is complete, which re- 
 quires about ten or twelve days. It is claimed that pa- 
 tients treated in the old way are able to be up and at busi- 
 ness in a few days, but better results are obtained by taking 
 more time. 
 
 Finally, comj^lete recovery takes place in less time than 
 after any other method of operating that I have ever known. 
 
 FISSURE OR IRRITABLE ULCER AT THE TERMUS'AL EIS'D OF 
 
 THE RECTUM 
 
 To comprehend the treatment of this affection with the 
 galvano-cautery it is necessary to understand its true pathol- 
 ogy and causation, especially the latter. Van Buren gives 
 such a graphic description of that disease that I prefer 
 to quote in toto : " There is no disease to which humanity 
 is liable — certainly none so insignificant in extent — which 
 is capable of causing more intolerable suffering than the 
 ailment generally known as fissure of the anus. It is more 
 properly styled irritable ulcer of the rectum, for this desig- 
 nation describes accurately the true pathological nature of 
 the disease. The ulcer originates in a fissure or crack in 
 the delicate integument lining the orifice of the anus, or, to 
 speak with greater exactness, in the mucous membrane just 
 about assuming the character of skin which lines that por- 
 tion of the rectum embraced by the sphincter-ani muscle. 
 Doubtless there are cracks and fissures occurring frequently 
 in this exposed locality, under the influence of costiveness 
 
126 electro-HtEmostasis in operative surgery. 
 
 and violent stretcMng, whicli get well promptly without 
 their existence having been suspected; and others again 
 which last a longer or shorter time, and give but little 
 trouble. But in certain conditions of the system, and where, 
 under the necessity imposed by habitual constipation, this 
 forcible distention is repeated daily, the fissure fails to heal 
 promptly ; and then, as nnder all similar circumstances of 
 constantly repeated mechanical irritation, inflammation de- 
 velops itself in the little wound, and just in proportion as 
 the inflammation advances the effort at repair diminishes, 
 until finally it ceases entirely. The solution of continuity, 
 or ulcer as it is now, being still exposed to constantly recur- 
 ring mechanical violence and to the contact of chemically 
 irritating substances, is kept thus in an actively inflamed 
 condition and soon puts on all the features of an irritable 
 ulcer." 
 
 Van Buren's description is complete, perfect, and accept- 
 able in all respects, except that the causation given is not 
 fully in harmony with the clinical facts as I have observed 
 them. The actual cause of the persistence of certain fissures 
 is that they extend outward from the mucous membrane 
 to the skin, and a small pocket is formed beneath the skin 
 in the terminal end of the fissure. That portion of the skin 
 overlying the lower end of the fissure in the mucous mem- 
 brane becomes indurated and stands outward so that the 
 pocket remains open and filled with irritable substances, 
 which prevent the parts from healing. Fissures wholly in 
 the mucous membrane and not having this pocket heal 
 promptly. 
 
 Fig. 75, A, shows a sketch of the anus with the fissure 
 and pocket. 
 
 The diagnosis is completed by a physical examination. 
 The books direct that the parts should be separated and a 
 slight inversion produced, which brings the ulcer or part of 
 it into view. It is possible to do this when the sphincter- 
 ani muscle is relaxed, but it is generally contracted, and the 
 patients resist the efforts to bring the lesion into view. 
 
TREATMENT OF RECTAL HEMORRHOIDS. 
 
 127 
 
 Tlie most satisfactory examination is with tlie glass endo- 
 scope. In fact, that is the only instrument with w^hich anal 
 fissures can be clearly seen. The glass tube distends the 
 parts sufficiently to lay the fissure open and bring it fully 
 into view, and its use causes no suffering on the part of the 
 patient and is far more agreeable to the surgeon than rectal 
 specula or endoscopes in general use. 
 
 'Hj:. 
 
 Fig. 75. — A, fissura in ano, showing indurated edge and pocket ; B, treatment with 
 fine cautery point. The pocket is being laid open. 
 
 The treatment consists in applying cocaine to the ulcer 
 by means of a pipette, a small Sims speculum is introduced, 
 and then I lay open the pocket at the most dependent part 
 of the fissure with a fine cautery point. (See Fig. 75, £.) 
 This exposes the entire ulcerated surface, which is then 
 
128 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 cauterized tlironghout, but only superficially. The cauteri- 
 zation slioulcl include the indurated edges of the ulcer, but 
 should not be carried deep into the mucous membrane ; only 
 far enough to destroy the diseased tissue. No after-treat- 
 ment is required. The charred tissue protects the parts 
 below until healing has been completed. 
 
 The treatment is not sufficiently painful to require gen- 
 eral anaesthesia, and relief from suffering is almost immediate. 
 The ultimate results are quite as satisfactoiy as the old 
 treatment by stretching the sphincter to divide the fibers of 
 the sphincter beneath the fissure. 
 
 The following case recently treated is typical of many 
 that I have relieved in the same way : This patient became 
 constipated after the birth of her third child, and about two 
 months after that confinement began to have all the symp- 
 toms of fissure of the anus. Her physician gave her oint- 
 ments and suppositories of various kinds to use, and treated 
 successfully her constipation, but she obtained no relief 
 from her rectal j)ain. After three months of suffering her 
 health became impaired and a surgeon was called in consul- 
 tation who made a diagnosis of fissure, and advised oper- 
 ative treatment. This proposition was accej)ted by the 
 p)atient, but her husband was fearful of anaesthetics, so he 
 brought her to my office. The history was fully given, in- 
 cluding the fact that she had been treated with local appli- 
 cations, but finding no relief had given up. No mention 
 was made of the proposed operation. A well-developed 
 irritable ulcer was found, and I suggested immediate treat- 
 ment, and the patient agreeing, I operated there and then. 
 The patient told me that I caused less pain than the exam- 
 ination made by the surgeon who had previously seen her. 
 When I asked her why she had not told me about that, she 
 replied that she wished to find out if I would advise the same 
 treatment or something else that would relieve her without 
 having to take an anaesthetic. Her recovery was perfect. 
 
CHAPTER XIV 
 
 THE TEEATMEISTT OF NEOPLASMS OF THE SKIIST AI^D MUCOUS 
 MEMBRAJSTES WITH THE ELECTRO-CAUTEEY Al^D ELECTEOLYSIS 
 
 My attention has been called to tliis subject especially 
 by seeing three patients who were treated a long time ago, 
 one with electrolysis and two with galvano-cautery. The 
 results were so very satisfactory that they recalled many 
 other cases equally complimentary to this method of treat- 
 ment. One of the three cases was a nevus situated between 
 the eyebrows of a child five months old. The skin cover- 
 ing the elevation was of a bluish red for about half an inch 
 across, and three quarters of an inch vertically. The tumor 
 disappeared on pressure, showing that the enlarged vessels 
 were mostly in the cellular tissue. It was growing very 
 rapidly. Electrolysis was employed, and that child is now 
 a boy fourteen years old, with no trace of the nevus or the 
 treatment to be seen. The second case was one of epithe- 
 lioma of the lower lip of a lady. She was examined by a 
 surgeon of reputation, who advised its removal. I fully 
 <?onfirmed the diagnosis by clinical and microscopic exami- 
 nation, and removed the growth with the galvano-cautery. 
 It is now four years since that opei^ation, and there is no 
 deformity of the lip nor any trace of the disease. The third 
 case was nevus pilaris, or hairy papilloma on the cheek. 
 This was removed with the cautery, and there is only a small 
 speck of scar tissue, which is barely visible on close inspec- 
 tion. A hundred or more cases to illustrate the results of 
 this mode of treatment might be given, but these will suf- 
 fice to bring the subject to the attention of the reader. 
 
 129 
 
130 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 Excepting in vascular tumors, in wliicli tlie large vessels 
 are subcuticular, and in whicli it is desirable to preserve 
 tlie skin covering the vascular growth, the galvano-cautery 
 best answers the purpose in all cases. In the exceptional 
 cases electrolysis gives the best results. Skill and accuracy 
 in operating are very essential. The needles should be 
 round-pointed, so that they may close their tracks and pre- 
 vent bleeding. They should be insulated to within a dis- 
 tance from the point nearly the length of the diameter of 
 the tumor. This enables the operator to bring the acting 
 part of the needle into contact with the tissue to be de- 
 stroyed, and yet preserve the normal skin at the point of 
 puncture. The electric current used should be strong 
 enough to produce chemical decomposition at the negative 
 and desiccation or cooking, but not charring, at the positive 
 needle. These changes in the tissue are manifested by its 
 becoming hard, especially along the line of the joositive 
 needle, which becomes immovable by sticking to the tissue. 
 When these changes have taken place the current should be 
 reversed and continued until the positive needle becomes loose. 
 
 If the needles are withdrawn without reversing the 
 current, troublesome haemorrhage follows and interrupts 
 the treatment. If there is no disposition to bleeding when 
 the needles are partially withdrawn, they should be re- 
 moved and again introduced into the parts of the tumor 
 remaining unaffected, and the current used as in the first 
 instance. In medium-sized tumors the treatment can be 
 completed by two introductions of the needle, but if any 
 part escapes, as shown by the soft condition due to the 
 circulation continuing in some of the vessels, the procedure 
 should be repeated. The needle punctures on the surface 
 should be closed with collodion to prevent the entrance of 
 anything that might cause suppuration. Usually repair 
 goes on favorably along with the absorption of the de- 
 stroyed tissue. If suppuration takes place the pus should 
 be washed out through the needle punctures, and drainage 
 kept up with a few horsehairs or some twisted silk. 
 
NEOPLASMS OF THE SKIN AND MUCOUS MEMBRANES. 131 
 
 The galvano-cauteiy, certainly, so far as results are con- 
 cerned, is infinitely tlie best method of removing neoplasms 
 from the skin and mucous membranes, excepting in such 
 cases as Just mentioned. When properly employed it 
 causes less pain during the operation, the recovery is much 
 more prompt and complete, and the scar tissue that follows 
 is v«ry much less in extent than by any other method of 
 dealing with these growths. The objections to the various 
 forms of caustics, such as nitric and chromic acid, are that 
 they do not completely destroy the tissue ; that they cause 
 very much more pain and suffering ; that they are not so 
 certain in their results ; and that they leave far more un- 
 sightly scars. 
 
 That which comes the nearest to the galvano-cautery is 
 the paste of chloride of zinc, lactic acid, and caustic potash. 
 These have been employed by Dr. I. N. Bloom, of Louis- 
 ville, Ky. Of any results with which I am familiar his 
 approach most nearly those obtained by the galvano-cautery ; 
 but they fall short of accomplishing the objects that are 
 obtained so thoroughly and completely by the use of the 
 galvano-cautery. Considerable practice is necessary to ac- 
 quire facility in technique. 
 
 The great object is to thoroughly destroy the diseased 
 or abnormal tissue with the cautery at a degree of about 
 red heat, and, while destroying all that is abnormal, not 
 to go beyond the boundary line or encroach upon the 
 normal tissue. It is very important, especially in vascular 
 growths, to apply the cautery to the tissue to be destroyed 
 before turning on the heat. If it is heated and then ap- 
 plied, there is very great danger of haemorrhage, especially 
 in vascular tumors. A small cautery j)oint should be used, 
 unless the growth is very large, and it is most convenient 
 to place it into the center of the mass to be destroyed while 
 it is cold. The heat being turned on, the cautei^ization or 
 destruction of the tissue should proceed from the center 
 toward the circumference, so as to make it complete with- 
 out going beyond the boundary of abnormal tissue. It is 
 
132 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 always well not to go too deep at first. If it is found 
 that there is still some diseased tissue deeper dowm, the 
 ground can be gone over again until the destruction is com- 
 plete. 
 
 In operating upon small tumors about the mouth, cheeks, 
 or forehead the parts should be held perfectly to prevent 
 twitching of the muscles. Neglect of this may cause the 
 cautery to slip and injure the normal skin and lead to un- 
 necessary scars. 
 
 In angioma, nevus, and epithelioma, especially when the 
 mass or growth is large and vascular, it is better to begin 
 at the circumference and work toward the center, always 
 using the cautery at a dull-red heat, since if the heat is too 
 great — that is, white heat — there is sure to be bleeding. 
 In fact, in cases of angioma it is impossible sometimes to 
 operate in this way without having very decided hsemor- 
 rhao"e. In such cases I have adopted another method which 
 answers very well, and that is to seize the mass with a 
 haemostatic forceps in the central portion or where the ves- 
 sels are largest, and strongly compress it, then turn on the 
 electric heat, and desiccate it before letting go. This will 
 control the bleeding in the larger vessels, and then mth the 
 cautery point the rest of the tissue at the outer margins of 
 the growth can be destroyed in the way already described. 
 That method of operating can also be done in cases of epi- 
 thelioma, but the results are not quite so satisfactory, be- 
 cause the friable tissue breaks down in the grasj) of the 
 haemostatic forceps and so can not be controlled in that 
 way ; but in small vascular growths the results are very satis- 
 factory in operating as described. 
 
 This method is equally applicable in case the part 
 operated upon be mucous membrane or skin. Where the 
 diseased part is located on the mucous membrane, say of 
 the cervix uteri, the lip, the tongue, or any portion of the 
 mouth, the pain is slight, and in the most sensitive cases it 
 is only necessary to use a little cocaine to be able to oper- 
 ate without causing any great distress. Indeed, this is the 
 
NEOPLASMS OF THE SKIN AND MUCOUS MEMBRANES. 133 
 
 most painless method of operating, as it causes mucli less 
 pain than any caustic or paste that I know anything about. 
 In fact, it is not necessary to employ an ansesthetic except 
 in large epitheliomatous growths about the face. The most 
 sensitive patients usually tolerate well the operation any- 
 where on the skin, unless the growth is unusually large. In 
 case one fails to remove all the diseased tissue, which some- 
 times happens, it is very easy to make a second application 
 after the healing process has been completed and the eschar 
 has separated and come away, which usually happens at the 
 end of a week. 
 
 The condition of the parts when the operation has been 
 well done is simply this : All the tissues are burned away 
 or destroyed, and the surface is covered with a thin layer of 
 charred tissue, which shows as a black mark outlining the 
 extent of the original tumor. A few hours after the treat- 
 ment the mucous membrane or skin around the cauterized 
 portion becomes quite red, but this redness passes off by the 
 following morning, or sometimes very much sooner; and 
 then all that remains to indicate the field of operation is the 
 spot of charred tissue, which is not by any means unsightly. 
 There is, of course, no dressing necessary. The char forms a 
 perfect crust, under which the tissues heal kindly and very 
 quickly. It is needless to say that the operation is aseptic, 
 and hence there is no way by which any pathogenic germs 
 can be left in the wound to set up inflammation. This 
 probably accounts for the rapid healing, as in about five or 
 six days the charred tissue usually separates, comes away, 
 and leaves a red surface which requires no further care. 
 When the charred tissue separates the surface is usually 
 completely healed, and differs from the surrounding tissue 
 only in being of a deeper color. During the healing pro- 
 cess the parts contract, so that on the separation of the 
 charred crust the scar is very much smaller than it was at 
 the close of the operation. The redness fades away gradu- 
 ally, and at the same time the parts keep contracting, so that 
 in the course of time the scar is almost, if not completely^ 
 
134 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 imperceptible. A scar of a magnitude that is noticeable is 
 left only in case the tumor is very large. 
 
 A point of interest in the management of nevi pilares, 
 that are so frequently seen on the face, is that in such cases 
 it is necessary to carry the cauterization deep down, almost 
 through the true skin, so as to destroy the hair bulb 
 completely. If one cauterizes only superficially, the hairs 
 will grow up again and no great benefit will result. The 
 cauterization should be carried down deeply into the center 
 where the hairs are, and then continued upward and out- 
 ward toward the surface, so that when the entire growth is 
 destroyed the cavity left is cone-shaped, the apex of the 
 cone being deep down in the skin. Cases treated in this 
 way do remarkably well, because this cone-shaped opening 
 contracts nicely and the results are finally very gratifying. 
 I have in mind at this moment a large number of such 
 growths on the face which were so treated. The great 
 point is to obtain complete, perfect results with the most 
 desirable cosmetic effect, and the least possible or no dis- 
 figurement from scars. 
 
 This method of operating gives vastly better results 
 than any other means at our command. From quite an ex- 
 tensive experience I know that the results obtained are 
 better than those with excision by means of a knife. In 
 operating with a knife it is necessary to make a long in- 
 cision and unite the parts with sutures, and the result 
 invariably is that the suture marks and a long scar are left. 
 This is the fact even if every precaution is taken, and the 
 best possible results are obtained in the way of immediate 
 union. 
 
 In case there is any suppuration, as may happen at any 
 time in spite of the utmost care to obtain aseptic conditions, 
 there will sometimes be a little failure of union, and an 
 ugly scar is left to annoy the patient. When the cautery 
 is used no dressing is necessary, as the cauterized or charred 
 tissue is itself by far the best dressing possible. 
 
 Again, if we compare the results with the caustics, such 
 
NEOPLASMS OF THE SKIN AND MUCOUS MEMBRANES. I35 
 
 as uitric or chromic acid, the advantages are markedly 
 apparent in that these invariably leave a very ugly scar that 
 does not disappear completely, and remains a glaring de- 
 fect for a long time to mar the beauty of the patient. The 
 same may be said with reference to the use of pastes, such 
 as already have been alluded to. They all leave very ugly 
 scars compared with the scar that is left, or the absence of 
 scar, as it might be called, when the cautery is employed. 
 This is one of the most important advantages of this way of 
 operating ; and it is not the only one, for the method has 
 advantages in every particular over all other known methods. 
 My attention was first called to the galvano-cantery in the 
 treatment of cancer of the uterus by my friend Dr. John 
 Byrne, and I have always felt grateful to him for his valua- 
 ble instruction. Dr. George M. Beard taught me how to 
 pi'actice electrolysis in the treatment of vascular nevi, and 
 I desii'e to pay tribute to the memory of that gifted man 
 who was one of the first to develop scientific electro-thera- 
 peutics. 
 
 10 
 
CHAPTEE XV 
 
 ASEPSIS AND ANTISEPSIS IN SUEGEEY 
 
 Success in surgery depends upon cleanliness as well as 
 skillful and accurate operating, and in estimating one's work 
 tlie methods of obtaining aseptic conditions by means of 
 antiseptic methods must be taken into account. 
 
 Therefore I have deemed it expedient to give a chapter 
 on this subject to show the conditions under which my 
 operative work has been done. Much of detail has been 
 omitted to make room for that which is considered impor- 
 tant in the writer's practice. 
 
 Surgeons are faiiiy well united in their opinions regard- 
 ino- the beneficence of the modern discoveries in bacteri- 
 ology, the germ causation of disease, and the inestimable 
 value of disinfection and sterilization as means of preven- 
 tion of surgical affections. Harmony prevails also to a 
 gratifying extent regarding the principles of aseptic and 
 antiseptic surgery. Still there is much diversity of opinion 
 regarding the methods of practical cleanliness in all opera- 
 tive work. 
 
 There are, indeed, many ways of trying to keep wounds 
 free from septic contamination and keeping them clean 
 during the healing process. In fact, there are nearly as 
 many methods as there are distinguished surgeons. The 
 aim and objects are the same mth all, but the means by 
 which the results are obtained differ in detail very greatly. 
 The methods of asepsis in surgery were very complicated 
 at first, and they are still somewhat so. The tendency has 
 been toward simplicity, and in proportion to the discovery 
 of uncomplicated methods efficiency has been attained. 
 
 136 
 
ASEPSIS AND ANTISEPSIS IN SUKGERY. 13 7 
 
 The same light that revealed the part that germs play 
 in the causation of disease, and that made clear the preven- 
 tion of all kinds of sepsis, led with equal scientific certainty 
 to improvements in sanitary architecture or construction of 
 hospitals and homes for the sick. 
 
 In this department of hygiene and preventative medi- 
 cine the progress toward perfection has been so vast and 
 varied that volumes might be filled with the records. 
 Specialists in sanitaiy science, aided by skilled engineers, 
 intelligent, honest plumbers — there are such nowadays — 
 make the selection of proper sites for institutions for sick 
 and injured, and by faultless construction fulfill all the re- 
 quirements in foundations, ventilation, lighting, heating, and 
 draining. The recent improvements in this regard are well- 
 nigh perfect and quite familiar to all who take an interest 
 in the subject. The sj)ecial efforts now being made relating 
 to sanitary architecture are directed to facilitating disinfec- 
 tion and maintenance of cleanliness. This is more directly 
 related to operative surgery ; hence I may with propriety 
 note some of the improvements that have been recently 
 made and especially connected with the subject now under 
 consideration. The first architectural principles in the 
 construction of rooms for the sick are to guard against 
 places for the accumulation of dirt and lodgment of dis- 
 ease germs. 
 
 The best work on design and construction of institu- 
 tions for the care of the sick that I have seen anywhere is 
 that of Marshall L. Emery, an architect who has taken 
 great interest in this branch of his art. Evidently he first 
 informed himself by consultation with medical men regard- 
 ing the requirements of a hospital and endeavored to meet 
 them. The following is taken from Mr. Emery's writing 
 on the subject : 
 
 SANITABT HOSPITAL CONSTRUCTIOlSr 
 
 A modern hospital, designed and arranged to meet mod- 
 ern requirements, is the result of an evolution extending 
 
138 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 over many years and embracing the conscientious labors of 
 many able investigators in both the medical and architec- 
 tural professions. 
 
 The progress in the science of medicine and surgery has 
 made from time to time new demands upon the architect 
 and the builder, and while a great many of these demands 
 have been fully met, there are some which require still fur- 
 ther study and invention in both the material and the mode 
 of construction. It may be assumed for present pui'poses 
 that the science of hospital planning is well advanced 
 toward the ideal ; the size, shape, and sequence of the 
 various dej)artments have been gradually reduced to a 
 typical or standard arrangement which is capable of being 
 carried out, and a satisfactory result obtained where space 
 and means are available. In the matter of constructive 
 detail, however, the requirements of modern medical science 
 are greater than can be pi'ovided by the means and methods 
 of building at present in use. This may be show^n by taking 
 for example a single room, and as an operating room is 
 probably the most severe in its demands, it may be taken 
 as a type for all the rest, on the assumption that any detail 
 which meets the conditions in such a room will be satisfac- 
 tory in any of the others, though the matter of cost would 
 undoubtedly preclude the use of this construction through- 
 out the whole building. 
 
 An operating room consists, in common with all other 
 rooms, of the following parts : Walls, floor, ceiling, doors, 
 windows, sash, door- and window-jambs and casings and 
 base. All the matters of detail must conform to the follow- 
 ing principles : They must be hard, non-porous, durable, as 
 free from joints of any kind as possible, and fi'ee from all 
 sharp corners or angles, or any other feature tending to col- 
 lect dirt or septic matter, or offer any obstruction to its 
 ready and complete removal ; furthermore, they must be of 
 such a nature that they shall not change their size, shape, 
 or positions after erection, but shall remain as originally set 
 up — in short, they must not shrink, warp, or settle, or do 
 
ASEPSIS AND ANTISEPSIS IN SURGERY. 139 
 
 any of the disagreeable things that building material is 
 constantly doing. 
 
 In some of the details the principles are easily lived up 
 to, and with some forms of construction and sufficient 
 means many of the demands can be complied with ; but 
 even at best, there are some required features which present 
 material and building methods can not provide. 
 
 It might, of course, be possible, theoretically, to design 
 a room where all the conditions should be supplied, but 
 such a room would be a practical impossibility, owing prin- 
 cipally to its great cost and the difficulty of procuiing 
 sufficiently skilled labor in its construction. 
 
 The greatest obstacle to be overcome lies in the almost 
 imperative necessity for the use of wood to a greater or less 
 extent, depending upon the money to be expended. 
 
 We can best proceed by taking up the details of con- 
 truction as already enumerated, beginning with the walls. 
 One or more of these will, of course, be an exterior wall con- 
 taining one or more windows. As the ordinary form of con- 
 struction suffices and is generally familiar, we shall discuss 
 but one feature, namely, that of insulation. All outside w^alls 
 have to be built to prevent condensation of the warm air of 
 the room, and to prevent loss of heat by conduction through 
 the material of the wall. This is generally accomplished in 
 one of three ways — building the wall so as to leave a hollow 
 space in the wall itself of from two to four inches ; building 
 in the wall a course of hollow bricks extending from bot- 
 tom to top ; or lining the wall on the inside with hollow 
 terra-cotta tile. In cheap construction wood furring strips 
 are used to which the lathing is nailed, an air space being 
 formed thereby about equal to the thickness of the furring 
 strips, usually from one to two inches. Either of the first 
 three methods is good, and possibly the first the best, if 
 properly built ; though the terra-cotta tiles are most fre- 
 quently used. 
 
 The partition or interior walls may be of three forms : 
 Solid brick, rough, pressed, or enameled ; hollow brick, terra- 
 
140 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 cotta tiles, or solid plaster cement ; or a light framework, 
 for high ceilings, long spans, etc. The solid brickwork is the 
 best ; but for small walls, or where walls are carried by the 
 floor construction or girders, it is generally more advan- 
 tao-eous to use one of the latter forms. The hollow tile 
 ran2:e from two inches to eight inches in thickness, and 
 averao-e about sixteen inch squares. They are laid in mortar 
 in very much the same manner as common brick. The solid 
 plaster partitions have come into use within this last five 
 years, and have many advantages. They cost less than solid 
 brick or terra-cotta, and as they are but two to tw^o and a half 
 inches thick they save considerable floor space. They are 
 lighter than brick partitions and do not require any spe- 
 cially heavy floor construction, but can be placed where de- 
 sirable without reference to beams and girders. 
 
 The floor construction is important, as the ceilings and 
 other matters depend largely on their stability. 
 
 If the money at disposal will allow, steel beams should 
 of course be used ; and if not, then Georgia pine beams of 
 large section and as free from sap as j)ossible. 
 
 In the case of steel beams, the spaces between beams 
 may be spanned in various ways — either by several forms of 
 hollow-tile arches, or by a number of patented systems 
 consistino; of a combination of iron bars or nettins^ and con- 
 Crete. There is little choice among the several forms for 
 hospital use. Where the loads on the floors are compara- 
 tively light, the cost is generally in favor of concrete and iron. 
 If wood beams are used, there should always be double 
 floors laid, with layers of water- and fire-proof material be- 
 tween them, unless a tile or other non-combustible flooring 
 be used. Tile, concrete, or mosaic floors are sometimes laid 
 on wood beams, but the result is bound to be unsatisfactory, 
 and the practice is to be avoided as far as possible. Should 
 it be necessary, however, it is accomplished by nailing cleats 
 to the sides of the beams two to three inches below their 
 tops, to which a rough floor is nailed. On this rough floor 
 is laid a bed of concrete to within about an inch of the 
 
ASEPSIS AND ANTISEPSIS IN SURGERY. 141 
 
 finished floor ; this inch being left for the tile, marble, or 
 cement finishing surface. As ceilings are almost invariably 
 finished in plaster, it is only necessary in the ceiling con- 
 struction to provide a sufiiciently strong and rigid foundation 
 to support the plaster. If steel beams be used, a system of 
 light iron framework is secured to the lower edges or 
 " flanges " of the beams, upon which wire or sheet-metal lath 
 is stretched and plastered. 
 
 In the use of wood beams the wire or metal lath is 
 nailed directly to the beams, or to wood furring strips nailed 
 to them. 
 
 The floors may be finished in either tile, marble, mosaic, 
 concrete, or wood block. The first three forms are all familiar, 
 and of these the tile is preferable, provided a hard " vitrified " 
 tile be used not exceeding two inches square, larger tiles 
 being apt to loosen. Hardwood blocks, about two inches 
 wide and twelve inches long, put down on a concrete foun- 
 dation with asphaltic cement, have been used lately to some 
 extent, but as they cost nearly as much as tile or mosaic, 
 and have to be kept constantly " filled," waxed, or varnished 
 there seems to be little if any advantage in their use. 
 
 If necessary to use an ordinary wood floor, it should be 
 laid double, as already mentioned ; the upper flooring not 
 exceeding two inches in width, and of hard, close-grained 
 wood, thoroughly seasoned, dry, and well nailed. The rough 
 or under floor should be laid diagonally across the floor 
 beams and the top or finished floor laid at right angles to 
 them. The top floor should be smoothed off and planed 
 over the whole surface, and " filled " and finished imme- 
 diately after. 
 
 Wood floors are often laid on a fireproof construction 
 by bedding wood sleepers two inches thick on the steel 
 beams and anchoring them there by leveling up to the top 
 of the sleepers with concrete, and then laying a double floor^ 
 as just described. 
 
 The obvious objections to wood as a flooring material 
 will, of course, apply to all wood floors, and they should 
 
142 ELEOTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 never be used except where necessitated by lack of means. 
 A cement floor will cost but little more than a good wood 
 floor, and is certainly far better in sanitation, permanence 
 and ultimate economy. 
 
 The best material for wall and ceiling finish is " Keen's " 
 cement, the best brands being imported from England, 
 where it is more largely used in hospital construction than 
 here. When properly applied it presents a very dense, 
 hard surface, and, skillfully worked, is capable of great 
 smoothness and polish. Incidentally it may be mentioned 
 that it is the basis of artificial marbles. The cost of this ma- 
 terial is a great drawback, and in ordinary work its use is 
 limited to wainscots, bases, window sills, and similar exposed 
 places. For the upper part of the w^alls and for ceilings 
 patent plaster or " dry mortar " answers very well, though, 
 while not so dense or hard as the " Keen's " cement, it is a 
 great improvement over common lime mortar. "Patent 
 plaster " is merely a basis of plaster of Paris mixed with 
 sand and a retarding agent, kept secret by the makers, 
 which slows the setting of the plaster of Paris sufficiently 
 to allow the w-alls to be properly worked. The mixing and 
 proportioning of patent plasters is done by machinery, and 
 is consequently done in a more thorough manner than if 
 done by the hand of an indifferent laborer, w^hich is one 
 reason for its superiority over common plastering mortar. 
 
 The angles formed by the walls, and the walls and ceil- 
 ings, should be " rounded " or finished with a cove, instead 
 of forming a sharp corner. This cove should not be too 
 large, as it will be liable to crack if formed wdth a large 
 radius. A radius of two inches w^ill be found sufficient for 
 all purposes, and is easily made. 
 
 The forming of the curve in wall and ceiling angles, 
 while simple, requires a considerable degree of care and 
 skill on the part of the plasterer to make it straight and 
 true, and to make all miters and intersections meet and 
 join properly. 
 
 The angle between the floor and wall should be coved 
 
ASEPSIS AND ANTISEPSIS IN SURGERY. 143 
 
 in the same manner, and where a tile, mosaic, or cement 
 floor is used there is no trouble ; where a wood floor is 
 used, however, it is impossible to make a joint or connec- 
 tion between the Avood and plaster which will not open, 
 even if it be made tight when first put down. This is an- 
 other strong objection to the wood floor. 
 
 If tile be used for a wainscot or wall finish the coved 
 corners are formed in the tile themselves, and, if necessary, 
 special tile may be designed to suit diiferent conditions or 
 positions. 
 
 The demands of hospital design present little that can 
 not be provided in construction as far as walls, floors, and 
 ceilings are concerned. With doors and windows the case 
 is diiferent, and it is here especially that future study and 
 invention are to be employed. 
 
 The difiiculties presented may be best appreciated by 
 referring to drawings. Fig. 76 shows a window frame and 
 sash in ordinary work, and in fact even in some hospital 
 work. A glance will show how unfit it is for any use 
 where it is essential to obtain thorough cleanliness; tlie 
 corners and angles offer abundant opportunity for the col- 
 lection of dust, which ^^dll increase as the wood shrinks 
 and joints open. 
 
 Fig. 77 shows a window designed to oifer as far as pos- 
 sible the least chance for tke lodgment of dirt and least ob- 
 struction to its removal, but even this construction leaves 
 much to be desired. The angle, A, between the casing and 
 jamb has to be covered with a molding, because it is im- 
 possible to make the wood and plaster join together closely 
 enough to avoid a ragged joint, and even wath this mold- 
 ing there will be an open joint somewhere unless the work- 
 manship is far above the average ; and the sash itself ofl^ers 
 a sharp angle between the glass and wood, which it is as 
 yet impossible to avoid. 
 
 The stop bead against the stile offers another joint, £, 
 which is sure to open through the effect of atmospheric 
 changes ; still, the improvement of one over the other is 
 
lU 
 
 ELECTRO-HiEMOSTASIS IX OPERATIVE SURGERY. 
 
 quite encouraging, and the time ^vill undoubtedly come 
 Avhen many present objections will be overcome. 
 
 SECTION 
 THROUGH JAMB 
 
 BRICK OR STONE WALL 
 
 WOOD INNER 4 ^5^ 
 
 51LL ^^^^^ 
 
 FURRING 
 
 WOOD TRIM- 
 
 
 PLASTER 
 
 :/ 
 
 5KETCH 
 
 OF 
 U5UAL rORM 
 
 OF 
 
 WINDOW FRAME 
 
 IN 
 ,MA50MRY WALLS 
 
 J ELEVATION OF 
 JiNSIDE LOWER CORNER 
 
 Fig. 76. 
 
 What is true of the windows is equally true of the 
 doors. Fig. 78 shows a door in an ordinaiy twelve-inch 
 
ASEPSIS AND ANTISEPSIS IX SURGEHY. 
 
 145 
 
 partition finished in the usual way, and Fig. 79 shows the 
 best that can be done at present in the way of elimination 
 of the corners, joints, etc., which remain and are objection- 
 
 5ECTION 
 
 THROUGH JAMB 
 
 WOOD T RIM 
 
 CEMENT INNER SILL Wi 
 
 PLANTER JAMB- 
 
 BRICK OR 5T0NE\ 
 WALL 
 
 ^^^J TER RA COTTaJ F^ URRir ,0 
 
 ami 
 
 PLA5TER^ 
 
 :^ 
 
 5HETCH OF 
 
 IMPROVED FORM 
 
 OFWINDOW FRAME 
 
 m MASONRY WALL5 
 FOR HOSPITAL USE 
 
 ELEVATION OF INSIDE LOWER CORNER 
 
 Fig 
 
 able, but at present unavoidable. Where the partition of 
 wall is less than five or six inches thick it is necessary to 
 have a casing on one side, and in a two- or three-inch ^vall a 
 casing on both sides is necessary. (See Fig. 80.) 
 
146 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 AVliere a casiug is used, the cove at the floor is inter- 
 rupted, and more corners formed. The wood casing is 
 usually received by a marble base block, which prevents 
 
 ELEVATION 
 
 OF 
 
 UPPER CORNER 
 
 rPLASTER 
 
 
 PANELLED WOODJAMB 
 
 SKETCH OF USUAL FORM 
 OF DOOR FRAME 
 AND FINISH 
 
 IN THICK WALL5 
 
 It J." •J>"\^'-''>1 
 
 PLA5TER 
 
 WOOD TRIM ^ 
 SECTION THROUGH JAMB 
 
 Fig. 78. 
 
ASEPSIS AND ANTISEPSIS IN SURGERY. 
 
 147 
 
 the casing reaching to the floor, where it is liable to injury 
 by frequent wetting in washing. 
 
 SKETCH OF 
 IMPROVED FORM 
 OF DOOR FRAME 
 AnDFmi5H f 
 
 FOR H05P1TAL5 / 
 
 PLASTER- 
 ROUNDED CORNER 
 
 5ECTION THROUGH 
 JAMB 
 
 Fig. 79. 
 
 Where the casino^ is omitted, the cove at the floor re- 
 turns around the wall jamb, or finishes against the wood 
 door jamb. 
 
 With reference to the doors themselves, the usual pan- 
 
148 
 
 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 eled door is obviously objectionable, on account of tlie 
 numerous shar^D corners and angles. 
 
 The best substitute for practical use is a "solid ve- 
 
 ELEVATiON 
 
 OF 
 
 UPPER CORISEFI 
 
 VENEERED DOOR 
 
 PLAIN JAMB • 
 WOODTRIM 
 
 2" WALL 
 
 ^PLASTER 
 
 5ECTI0N THROUGH JAMB 
 
 5KETCH 5H0W1NG IMPROVED FORM 
 OF DOOR FRAME AMD FIHISH, WHEN 
 HECE55ARY TO U5E WOOD TRIM. 
 
 SECTION THROUGH JAMB 
 
 Fig. 80. 
 
ASEPSIS AND ANTISEPSIS IN SURGERY. I49 
 
 neered " door ; that is, a door formed of a glued-up pine 
 core, and veneered on sides and edges with a hardwood 
 veneer, forming a perfectly plain surface, which may be 
 kept filled and polished. 
 
 Marble doors have been used to a very limited extent, 
 but they are heavy and expensive, hard to move, and unless 
 the hinges or pivots are very hard, and carefully made and 
 adjusted, they are liable to wear down and sag. The mar- 
 ble, however, is porous, easily stained, and altogether the 
 most objectionable of all. Bronze doors would answer best, 
 but they are too expensive for hospitals as a general rule. 
 
 HOSPITAL PLUMBING 
 
 In the matter of plumbing, improvements in material 
 and fixtures have reduced in a great degree many of the 
 difficulties formerly encountered in the proper equipment 
 of hospitals. Fixtures for almost all purposes are now 
 made of heavy glazed earthenware, in designs or forms 
 needing no encasing or surrounding material. A porcelain 
 bath tub is a typical example ; when set it is complete, no 
 wood curbing or boxing being required, as in the case of 
 the older copper-lined tub. 
 
 The price of these earthenware goods is practically 
 within the reach of an institution with but limited means ; 
 for instance, they are now being used in a certain small vil- 
 lage hospital, costing less than eight thousand dollars. 
 
 In some ways, however, the " improvements " in modern 
 plumbing fixtures are of doubtful character, such as a wash 
 basin with supply and waste cocks operated by treadles on 
 the floor. In a general way the questionable value of these 
 improvements lies in their complexity, rendering them diffi- 
 cult to keep clean or to keep in order. The number of 
 valve mechanisms, traps, wastes, etc., is almost without end, 
 while the really desirable patterns are very few. 
 
 In short, the simplest form of any fixture w^th its acces- 
 sories is always the best, provided the construction is satis- 
 factory. A plain " S " trap with vent connection seems at 
 
150 ELECTRO-HiEMOSTASIS IN OPERATIVE SURGERY. 
 
 tlie present stage of progress to be the best to be had, and 
 a " standing " waste and ov^erflow the most satisfactory for 
 general use. By a " standing " waste and overflow is meant 
 a simple tube whose lower end fills the outlet of bowl, sink, 
 or tub, and whose upper end is open, the tube standing 
 vertically, and its height determining the depth of w^ater in 
 the fixture. Such a waste is the simplest possible thing to 
 keep clean, and, being wholly exposed, is always open for 
 complete inspection. 
 
 The trap should in all cases be placed as near the outlet 
 of the fixture as it is possible to get it, and the w^aste from 
 fixture to trap should be perfectly straight. The strainer 
 in the outlet of the fixture should be removable so that the 
 waste can be thoroughly cleaned. 
 
 The bad air in many bath and toilet rooms is due to the 
 fouling of the inaccessible waste and overflow connections 
 from fixture outlets to traps, and these same connections 
 may easily form favorable germinating places for dangerous 
 bacilli. 
 
 The whole aim in the plumbing of a hospital, as well as 
 any building, should be the greatest possible simplicity. 
 The number of fixtures should be cut down to the lowest 
 possible minimum, they should be grouped together as 
 nearly as possible to a few vertical lines, and the fixtures 
 themselves should be of the best material and plainest 
 design and construction consistent with specific require- 
 ments. 
 
 The arrangement of fixtures in the various rooms 
 should be such as to permit all piping to and from them to 
 be run in the most direct manner and so as to make the 
 distance from main lines of supply and waste as short and 
 as straight as possible. All waste pipes should have a 
 pitch of not less than one quarter of an inch to a foot. All 
 bends should be of large radius and clean-outs placed at 
 frequent and readily accessible points. All connections, at 
 least in the rooms containing the fixtures, should be made 
 with screw joints, so as to be easily taken down and put up. 
 
ASEPSIS AND ANTISEPSIS IN SURGERY. 151 
 
 Where the means at hand will permit, the main lines of 
 waste, soil, and vent pipes should be of galvanized wrought 
 iron screwed together, rather than the usual form of cast 
 iron with lead calked joints which can not be depended 
 upon to remain tight. 
 
 The principle of placing all bathrooms, water-closets, 
 etc., in a pavilion separate from the hospital wards is good. 
 In such an arrangement the pavilion is reached by short, 
 connecting corridors having openings on both sides so that a 
 cross current of fresh air is always maintained between the 
 main building and the pavilion containing the plumbing. 
 This separation, of course, requires space and money, and 
 may not always be had ; some modifications costing less 
 may, however, be within reach, and the nearer the ap- 
 proach to the ideal the more satisfactory will be the result. 
 
 Whether the plumbing fixtures are contained in a sepa- 
 rate pavilion or inclosed in the main building, the main ver- 
 tical lines of piping should be placed in a specially arranged 
 vertical shaft extending from the house drain at bottom up 
 to and above the roof. This shaft should be large enough 
 to permit of the proper spacing and arrangement of all 
 pipes, and for a man to conveiiieutly reach all connec- 
 tions and branches to fixtures. The branches to fixtures 
 should be run in this shaft so that there would be only the 
 supply cocks and trap visible in the room. If impossible 
 to reach a fixture by a branch in the shaft, then only so 
 much as is necessary should be run on the ceiling of the 
 room below so as to avoid horizontal pipes at or near the 
 floor, as these present almost insurmountable obstacles to 
 thorough cleaning. 
 
 The vertical shaft containing the main pipes should have 
 open iron gratings at floor levels instead of solid floors, and 
 should have no openings into it except a small " manhole " 
 or door at the bottom, the various floor levels being reached 
 by an iron ladder built in the shaft itself. To complete the 
 scheme the shaft should be heated so as to produce a strong 
 upward draught in the soil, waste, and vent pipes and their 
 11 
 
152 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 branches, so as to quickly and thoroughly oxidize any or- 
 ganic matter adhering to their sides. 
 
 Floor drains should be avoided as far as possible, and 
 where necessary should discharge into a water-supplied sink 
 placed in a shaft as already described or in a room below. 
 The sink being connected to the waste ]3ipe in the same 
 manner as other fixtures, the outlet in the floor should have 
 a cover which could not be closed until a cap had been 
 screwed down over the waste, thus insuring complete isola- 
 tion of the floor drain from the main drains and wastes. 
 
 The sink or basin in an operating room should discharge 
 in the same manner as the floor drains, so as to have no di- 
 rect connection with the drainage system. 
 
 Polished brass or nickel-plated piping requires too much 
 time in cleaning for general use ; unpolished brass pipe and 
 fittings, painted with enamel paint, will be found more ser- 
 viceable where economy of labor is to be considered. 
 
 Much attention and care is necessary to make water- 
 tight connections where pipes pass through tile or similar 
 flooring, especially hot- water pipes, so that the floors may be 
 thoroughly washed without leaking. 
 
 HEATING AND VENTILATION OF HOSPITALS 
 
 Possibly no part of hospital construction has received 
 more attention than the heating and ventilating. The 
 amount of fresh air required for each patient and its tem- 
 perature have both been satisfactorily determined ; the prac- 
 tical operation of supplying the air, warming it, and causing 
 it to circulate completely throughout the whole of each 
 room is beset with many difficulties. For ordinary work it 
 has been found more desirable to divide the problem into 
 two distinct parts, one the heating and the other the venti- 
 lating. In this method the air is heated, by large heating 
 stacks located in the lower part of the building, to the tem- 
 perature desired for the room, say 70° F., the air being at 
 this comparatively low temperature can not counteract the 
 cooling effect of doors and windows and walls ; to do this 
 
ASEPSIS AND ANTISEPSIS IN SURGERY. 153 
 
 direct radiators are placed at proper points in tlie rooms to 
 be heated. This system works well, but the direct radi- 
 ators in the rooms rapidly collect dust and are very difficult 
 to clean. A more satisfactory but a more expensive method 
 consists in heating the ^vhole volume of air, at a central 
 point or station, to nearly the temperature required by the 
 various rooms, the air passing along main ducts or con- 
 duits to the vertical flues leading to the rooms. At the 
 base of each vertical flue is placed a separate and inde- 
 pendent stack or indirect radiator, w^hich further heats the 
 air to the temperature required. In this method, every 
 room governing its own temperature, the air may be suffi- 
 ciently warmed to overcome the cooling effect of outside 
 walls, doors, and windows. This method would probably 
 be as near an ideal scheme as possible to provide. 
 
 The matter of automatic control of heating surfaces, 
 such as stacks and radiators, has been brought very near 
 perfection by vaiious forms of thermostatic valves operated 
 by the temperature of the rooms they control. These valves 
 have been found to act with great certainty, so that the 
 temperature may be maintained within a variation of a 
 degree above or below the required temperature. The 
 thermostatic valves are applicable to both systems described 
 above, and as it eliminates the necessity of depending upon 
 attendants to operate hand valves, the temperature is more 
 uniformly maintained. 
 
 In the best work the air is filtered through screens of 
 gauze before entering the heating chambers. These screens 
 take out nearly all the dust, so that the air in the flues and 
 ducts is practically clean. A fiu-ther application of the 
 screen system to special rooms, such as operating rooms, 
 would be of great advantage. 
 
 It has been found that by passing the air through screens 
 formed of sterilized cotton batting it is not only cleaned of 
 dust but is also sterilized, and the advantages of sterilized 
 air in an operating room is of course obvious. This steri- 
 lizing is readily accomplished by arranging a set of cotton- 
 
154 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 batting screens in the flue leading to the room where ster- 
 ilized air is required, the screens being made somewhat upon 
 the principle of a photographer's " plate-holder," allowing 
 the frame to be withdrawn for the purpose of changing the 
 cotton fi'om time to time, the frame sliding in and out of a 
 trunk or other device built in the flue in very much the 
 same manner as a plate-holder is put into a camera. 
 
 The increased resistance offered by the cotton would 
 of course require a stronger draught or pressui'e of air in 
 the flue, but there is nothins; in the scheme which would 
 make it impracticable. 
 
 Direct-indirect radiation should never be used where an 
 indirect system can possibly be aiforded. 
 
 The direct-indirect scheme, as is well known, consists of 
 a radiator -with a " box base," into which air is admitted 
 through an opening in the wall directly behind it, the air 
 entering the base of the radiator passes over it, and, be- 
 coming heated, enters the room. It is impossible to prop- 
 erly filter the air with this method, and it is also impossible 
 to properly regulate the temperature or supply. As a mat- 
 ter of economy it may answer for some small unimportant 
 rooms in case an outlet flue is provided leading to a main 
 exhaust stack or duct. 
 
 Storerooms, clothesroom, and closets should not be over- 
 looked, but should have as thorough ventilation as any other 
 rooms. This is often neglected. 
 
 Lavatories and rooms containing water-closets and 
 urinals should be ventilated throuo-h the fixtures — that is, 
 the air should be drawn out of the room through the bowls 
 of the fixtures themselves and conveyed by separate flues 
 to the top of the building. In this way all odor may be 
 entu'ely eliminated from these rooms. 
 
 Xo building can be thoroughly ventilated without the 
 use of a mechanical system, including the use of fans or 
 blowers. Generally, it ^vill be found best to provide two 
 sets of fans, one to force air into the rooms and the other 
 to draw it out. 
 
ASEPSIS AND ANTISEPSIS IN SURGERY. 155 
 
 All rooms should be under a slight pressure, so that the 
 warm air of the room will be escaping through the cracks 
 and openings around doors and windows instead of the 
 cold ail* outside leaking in and causing draughts. 
 
 Double sash or double glazing will be found of great 
 service in making the temperature of a room more uniform, 
 as well as reducing the consumption of fuel. It will also 
 have the effect of reducing the cost of the whole plant, as 
 the glass in windows is by far the most effective medium 
 in cooling the air, and is a very important factor in deter- 
 mining and proportioning the heating surfaces and other 
 parts of the heating system. 
 
 The system of exhaust flues and ducts is quite as im- 
 portant as the supply, and should be as carefully develoj)ed. 
 
 The location of registers in the rooms is also a very im- 
 portant item in securing a complete cii'culation of air in all 
 parts of the room. ExjDerience has demonstrated that they 
 should both be placed on the same side of a room and near 
 together, the supply being about eight feet above the floor 
 and the exhaust at or near the floor level. 
 
 In furnishing hospital rooms and wards the same rules 
 should be followed as in the construction of the building. 
 The furniture should be such as mil not lodge dirt or 
 absorb the germs of disease. Simplicity in design and 
 construction guards against the accumulation of dust and 
 dirt, and the material used should be impenetrable as far 
 as possible. .Metal bedsteads and washstands are the best 
 in use at the present time when well plated. When these 
 expensive articles can not be afforded, white enamel iron 
 answers as well. Bureaus and cabinets should not be used 
 as a rule ; but if permitted, to please lady patients, they 
 should be severely plain, and enameled within and without. 
 Such fui'niture is easily kept clean all the time, and can be 
 sterilized when the room is treated by disinfection in the 
 way to be hereafter described. 
 
CHAPTEE XYI 
 
 ASEPSIS AISTD ANTISEPSIS (cOISTTINIJEd) 
 
 AccoEDijsTG to my observations most of the imperfec- 
 tions in carrying out aseptic methods in surgery occur in 
 admission of patients and the management of their clothing. 
 To guard against all possible infection from without the 
 hospital requires a thorough disinfection of everything 
 which conges into the building. Patients do not always 
 know that they have been exposed to contagious disease ; 
 sometimes they will not admit the exposure if they do know 
 of it. One may not disregard this possible danger of pa- 
 tients bringing from infected parts of the city sepsis and 
 infectious diseases. The only safe course is to insist upon 
 the sterilization of every new patient immediately upon 
 her arrival and the disinfection of all her clothing. 
 
 The method which I practice is as follows : The patient 
 is at ohce taken to the dressing room adjoining the bath- 
 room, where her clothing is removed and put into a clean 
 bag and sent to the sterilizer. She leaves her street costume 
 here and is conducted to the bathroom to receive an ammo- 
 nia bath, and then dressed in a full change of clothing, 
 which had been sent to the hospital the previous day and 
 sterilized. All her clothing and everything which she has 
 brought with her is sterilized by fonnaldehyde before being 
 taken to her room. By this means the surgeon -will assure 
 himself that his new patient has at least rightly begun her 
 hospital life. 
 
 The Preparation of a Patient for all Major Operations. 
 — The previous night she receives a full ammonia bath, in 
 giving which the nurse is careful to clean all folds of the 
 
 156 
 
ASEPSIS AND ANTISEPSIS IN SURGERY. 157 
 
 skin. It is to be kept in mind that the nurse in charge of 
 the bath must herself be clean. Thorough scrubbing 
 should be practiced and then the body rinsed off with 
 boiled water. The head should be shampooed with alcohol 
 and quickly dried. This having been accomplished, the 
 patient is dressed in sterilized under and night clothes and 
 then put into the bed newly made up with sterilized bedding 
 and bedclothes. A further cleansing is now given the 
 whole abdomen in cases of abdominal section ; it is thor- 
 oughly scrubbed with soap and water, then washed off with 
 a one-in-two-thousand bichloride solution ; finally, a bichlo- 
 ride compress (one in one thousand) and a clean binder are 
 put on. The next morning this last cleansing process is 
 repeated and a new compress and binder are applied. Now 
 that the patient is clean, the utmost care must be exercised 
 to protect her against contamination. She must be con- 
 veyed to the ansBsthetizing room in a clean carriage or 
 stretcher by clean attendants. The anaesthetist and the at- 
 tending nurses are dressed in clean garments. The anaes- 
 thetizing instruments have been cleaned the same as the 
 instruments for the operation. If the narcosis is not given 
 while the patient remains in her carriage, the couch or table 
 on which she is placed is to be covered with sterilized ma- 
 terial. As soon as the patient does not recognize her sur- 
 roundings she is finally prepared for the operation by 
 scrubbing the abdomen with soap and water, the hypogas- 
 trium is then shaved with a sterilized razor, dried and 
 bathed first in alcohol, then ether, and finally bichloride 
 solution, one in one thousand. The umbilicus is covered 
 with collodion, in case it is not to be incised ; a clean com- 
 press and a new binder complete all and the patient is ready 
 to be taken into the operation. 
 
 The room used for operations is twice cleaned, once just 
 after the preceding operation and again in preparation for 
 the next one. Everything which is needed for the opera- 
 tion, except instruments, is brought in ; then the formalde- 
 hyde is introduced, and the room sealed for five hours. 
 
158 ELECTRO-H^MOSTASTS IX OPERATIVE SURGERY. 
 
 Blunt instruments are sterilized by exposure in live 
 steam for fifteen minutes ; edged instruments are immersed 
 in alcohol (ninety -five per cent) for ten minutes. Of late 
 instruments are sterilized in formaldehyde ; and I believe it 
 will prove to be the best method. When needed they are 
 placed into the trays and covered with hot carbolized solu- 
 tion. Formula : Carbolic acid, three per cent ; glycerin, 
 twentv-two per cent ; water, seventy-five per cent. Xatu- 
 ral sponges are washed for twenty-four hours in Javell 
 water, the grit is taken out, and then they are washed in 
 sterilized water ; they are preserved in five-per-cent carbolic 
 solution. A careful rinsing in running sterilized water 
 prepares them for immediate use. They should not be 
 used a second time in abdominal work. Gauze sponges, 
 the towels, binders, and gowns are cleansed by the ordinar}" 
 steam apparatus. The primary gauze dressing is prepared 
 in quantities by saturating it in a solution of carbolic acid, 
 one paii: to glycerin eight parts. It is always ready, and 
 requires but to have the excess of the solution rung out of 
 it with a sterilized towel immediately before using. 
 
 The suture material used is the ordinary braided silk, 
 which is sterilized perfectly by boiling in salicylated wax 
 for twenty hours, in five-hour fractions, with an hour inter- 
 val. Suture material prepared in this way is perfectly 
 sterile and can be kept so for any length of time. More 
 than that, it ^vill remain sterile in the tissues as long as 
 silver wii'e. This was demonstrated by both laboratoiy 
 and clinical experiments many years ago. 
 
 Cleansing and sterilizing the hands has always been one 
 of the subjects which claim the most careful attention of 
 surgeons. Even at the present time all methods, and they 
 are many, are questioned regarding their efiSciency or prac- 
 tical application. "Without discussing the subject I shall 
 give the methods employed in my own practice and which 
 have given the best results in re^rard to both the patient 
 and the operator. 
 
 The method employed is as as follovzs : Soft srreen ster- 
 
ASEPSIS AND ANTISEPSIS IN SURGERY. 159 
 
 ile soap is used with a sterile brush and running water that 
 has been sterilized by boiling or distillation. The soap is 
 thoroughly applied with the brush, then washed oi£ in 
 the stream of water. This process is repeated four or five 
 times, according to the condition of the hands. The water 
 is made to play with force upon all parts of the hands and 
 arms until all particles of the soap and dirt are washed off. 
 Finally, the liands are placed in a solution of carbolic acid 
 three per cent, glycerin twenty-two per cent, and water 
 seventy-five per cent, and scrubbed or rubbed in with a 
 brush. The excess of the solution is wiped oif with a clean 
 towel, and they are ready for use. This is sufiicient treat- 
 ment of the hands, unless the surgeon has been contaminated 
 by examining or operating upon septic cases ; then a more 
 careful disinfection is necessary. In such conditions of the 
 hands more prolonged washing is employed, and then they 
 are thoroughly anointed with carbolic acid pure one part and 
 glycerin seven or eight parts. This is applied to the hands 
 and arms and rubbed in with a soft, clean brush and 
 allowed to remain about five minutes. It is then rapidly 
 washed off with a strong stream of rapid-running water. 
 The reason for doing this quickly is that the added water 
 develops the caustic properties of the carbolic acid so that 
 it will injure the skin if permitted to remain in contact 
 with it. 
 
 The advantages which this glycerin and carbolic-acid 
 solution has is that the glycerin neutralizes the caustic 
 properties of the acid and does not diminish its power as a 
 germicide. Furthermore, it keeps the hands in good condi- 
 tion. I am quite confident that this is a most satisfactory 
 way of treating the hands so far as sterilizing them, not on 
 the surface only but deep into the cuticle as far as germs 
 go. The mercuric solutions which I formerly used hard- 
 ened the skin and left living organisms beneath the crust 
 of sterilized tissue. This hardened epithelium became 
 softened in abdominal work and set free the living germs 
 that escaped the sterilizing. That is one of the imperfec- 
 
160 ELECTRO-H.EMOSTASIS IN OPERATIVE SURGERY. 
 
 tions of the usual way of cleaning tlie hands, which has 
 been pointed out, and has driven some surgeons to the use 
 of gloves while operating. 
 
 I prefer to wear gloves when examining doubtful cases, 
 dressing wounds, or handling pathological specimens, and 
 so keep the hands free from infecting germs that can not be 
 destroyed by the method of cleansing which I practice, or 
 any other method known to me. 
 
 There is but one objection to the carbolic and glycerin 
 solution, and that is the expense, but that is hardly worth 
 naming in view of the advantages given by its use. 
 
 The subject of room disinfection, which has been far 
 from satisfactory in the past, has been greatly improved of 
 late. Indeed, I feel sure that the recent improvements in 
 this direction meet the requirements. 
 
 The recent work of Ezra H. Wilson, M. D., is the most 
 perfect that is known to me ; and I give here, by permission, 
 his essay on this subject : 
 
 The requirements to be met in a proj^er disinfection of 
 an apartment in which there has been infectious diseases are : 
 
 First. Absolute disinfection ; by that is meant the 
 destruction of all infectious material. 
 
 Second. Ease and rapidity in application. 
 
 Thii'd. Economy. 
 
 Fourth, The least possible damage to disinfected goods. 
 
 The best disinfectant applicable to infected goods such 
 as wearing apparel, bedding, etc., is heat in the form of 
 steam, and it is safe to say that up to the present time no 
 substitute has been found which will disinfect so thoroughly, 
 rapidly, and economically as steam. The objections to its 
 universal application are, that it can not be applied in the 
 disinfection of apartments (walls, floors, ceilings, etc.), and 
 that certain cheap grades of colored goods are often injured 
 by it. The disinfection of apartments by the mechanical 
 process of rubbing and scrubbing with disinfecting solutions, 
 while veiy thorough, is tedious, expensive, and often dam- 
 aging to painted and frescoed walls and ceilings. 
 
 If, therefore, an agent can be found which can be used 
 for the disinfection of apartments which will be an efficient 
 
ASEPSIS AND ANTISEPSIS IN SURaERY. 161 
 
 germicide and not cause any damage, it is very desirable to 
 investigate it. Such an agent we believe we have in for- 
 maldehyde gas, used in a proper manner and in proper 
 amounts. The original method was to produce the gas by 
 the oxidation of methyl alcohol in the presence of incan- 
 descent platinum or platinized asbestos, and that is the 
 method now used in the many lamps now in the market, 
 and for which extravagant claims are made. There are 
 many objections to these lamps. In the first place, and 
 what is most important, they do not produce enough of the 
 gas to be of any value. Second, they involve the use of 
 an inflammable and explosive compound, the methyl alcohol, 
 in proximity to an open flame. Third, they have to be 
 lighted and shut up in a room where they are hidden from 
 observation. Fourth, it is impossible in practice to regulate 
 the lamp so as to get the maximum amount of gas, and so 
 to allow of the escape of unoxidized methyl alcohol vapor. 
 
 Roux, Baudet, Trillat, and others devised a method of 
 evolving formaldehyde gas from formalin. Formalin or 
 formol is a saturated (forty per cent) solution of the gas 
 in water. If a quantity of formalin is mixed with an equal 
 quantity of a five- to ten-per-cent solution of calcium chloride, 
 it will be found that the boiling point of the mixture is 
 considerably above 100° F. (103° to 106°), and the most 
 favorable temperature for evolving formaldehyde gas is 
 between 95° and 100° F. Thus nearly all the gas is evolved 
 before the mixture is giving off steam. Moreover, it pre- 
 vents the polymerization of the gas into trioxymethelene. 
 
 I will now describe an apparatus for carrying out this 
 process. 
 
 PARTIAL DESCRIPTION OF AND DIRECTIONS FOR THE USE OF 
 THE TRILLAT AUTOCLAVE 
 
 The Apparatus is pached in Tivo Cases. 
 
 Autoclave Case. — Containing autoclave with gauge; 
 thermometer ; two handles and a tin case containing two 
 outlet tubes and a wire to clean same. 
 
 Case of Accessories. — Special lamp and small can con- 
 taining alcohol to light same ; copper can for the formo- 
 chloral ; tin can for kerosene ; cotton wadding for stuflfing 
 cracks in windows, doors, etc. ; pair of spectacles to protect 
 eyes. 
 
162 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 Trillat Autoclave. — The vessel of the apparatus is made 
 of heavy copper which is silver-lined and has a capacity of 
 about one and one half gallons. The remainder of the 
 apparatus is mostly brass, highly polished and carefully 
 finished. 
 
 The cover of the autoclave, which rests on a rubber 
 band so that it can be tightened to avoid any leakage, is 
 equipped with a pressure gauge, a sleeve in which the ther- 
 mometer is placed and a stopcock by which one regulates 
 the escape of formaldehyde gas. 
 
 Lamp, — The apparatus is heated by means of a special 
 lamp, the flame of which is fed by kerosene vapors. By a 
 small screw one can regulate the heat, and by using the 
 pump occasionally one can increase the heat. 
 
 Formocliloral is a saturated solution of formic aldehyde 
 and a neutral or indifferent mineral salt and absolutely free 
 fi'om methyl alcohol. When heated under pressure, formal- 
 dehyde vapors are evolved in a non-polymerized condition. 
 
 Before putting the formochloral into the autoclave, it 
 should be well mixed so as to distribute any precipitate 
 which may be in the same. This deposit is not an im- 
 purity, but on the contrary is one of the essential parts of 
 the solution. 
 
 Directions. — All cracks around windows, doors, fire- 
 places, etc., should be stuifed to reduce the possibility of 
 the gas escaping as far as possible. 
 
 The formochloral is put into the autoclave, which should 
 never be more than three quarters full, about one gallon or 
 ten pounds by weight maximum. The minimum should 
 not be less than a quart, or about two and one half pounds 
 by weight on account of the possibility of injuring the auto- 
 clave. One calculates that one pound of formochloral is 
 sufficient for 2,500 to 5,000 cubic feet of air space. 
 
 When tightening the cover, one should screw the op- 
 posite bolts little by little so as not to press on one side of 
 the rubber band. 
 
 The apparatus after being closed is placed in front of 
 the door of the room that is to be disinfected at a conven- 
 ient height so that the stopcock is level with the keyhole. 
 
 Carefully examine the outlet tube through which the 
 formaldehyde gas is allowed to escape and see that it is 
 free from any obstructions. Then put it through the key- 
 
ASEPSIS AND ANTISEPSIS IN SURGERY. 163 
 
 hole, allowing it to project inside of the room from about 
 four to six inches ; then attach it to the autoclave by means 
 of the screw bolt attached to the same. Put the thermome- 
 ter in place, close the stopcock, and light the lamp. 
 
 When the gauge indicates a pressure of a little over or 
 about three atmospheres, carefully open the stopcock little 
 by little, otherwise, should it be opened too rapidly, the 
 liquid in the autoclave is apt to force itself out through 
 the tube and is liable to produce disagreeable results, and 
 for this reason it is well to take the precaution of removing 
 the furniture and to cover carpets that may be directly in 
 the vicinity of where the outlet tube projects. 
 
 One knows that the gas flow is well regulated by the 
 very gradual falling of the pressure as indicated by the 
 gauge. The pressure should be kept as near as possible 
 between two and three atmospheres. The vaporization can 
 be considered finished in about one and one half hours 
 when two and one half pounds of formochloral is used ; 
 for the maximum charge, ten pounds, two hours sufiices 
 ordinanly, and one must always stop the operation when 
 the thermometer is over 135° and the pressure is below 
 two or three atmospheres. When the operation is over 
 the outlet tube can be withdrawn and keyhole stopped. 
 
 It is preferable to allow the formaldehyde gas to re- 
 main as long as possible, but from three to four hours' con- 
 tact is sufficient for a good disinfection. Afterward it is 
 necessary to air the apartment. To do this, enter rapidly, 
 wearing the glasses and, without breathing, open the win- 
 dow. One half hour later, one can without inconvenience 
 enter the room. The order of formaldehyde can be neu- 
 tralized more rapidly by injecting a little ammonia into 
 the room. 
 
 After the apparatus is cooled remove the thermometer, 
 take off the cover of the autoclave, and empty the residue, 
 which should be in a liquid form. Clean with water and 
 dry with a linen rag. 
 
 It will be seen from the experiment that the organisms 
 protected by the folds of blanket were not killed, and this 
 brings up another consideration, namely, that of penetra- 
 tion. No matter how valuable this agent in a free state 
 may be as a disinfector of superficially infected areas, such 
 as walls, floors, and ceilings, it must be admitted that its 
 
164 
 
 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
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ASEPSIS AND ANTISEPSIS IN SURGERY. 
 
 165 
 
 power of penetration is not great, and although somewhat 
 foreign to the subject of this paper, I will describe some 
 experiments which were made to test this matter of pene- 
 tration. These were made at the City Disinfecting Station 
 by R. B. F. Randolph, assistant bacteriologist. 
 
 Table 1 
 
 No. 
 
 Culture. 
 
 1 
 
 Anthrax. . . : . . 
 
 2 
 
 " 
 
 3 
 4 
 
 Typhoid 
 
 S. P. A 
 
 5 
 
 Anthrax 
 
 6 
 
 7 
 
 Diphtheria . . . 
 S. P. A 
 
 8 
 9 
 
 Typhoid 
 
 Anthrax 
 
 10 
 11 
 
 Diphtheria . . . 
 S. P. A 
 
 13 
 13 
 
 Typhoid 
 
 Anthrax 
 
 14 
 15 
 
 Diphtheria . . . 
 S. P. A 
 
 16 
 17 
 
 Typhoid .... 
 Anthrax 
 
 18 
 19 
 
 Diphtheria . . . 
 S. P. A 
 
 20 
 
 21 
 
 Typhoid 
 
 Anthrax 
 
 22 
 23 
 
 Diphtheria . . . 
 S. P. A 
 
 24 
 25 
 
 Typhoid 
 
 Anthrax 
 
 26 
 
 27 
 
 Diphtheria . . . 
 S. P. A 
 
 28 
 29 
 
 Typhoid 
 
 Anthrax 
 
 Location. 
 
 Inside a straw mattress. 
 
 Folded in the middle of an excelsior mattress. 
 
 Between mattress and feather bed. 
 
 Surrounded by two layers of blankets. 
 
 ' one layer of blanket. 
 
 ' four layers of blankets. 
 
 eight " 
 
 Exposed on top of the pile of goods. 
 
 Result. 
 
 Lived. 
 
 Died. 
 
 Lived. 
 Died. 
 
 Lived. 
 
 Died. 
 Lived. 
 
 Died. 
 
 Experiment No. 2 
 
 A Trillat autoclave was so arranged that a stream of 
 formaldehyde gas could be forced into the inner chamber of 
 the disinfecting oven. Sterile silk threads were immersed in 
 cultures of sporulating anthrax, B. typhosus, B. diphtherise, 
 and staphylococcus pyogenes aureus, and allowed to dry at 
 ordinary temperatures. When dry they were inclosed in 
 sterile filter-paper envelopes and arranged as described in 
 Table 1. 
 
 The conditions of the experiment were as follows : 
 
 Quantity of formochloral used, 1,250 c. c. 
 
 Capacity of the chamber, 340 cubic feet. 
 
166 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 Vacuum at the beginning of tlie test, 14 inches of 
 mercury. 
 
 Vacuum after the admission of the formaldehyde, 11 
 inches. 
 
 Gas was run in for thirty minutes. 
 
 After the gas had ceased to flow, air was admitted until 
 the o'auo'e stood at zero. 
 
 One hour after the gas was shut off the chamber was 
 twice exhausted and filled with air. 
 
 The chamber was opened at 10 a. m. the following day. 
 
 There was a slight odor of formaldehyde, but not enough 
 to prevent a man from going in immediately. About two 
 gallons of water smelling strongly of the gas was found on 
 the floor of the chamber. The goods were dry and uninjured. 
 
 It will be seen that the disinfection was far from com- 
 plete, the anthrax not being killed except in one instance, 
 and the other organisms in the more protected portions of 
 the pile not being affected. This lack of penetration, how- 
 ever, can be partially accounted for. The air admitted to 
 the chamber immediately after the gas was shut off was 
 taken through the sewer outlet, and in doing this the con- 
 tents of the trap were sucked up into the chamber and 
 possibly dissolved, and thus rendered inoperative a large 
 amount of the gas. 
 
 It was thought that a greater and more uniform degree 
 of penetration could be secured by slightly heating the 
 chamber, inasmuch as the diffusion power of a gas is 
 largely influenced by its temperature. The following ex- 
 periment was therefore made : 
 
 The formaldehyde was generated in an autoclave built 
 for that i^urpose by the Kny-Scheerer Co, It consisted of 
 a copper boiler nickeled inside and out and provided with 
 a water gauge, safety valve, thermometer, and exit tubes for 
 the gas evolved. Heat was produced by a triple "Piis- 
 Hius " oil burner. The apparatus was connected "with the 
 disinfecting chamber by a rubber tube which connected 
 with a small iron pipe entering the chamber at the top. 
 The formaldehyde was generated from a mixture of Kny- 
 Scheerer formalin 38.7 per cent of CHoO. The mixture 
 was made u]) as follows : 
 
 Formalin 1,350 c. c. 
 
 Calcium chloride (anhydrous) 200 grs. 
 
 Water to make up to 4,000 c. c. 
 
ASEPSIS AND ANTISEPSIS IN SURGERY. 
 
 167 
 
 The determination of formaldehyde was made by the 
 ammonia method as given by Struver (Zeit. f. Hyg., Bd. 
 
 XXV, Heft 2). -, . T V ^ 1. 1. +1. 
 
 All determinations were made m duplicate by botn 
 gravimetric and volumetric methods. It would have_ been 
 advisable to determine the amount of mythyl alcohol m the 
 formalin, as this reacts with formaldehyde at the tempera- 
 ture of the operation, giving methylal, a substance havmg 
 little or no disinfecting action. Any methyl alcohol pres- 
 ent therefore, diminishes the efficiency of the iormahn. 
 No' satisfactory method of determining methyl alcohol m 
 such a mixture has yet been devised, and the results ot 
 this experiment are therefore subject to a correction on 
 this account. We have been assured by the manuiacturer 
 of the formalin used, however, that it contains less than 
 one per cent of methyl alcohol, and no serious error wdl 
 be made by neglecting it. -, n • ^ ^ 
 
 Silk threads were soaked for several hours m twenty- 
 four-hour cultures of the bacteria used, and dried at room 
 temperatures. These threads were then inclosed m sterile 
 filter-paper envelopes as in the previous experiment, and 
 were aiTanged as shown in Table 2, which also shows the 
 result of the experiment. 
 
 Table 2 
 
 Organism used. 
 
 Location. 
 
 Diphtheria 
 
 Typhoid 
 
 Anthrax spores 
 
 Staph, pyogenes aureus . 
 
 Diphtheria 
 
 Typhoid 
 
 Anthrax spores 
 
 Staph, pyogenes aureus , 
 
 Diphtheria 
 
 Typhoid 
 
 Anthrax spores 
 
 Staph, pyogenes aureus 
 
 Diphtheria 
 
 Typhoid 
 
 Anthrax spores 
 
 Staph, pyogenes aureus 
 
 Within a folded mattress, 
 
 U '^ " 
 
 In the middle of a folded blanket. 
 Between two folded blankets. 
 Exposed on top of pile. 
 
 Result. 
 
 Killed. 
 
 The pile of material was placed on the truck and run 
 into the' oven, being as nearly as possible m tl^e center of 
 the chamber. The doors were then tightly closed and 
 
 12 
 
168 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY. 
 
 the vacuum pump started, and steam turned into the outer 
 jacket in order to heat the inner chamber. In thirty 
 minutes a vacuum of 14.25 inches was obtained, and the 
 temperature of the inner chamber was then 40*^ C. In the 
 meantime the lamp under the autoclave had been lighted, 
 and the pressure raised to 37.5 pounds. The valves were 
 then opened and the formaldehyde gas admitted to the 
 chamber, the pressure of the autoclave being kept above 
 30 pounds. The gas was allowed to flow thirty minutes 
 and was then shut off, the vacuum in the chamber having 
 fallen to 10 inches and the temperature risen to 49° C. 
 Air was then admitted to the chamber through the safety 
 valve until the vacuum was reduced to zero. The temper- 
 ature of the inner chamber was then raised to 65° C. and 
 kept there during the rest of the experiment, which lasted 
 altogether an hour and a half. At the expiration of this 
 time the chamber was opened, the threads in the enve- 
 lopes were removed and taken to the laboratory, where 
 they were planted in sterile broth and incubated for a 
 week. No moist cultures were used, as it was intended to 
 make the experiment correspond as closely as possible to 
 actual working conditions, and in practice we are seldom 
 called upon to disinfect articles that are not dry. The for- 
 malin mixture remaining in the autoclave was carefully 
 removed and measured. It amounted to 2,300 c. c. and con- 
 tained 9.27 per cent of formaldehyde, corresponding to 
 213.2 grammes. As the original mixture contained 500 
 grammes 286.8 were present in the chamber, and as the 
 capacity of the chamber is 10,188 cubic metres, each cubic 
 metre contains 28.11 grammes of CHgO. This corresponds 
 to a volume per cent of 1.93, or, in round numbers, two per 
 cent. 
 
 This experiment proves that, under the conditions 
 adoped, two per cent is sufficient to disinfect anthrax 
 spores in the middle of a mattress — a very severe test — 
 and, on this account, it is recommended that two per cent 
 be the minimum of gas allowed. As regards the temper- 
 ature and the vacuum, the experiment shows that a temper- 
 ature of 65° C. is high enough, and that a vacuum of at 
 least half an atmosphere is desirable. 
 
 It will be seen that the temperature exercises a marked 
 effect on the disinfection, and the failure of the first experi- 
 
ASEPSIS AND ANTISEPSIS IN SURGERY. 159 
 
 ment, where a much larger percentage of gas was used, 
 must be attributed to the low temperature at which it was 
 conducted. 
 
 This method, therefore, gives a convenient and satisfac- 
 tory disinfection of goods that would certainly be injured, 
 if not ruined, by the use of steam. 
 
 The advantages of the autoclave over the lamps are 
 at once apparent : 
 
 First. It produces a large volume of the gas. 
 
 Second. Rapidity of application. 
 
 Third. It is constantly under observation and located 
 outside the room. 
 
 Fourth. No damage to disinfected goods. 
 
 CLEANLINESS IN THE CARE OF PATIENTS AND SICK ROOMS 
 
 The older methods of disposing of soiled clothing, 
 dressings, and discharges were most objectionable. Old foul 
 dressings were carried from the halls, some of them to the 
 laundry, to be washed and used again. Excrements were 
 carried in open vessels to the closets, deposited tbere, and 
 in the best-regulated hospitals or homes some disinfectant 
 poured down the closet every time it was used, or several 
 times a day, and the results were easily to be imagined. 
 
 The methods pursued at the present time in my practice 
 are to place all soiled dressings directly on their removal into 
 a vessel. The vessel is closed witli an air-tight rubber cover 
 and taken away and the dressings at once cremated. The 
 vessel is disinfected at once, and made ready for further use. 
 Vessels used for the reception of excrement, urinals included, 
 receive before using some disinfectant and deodorizer, and 
 when used are covered with air-tight rubber covers and 
 taken away. Wash basins are emptied into slop pails that 
 can be closed with rubber covers while conveying them to 
 the closets to be emptied and cleansed. 
 
 Bed linen is placed in a clean bag of rubber cloth and 
 conveyed to the laundry. In this way the halls, stairways, 
 and elevator are kept free from contamination and mal- 
 odors. 
 
INDEX 
 
 Abdominal incision, ha3morrhage, 30. 
 Abscess, pelvic, 85. 
 Acetic acid, 104. 
 Adenomectomy, 97, 100. 
 Adhesions, not possible, 25. 
 
 of appendix vermiformis, 33. 
 
 of bladder, 34. 
 
 of intestines, 33, 52. 
 
 of omentum, 31, 52, 
 
 of rectum, 34. 
 
 recent, 35. 
 
 vascular, old, 55. 
 Advantages of method, 25, 83, 134. 
 Ansesthesia, 64, 77, 119. 
 Angioma, 115, 132. 
 
 of urethra, 113. 
 Antisepsis and asepsis, 136 et seq. 
 Appendectomy, 57. 
 AppendLx vermiformis, adhesions, 32. 
 
 treatment, 23. 
 Artery, treatment, 23. 
 
 treatment of isolated, 18. 
 Aspiration of Fallopian tube, 56. 
 
 Battery outfits, 14 et seq. 
 Belladonna tr., 124. 
 Bichloride of mercury, 77. 
 Bismuth subgallate, 124. 
 Bladder, adhesions, 34. 
 
 tumors, 102. 
 
 ulcer, 110, 118. 
 
 Cancer, of uterus, 65. 
 
 of cervix, 65, 69. 
 
 of bladder, 106. 
 
 cures, 83. 
 Carbolic acid, 77. 
 Carbuncle, 93. 
 Caruncle, 113. 
 
 Case histories — appendectomy, 60. 
 
 bladder, neoplasm, 107. 
 
 epithelioma of lip, 129. 
 
 Fallopian tube, patency, 49, 51. 
 
 fissura in ano, 128. 
 
 mammectomy, 3, 97, 99. 
 
 migrated ligature, 7, 51. 
 
 nasvus, 129. 
 
 nfevus pilaris, 129. 
 
 ovariotomy, 50, 51. 
 
 post-mortem condition of stump, 6. 
 Catgut ligatures, objection to, 1, 25, 96. 
 
 for peritoneum, 83. 
 Caustics, 131. 
 Cautery, galvano, 129. 
 
 knife, 72, 78. 
 
 loop, 69. 
 Cervix, amputation, 45. 
 Clamp, ovariotomy, 35. 
 
 hjemorrhoidal, 121. 
 Coagulation necrosis, 27, 29. 
 Cocaine, 127. 
 Current, strength of, 10, 13, 26, 130. 
 
 length of time to be maintained, 
 18. 
 Cystotomy, 102. 
 Cysts, labial, 87. 
 
 vaginal, 88. 
 
 Directions for use of instruments, 12. 
 Dome electrode, 75. 
 
 point, 32, 41, 55. 
 Doors, sanitary construction, 149. 
 Drainage in pelvic abscess, 86. 
 Dressings, disposal of soiled, 169. 
 Dry dissector, 40. 
 
 Electrolysis, 130. 
 Endoscope, glass, 118, 127. 
 171 
 
172 
 
 ELECTRO-HiEMOSTASIS IN OPERATIVE SURGERY. 
 
 Epithelioma of cervix, 69. 
 
 of skin, 132. 
 Experiments, 23, 26, 29. 
 Experimental results, 21, 25, 29. 
 
 Fallopian tube, experiments, 26, 29. 
 
 patency, 6, 49, 51, 59. 
 
 operation upon, 49. 
 
 aspiration, 56. 
 Fibroid, 39 et seq. 
 Fissure of anus, 125. 
 Fissure of neck of bladder, 118. 
 Fistula of rectum, 57. 
 Flaxseed tea enema, 124, 125. 
 Floors, sanitary construction, 140. 
 Forceps, plain, 9. 
 
 hpemorrhoidal, 121. 
 
 for ovariotomy, 35. 
 
 shield, laparotomy, 34. 
 elytrotomy, 80. 
 
 the dome, 32. 
 
 temperature required, 35. 
 
 time required, 18. 
 Formaldehyde disinfection, 160 et seq. 
 French method for hysterectomy, 82, 84. 
 Friable tissue, 25, 132. 
 
 Galvano-cautery, 67, 129. 
 Glands, lymphatic, 100. 
 
 of urethra, 116. 
 Glycerin and carbolic for hands, 59. 
 Glycerrhiza comp. ext., 124. 
 
 Healing process, 23, 30, 107. 
 Heat, 10, 104, 152. 
 Hsematocele, pudendal, 92. 
 Haemorrhage in abdominal section, 30. 
 
 capillary, 32. 
 
 control of, 25. 
 
 in sac of Douglas, 32. 
 
 secondary, 18. 
 
 with cautery knife, 73, 131. 
 Hsemorrhoidal clamp, 121. 
 Haemorrhoids, 120. 
 Hernia, 30. 
 
 High amputation of cervix, 71. 
 Hospital construction, 187 et seq. 
 Hydrosalpinx, 52. 
 Hysterectomy, advantage of method, 83. 
 
 for cancer, abdominal, 65. 
 vaginal, 76. 
 
 for fibroid, 42. 
 
 mortality, 84. 
 
 Instruments, sterilization, 158. 
 Intestine, adhesions, 33. 
 
 protection to, 31. 
 
 operation upon, 23, 57. 
 
 Labial cysts, 87. 
 Laboratory experiments, 21, 23. 
 Ligature, objections to, 1, 25, 30, 32, 49. 
 Lymphatics, treatment, 25. 
 
 Maramectomy, 95. 
 
 Mesosalpinx treatment, 54. 
 
 Mortality of method, 84. 
 
 Mucous surfaces, treatment, 23, 25, 57. 
 
 Myomectomy, 39. 
 
 Neoplasms, bladder, 102. 
 
 of mucous membranes and skin, 129. 
 Nerves are devitalized, 25. 
 
 Omentum, adhesions, 32, 52. 
 
 treatment, 31. 
 Opii comp. liq., 124. 
 Ovariotomy, 30. 
 Ovario-salpingectomy, 52. 
 
 Pain, 5, 25, 97, 138. 
 Pedicle, formation, 53. 
 
 forceps, small, 35. 
 large, 36, 37. 
 
 post-operationem, 5. 
 
 repair, 23. 
 
 treatment, 35 et seq. 
 Pelvic abscess, 85. 
 Peritoneum, 37, 45, 72. 
 
 suturing of, 83. 
 Plumbing, sanitary, 149. 
 Preparatory treatment, haemorrhoids, 
 120. 
 
 major operations, 156. 
 Pudendal vrounds, 90. 
 Pyosalpinx, 54. • 
 
 Reparative process, 23, 25, 59, 64, 107, 
 
 122. 
 with ligature, 5. 
 Recoveries incomplete with ligature, 49, 
 
 50. 
 Rheostat, 12. 
 
 Salpingectomy, 49. 
 
 Septic processes inhibited, 25, 60. 
 
 Sequelae, operative, unfavorable, 5. 
 
INDEX. 
 
 173 
 
 Shield forceps, 40, 80. 
 Silk ligatures post-operationem, 5. 
 Sloughing from pressure, 44. 
 Soda bicarbonate, 124. 
 Speculum, Byrne's, 68. 
 Sterilizing effect of method, 25. 
 Stump ablation, 58. 
 
 aseptic conditions, 25. 
 
 exudates, with ligature, 50, 59, 60. 
 
 ligation, 6. 
 
 conditions after treatment, 19, 63. 
 
 size after treatment, 25. 
 
 reparatory processes, 25. 
 Suture material, 158. 
 
 Temperature of heated forceps, 12. 
 Time necessary for desiccation, 18, 
 
 81, 96, 121. 
 Transformer, 11. 
 
 Ulcer of bladder, 110, 118. 
 of rectum, 125. 
 
 31. 
 
 Ureter, treatment, 23. 
 Urethra, glands of, 116. 
 
 papilloma of, 117. 
 
 stenosis of, 117. 
 
 Vagina, cysts of, 88. 
 
 disinfection of, 76. 
 
 hysterectomy through, 76. 
 
 indications for section of, 85. 
 Varix of vulva, 89. 
 Vascular tumors, 130. 
 Vaseline for forceps, 13, 36. 
 Ventilation, sterile, methods of, 152. 
 Vessels, treatment of, in hysterectomy, 
 
 43. 
 Volsellum forceps diverging, 72. 
 Voltage required, 11. 
 Vulva, diseases of, 85. 
 
 Walls, sanitary construction, 139. 
 
 Watts required, 10. 
 
 Windows, sanitary construction, 143. 
 
 LIST OF AUTHORS CITED 
 
 Armstrong, 57. 
 Barker, 100. 
 Beard, 135. 
 Bloom, 131. 
 Bovee, 51. 
 Byrne, 65, 135. 
 Chrobak, 50. 
 Clark, 65. 
 Dickinson, 123. 
 Emery, 137. 
 Ferguson, 6. 
 Haggard, 55. 
 
 Keith, 7, 49. 
 Kelly, 4, 47, 65. 
 Pignolet, 8. 
 Randolph, 165. 
 Ries, 49. 
 Routh, 88. 
 Schauta, 50. 
 Schleich, 64. 
 Seymour, 23. 
 Smith, 57. 
 Van Buren, 125. 
 Wilson, 160. 
 
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